eMedicine Specialties > Infectious Diseases > Bacterial Infections

Propionibacterium Infections

Sajeev Handa, MB, BCh, BAO, LRCSI, LRCPI, Director, Division of Hospital Medicine, Department of Medicine, Rhode Island Hospital

Updated: Mar 30, 2009

Introduction

Background

Propionibacterium species are inhabitants of the skin and are usually nonpathogenic. As a result, they are common contaminants of blood and body-fluid cultures. These species are slow-growing, nonsporulating, gram-positive anaerobic bacilli and require at least 6 days for growth in culture.¹

Propionibacterium species belong to the genera of coryneforms and are the best studied because of their association with acne vulgaris. However, Propionibacterium species can cause numerous other types of infections, and these are described briefly in this article.

Propionibacterium acnes is found briefly on the skin of neonates, but true colonization begins during the 1-3 years prior to sexual maturity. During this time, numbers of P acnes rise from fewer than 10/cm² to about 10⁶/cm², chiefly on the face and upper thorax. In the lipid-rich microenvironment of the hair follicle, P acnes produces inflammatory mediators that result in papules, pustules, and later, nodulocystic lesions that are typical of inflammatory acne.

Propionibacterium granulosum is found in the same areas but at numbers about one hundredth of those of P acnes.

Both P acnes and P granulosum may be isolated from the gastrointestinal tract.

Propionibacterium avidum is found in the axilla rather than on exposed areas and increases in numbers at puberty.

Propionibacterium propionicus has been implicated as a less-common causative agent of a disease process similar to that of actinomycosis. The most common cause of actinomycosis is Actinomyces israeli infection.

Frequency

United States

Acne vulgaris is sufficiently common that it may be considered physiologic.

Race

Acne appears to be a familial condition and is less common in Japanese people than in the white American population.

Sex

In girls, acne may precede menarche by more than 1 year. The peak of acne activity occurs during the mid-to-late teenaged period, and the incidence subsequently decreases. Acne is more common in males than in females, and it tends to be more severe in males.

Age

Acne vulgaris is a self-limited disease that involves the sebaceous follicles, primarily in adolescents. In some cases, it is present at birth, and mild cases of acne vulgaris may be observed in the neonatal period. During puberty, acne typically becomes a common problem. The condition is often an early manifestation of puberty. In very young individuals, the predominant lesions are comedones, and inflammatory lesions are rare.

Clinical

History

• Acne vulgaris
  • P acnes plays an important role in the pathogenesis of inflammatory acne–producing proinflammatory mediators, including lipases, neuraminidases, phosphatases, and proteases.
  • Acne usually affects the face and, to a lesser degree, the back, chest, and shoulders. On the trunk, lesions tend to be near the midline.
  • The 4 major pathophysiologic features of acne include the following:
    • Hyperkeratinization
    • Sebum production
    • Bacterial proliferation
    • Inflammation
  • Lesions can be described in 3 categories, as follows:
    • Noninflammatory: Comedones are either open (blackheads) or closed (whiteheads). The open comedo appears as a flat or slightly raised lesion with a central dark-colored follicular impaction of keratin and lipid. The closed comedo is a pale, slightly elevated, small papule without a visible orifice and is a potential precursor for the larger inflammatory lesions.
    • Inflammatory: Inflammatory lesions vary from small papules with an inflammatory areola to pustules (papulopustular) to large, tender, fluctuant nodules (nodular).
      
      

      

      Propionibacterium infection. Nodular-cystic acne.

      
      
      

      

      Propionibacterium infection. Pustular acne.

