eMedicine Specialties > Infectious Diseases > Mycobacterial Infections
Mycobacterium Marinum: Treatment & Medication
Updated: Jan 16, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
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Treatment
Medical Care
The mainstay of treatment in M marinum infection is antimicrobial therapy. The duration of therapy is not well defined, but treatment of skin and soft-tissue infections should be continued for 1-2 months after resolution of symptoms and lesions. Therefore, the treatment duration is typically 3-4 months, longer if deeper structures are involved. Some authors have suggested a minimum duration of 6 months. In some cases, a treatment duration of up to 2 years has been reported. Combination treatment with 2 active agents is preferred, although success has been obtained with single-agent approach. Spontaneous resolution of M marinum infection has been reported.
Surgical Care
Surgical drainage of skin lesions may be unnecessary. A French study revealed no clear benefit or change in outcome using a concomitant surgical approach. Deeper-structure infections may require surgery, although its definite role is not well established. Reports have suggested that antibiotic therapy alone is enough to cure most patients and that additional surgical debridement provides cure in remaining cases.
Consultations
An infectious disease specialist can establish the diagnosis and suggest management. A dermatologist can also provide expertise.
Medication
M marinum is resistant to the antituberculosis medications isoniazid, pyrazinamide, and para-aminosalicylic acid and shows intermediate sensitivity to streptomycin. Isolates are sensitive to rifampin, rifabutin, ethambutol, clarithromycin, and sulfonamides, including trimethoprim-sulfamethoxazole (TMP-SMX). Intermediate or complete sensitivity has been reported for both doxycycline and minocycline. Fluoroquinolones also show activity against M marinum. Routine susceptibility testing is not recommended and should be reserved for cases of treatment failure.
No comparative trials of treatment regimens for M marinum skin and soft-tissue infections have been performed. The recommended approach is to use combination of 2 active agents until 1-2 months after resolution of lesions or for a minimum of 6 months. Clarithromycin and ethambutol combination treatment is likely to provide optimal efficacy and tolerability. Rifampin should be added to the treatment regimen when osteomyelitis or other deeper-structure infections are present. Other combinations that have also been used include ethambutol/rifampin, clarithromycin/rifampin, cyclines/clarithromycin, and cyclines/rifampin.
Treatment failure is associated with deeper-structure involvement and is not related to drug therapy. Doxycycline and minocycline monotherapy should probably be used for more superficial soft-tissue infections, as treatment failure has been reported. Clarithromycin monotherapy has been used with some success. Azithromycin can be an alternative to clarithromycin in other nontuberculous mycobacterial infections, but its efficacy is unknown in M marinum infection.
A recent case report showed that lenalidomide, a thalidomide derivative used to treat chronic lymphocytic leukemia, rapidly resolved a chronic biopsy-proven M marinum skin infection refractory to conventional treatment. The mechanism is unknown but is likely related to the immunomodulation effect of lenalidomide.2
Antimycobacterials
Empiric antimycobacterial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.
Rifampin (Rifadin)
Inhibits bacterial RNA synthesis by binding to DNA-dependent RNA polymerase, blocking RNA transcription. Effective for treating tuberculosis and atypical mycobacterial infections and for eliminating meningococci carriage states. Also useful for prophylaxis of Haemophilus influenzae type b infection. Used in combination with other antibiotics for prophylaxis and to treat staphylococcal infections.
Adult
10 mg/kg/d PO/IV usually as a single dose; not to exceed 600 mg/d
Pediatric
10-20 mg/kg/d PO/IV usually as a single dose; not to exceed 600 mg/d
Induces microsomal enzymes, which may decrease effects of acetaminophen, oral anticoagulants, barbiturates, benzodiazepines, beta-blockers, chloramphenicol, oral contraceptives, corticosteroids, mexiletine, cyclosporine, digitoxin, disopyramide, estrogens, hydantoins, methadone, clofibrate, quinidine, dapsone, tazobactam, sulfonylureas, theophyllines, tocainide, and digoxin; blood pressure may increase with coadministration of enalapril; coadministration with isoniazid may result in higher rate of hepatotoxicity than with either agent alone (discontinue 1 or both agents if alterations in LFTs occur)
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Use with caution in patients with liver impairment; observe for hyperbilirubinemia; urine, feces, saliva, sweat, tears, and CSF may be discolored to red/orange; remove contact lenses while on treatment; obtain CBCs and baseline clinical chemistries prior to and throughout therapy; interruption of therapy and high-dose intermittent therapy are associated with thrombocytopenia that is reversible if therapy is discontinued as soon as purpura occurs; if treatment is continued or resumed after appearance of purpura, cerebral hemorrhage or death may occur
Ethambutol (Myambutol)
Suppresses mycobacteria multiplication by interfering with RNA synthesis. Bacteriostatic against tubercle bacilli.
