Propionibacterium Infections Medication

Updated: Oct 07, 2015
  • Author: Sajeev Handa, MBBCh, BAO, LRCSI, LRCPI; Chief Editor: Mark R Wallace, MD, FACP, FIDSA  more...
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Medication

Medication Summary

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. Daptomycin has been used for the treatment of Propionibacterium osteomyelitis. [25]

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Retinoid-like Agents

Class Summary

These agents stimulate cellular retinoid receptors and help normalize keratinocyte differentiation and are comedolytic. In addition, they have anti-inflammatory properties. Oral isotretinoin also reduces sebum production in the skin. Retinoids are classified into 3 generations. The first comprises topical tretinoin and systemic isotretinoin. Acitretin is a second-generation retinoid used to treat psoriasis. The third-generation retinoids include topical adapalene and tazarotene.

Topical tretinoin (Retin-A Micro, Atralin, Tretin-X Avita)

Inhibits microcomedo formation. Decreases cohesiveness of keratinocytes in sebaceous follicles, which allows for easy removal. Anti-inflammatory properties. Available as creams and gels.

Adapalene (Differin)

Inhibits microcomedo formation. Decreases cohesiveness of keratinocytes in sebaceous follicles, which allows for easy removal. Anti-inflammatory properties. Available as creams and gels.

Tazarotene (Tazorac)

Inhibits microcomedo formation. Decreases cohesiveness of keratinocytes in sebaceous follicles, which allows for easy removal. Anti-inflammatory properties. Available as creams and gels.

Isotretinoin (Claravis, Amnesteem, Sotret, Myorisan)

Oral retinoid indicated for recalcitrant, nodulocystic acne. Addresses all four pathogenic factors involved the development of acne: follicular hyperkeratinization, inflammation, sebum production, and Propionibacterium acnes growth. Treatment is weight-based, usually dosed initially 0.5 mg/kg and increased to 1 mg/kg in 2 divided doses for 15-20 weeks. Once-daily dosing is not recommended. May adjust dose to administer up to 2 mg/kg/day. Patients must be registered into government regulated iPledge program in order to receive the medication.

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Antibiotics, Other

Class Summary

Oral antibiotics are useful in inflammatory acne, and improvement is usually seen after several weeks of use. Antibiotic monotherapy is discouraged due to risk of development of resistant bacteria.

Females should be warned about the development of Candida albicans vaginitis. A rare complication of long term oral antibiotic use is the development of gram-negative follculitis. Tetracycline class antibiotics can cause sun sensitivity. Doxycycline is associated with GERD, and should be taken at least 30 minutes prior to go to sleep. Minocycline is rarely associated with a lupus like syndrome, minocycline-induced hyperpigmentation, and pseudotumor cerebri.

Topical antibiotics are used in almost all acne patients. Monotherapy should be avoided to reduce risk of antibiotic resistance. Concurrent use of benzoyl peroxide eliminates the risk of development of resistance. Topical antibiotics are available as monotherapy or in fixed-dose combination products along with benzoyl peroxide or retinoids. Topical antibiotics used include clindamycin and erythromycin, though resistance to erythromycin favors the use of clindamycin.

Tetracycline

Inhibits bacterial protein synthesis by binding with 30S and, possibly, 50S ribosomal subunit(s). Tetracycline has anti-inflammatory activity. May administer 250-500 mg PO bid.

Minocycline (Solodyn, Minocin)

Treats infections caused by susceptible gram-negative and gram-positive organisms, in addition to infections caused by susceptible Chlamydia, Rickettsia, and Mycoplasma species. Brand name Solodyn is an extended-release formulation indicated for acne and prescribed as a weight based 1mg/kg dose per day. Minocycline dose should be lowered in patients with renal impairment.

Erythromycin topical (Akne-mycin)

Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. Commonly prescribed for acne as a topical gel in combination with benzoyl peroxide. Use limited due to resistant P acnes strains. Apply bid after washing the skin and drying it.

Trimethoprim/sulfamethoxazole (Bactrim, Bactrim DS, Septra DS)

Antibiotic with activity against many gram-positive and gram-negative organisms. Inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid. Available as 80 mg trimethoprim and 400 mg sulfamethoxazole or as 160 mg trimethoprim and 800 mg sulfamethoxazole (double strength).

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. Commonly used topically, but can be given orally. Oral monotherapy administration should be avoided to reduce risk of antibiotic resistance. May administer 75-300 mg/day in divided doses.

Clindamycin topical (ClindaGel, Cleocin-T)

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. Commonly used topically but can be given orally. Apply thin film twice daily except for the gel form. Apply gel form once daily.

Daptomycin (Cubicin)

Daptomycin binds to bacterial membranes and causes rapid membrane potential depolarization, thereby inhibiting protein, DNA, and RNA synthesis, ultimately causing cell death. It is indicated to treat complicated skin and skin-structure infections caused by S aureus (including methicillin-resistant strains), S pyogenes, S agalactiae, S dysgalactiae, and E faecalis (Vancomycin-susceptible strains only). Daptomycin has been used for the treatment of Propionibacterium osteomyelitis.

Doxycycline (Doryx, Doxy 100, Adoxa, Monodox)

Broad-spectrum, synthetically derived bacteriostatic antibiotic in the tetracycline class. Almost completely absorbed, concentrates in bile, and is excreted in urine and feces as a biologically active metabolite in high concentrations.