      
      
    • Scars: These appear as punched out pits of varying size and may have multiple openings.
  • Exacerbations of acne vulgaris may follow the ingestion of numerous types of drugs, such as iodides, bromides, glucocorticoids, and lithium, as well as the application of oil-containing compounds.
• Other infections
  • In rare cases, Propionibacterium species have been implicated as a cause of brain abscess,² subdural empyema, dental infections, endocarditis (particularly in association with implanted cardiac devices), continuous ambulatory peritoneal dialysis (CAPD), conjunctivitis associated with contact lenses, peritonitis, and breast-implant infections.
  • P acnes is frequently implicated in anaerobic arthritis in association with prosthetic joints. In rare cases, it has also been found to be responsible for osteomyelitis and prosthetic vascular graft infections. P acnes cardiovascular device–related infections typically have a subtle presentation: low grade fever, weight loss, malaise, and myalgias.
  • P acnes has been isolated from involved joints in rare cases of rheumatoid arthritis and chronic juvenile arthritis, presumably as a result of bacterial inoculation, usually during infiltration (injection).
  • P acnes has been implicated in certain spondyloarthropathies associated with florid acne vulgaris, in which it was isolated from bone foci and joints.³
  • P acnes has been implicated in infections following rotator cuff repair, as well as an outbreak of postoperative shoulder infections linked to a ventilation system.¹
  • P acnes has been known to infect internal or external shunts, including Ommaya reservoirs.⁴ In a retrospective analysis of shunt infections in 78 adults, P acnes was isolated in 9% of cases.⁵ P acnes shunt infections characteristically present with a paucity of symptoms; when present, they are related to obstruction and/or shunt malfunction with signs of raised intracranial pressure (ie, headache, nausea, vomiting, lethargy, and/or mental status changes). Fever and meningeal symptoms may or may not be present. Because P acnes is a low-virulence organism, clinical symptoms may be nonspecific.⁵ Ventriculoperitoneal shunt infections may manifest as peritonitis; ventriculoatrial shunt infections may manifest as fever and bacteremia with the potential to progress to endocarditis. P acnes infection of a distal external shunt typically manifests as a soft-tissue infection.
  • P acnes has been reported as a cause of vision-threatening infectious keratitis when the cornea is compromised. P acnes has also been implicated in chronic pseudophakic-related endophthalmitis following cataract surgery and placement of an artificial intraocular lens. The presentation is characterized by low-grade intraocular inflammation, possibly chronic, and may be misdiagnosed as noninfectious iritis.
  • P acnes has been isolated in cases of transfusion-transmitted bacterial infection, which typically manifests as fever and chills with or without tachycardia and hypotension during or after transfusion of blood or blood products.⁶
  • In rare cases, P granulosum has been isolated as a cause of endocarditis.⁷
  • P acnes infection has been suggested as a possible trigger for primary biliary cirrhosis.⁸ P granulosum infection has been reported as a potential primer of the immune system prior to the development of sarcoidosis.⁹

Differential Diagnoses

Actinomycosis
Behcet Disease
Cryptococcosis

Other Problems to Be Considered

Acne vulgaris: Comedones are not unique to acne. Senile comedones are common, particularly in the periorbital area of elderly persons. In addition, radiation therapy may result in comedones.

Acnelike lesions may develop in individuals with Behçet disease and in immunocompromised hosts.

Disseminated cryptococcosis may present as an acneiform eruption.

Other diseases associated with sebaceous cysts include atheromas, keratin cysts, and pilar cysts.

Workup

Laboratory Studies

• Although many laboratory studies have been performed in acne vulgaris, the findings have not generally been significant. Androgen studies may be appropriate in select cases.
• Other infections: In some high-risk patients, Propionibacterium species are capable of causing significant infections, and efforts should be made to obtain specimens free of contamination by the normal flora of the mucous membranes and skin, where they reside. In addition, strict anaerobic technique should be followed to ensure isolation in suspected cases of Propionibacterium infection.
• CNS shunt infections require evaluation of cerebrospinal fluid (CSF) and blood cultures, particularly in cases of suspected ventriculoatrial shunt infections, in which case the yield may be higher.
• In cases of P acnes infectious keratitis, cultures were positive for P acnes using thioglycolate broth. None became positive before 7 days of growth, and the recommendation is to monitor the culture for at least 10 days to ensure isolation of this fastidious organism.¹⁰
• In chronic pseudophakic-related endophthalmitis, culture of a vitreous biopsy sample may be positive for P acnes. If the artificial lens is removed, Gram stain and electron microscopy of the capsule may demonstrate gram-positive rods.
• In transfusion-transmitted bacterial infection, blood should be collected from the opposite arm; aside from appropriate hematologic tests, this blood should be sent for culture. Following reporting, the blood-product bag should be sent to the microbiology laboratory for Gram stain and culture.

