eMedicine Specialties > Infectious Diseases > Medical Topics
Bacteroides Infection: Treatment & Medication
Updated: Jun 20, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
- The patient's recovery from anaerobic infection depends on prompt and proper management according to the following 3 principles:
- Toxins produced by anaerobes must be neutralized.
- The environment must be changed to prevent local bacterial proliferation.
- The spread of bacteria must be limited.
- The environment is controlled by debriding necrotic tissue, draining pus, improving circulation, alleviating obstruction, and increasing tissue oxygenation.
- Certain types of adjunctive therapy, such as hyperbaric oxygen therapy, may be useful but remain unproven.
- In many cases, antimicrobial therapy is the only form of therapy required, but it can also be used as an adjunct to a surgical approach.
- Because anaerobic bacteria are generally recovered mixed with aerobic organisms, the appropriate choice for antimicrobial agents should provide adequate treatment of both groups of pathogens.
- When choosing antimicrobials for the treatment of mixed infections, consider their aerobic and anaerobic antibacterial spectrum and their availability in oral or parenteral form.
- Some antimicrobials have a limited range of activity. For example, metronidazole is active only against anaerobes and cannot be administered as a single agent in mixed infections. Others, such as imipenem, have wide spectra of activity against aerobes and anaerobes.
- Because culture results are often not available, many patients are treated empirically.
- Antimicrobial resistance patterns may vary. Some anaerobes have become, or may become, resistant to antimicrobials.
- The B fragilis group is almost uniformly susceptible to metronidazole, carbapenems, chloramphenicol, and combinations of a penicillin and beta-lactamase inhibitors. Resistance to other agents varies.
- Aside from susceptibility patterns, other factors that influence the choice of antimicrobials include their pharmacokinetics, their toxicity, their effect on the normal florae, their bactericidal activity, and their ability to penetrate into sites of infection.
- Although identification of organisms and their susceptibility is needed for optimal therapy, the clinical setting and the Gram stain results from the specimen are often helpful.
- Antimicrobials useful in anaerobic infection are as follows:23
- Penicillins
- Penicillin G is still the drug of choice against most non–beta-lactamase–producing AGNB. However, in addition to the B fragilis group, which is resistant to penicillin, other AGNB show increased resistance. These include pigmented Prevotella and Porphyromonas species, P bivia, P disiens, Bilophila wadsworthia, and Bacteroides splanchnicus.
- The combination of beta-lactamase inhibitors (eg, clavulanic acid, sulbactam, tazobactam) with a beta-lactam antibiotic (eg, ampicillin, amoxicillin, ticarcillin, piperacillin) can overcome these beta-lactamase–producing AGNB.
- In high concentrations, carbenicillin, ticarcillin, piperacillin, and mezlocillin have good activity against gram-negative enterics and most anaerobes; however, they are not completely resistant to beta-lactamase.
- Cephalosporins
- The B fragilis group, Prevotella species, and Porphyromonas species are resistant to first-generation cephalosporins by virtue of cephalosporinase production.
- Cefoxitin is the most effective cephalosporin against the B fragilis group, although 5-15% may be resistant. Cefoxitin is inactive against most clostridial organisms, except Clostridium perfringens. Other second-generation cephalosporins, such as cefotetan and cefmetazole, have a longer half-life than cefoxitin and are as effective as cefoxitin against B fragilis; however, they are less efficacious against other members of the B fragilis group.
- Carbapenems: These agents, including imipenem, meropenem, doripenem (recently approved by the FDA for the treatment of complicated intra-abdominal infections), and ertapenem have excellent activity against a broad spectrum of aerobic and anaerobic bacteria.
- Chloramphenicol: This agent shows excellent in vitro activity against most anaerobic bacteria, and resistance is rare; however, the development of less-toxic newer agents has limited their use.
- Clindamycin: This antimicrobial is effective against anaerobes and has good activity against aerobic gram-positive cocci. Resistance of the B fragilis group is 5-25%. Antibiotic-associated colitis due to Clostridium difficile, although associated with most antimicrobials, was first described following clindamycin therapy.
