Medical Care

The treatment of actinomycosis may require extended antibiotic therapy and surgical interventions as pertinent. Medications should be adjusted based on individual patient needs. Actinomyces species are in general susceptible to penicillin and other beta-lactam antibiotics, as well as to most agents used to treat infections by gram-positive anaerobic rods. Susceptibility to clindamycin is variable, with resistance varying from 17-33%.^[34]Metronidazole and aminoglycosides are ineffective against these species.^[3]

If the actinomycosis is recognized early, cervicofacial infection has a good prognosis with the use of antibiotics alone. In the treatment of actinomycosis, tetracyclines are as effective as penicillin. Intravenous or intramuscular benzylpenicillin at a dose of 20 million IU/day is not uncommon. Oral amoxicillin is recommended at a dose of 2-4 g/day. Patients should be treated for a minimum of 3 months, preferably extending the treatment 2-3 weeks after symptoms have subsided.^[3]Medication adjustments based on individual minimum inhibitory concentrations (MICs) may be required. Differences in MICs among Actinomyces species are known, with Actinomyces europaeus and Actinomyces turicensis being the most resistant.^[5]

Surgical Care

Surgical management in actinomycosis has consisted of various treatment modalities, including excision of sinus tracts, drainage of the abscess cavities, removal of bulky infected masses, and irrigation and curettage of the osteomyelitic bony lesions.^[35]