Adult
No previous antituberculous therapy: 15 mg/kg (7 mg/lb) PO qd as a single dose
Previous antituberculous therapy: 25 mg/kg (11 mg/lb) PO qd
Pediatric
Not generally used in children >6 y who are not able to take visual acuity and color perception tests reliably
<13 years: Not recommended
>13 years: Administer as in adults
Decreased absorption with aluminum salts (administer several h before or after ethambutol dose)
Documented hypersensitivity; presence of optic neuritis (unless clinically indicated)
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Major toxicity of ethambutol is retrobulbar neuritis and peripheral neuropathy; visual field constriction or impairment of acuity or color vision may develop, perform visual acuity and color perception testing q4-6wk while on therapy; reduce dose in impaired renal function
Antimicrobials
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.
Doxycycline (Vibramycin)
Used to treat infections caused by Rickettsia, Chlamydia, and Mycoplasma. Used for community-acquired pneumonia and other common infections due to susceptible organisms. Has activity against M marinum, M fortuitum, and M chelonae. Inhibits protein synthesis and thus bacterial growth by binding to 30S, and possibly 50S, ribosomal subunits of susceptible bacteria.
Adult
100 mg PO/IV bid
Pediatric
<8 years: Not recommended
>8 years: 100-200 mg/d PO/IV in 1-2 divided doses; not to exceed 200 mg/d
Bioavailability decreases minimally with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate
Documented hypersensitivity; children <8 y; severe hepatic dysfunction
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Use of tetracyclines during tooth development may cause permanent discoloration of the teeth, do not administer in last one-half of pregnancy through age 8 y; photosensitivity reactions are rare
Clarithromycin (Biaxin)
Effective against most strains on nontuberculous mycobacterium species, including M marinum, Mycobacterium avium-intracellulare, M fortuitum, M chelonae, and Mycobacterium abscessus. Exerts antibacterial action by binding to 50S ribosomal subunit, resulting in inhibition of protein synthesis.
Adult
500 mg PO q12h
Pediatric
<6 months: Not established
>6 months: 15 mg/kg/d PO divided q12h
Toxicity increases with coadministration of fluconazole and pimozide; clarithromycin effects decrease and GI adverse effects may increase with coadministration of rifabutin or rifampin; may increase toxicity of anticoagulants, cyclosporine, tacrolimus, digoxin, omeprazole, carbamazepine, ergot alkaloids, triazolam, and HMG CoA-reductase inhibitors; plasma levels of certain benzodiazepines may increase, prolonging CNS depression; arrhythmias and increase in QTc intervals occur with disopyramide; coadministration with omeprazole may increase plasma levels of both agents
Documented hypersensitivity; concurrent use with pimozide
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Coadministration with ranitidine or bismuth citrate is not recommended with CrCl <25 mL/min; administer half dose or increase dosing interval if CrCl <30 mL/min; diarrhea may be sign of pseudomembranous colitis; superinfections may occur with prolonged or repeated antibiotic therapies
Levofloxacin (Levaquin)
For treatment of tuberculosis and some atypical mycobacterial infections in combination with rifampin and other antituberculosis agents.
Adult
500-1000 mg PO qd or divided bid
Pediatric
<18 years: Not recommended
>18 years: Administer as in adults
Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 1-2 h before or after taking fluoroquinolones
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy
Azithromycin (Zithromax)
Treats mild-to-moderate microbial infections.
Adult
500 mg PO qd
Pediatric
<6 months: Not established
>6 months:
Day 1: 10 mg/kg PO once; not to exceed 500 mg/d
Days 2-5: 5 mg/kg PO qd; not to exceed 250 mg/d
May increase toxicity of theophylline, warfarin, and digoxin; effects are reduced with coadministration of aluminum and/or magnesium antacids; nephrotoxicity and neurotoxicity may occur when coadministered with cyclosporine
Documented hypersensitivity; hepatic impairment; do not administer with pimozide
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Site reactions can occur with IV route; bacterial or fungal overgrowth may result with prolonged antibiotic use; may increase hepatic enzymes and cholestatic jaundice; caution in patients with impaired hepatic function, prolonged QT intervals, or pneumonia; caution in hospitalized, geriatric, or debilitated patients
Rifabutin (Mycobutin)
Indicated for the treatment of tuberculosis and several atypical mycobacterial infections. If GI upset occurs, administer dose bid with food.