- Metronidazole: This has excellent activity against anaerobes, including AGNB; however, this efficacy is limited to anaerobes. Microaerophilic streptococci, P acnes, and Actinomyces species are often resistant; therefore; adding an antimicrobial that is effective against these organisms (eg, penicillin) is often necessary.
- Tigecycline: This glycylcycline has effective in vitro activity against both gram-positive and gram-negative anaerobes, as well as against gram-positive aerobic strains such as methicillin-resistant staphylococci, streptococci, and enterococci. Tigecycline was recently approved by the FDA for the treatment of complicated skin and skin-structure infections and complicated intra-abdominal infections.
- Quinolones: Trovafloxacin, moxifloxacin, and gatifloxacin yield low minimum inhibitory concentrations (MICs) against most groups of anaerobes. Moxifloxacin was recently approved by the FDA for the treatment of complicated skin and skin-structure infections and complicated intra-abdominal infections. The use of the quinolones is restricted in growing children and pregnancy because of their possible adverse effects on the cartilage.
- Penicillins
Surgical Care
- In most cases, surgical therapy is of critical importance. Surgical therapy includes draining abscesses, debriding necrotic tissues, decompressing closed-space infections, and relieving obstructions.
- When surgical drainage is not used, the infection may persist and serious complications may develop.
Medication
Clinical judgment, personal experience, safety, and patient compliance should direct the physician in the choice of the appropriate antimicrobial agents. When choosing antimicrobials for the therapy of mixed infections, their aerobic and anaerobic antibacterial spectrum and their availability in oral or parenteral form should be considered. Some antimicrobials have a limited range of activity. For example, metronidazole is active only against anaerobes and therefore cannot be administered as a single agent for the therapy of mixed infections. Others (ie, carbapenems) have wide spectra of activity against aerobes and anaerobes.
Aside from susceptibility patterns, other factors that influence the choice of antimicrobial therapy include the pharmacologic characteristics of the various drugs, their toxicity, their effect on the normal florae, and their bactericidal activity. Although identification of the infecting organisms and their antimicrobial susceptibility may be needed for selection of optimal therapy, the clinical setting and Gram-stain preparation of the specimen may indicate the types of anaerobes present in the infection and the nature of the infectious process.
Although the duration of therapy for anaerobic infections is generally longer than for aerobes and facultative infections, the duration of treatment must be individualized, depending on the response. In some cases, treatment may require 6-8 weeks, but therapy may be shortened with proper surgical drainage. An anti–gram-negative enteric agent is generally added to treat Enterobacteriaceae when treating intra-abdominal infections.
The available parenteral antimicrobials for most infections include clindamycin, metronidazole, chloramphenicol, cefoxitin, a penicillin (ie, ticarcillin, ampicillin, piperacillin) and a beta-lactamase inhibitor (ie, clavulanic acid, sulbactam, tazobactam), tigecycline, and the carbapenems (eg, imipenem, meropenem, doripenem, ertapenem).23
An agent effective against gram-negative enteric bacilli (ie, aminoglycoside) or an antipseudomonal cephalosporin (ie, cefepime) is generally added to clindamycin, metronidazole, and, occasionally, cefoxitin when treating intra-abdominal infections to provide coverage for these bacteria.
Penicillin can be added to metronidazole in the therapy of intracranial, pulmonary, or dental infections to cover microaerophilic streptococci and Actinomyces species.
A macrolide (ie, erythromycin) is added to metronidazole for upper respiratory tract infections to treat Staphylococcus aureus and aerobic streptococci.
Penicillin is added to clindamycin to supplement its coverage against Peptostreptococcus species and other gram-positive anaerobic organisms.
Penicillin is still the drug of choice for bacteremia caused by non–beta-lactamase producers. However, other agents should be used for the therapy of bacteremia caused by beta-lactamase producers.
For Chlamydia and Mycoplasma species, doxycycline is added to most regimens when treating pelvic infections.
Oral therapy is often substituted for parenteral therapy. The agents available for oral therapy include clindamycin, amoxicillin and clavulanate, and metronidazole.
Antimicrobials
Empiric antimicrobial therapy must cover all likely pathogens in the context of this clinical setting.
