Mycobacterium marinum Infection Medication

Updated: Jun 04, 2019
  • Author: Shirin A Mazumder, MD, FIDSA; Chief Editor: Mark R Wallace, MD, FACP, FIDSA  more...
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Medication

Medication Summary

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. Resistance to doxycycline and rifampin has been reported. [11] 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. [12]

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Antimycobacterials

Class Summary

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.

Ethambutol (Myambutol)

Suppresses mycobacteria multiplication by interfering with RNA synthesis. Bacteriostatic against tubercle bacilli.

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Antimicrobials

Class Summary

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.

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.

Levofloxacin (Levaquin)

For treatment of tuberculosis and some atypical mycobacterial infections in combination with rifampin and other antituberculosis agents.

Azithromycin (Zithromax)

Treats mild-to-moderate microbial infections.

Rifabutin (Mycobutin)

Indicated for the treatment of tuberculosis and several atypical mycobacterial infections. If GI upset occurs, administer dose bid with food.

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.

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.

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