Adult
300-600 mg PO qd; alternatively, 10-20 mg/kg/d; not to exceed 600 mg/d
Pediatric
Not established; suggested dose is 5 mg/kg/d PO
Steady-state zidovudine plasma levels may decrease after repeated rifabutin dosing but does not affect inhibition of HIV by zidovudine
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Do not administer to patients with active tuberculosis; no evidence exists that rifabutin is effective in prophylaxis against Mycobacterium tuberculosis; may administer isoniazid and rifabutin concurrently in patients requiring prophylaxis against both M tuberculosis and M avium complex; perform hematologic studies periodically in patients receiving prophylaxis due to association with neutropenia and, more rarely, thrombocytopenia
Minocycline (Dynacin, Minocin)
Effective monotherapy. However, resistant strains of M marinum have been reported. Treats infections caused by susceptible gram-negative and gram-positive organisms, in addition to infections caused by susceptible Chlamydia, Rickettsia, and Mycoplasma species.
Adult
100 mg PO bid
Pediatric
<8 years: Not recommended
>8 years: 4 mg/kg PO initially, followed with 2 mg/kg q12h
Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy; tetracyclines can increase hypoprothrombinemic effects of anticoagulants
Documented hypersensitivity; severe hepatic dysfunction
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last one-half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines; hepatitis or lupus-like syndromes may occur
Sulfamethoxazole and Trimethoprim (Bactrim, Bactrim DS, Septra, Septra DS)
Inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid. Several case reports have shown the effectiveness of this drug. Reports indicate that it can help eradicate an organism unresponsive to either antituberculars or tetracyclines.
Adult
160 mg TMP/800 mg SMZ (1 tab DS) PO q12h
Pediatric
<2 months: Not recommended
>2 months: 15-20 mg TMP/kg/d PO in 3-4 divided doses for 14 d
May increase PT when used with warfarin (perform coagulation tests and adjust dose accordingly); coadministration with dapsone may increase blood levels of both drugs; coadministration of diuretics increases incidence of thrombocytopenia purpura in elderly; phenytoin levels may increase with coadministration; may potentiate effects of methotrexate in bone marrow depression; hypoglycemic response to sulfonylureas may increase with coadministration; may increase levels of zidovudine
Documented hypersensitivity; megaloblastic anemia due to folate deficiency; age <2 mo
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Do not use during last trimester of pregnancy due to potential toxicity to newborn (eg, jaundice, hemolytic anemia, kernicterus)
Dosage adjustments (adult adjustments)
CrCl (mL/min) 80-50: Recommended IV dose q18h
CrCl 50-10: Recommended IV dose q24h
CrCl <10: Not recommended
HD: 4-5 mg/kg after HD
During peritoneal dialysis: 0.16-0.8 g q48h
Discontinue at first appearance of skin rash or sign of adverse reaction; obtain CBCs frequently; discontinue therapy if significant hematologic changes occur; goiter, diuresis, and hypoglycemia may occur with sulfonamides; prolonged IV infusions or high doses may cause bone marrow depression (if signs occur, give 5-15 mg/d leucovorin); caution in folate deficiency (eg, chronic alcoholics, elderly, those receiving anticonvulsant therapy, or those with malabsorption syndrome); hemolysis may occur in G-6-PD deficient individuals; AIDS patients may not tolerate or respond to TMP-SMZ; caution in renal or hepatic impairment (perform urinalyses and renal function tests during therapy); give fluids to prevent crystalluria and stone formation
More on Mycobacterium Marinum |
| Overview: Mycobacterium Marinum |
| Differential Diagnoses & Workup: Mycobacterium Marinum |
 Treatment & Medication: Mycobacterium Marinum |
| Follow-up: Mycobacterium Marinum |
| Multimedia: Mycobacterium Marinum |
| References |
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Further Reading
Keywords
Mycobacterium marinum infection, M marinum infection, fish tank granuloma, swimming pool granuloma, fish fancier's finger