Imaging Studies

• In cardiovascular device–related infections, P acnes can be difficult to recover in cultures of clinical specimens unless anaerobic cultures are obtained and held for extended periods. CT scanning, ultrasonography, and MRI are useful in demonstrating fluid collection around a device, which can suggest infection. Percutaneous aspirate of the fluid with ultrasound or CT guidance may confirm device infection. Transesophageal echocardiography is required to visualize a vegetation in prosthetic valve endocarditis.¹¹
• In CNS shunt infections, neuroimaging studies may be used to look for evidence of ventriculitis or CSF obstruction. CT scanning or ultrasonography may be helpful in evaluating loculations at the distal end of a ventriculoperitoneal shunt.

Treatment

Medical Care

• Acne vulgaris:¹² Topical and oral agents act at various stages in the evolution of an acne lesion and may be used alone or in combination to enhance efficacy. Most cases of acne vulgaris are controlled with combinations of vitamin A acid, benzoyl peroxide, drying and peeling agents, and antibiotics. Topical agents should be applied to the entire affected area to treat existing lesions and to prevent the development of new ones. Potent topical steroid creams do not provide any short-term improvement in moderate acne. Laser therapy is being studied as a future treatment.
• CNS shunt infections: Device removal is indicated for CNS shunt infections, and antibiotic treatment should be focused once results of Gram staining and culture are available.¹³ Empiric initial coverage with vancomycin plus ceftazidime, cefepime, or meropenem would be appropriate.
• Other infections: Determination of the clinical significance of an isolate of Propionibacterium species must be made with caution because this will influence the need to direct therapy against that isolate.
• Transfusion-transmitted bacterial infection: This requires stoppage of the blood transfusion, resuscitation of the patient, and, if suspicion is high, administration of empiric broad-spectrum antibiotics until results are available. A typical combination would be intravenous vancomycin and gentamicin.

Surgical Care

• Acne vulgaris: Surgical care involves manual removal of comedones and drainage of pustules and cysts. When performed correctly, acne surgery speeds resolution and rapidly enhances cosmetic appearance. Scar revision via dermabrasion, excision, and gelatin matrix collagen implantation is performed in patients who are self-conscious about the pitted and craterlike scars that remain.
• Cardiovascular device–related infections: Removal of the device is usually recommended.¹⁴ Bacteremia without a clear source may warrant an aggressive course of intravenous antibiotic therapy.
• Chronic pseudophakic-related endophthalmitis: This may require vitrectomy,¹⁵ intravitreal vancomycin therapy, and replacement of the intraocular lens to ensure cure.¹⁶
• CNS shunt infections: Device removal, external drainage, and subsequent shunt replacement should be performed once the CSF is sterile.¹³

Consultations

• Acne vulgaris: Referral to a dermatologist may be appropriate for patients who do not respond to conventional treatment.
• Other infections: Isolation of Propionibacterium species in the settings described above may require the assistance of an infectious diseases specialist for interpretation.

Diet

In cases of acne vulgaris, no evidence supports the elimination of various foods such as sweets, chocolate, milk, and fatty foods. However, many patients report that they notice flares after the consumption of certain foods, such as chocolate. In these scenarios, eliminating the implicated food item would be reasonable if the patient feels that it is aggravating the condition.

Medication

The following information primarily pertains to the treatment of Propionibacterium acne vulgaris.

Antibiotics used to treat anaerobic infections usually suffice for other types of Propionibacterium infections. These include the penicillins, carbapenems, and clindamycin. In addition, vancomycin and teicoplanin have been used. Some of these antibiotics are discussed after the treatment of acne vulgaris.

Keratolytics

These agents cause cornified epithelium to swell, soften, macerate, and then desquamate. Retinoids are now classified into 3 generations. The first comprises topical tretinoin and systemic isotretinoin. The second-generation retinoids are used to treat psoriasis. The third-generation retinoids include adapalene and tazarotene, which are topical agents.

