eMedicine Specialties > Infectious Diseases > Bacterial Infections

Propionibacterium Infections: Treatment & Medication

Author: Sajeev Handa, MB, BCh, BAO, LRCSI, LRCPI, Director, Division of Hospital Medicine, Department of Medicine, Rhode Island Hospital
Contributor Information and Disclosures

Updated: Mar 30, 2009

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.

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.

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.

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.

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).

Tetracycline (Sumycin)

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

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.

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.

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.

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.

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.

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.

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.

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.

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.

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