Guidelines

Mylonas A. Bernhard von Langenbeck: The great skillful surgeon of craniofacial clefts. Hellenic Arch Oral Maxillofacial Surg. 2019. 19:190-192.
Cone LA, Leung MM, Hirschberg J. Actinomyces odontolyticus bacteremia. Emerg Infect Dis. 2003 Dec. 9 (12):1629-32. [QxMD MEDLINE Link].
Vandeplas C, Politis C, Van Eldere J, Hauben E. Cervicofacial actinomycosis following third molar removal: case-series and review. Oral Maxillofac Surg. 2020 Aug 20. [QxMD MEDLINE Link].
Plummer PJ. Actinomycosis: Histological Differentiation of Actinomycosis and Actinobacilliosis. Can J Comp Med Vet Sci. 1946 Dec. 10 (12):331-7. [QxMD MEDLINE Link].
Könönen E, Wade WG. Actinomyces and related organisms in human infections. Clin Microbiol Rev. 2015 Apr. 28 (2):419-42. [QxMD MEDLINE Link].
Heo SH, Shin SS, Kim JW, Lim HS, Seon HJ, Jung SI, et al. Imaging of actinomycosis in various organs: a comprehensive review. Radiographics. 2014 Jan-Feb. 34 (1):19-33. [QxMD MEDLINE Link].
Russo TA. Agents of Actinomycosis. Mandell GL, Bennett JE, Dolin R, eds. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases. 7th ed. Churchill Livingstone Elsevier; 2010. 3209-19.
Wong VK, Turmezei TD, Weston VC. Actinomycosis. BMJ. 2011 Oct 11. 343:d6099. [QxMD MEDLINE Link].
Sullivan DC, Chapman SW. Bacteria that masquerade as fungi: actinomycosis/nocardia. Proc Am Thorac Soc. 2010 May. 7 (3):216-21. [QxMD MEDLINE Link].
Smego RA Jr, Foglia G. Actinomycosis. Clin Infect Dis. 1998 Jun. 26 (6):1255-61; quiz 1262-3. [QxMD MEDLINE Link].
Oostman O, Smego RA. Cervicofacial Actinomycosis: Diagnosis and Management. Curr Infect Dis Rep. 2005 May. 7 (3):170-174. [QxMD MEDLINE Link].
Fazeli MS, Bateni H. Actinomycosis: a rare soft tissue infection. Dermatol Online J. 2005 Dec 1. 11 (3):18. [QxMD MEDLINE Link].
Patil D, Siddaramappa B, Manjunathswamy BS, Pandit AM, Dastikop S, Fernandes C, et al. Primary cutaneous actinomycosis. Int J Dermatol. 2008 Dec. 47 (12):1271-3. [QxMD MEDLINE Link].
Kolbert CP, Persing DH. Ribosomal DNA sequencing as a tool for identification of bacterial pathogens. Curr Opin Microbiol. 1999 Jun. 2 (3):299-305. [QxMD MEDLINE Link].
Seng P, Drancourt M, Gouriet F, La Scola B, Fournier PE, Rolain JM, et al. Ongoing revolution in bacteriology: routine identification of bacteria by matrix-assisted laser desorption ionization time-of-flight mass spectrometry. Clin Infect Dis. 2009 Aug 15. 49 (4):543-51. [QxMD MEDLINE Link].
Ng LS, Sim JH, Eng LC, Menon S, Tan TY. Comparison of phenotypic methods and matrix-assisted laser desorption ionisation time-of-flight mass spectrometry for the identification of aero-tolerant Actinomyces spp. isolated from soft-tissue infections. Eur J Clin Microbiol Infect Dis. 2012 Aug. 31 (8):1749-52. [QxMD MEDLINE Link].
Schaal KP, Schofield GM. Classification and identification of clinically significant Actinomycetaceae. Ortiz-Ortiz L, Bojalil LF, Yakoleff V, eds. Biological, Biochemical, and Biomedical Aspects of Actinomycetes. Orlando, Fla: Academic Press; 1984. 505-20.
Parte AC. Family Actinomycetaceae. LPSN - List of Prokaryotic names with Standing in Nomenclature. Available at https://lpsn.dsmz.de/family/actinomycetaceae. Accessed: November 15, 2020.
Fisher BT. Actinomyces. Kliegman RM, St Geme JW, Blum NJ, Shah SS, Tasker RC, Wilson KM, eds. Nelson Textbook of Pediatrics. 21st ed. Elsevier; 2020. 1465-67.
Escapa IF, Chen T, Huang Y, Gajare P, Dewhirst FE, Lemon KP. New Insights into Human Nostril Microbiome from the Expanded Human Oral Microbiome Database (eHOMD): a Resource for the Microbiome of the Human Aerodigestive Tract. mSystems. 2018 Nov-Dec. 3 (6):[QxMD MEDLINE Link].
Zijnge V, van Leeuwen MB, Degener JE, Abbas F, Thurnheer T, Gmür R, et al. Oral biofilm architecture on natural teeth. PLoS One. 2010 Feb 24. 5 (2):e9321. [QxMD MEDLINE Link].
Abusleme L, Dupuy AK, Dutzan N, Silva N, Burleson JA, Strausbaugh LD, et al. The subgingival microbiome in health and periodontitis and its relationship with community biomass and inflammation. ISME J. 2013 May. 7 (5):1016-25. [QxMD MEDLINE Link].
Gajdács M, Urbán E, Terhes G. Microbiological and Clinical Aspects of Cervicofacial Actinomyces Infections: An Overview. Dent J (Basel). 2019 Sep 1. 7 (3):[QxMD MEDLINE Link].
Hansen T, Kunkel M, Kirkpatrick CJ, Weber A. Actinomyces in infected osteoradionecrosis--underestimated?. Hum Pathol. 2006 Jan. 37 (1):61-7. [QxMD MEDLINE Link].
Schipmann S, Metzler P, Rössle M, Zemann W, von Jackowski J, Obwegeser JA, et al. Osteopathology associated with bone resorption inhibitors - which role does Actinomyces play? A presentation of 51 cases with systematic review of the literature. J Oral Pathol Med. 2013 Sep. 42 (8):587-93. [QxMD MEDLINE Link].
Eng RH, Corrado ML, Cleri D, Cherubin C, Goldstein EJ. Infections caused by Actinomyces viscosus. Am J Clin Pathol. 1981 Jan. 75(1):113-6. [QxMD MEDLINE Link].
McCann A, Alvi SA, Newman J, Kakarala K, Staecker H, Chiu A, et al. Atypical Form of Cervicofacial Actinomycosis Involving the Skull Base and Temporal Bone. Ann Otol Rhinol Laryngol. 2019 Feb. 128 (2):152-156. [QxMD MEDLINE Link].
Valour F, Sénéchal A, Dupieux C, Karsenty J, Lustig S, Breton P, et al. Actinomycosis: etiology, clinical features, diagnosis, treatment, and management. Infect Drug Resist. 2014. 7:183-97. [QxMD MEDLINE Link].
Gupta A, Lodato RF. Empyema necessitatis due to Actinomyces israelii. Am J Respir Crit Care Med. 2012 Jun 15. 185 (12):e16. [QxMD MEDLINE Link].
Llamas-Velasco M, Domínguez I, Ovejero E, Pérez-Gala S, García-Diez A. Empyema necessitatis revisited. Eur J Dermatol. 2010 Jan-Feb. 20 (1):115-9. [QxMD MEDLINE Link].
Kalaichelvan V, Maw AA, Singh K. Actinomyces in cervical smears of women using the intrauterine device in Singapore. Contraception. 2006 Apr. 73 (4):352-5. [QxMD MEDLINE Link].
Westhoff C. IUDs and colonization or infection with Actinomyces. Contraception. 2007 Jun. 75 (6 Suppl):S48-50. [QxMD MEDLINE Link].
Felz MW, Smith MR. Disseminated actinomycosis: multisystem mimicry in primary care. South Med J. 2003 Mar. 96 (3):294-9. [QxMD MEDLINE Link].
Butler-Wu SM and She RC. Actinomyces, Lactobacillus, Cutibacterium, and other Non-Spore-Forming Anaerobic Gram-Positive Rods. Carrol KC, Pfaller MA, ed-in-chief; Landry LL, Patel R, McAdam AJ, Richter S, Warnock DW, eds. Manual of Clinical Microbiology. 12th. Washington, DC: American Society for Microbiology; 2019. Vol 1: 938-967.
Jeong YJ, Suh HW, Shim HS. Cervicofacial Primary Cutaneous Actinomycosis: Surgical Treatment for Complete Remission of the Disease. J Craniofac Surg. 2017 May. 28 (3):e269-e271. [QxMD MEDLINE Link].
[Guideline] Miller JM, Binnicker MJ, Campbell S, Carroll KC, Chapin KC, et al. A Guide to Utilization of the Microbiology Laboratory for Diagnosis of Infectious Diseases: 2018 Update by the Infectious Diseases Society of America and the American Society for Microbiology. Infectious Diseases Society of America. Available at https://www.idsociety.org/practice-guideline/laboratory-diagnosis-of-infectious-diseases/. June 28, 2018; Accessed: November 24, 2020.