Inhibits protein synthesis and, thus, bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria. May block dissociation of peptidyl t-RNA from ribosomes, causing RNA-dependent protein synthesis to arrest.

Vancomycin (Vancocin)

Used in prophylaxis. 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 can not receive, or have failed to respond to penicillins and cephalosporins or have infections with resistant staphylococci. For abdominal penetrating injuries, it is combined with an agent active against enteric flora and/or anaerobes.

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.

Used in conjunction with gentamicin for prophylaxis in penicillin allergic patients undergoing gastrointestinal or genitourinary procedures.

Meropenem (Merrem IV)

Bactericidal broad-spectrum carbapenem antibiotic that inhibits cell-wall synthesis. Effective against most gram-positive and gram-negative bacteria.

Has slightly increased activity against gram-negatives and slightly decreased activity against staphylococci and streptococci compared to imipenem.

Cefepime (Maxipime)

Fourth-generation cephalosporin. Gram-negative coverage comparable to ceftazidime but has better gram-positive coverage (comparable to ceftriaxone). Cefepime is a zwitter ion; rapidly penetrates gram-negative cells. Best beta-lactam for IM administration. Poor capacity to cross blood-brain barrier precludes use for treatment of meningitis.

Gentamicin (Garamycin, Gentamicin IV/IM)

Aminoglycoside antibiotic for gram-negative coverage bacteria including Pseudomonas species. Synergistic with beta-lactamse against enterococci. Interferes with bacterial protein synthesis by binding to 30S and 50S ribosomal subunits.

Dosing regimens are numerous and are adjusted based on CrCl and changes in volume of distribution, as well as body space into which agent needs to distribute. Dose of gentamicin may be given IV/IM. Each regimen must be followed by at least trough level drawn on third or fourth dose, 0.5 h before dosing; may draw peak level 0.5 h after 30-min infusion.

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Aldosterone Antagonists, Selective

Class Summary

Aldosterone antagonist may reduce free testosterone levels and compete with androgens binding at the sebaceous gland.

Spironolactone (Aldactone)

Aldosterone antagonist that competes with testosterone and dihydrotestosterone binding at the receptor in the sebaceous gland. It also reduces free testosterone levels as more is bound by the increased quantity of SHBG. To treat acne in women may administer 25-200 mg once daily.

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Estrogens/Progestins

Class Summary

Hormonal therapies can be used in females with acne, especially those with premenstrual acne flares, who have failed other therapies. Patients may also have signs of hyperandrogenism (eg, hirsutism, irregular menses, menstrual dysfunction). Serum androgen levels may or may not be elevated.

Available options include combination estrogen-progestin oral contraceptive pills, which suppress ovarian androgen production as well as androgen receptor blockers that block the effect of androgens peripherally at the sebaceous gland.

Ethinyl estradiol, drospirenone, and levomefolate (Beyaz)

Combination of estrogen and progestin treats acne in adult women. Suppresses ovarian production of androgens.

Ethinyl estradiol and norethindrone (Estrostep Fe)

Combination of estrogen and progestin treats acne in adult women. Suppresses ovarian production of androgens.

Ethinyl estradiol and norgestimate (Ortho Tri-Cyclen)

Combination of estrogen and progestin treats acne in adult women. Suppresses ovarian production of androgens.

Ethinyl estradiol and drospirenone (Yaz)

Combination of estrogen and progestin treats acne in adult women. Suppresses ovarian production of androgens.

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Acne Products

Class Summary

Acne products are used for the treatment of mild to moderate acne vulgaris. These agents may have antibacterial and comedolytic properties. In severe cases, the agents may be used as an adjunct in the therapeutic regimens.

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.

The combination drug may be applied topically twice daily.

Clindamycin and tretinoin (Ziana, Veltin)

Contains the topical antibiotic clindamycin 1.2% as well as tretinoin 0.025%. Clindamycin reduces P acnes levels and is anti-inflammatory. Tretinoin normalizes differentiation of keratinocytes and is anti-inflammatory. Apply daily to affected areas.

Clindamycin and benzoyl peroxide (Acanya, Duac CS, BenzaClin)

Contains the topical antibiotic clindamycin as well as benzoyl peroxide. Clindamycin reduces P acnes levels and is anti-inflammatory. Benzoyl peroxide is antibacterial agent, comedolytic, and anti-inflammatory. Benzoyl peroxide reduces risk of development of bacterial resistance to clindamycin. Acanya gel contains 2.5% benzoyl peroxide and Duac CS and BenzaClin contain 5% benzoyl peroxide. Apply Acanya and Duac CS once daily. BenzaClin is applied twice daily.

Azelaic acid (Azelex, Finacea)

Has been shown to help reduce inflamation and may aid in treatment of postinflammatory hyperpigmentation. Apply twice daily. Improvement may be seen within 4 weeks.

Benzoyl peroxide (BenzEFoam, PanOxyl, Neutrogena On The Spot, Invisible Acne Treatment)

Benzoyl peroxide is an oxidizing agent that possesses antibacterial properties and is comedolytic. The antibacterial activity results from the release of active or free-radical oxygen that can oxidize bacterial proteins. Benzoyl peroxide is oxidized into benzoic acid with contact to the skin. It is available OTC and by prescription.

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