Tretinoin (Retin-A, Avita)

Inhibits microcomedo formation and eliminates lesions present. Makes keratinocytes in sebaceous follicles less adherent and easier to remove. Available as 0.025%, 0.05%, and 0.1% creams. Available also as 0.01% and 0.025% gels.

Dosing

Adult

Begin with lowest tretinoin formulation and increase as tolerated; apply hs or qod; reduce frequency of application if irritation develops

Pediatric

<12 years: Not established
>12 years: Apply as in adults

Interactions

Toxicity increases with coadministration of benzoyl peroxide, salicylic acid, and resorcinol; avoid topical sulfur, resorcinol, salicylic acid, other keratolytics, abrasives, astringents, spices, and lime

Contraindications

Documented hypersensitivity

Precautions

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

Photosensitivity may occur with excessive sunlight exposure; caution in eczema; not to be applied to mucous membranes, mouth, and angles of nose

Benzoyl peroxide (Benzac, Benoxyl)

Free-radical oxygen is released upon administration and oxidizes bacterial proteins in sebaceous follicles, decreasing the quantity of irritating free fatty acids and of anaerobic bacteria. It also has keratolytic and comedolytic effects. This agent is most effective for inflammatory acne. It is available OTC and by prescription.

Dosing

Adult

Apply sparingly qd; gradually increase to bid/tid prn; reduce dose, frequency, or concentration if excessive dryness or peeling occurs

Pediatric

Not established

Interactions

Potentiates adverse effects of tretinoin

Contraindications

Documented hypersensitivity

Precautions

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

Avoid contact with lips, eyelids, mucous membranes, and eyes; for external use only; discontinue if swelling, burning, or excessive dryness occurs

Azelaic acid (Azelex, Finevin)

Has been shown to help normalize keratinization and to reduce proliferation of P acnes and has proven to be effective against both noninflammatory and inflammatory lesions. This medication may decrease microcomedo formation in acne vulgaris and may have a bleaching effect on skin. May also have antimicrobial effect. Efficacy may be enhanced when used in combination with other topical medications (eg, benzoyl peroxide, clindamycin, tretinoin). Hands should be washed following application. Duration of treatment can vary from person to person and varies depending on severity. Improvement occurs in the majority of patients with inflammatory lesions within 4 wk.

Dosing

Adult

Wash area and apply sparingly bid; duration of use can vary from person to person and depends on severity of acne

Pediatric

Not established

Interactions

None reported

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Avoid contact with eyes; discontinue use if severe irritation develops; adverse reactions generally are mild and transient; most common adverse reactions (occurring in approximately 1-5% of patients) are pruritus, burning, stinging, and tingling

Tazarotene (Tazorac, Avage)

Retinoid prodrug whose active metabolite modulates differentiation and proliferation of epithelial tissue; may also have anti-inflammatory and immunomodulatory properties. This agent is strictly contraindicated in pregnancy.

Dosing

Adult

Apply thin film (ie, 2 mg/cm²) hs to clean, dry skin where acne appears

Pediatric

Children: Not established
Adolescents: Apply as in adults

Interactions

Do not use concomitantly with dermatologic drugs or cosmetics that have a strong drying effect on the skin (eg, salicylic acid, benzoyl peroxide, astringents)

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

X - Contraindicated; benefit does not outweigh risk

Precautions

May cause burning or stinging; discontinue upon excessive irritation; rinse thoroughly upon contact with eyes, eyelids, or mouth; may cause severe irritation in eczematous skin; photosensitivity may occur

Antibiotics

These agents are useful in papular, pustular, and cystic acne and must be taken for weeks to be effective. They are typically used for many weeks or months to achieve maximum benefit.

Long-term antibiotics may be required and necessitate monitoring for adverse drug events. Females should be warned about the development of Candida albicans vaginitis.

Topical antibiotics are useful in mild pustular and comedone acne. These preparations include clindamycin, erythromycin, and Benzamycin (erythromycin 3%-benzoyl peroxide 5% gel).

P acnes has been developing increasing resistance to erythromycin, so the oral formulation is of less benefit than it once was.

Oxytetracycline (Terramycin)

Treats gram-positive and gram-negative organisms as well as mycoplasmal, chlamydial, and rickettsial infections. Inhibits bacterial protein synthesis by binding with 30S and possibly 50S ribosomal subunit(s).