Media Gallery

Photomicrograph of gram-positive organisms in actinomycosis, which may be confused with those causing a mycotic infection (hematoxylin and eosin, original magnification X40).
Photomicrograph of a characteristic sulfur granule of actinomycosis (hematoxylin and eosin, original magnification X10).
Oral fistula due to actinomycosis.
Periapical radiograph shows infection in the premolar tooth.

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Author

Juanita Duran, MD Fellow in Surgical Pathology, Department of Pathology and Genomic Medicine, Houston Methodist Hospital

Juanita Duran, MD is a member of the following medical societies: American Society of Dermatopathology, College of American Pathologists

Disclosure: Nothing to disclose.

Coauthor(s)

Jose A Plaza, MD Director of Dermatopathology, Professor of Pathology and Dermatology, The Ohio State University Wexner Medical Center

Jose A Plaza, MD is a member of the following medical societies: American Medical Association, American Society for Clinical Pathology, American Society of Dermatopathology, International Society of Dermatopathology

Disclosure: Nothing to disclose.

Specialty Editor Board

Michael J Wells, MD, FAAD Dermatologic/Mohs Surgeon, The Surgery Center at Plano Dermatology

Michael J Wells, MD, FAAD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, Texas Medical Association

Disclosure: Nothing to disclose.

Drore Eisen, MD, DDS Consulting Staff, Dermatology of Southwest Ohio

Drore Eisen, MD, DDS is a member of the following medical societies: American Academy of Dermatology, American Academy of Oral Medicine, American Dental Association

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

Janet Fairley, MD Professor and Head, Department of Dermatology, University of Iowa, Roy J and Lucille A Carver College of Medicine

Janet Fairley, MD is a member of the following medical societies: American Academy of Dermatology, American Federation for Medical Research, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Talib Najjar, DMD, MDS, PhD Professor of Oral and Maxillofacial Surgery and Pathology, Rutgers School of Dental Medicine

Talib Najjar, DMD, MDS, PhD is a member of the following medical societies: American Society for Clinical Pathology

Disclosure: Nothing to disclose.

Acknowledgements

The authors would like to thank William D Lainhart, PhD, D(ABMM), Medical Director, Clinical and Molecular Microbiology, Department of Pathology, University of Arizona College of Medicine, for his advice and guidance in the updating of this article.

Sections Dermatologic Aspects of Actinomycosis
Overview
Presentation
DDx
Workup
Treatment
Guidelines
Medication
Media Gallery
References

Dermatologic Aspects of Actinomycosis Treatment & Management

Medical Care

Surgical Care

References

Tables

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