Penicillin G (Pfizerpen)
Interferes with synthesis of cell wall mucopeptide during active multiplication, resulting in bactericidal activity against susceptible microorganisms (beta-lactam).
Adult
10-28 million U/d IV
Pediatric
50,000-100,000 U/d IV
Probenecid can increase effects; coadministration of tetracyclines can decrease effects
Documented hypersensitivity
Pregnancy
A - Fetal risk not revealed in controlled studies in humans
Precautions
Caution in impaired renal function
Cefoxitin (Mefoxin)
Second-generation cephalosporin indicated for gram-positive cocci and gram-negative rod infections. Infections caused by cephalosporin- or penicillin-resistant gram-negative bacteria may respond.
Adult
1-2 g IV q6h
Pediatric
40 mg/kg/d IV q6h
Probenecid may increase effects; coadministration with aminoglycosides or furosemide may increase nephrotoxicity (closely monitor renal function)
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Bacterial or fungal overgrowth of nonsusceptible organisms may occur with prolonged use or repeated treatment; caution in patients with previously diagnosed colitis
Cefotetan (Cefotan)
Second-generation cephalosporin indicated for infections caused by susceptible gram-positive cocci and gram-negative rods. Dosage and route of administration depend on condition of patient, severity of infection, and susceptibility of causative organism.
Adult
1-2 g IV q12h; not to exceed 4 g/d
Pediatric
20-40 mg/kg/dose IV q12h for 5-10 d
Consumption of alcohol within 72 h of administration may produce disulfiramlike reactions; may increase hypoprothrombinemic effects of anticoagulants; coadministration with potent diuretics (eg, loop diuretics) or aminoglycosides may increase nephrotoxicity
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Reduce dosage by half if CrCl <10-30 mL/min and by one fourth if CrCl <10 mL/min; bacterial or fungal overgrowth of nonsusceptible organisms may occur with prolonged or repeated therapy
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.
Adult
150-450 mg PO q6h
450-900 mg IV q8h
Pediatric
20-30 mg/kg/d PO divided q6h
25-40 mg/kg/d PO divided q6-8h
Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects; antidiarrheals may delay absorption
Documented hypersensitivity; regional enteritis; ulcerative colitis; hepatic impairment; antibiotic-associated colitis
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis
Amoxicillin and clavulanate (Augmentin)
Amoxicillin inhibits bacterial cell wall synthesis by binding to penicillin-binding proteins. Addition of clavulanate inhibits beta-lactamase–producing bacteria.
Good alternative antibiotic for patients allergic to or intolerant to macrolides. Usually is well tolerated and provides good coverage for most infectious agents. Not effective against Mycoplasma and Legionella species. Half-life of oral dosage form is 1-1.3 h. Has good tissue penetration but does not enter cerebrospinal fluid.
For children >3 mo, base dosing protocol on amoxicillin content. Because of different ratios of amoxicillin to clavulanic acid in 250-mg tab (250/125) vs 250-mg chewable tab (250/62.5), do not use 250-mg tab until child weighs >40 kg.
Adult
500 mg PO q8h or 875 mg PO q12h
Pediatric
<3 months: 125 mg/5 mL PO susp based on amoxicillin; 30 mg/kg/d divided bid
>3 months: If using 200 mg/5 mL or 400 mg/5 mL susp, 45 mg/kg/d PO q12h; if using 125 mg/5 mL or 250 mg/5 mL susp, 40 mg/kg/d PO q8h
>40 kg: Administer as in adults
Coadministration with warfarin or heparin increases risk of bleeding
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Administer for a minimum of 10 d to eliminate organism and to prevent sequelae (eg, endocarditis, rheumatic fever); following treatment, perform cultures to confirm eradication of streptococci
Ticarcillin and clavulanate potassium (Timentin)
Inhibits biosynthesis of cell wall mucopeptide and is effective during stage of active growth. Antipseudomonal penicillin plus beta-lactamase inhibitor that provides coverage against most gram-positive organisms, most gram-negative organisms, and most anaerobes. Contains 4.7-5.0 mEq of Na+/g.