Dosing

Adult

500 mg PO bid

Pediatric

<8 years: Not recommended
>8 years: 25-50 mg/kg/d PO qid

Interactions

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; can increase hypoprothrombinemic effects of anticoagulants

Contraindications

Documented hypersensitivity; severe hepatic dysfunction

Precautions

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 half of pregnancy through 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines

Tetracycline (Sumycin)

Inhibits bacterial protein synthesis by binding with 30S and, possibly, 50S ribosomal subunit(s). Tetracycline has anti-inflammatory activity.

Dosing

Adult

250-500 mg PO q6h
Mild-to-moderate infections: 500 mg PO bid or 250 mg PO qid for 7-14 d

Pediatric

<8 years: Not recommended
>8 years: 25-50 mg/kg/d (10-20 mg/lb) PO qid

Interactions

Bioavailability decreases with antacids that contain 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

Contraindications

Documented hypersensitivity; severe hepatic dysfunction

Precautions

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 (second half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines

Minocycline (Minocin)

Treats infections caused by susceptible gram-negative and gram-positive organisms, in addition to infections caused by susceptible Chlamydia, Rickettsia, and Mycoplasma species.

Dosing

Adult

100 mg PO bid for 5-7 d or longer for acne

Pediatric

<8 years: Not recommended
>8 years: 4 mg/kg PO initially, followed with 2 mg/kg q12h

Interactions

Bioavailability decreases with antacids that contain 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

Contraindications

Documented hypersensitivity; severe hepatic dysfunction

Precautions

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 (second half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines; hepatitis or lupuslike syndromes may occur

Clindamycin (Cleocin)

Lincosamide for treatment of serious skin and soft tissue staphylococcal infections. Also effective against aerobic and anaerobic streptococci (except enterococci). Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest.

Dosing

Adult

75-300 mg PO bid/qid
Alternatively, 600 mg IV q8h

Pediatric

Not established; 20-40 mg/kg/d IV divided tid/qid suggested

Interactions

Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects of clindamycin; antidiarrheals may delay effect

Contraindications

Documented hypersensitivity; regional enteritis; ulcerative colitis; hepatic impairment; antibiotic-associated colitis

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis by allowing overgrowth of Clostridium difficile

Erythromycin (E.E.S., E-Mycin, Eryc)

Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. For treatment of staphylococcal and streptococcal infections. Age, weight, and severity of infection determine proper dosage in children. When bid dosing is desired, half the total daily dose may be taken q12h. For more severe infections, double the dose.

Dosing

Adult

250 mg erythromycin stearate/base (or 400 mg ethylsuccinate) PO q6h 1 h ac, or 500 mg q12h
Alternatively, 333 mg PO q8h; increase to 4 g/d depending on severity of infection

Pediatric

30-50 mg/kg/d (15-25 mg/lb/d) PO divided q6-8h; double dose for severe infection

Interactions

Coadministration may increase toxicity of theophylline, digoxin, carbamazepine, and cyclosporine; may potentiate anticoagulant effects of warfarin; coadministration with lovastatin and simvastatin increases risk of rhabdomyolysis

Contraindications

Documented hypersensitivity; hepatic impairment

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in liver disease; estolate formulation may cause cholestatic jaundice; GI adverse effects are common (administer doses pc); discontinue use upon nausea, vomiting, malaise, abdominal colic, or fever

Vancomycin (Vancocin, Vancoled, Lyphocin)

Potent antibiotic directed against gram-positive organisms and active against Enterococcus species. Useful in the treatment of septicemia and skin structure infections. Indicated for patients who cannot receive, or who have failed to respond to, penicillins and cephalosporins or have infections with resistant staphylococci.
To avoid toxicity, current recommendation is to assay vancomycin trough levels after third dose drawn 0.5 h prior to next dosing. Use creatinine clearance to adjust dose in patients diagnosed with renal impairment.

