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General - Drug s of Choice Penicillin in high doses, given over a period of weeks to months, has long been considered the antimicrobial therapy of choice for deep-seated actinomycoses.
Prolonged treatment with large doses of the drug is required to achieve drug serum concentrations high enough to ensure drug penetration into areas of fibrosis and suppuration and possibly to penetrate the granules themselves Complications in a given patient -- such as dissemination, critical locations e.
Clinical resistance to this type of penicillin G treatment may not be a major problem; however, there have been reports of clinical failures and apparently considerably more therapeutic problems that were not published in the literature following penicillin G therapy alone 26 In addition, there have been observations that appear to support the development of acquired resistance to penicillin 7.
Garrod claimed that unsuccessful penicillin treatment might be accompanied by increased in vitro resistance; the MICs for two strains of A.
Boand and Novak 7 found that strains of A. In vivo development of acquired antimicrobial resistance byActinomyces species, particularly to penicillin G, has not been reported subsequently. When the response to penicillin is poor, a search should be made for an undrained abscess, although it is more likely that unsatisfactory therapeutic results are due to the presence of resistant concomitant bacterial species.
The therapeutic concept outlined above is primarily based on the view that the pathogenic fermentative actinomycetes are the principal or even sole target against which the antimicrobial chemotherapy has to be directed. Considering the impressive amount of bacteriologic data that indicate that human actinomycoses are essentially always synergistic mixed infections, it appears at least worthy to discuss whether or not this concept should be modified.
Pulverer and Schaal 68 as well as several other authors have reported on characteristic clinical treatment failures of penicillin G therapy.
These findings could be related to the presence either of A.
SinceBacteroides species or Enterobacteriaceae are commonly found as concomitant organisms in abdominal and pelvic actinomycoses, the latter usually do not respond well to penicillin G treatment. Compared with narrow-spectrum penicillins, the aminopenicillins are similarly active against the pathogenic fermentative actinomycetes, but clearly much more effective against A.
Therefore, general treatment schemes for human actinomycoses should include drugs that are effective not only against the causative actinomycetes and A. On the basis of the above considerations, the current recommendations for antibiotic treatment of human actinomycoses, according to which several hundred cases were treated essentially without any therapeutic failure or relapse, are as follows The standard dose is 2.
Only rarely will delayed clinical improvement of long-term chronic cervicofacial infections indicate that antibiotic treatment of 3 or even 4 weeks, duration is required. Parenteral administration of the drugs is recommended; prolonged oral treatment was never found to be necessary For thoracic actinomycoses, the same therapeutic scheme may be sufficient, although this is still somewhat controversial.
The authors recommend against using antibiotic courses of less than 3 months in patients with pulmonary actinomycosis In addition, patients with either advanced chronic pulmonary or abdominal disease may require the addition of 2 g ampicillin every 8 h to increase the aminopenicillin tissue levels ampicillin is used in addition to amoxicillin to avoid possible side effects associated with high doses of amoxicillin.
This usually follows local extension of adjacent intrathoracic infective foci most commonly pulmonary lesions ; thus, endocardial involvement is usually secondary to involvement of the myocardium and pericardium. In their recent review of a total of eight cases seven from the literature of primary actinomycotic endocarditis, Lam et al.
No specific clinical feature distinguishes primary actinomycotic endocarditis from bacterial endocarditis caused by other organisms. The recommended initial therapy is high doses of parenteral penicillin Five patients reviewed by Lam et al.
In addition, these investigators opted to treat their patient with a 6-week course of intravenous penicillin 18 million units daily followed by 6 months of oral medication. Both the optimal duration of therapy and the optimal choice of drug in these patients is unknown; Gutschik 29 suggested at least a 4-week course of parenteral penicillin followed by a 4-to 6-week course of oral penicillin.
But, despite the use of several alternative agents to penicillin for other forms of actinomycosis, their effectiveness for treatment of endocarditis has not been shown 4. Four patients died because the diagnosis was missed or because ineffective antibiotics were administered.
However, the prognosis overall was considered to be good with early diagnosis and appropriate antibiotic therapy. CNS involvement by actinomycosis has been recently reviewed in detail Types of CNS lesions include, in order of frequency, brain abscess, meningitis or meningoencephalitis, subdural empyema, and epidural abscess.
For nonmeningitic lesions, the clinical presentation is commonly that of a "space-occupying lesion. In Smego's review of 70 reported cases of CNS actinomycosis 88several classes of antimicrobial agents were used for therapy.The Summary of Notifiable Infectious Diseases and Conditions — United States, (hereafter referred to as the summary) contains the official statistics, in tabular and graphical form, for the reported occurrence of nationally notifiable infectious diseases and conditions in the United States.
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