Adult
3.1 g IV q4-6h
Pediatric
200-300 mg/kg/d IV q4-6h
Tetracyclines may decrease effects; high concentrations may physically inactivate aminoglycosides if administered in same IV line; effects are synergistic when administered concurrently with aminoglycosides; probenecid may increase levels
Documented hypersensitivity; severe pneumonia, bacteremia, pericarditis, emphysema, meningitis, and purulent or septic arthritis should not be treated with oral penicillin during acute stage
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Perform CBC counts prior to initiation of therapy and at least weekly during therapy; monitor for liver function abnormalities by measuring AST and ALT during therapy; exercise caution in patients with hepatic insufficiencies; perform urinalysis and BUN/creatinine determinations during therapy, and adjust dose if values become elevated; monitor blood levels to avoid possible neurotoxic reactions
Chloramphenicol (Chloromycetin)
Binds to 50S bacterial ribosomal subunits and inhibits bacterial growth by inhibiting protein synthesis. Effective against gram-negative and gram-positive bacteria.
Adult
0.25-1 g IV q6h; not to exceed 4 g/d
Pediatric
80-100 mg/kg/d IV
Concurrently with barbiturates, chloramphenicol serum levels may decrease while barbiturate levels may increase, causing toxicity; manifestations of hypoglycemia may occur with sulfonylureas; rifampin may reduce serum levels, presumably through hepatic enzyme induction; may increase effects of anticoagulants; may increase serum hydantoin levels, possibly resulting in toxicity; levels may be increased or decreased
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Use only for indicated infections or as prophylaxis for bacterial infections; serious and fatal blood dyscrasias (eg, aplastic anemia, hypoplastic anemia, thrombocytopenia, granulocytopenia) can occur; evaluate baseline, and perform periodic blood studies approximately every 2 d while in therapy; discontinue upon appearance of reticulocytopenia, leukopenia, thrombocytopenia, or anemia or upon findings attributable to chloramphenicol; adjust dose in liver or kidney dysfunction; caution in pregnancy at term or during labor because of potential toxic effects on fetus (gray syndrome)
Imipenem and cilastatin (Primaxin)
Carbapenem used for treatment of multiple organism infections in which other agents do not have wide-spectrum therapeutic activity or are contraindicated because of potential toxicity.
Adult
500-750 mg IV q6h; not to exceed 3 g/d IV
Pediatric
<12 years: Not established; 15-25 mg/kg/d IV suggested
>12 years: 15-25 mg/kg/d IV
Coadministration with cyclosporine may increase CNS adverse effects of both agents; coadministration with ganciclovir may result in generalized seizures
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Adjust dose in impaired renal function; high doses can cause seizures and renal failure, especially in elderly persons and in those with prior seizure disorder; adverse effects include phlebitis, transitory hypotension, hepatotoxicity, vomiting, and diarrhea
Meropenem (Merrem)
Broad-spectrum carbapenem antibiotic that inhibits cell wall synthesis and has bactericidal activity. Effective against most gram-positive and gram-negative bacteria. Has slightly increased activity against gram-negative bacteria and slightly decreased activity against staphylococci and streptococci compared with imipenem. Also less likely to cause seizures compared with imipenem.
Adult
1 g IV q8h
Pediatric
40 mg/kg IV q8h
Probenecid may inhibit renal excretion, increasing levels
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Pseudomembranous colitis and thrombocytopenia may occur, requiring immediate discontinuation
Metronidazole (Flagyl)
Imidazole ring-based antibiotic active against various anaerobic bacteria and protozoa. Used in combination with other antimicrobial agents (except for C difficile enterocolitis).
Adult
375-750 mg IV q8h
Pediatric
30 mg/kg/d IV q6h
Cimetidine may increase toxicity; may increase effects of anticoagulants; may increase toxicity of lithium and phenytoin; disulfiramlike reaction may occur with orally ingested ethanol
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
X - Contraindicated; benefit does not outweigh risk
Precautions
Has shown mutagenicity in Ames test; tumorigenicity shown in animals but not in humans; adjust dose in hepatic disease; monitor for seizures and development of peripheral neuropathy
Ertapenem (Invanz)
Bactericidal activity results from inhibition of cell wall synthesis and is mediated through ertapenem binding to penicillin-binding proteins. Stable against hydrolysis by a variety of beta-lactamases, including penicillinases, cephalosporinases, and extended-spectrum beta-lactamases. Hydrolyzed by metallo-beta-lactamases.