Dosing

Adult

1 g IV q12h (normal renal function)

Pediatric

40 mg/kg/d IV divided tid/qid for 7-10 d

Interactions

Erythema, histaminelike flushing, and anaphylactic reactions may occur when administered with anesthetic agents; when taken concurrently with aminoglycosides, risk of nephrotoxicity may increase above that with aminoglycoside monotherapy; effects in neuromuscular blockade may be enhanced when coadministered with nondepolarizing muscle relaxants

Contraindications

Documented hypersensitivity

Precautions

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

Caution in renal failure, neutropenia; red man syndrome is caused by too rapid IV infusion (dose administered over a few min) but rarely happens when dose is administered IV over 2 h or as PO or IP administration; red man syndrome is not an allergic reaction

Antiandrogen therapies

These agents are reserved for patients with acne who have clinical signs of androgen excess and for those in whom other treatments have failed. It is used in women with treatment-resistant, late-onset, or persistent acne. Some of these women have signs suggestive of hyperandrogenism (eg, hirsutism, irregular menses, menstrual dysfunction), but others are without abnormalities. Serum androgen levels may or may not be elevated.

Three options are available. Estrogen suppresses ovarian androgens (oral contraceptives), glucocorticoids suppress adrenal androgen, and antiandrogens (eg, spironolactone, cyproterone acetate) act at the peripheral level.

Spironolactone (Aldactone)

Aldosterone antagonist inhibits ovarian and adrenal production of androgens. Competes with dihydrotestosterone, binding at hormone receptor sites on hair follicle cells. Also reduces 17-alpha-hydroxylase activity, lowering plasma levels of testosterone and androstenedione.

Dosing

Adult

200 mg PO qd

Pediatric

Not established

Interactions

May decrease effect of anticoagulants; potassium and potassium-sparing diuretics may increase toxicity of spironolactone

Contraindications

Documented hypersensitivity; anuria; renal failure; hyperkalemia

Precautions

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

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in renal and hepatic impairment

Cyproterone (Androcur)

Not available in the United States. This is an oral contraceptive that is highly effective in improving acne. An androgen receptor antagonist and weak gonadal androgen production inhibitor. Also a weak progestin.

Dosing

Adult

2 mg PO qd with either 0.035 or 0.050 mg ethynyl estradiol; clinical benefit can be enhanced by administering 50 or 100 mg PO qd from the 5th to the 14th day of cycle

Pediatric

Not established

Interactions

None reported

Contraindications

Documented hypersensitivity; pregnancy and breastfeeding; Dubin-Johnson syndrome; hepatic disease; blood-clotting disorder; Rotor syndrome

Precautions

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

Caution in chronic depression, diabetes with vascular changes, and sickle cell anemia

Oral retinoids

Isotretinoin is related to vitamin A and is very effective in controlling acne and inducing long-term remissions.

Isotretinoin (Accutane)

Oral agent that treats serious dermatologic conditions. Synthetic 13-cis isomer of the naturally occurring tretinoin (trans -retinoic acid). Both agents are structurally related to vitamin A. Isotretinoin decreases sebaceous gland size and sebum production and may inhibit sebaceous gland differentiation and abnormal keratinization. Treatment is weight-based, and the standard course of treatment usually is from 16-20 wk.

Dosing

Adult

0.5-1.5 mg/kg/d (usually 1 mg/kg/d) PO for 20 wk

Pediatric

Not established

Interactions

Toxicity may occur with vitamin A coadministration; pseudotumor cerebri or papilledema may occur when coadministered with tetracyclines; isotretinoin may reduce plasma levels of carbamazepine

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

X - Contraindicated; benefit does not outweigh risk

Precautions

Severity of adverse effects proportional to daily dose; monitor triglyceride levels, LFTs, and CBC counts prior to and during treatment; if triglyceride levels >700-800 mg/dL, discontinue medication to diminish risk of pancreatitis; perform pregnancy test prior to commencing treatment; additional adverse effects include hyperostoses, cheilitis, headache, and amenorrhea

Acne products

These agents may modify or inhibit the inflammatory process.

Erythromycin and benzoyl peroxide (Benzamycin)

Contains erythromycin, which is a macrolide antibiotic, as well as benzoyl peroxide. Benzoyl peroxide, in addition to being an antibacterial agent, is a keratolytic and desquamative agent. With benzoyl peroxide, free-radical oxygen is released upon administration, oxidizing bacterial proteins in sebaceous follicles and decreasing the number of anaerobic, bacterial, and irritating free fatty acids. Has keratolytic and comedolytic effects.
Erythromycin is indicated for infections caused by susceptible strains of microorganisms.

Dosing

Adult

Apply bid qam and qpm to affected areas after skin is washed thoroughly, rinsed with warm water, and gently patted dry

Pediatric

<12 years: Not established
>12 years: Administer as in adults

Interactions

None reported

Contraindications

Documented hypersensitivity

Precautions

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

For external use only; avoid contact with lips, eyelids, mucous membranes, and eyes; discontinue upon swelling, burning, or excessive dryness

Adapalene (Differin)

Modulates cellular differentiation, inflammation, and keratinization. May be tolerated by individuals who cannot tolerate tretinoin creams. A therapeutic response can be expected following 8-12 wk of therapy. Available as 0.1% gel or solution.

Dosing

Adult

Apply hs, some patients may tolerate bid dosing

Pediatric

Not established

Interactions

None Reported

Contraindications

Documented hypersensitivity

Precautions

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

Avoid contact with mucous membranes, eyes, mouth, and nostrils; avoid exposure to sunlight and sunlamps; dryness of skin, scaling, erythema, burning, and pruritus may occur

Follow-up

Complications

• Acne vulgaris: The prognosis of acne vulgaris is usually favorable, and the only sequela is scarring, which can be minimized. In patients with scarring, cosmetic options include superficial peeling, tissue augmentation with injected materials, and the use of deep abrasive therapy.
• Other infections: These complications are described in the Clinical section.

Miscellaneous

Medicolegal Pitfalls

• Isotretinoin is contraindicated in pregnancy. A pregnancy test should be performed prior to commencing treatment, and patients should be warned about the drug's teratogenic effects.
• Although Propionibacterium species are frequently nonpathogenic, the presence of Propionibacterium species in a sterile body fluid culture should never be automatically assumed as contamination until a thorough history and physical examination and assessment is completed.

Multimedia

Media file 1: Propionibacterium infection. Nodular-cystic acne.

Media file 2: Propionibacterium infection. Pustular acne.

References

1. Levy PY, Fenollar F, Stein A, Borrione F, Cohen E, Lebail B, et al. Propionibacterium acnes postoperative shoulder arthritis: an emerging clinical entity. Clin Infect Dis. Jun 15 2008;46(12):1884-6. [Medline].

2. Mandell GL, Bennett JE, Dolin R. Principles and Practice of Infectious Diseases. 6^th ed. New York, NY: Churchill Livingstone; 2005.

3. Delyle LG, Vittecoq O, Bourdel A, et al. Chronic destructive oligoarthritis associated with Propionibacterium acnes in a female patient with acne vulgaris: septic-reactive arthritis?. Arthritis Rheum. Dec 2000;43(12):2843-7. [Medline].

4. George R, Leibrock L, Epstein M. Long-term analysis of cerebrospinal fluid shunt infections. A 25-year experience. J Neurosurg. Dec 1979;51(6):804-11. [Medline].

5. Conen A, Walti LN, Merlo A, Fluckiger U, Battegay M, Trampuz A. Characteristics and treatment outcome of cerebrospinal fluid shunt-associated infections in adults: a retrospective analysis over an 11-year period. Clin Infect Dis. Jul 1 2008;47(1):73-82. [Medline].

6. Kunishima S, Inoue C, Kamiya T, Ozawa K. Presence of Propionibacterium acnes in blood components. Transfusion. Sep 2001;41(9):1126-9. [Medline].

7. Chaudhry R, Dhawan B, Pandey A, et al. Propionibacterium granulosum: a rare cause of endocarditis. J Infect. Nov 2000;41(3):284. [Medline].

8. Harada K, Tsuneyama K, Sudo Y, Masuda S, Nakanuma Y. Molecular identification of bacterial 16S ribosomal RNA gene in liver tissue of primary biliary cirrhosis: is Propionibacterium acnes involved in granuloma formation?. Hepatology. Mar 2001;33(3):530-6. [Medline].