Adult
1 g/d for 14 d if given IV and for 7 d if given IM; infuse over 30 min if given IV
Pediatric
Not established
Probenecid may reduce renal clearance and increase half-life but benefit is minimal and does not justify coadministration
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Pseudomembranous colitis may occur; seizures and adverse CNS reactions may occur; when using with lidocaine to administer IM, avoid inadvertent injection into blood vessel
Moxifloxacin (Avelox)
Inhibits the A subunits of DNA gyrase, resulting in inhibition of bacterial DNA replication and transcription.
Adult
400 mg PO/IV qd
Pediatric
<18 years: Not recommended
>18 years: Administer as in adults
Antacids and electrolyte supplements reduce absorption; loop diuretics, probenecid, and cimetidine increase serum levels; NSAIDs enhance CNS stimulating effect
May increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT); ferrous sulfate decreases bioavailability (administer moxifloxacin 4 h prior or 8 h following ferrous sulfate); coadministration with drugs that prolong QTc interval (quinidine, procainamide, amiodarone, sotalol, erythromycin, tricyclic antidepressants) increase risk of life-threatening arrhythmia
Documented hypersensitivity; known QT prolongation, concurrent administration of drugs that cause QT prolongation
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
In prolonged therapy, periodically evaluate organ system functions (eg, renal, hepatic, hematopoietic); superinfections may occur with prolonged or repeated antibiotic therapy; fluoroquinolones have induced seizures in CNS disorders and caused tendinitis or tendon rupture
Tigecycline (Tygacil)
A glycylcycline antibiotic that is structurally similar to tetracycline antibiotics. Inhibits bacterial protein translation by binding to 30S ribosomal subunit and blocks entry of amino-acyl tRNA molecules in ribosome A site. Indicated for complicated skin and skin structure infections caused by E coli, E faecalis (vancomycin-susceptible isolates only), S aureus (methicillin-susceptible and -resistant isolates), S agalactiae, S anginosus group (includes S anginosus, S intermedius, and S constellatus), S pyogenes, and B fragilis.
Adult
Infuse each dose over 30-60 min
100 mg IV once, then 50 mg IV q12h
Severe hepatic impairment (ie, Child Pugh class C): 100 mg IV once, then 25 mg IV q12h
Pediatric
<18 years: Not established
>18 years: Administer as in adults
Coadministration decreases warfarin clearance and increases warfarin Cmax and AUC (monitor aPTT and INR); coadministration of antibiotics with oral contraceptives may decrease contraceptive effect
Documented hypersensitivity
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in severe hepatic impairment (reduce dose); may adversely effect tooth development; may permit clostridia overgrowth, resulting in antibiotic-associated colitis; may have adverse effects similar to tetracyclines (eg, photosensitivity, pseudotumor cerebri, pancreatitis, antianabolic action)
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Further Reading
Keywords
anaerobic gram-negative bacilli, AGNB, Bacteroides fragilis, B fragilis, Prevotella species, Porphyromonas species, Bacteroides distasonis, B distasonis, Bacteroides ovatus, B ovatus, Bacteroides thetaiotaomicron, B thetaiotaomicron, Bacteroides vulgatus, B vulgatus, Prevotella melaninogenica, P melaninogenica, Prevotella intermedia, P intermedia, Porphyromonas asaccharolytica, P asaccharolytica, Prevotella oralis, P oralis, Prevotella oris, P oris, Prevotella bivia, P bivia, Bacteroides bivia, B bivia, Prevotella disiens, P disiens, Bacteroides disiens, Bacteroides melaninogenicus group, B melaninogenicus group, perirectal abscess, decubitus ulcer, bedsore, bed sore, pressure sore, intra-abdominal abscess, intraabdominal abscess, aspiration pneumonia, lung abscess, chronic otitis media, chronic sinusitis, oral cavity abscess, abscesses around the oral cavity, human bites, paronychia, brain abscesses, osteomyelitis, Bacteroidaceae