9. Nishiwaki T, Yoneyama H, Eishi Y, Matsuo N, Tatsumi K, Kimura H, et al. Indigenous pulmonary Propionibacterium acnes primes the host in the development of sarcoid-like pulmonary granulomatosis in mice. Am J Pathol. Aug 2004;165(2):631-9. [Medline].

10. Underdahl JP, Florakis GJ, Braunstein RE, Johnson DA, Cheung P, Briggs J, et al. Propionibacterium acnes as a cause of visually significant corneal ulcers. Cornea. Jul 2000;19(4):451-4. [Medline].

11. Klug D, Lacroix D, Savoye C, Goullard L, Grandmougin D, Hennequin JL, et al. Systemic infection related to endocarditis on pacemaker leads: clinical presentation and management. Circulation. Apr 15 1997;95(8):2098-107. [Medline].

12. Leyden JJ. Therapy for acne vulgaris. N Engl J Med. Apr 17 1997;336(16):1156-62. [Medline].

13. James HE, Walsh JW, Wilson HD, Connor JD, Bean JR, Tibbs PA. Prospective randomized study of therapy in cerebrospinal fluid shunt infection. Neurosurgery. Nov 1980;7(5):459-63. [Medline].

14. Sohail MR, Uslan DZ, Khan AH, Friedman PA, Hayes DL, Wilson WR, et al. Management and outcome of permanent pacemaker and implantable cardioverter-defibrillator infections. J Am Coll Cardiol. May 8 2007;49(18):1851-9. [Medline].

15. Aldave AJ, Stein JD, Deramo VA, Shah GK, Fischer DH, Maguire JI. Treatment strategies for postoperative Propionibacterium acnes endophthalmitis. Ophthalmology. Dec 1999;106(12):2395-401. [Medline].

16. Winward KE, Pflugfelder SC, Flynn HW Jr, Roussel TJ, Davis JL. Postoperative Propionibacterium endophthalmitis. Treatment strategies and long-term results. Ophthalmology. Apr 1993;100(4):447-51. [Medline].

17. Habif TP. Acne. In: Clinical Dermatology. St Louis, Mo: Mosby; 1996.

18. Webster G. Combination azelaic acid therapy for acne vulgaris. J Am Acad Dermatol. Aug 2000;43(2 Pt 3):S47-50. [Medline].

Keywords

Propionibacterium infection, Propionibacterium acnes, P acnes, Propionibacterium granulosum, P granulosum, Propionibacterium avidum, P avidum, Propionibacterium propionicus, P propionicus pustular acne, acne vulgaris, cystic acne, nodular acne, acneiform drug eruptions, Propionibacterium acne, inflammatory acne, Propionibacterium acne vulgaris

Contributor Information and Disclosures

Author

Sajeev Handa, MB, BCh, BAO, LRCSI, LRCPI, Director, Division of Hospital Medicine, Department of Medicine, Rhode Island Hospital
Sajeev Handa, MB, BCh, BAO, LRCSI, LRCPI is a member of the following medical societies: Infectious Diseases Society of America and Society of Hospital Medicine
Disclosure: Nothing to disclose.

Medical Editor

Douglas A Drevets, MD, Assistant Professor, Department of Medicine, Section of Infectious Disease, Oklahoma University Health Sciences Center
Douglas A Drevets, MD is a member of the following medical societies: American Association of Immunologists, American Society for Microbiology, Central Society for Clinical Research, and Christian Medical & Dental Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Aaron Glatt, MD, Professor of Clinical Medicine, New York Medical College; President and CEO, Former Chief Medical Officer, Departments of Medicine and Infectious Diseases, New Island Hospital
Aaron Glatt, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physician Executives, American College of Physicians, American College of Physicians-American Society of Internal Medicine, American Medical Association, American Society for Microbiology, American Thoracic Society, American Venereal Disease Association, Infectious Diseases Society of America, International AIDS Society, and Society for Healthcare Epidemiology of America
Disclosure: Nothing to disclose.

CME Editor

Eleftherios Mylonakis, MD, Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital
Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD, Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital
Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

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