Actinomycosis: a frequently forgotten disease.

Actinomycosis is a rare subacute or chronic, endogenous infection mainly by Actinomyces species, showing low virulence through fimbriae and biofilms. Cervicofacial, thoracic, abdominal, pelvic and sometimes cerebral, laryngeal, urinary and other regions can be affected. Actinomycosis mimics other diseases, often malignancy. Disease risk in immunocompromised subjects needs clarification. Diagnosis is often delayed and 'sulfur granules' are helpful but nonspecific. Culture requires immediate specimen transport and prolonged anaerobic incubation. Imaging, histology, cytology, matrix-assisted laser desorption ionization time-of-flight mass spectrometry and molecular methods improve the diagnosis. Actinomycetes are ß-lactam susceptible, occasionally resistant. Treatment includes surgery and/or long-term parenteral then oral antibiotics, but some 1-4-week regimens or oral therapy alone were curative. For prophylaxis, oral hygiene and regular intrauterine device replacement are important.

Recent evolution of antibiotic resistance in the anaerobes as compared to previous decades.

Evolution of antibiotic resistance in the anaerobes was reviewed using recent data covering 2000-2013 as compared to previous years. All studies reported growing moxifloxacin resistance in Bacteroides/Parabacteroides spp. in Europe and USA and in Clostridium difficile in Europe. In half or more studies, the resistance rates in Bacteroides/Parabacteroides spp. to amoxicillin-clavulanate or ampicillin-sulbactam and clindamycin rose. In some studies, an increase in resistance was found in Bacteroides/Parabacteroides spp. to cefoxitin/cefotetan and carbapenems, in Prevotella spp. to penicillins, in anaerobic cocci to clindamycin and in Bacteroides/Parabacteroides spp. and C. difficile to metronidazole. Decreasing resistance was also observed, e.g. in Bacteroides/Parabacteroides spp. to cephalosporins, in Prevotella spp. and C. difficile to tetracyclines and in C. difficile to rifampin. No resistance changes were found to tigecycline, in Bacteroides/Parabacteroides spp. to chloramphenicol and in C. difficile to vancomycin. Factors influencing the resistance were the species, ribotype, country, hospital centre, antibiotic consumption and specimen type. In conclusion, the antibiotic resistance changes in the anaerobes are diverse and dynamic. Regular national surveys of resistance and both anaerobic microbiology and susceptibility testing of the isolates become more and more valuable.

Trends in antibiotic resistance in Prevotella species from patients of the University Hospital of Maxillofacial Surgery, Sofia, Bulgaria, in 2003-2009.

Head-and-neck infections often involve anaerobes such as Prevotella species. Aim of the present study was to assess the evolution and the factors associated with resistance in Prevotella species to penicillin, clindamycin, metronidazole, tetracycline and ß-lactams/ß-lactamase inhibitors (BL/BLIs). In total, 192 Prevotella strains, isolated from patients with oral and head-and-neck infections, were evaluated. Common isolates were Prevotella intermedia and Prevotella melaninogenica within the pigmented species as well as Prevotella oris and Prevotella oralis group within the non-pigmented species. Overall resistance was 43.2% for penicillin, 10.9% for clindamycin, 0% for metronidazole. Nonsusceptibility to tetracycline was 29.1% without significant differences in resistance rates between pigmented and other species. Penicillin resistant strains were ß-lactamase positive. From 2003-2004 to 2007-2009, penicillin resistance rates increased about four-fold (from 15.4% to 60.6%). Clindamycin resistance did not show evolution, whereas tetracycline nonsusceptibility decreased from 43.3% in 2003-2004 to 20.7% in 2007-2009. Except for one (0.5%) P. oralis strain with intermediate susceptibility to BL/BLIs, the other strains were susceptible to the agents. In conclusion, in Prevotella strains from patients with head-and-neck infections, the resistance rate to penicillin increased, that to clindamycin remained stable and the nonsusceptibility rate to tetracycline decreased during the period. Activity against >99% of Prevotella strains was observed with metronidazole and BL/BLIs. The penicillin resistance and tetracycline nonsusceptibility were associated with the year of study, national antibiotic consumption and possibly with previous treatment (for tetracycline). The evolution of penicillin resistance in Prevotella strains was highly dynamic.

Antimicrobial resistance and the management of anaerobic infections.

Management of anaerobic infections encompasses surgical procedures, antibacterial therapy and adjuncts. At present, metronidazole, penems, beta-lactam/beta-lactamase inhibitor combinations and chloramphenicol have the highest activity against obligate anaerobes. Tigecycline is a promising new agent. Other antibacterials (e.g., nitazoxanide, moxifloxacin, garenoxacin and ramoplanin) and nonantibiotic agents show potential but need further investigation. The patient's characteristics, mixed anaerobic/aerobic infections, infection sites, bacterial resistance patterns, bactericidal activity of agents and their pharmacokinetics, toxicity and influence on the normal flora should be considered. Susceptibility patterns of anaerobes have become less predictable owing to increasing antibacterial resistance. Emergence of highly virulent or multidrug-resistant strains is challenging the current therapy. To counteract these trends, regular resistance surveillance in anaerobes, rational antibiotic use and evaluation of new treatment alternatives are important.

Anaerobic bacteria in 118 patients with deep-space head and neck infections from the University Hospital of Maxillofacial Surgery, Sofia, Bulgaria.

The aim of this study was to assess the incidence and susceptibility to antibacterial agents of anaerobic strains in 118 patients with head and neck abscesses (31) and cellulitis (87). Odontogenic infection was the most common identified source, occurring in 73 (77.7%) of 94 patients. The incidence of anaerobes in abscesses and cellulitis was 71 and 75.9%, respectively, and that in patients before (31 patients) and after (87) the start of empirical treatment was 80.6 and 72.4%, respectively. The detection rates of anaerobes in patients with odontogenic and other sources of infection were 82.2 and 71.4%, respectively. In total, 174 anaerobic strains were found. The predominant bacteria were Prevotella (49 strains), Fusobacterium species (22), Actinomyces spp. (21), anaerobic cocci (20) and Eubacterium spp. (18). Bacteroides fragilis strains were isolated from 7 (5.9%) specimens. The detection rate of Fusobacterium strains from non-treated patients (32.2%) was higher than that from treated patients (13.8%). Resistance rates to clindamycin and metronidazole of Gram-negative anaerobes were 5.4 and 2.5%, respectively, and those of Gram-positive species were 4.5 and 58.3%, respectively. One Prevotella strain was intermediately susceptible to ampicillin/sulbactam. In conclusion, the start of empirical treatment could influence the frequency or rate of isolation of Fusobacterium species. The involvement of the Bacteroides fragilis group in some head and neck infections should be considered.

In vitro activity of Bulgarian propolis against 94 clinical isolates of anaerobic bacteria.

UNLABELLED: The aim was to evaluate the effect of 30% ethanolic extract of Bulgarian propolis on 94 clinical anaerobic strains. The strains were tested by both agar-well diffusion (wells, 7 mm diameter) and disk-diffusion methods. Only 15% of Clostridium-, 3.3% of other Gram-positive- and 9.1% of Gram-negative anaerobic strains were not inhibited by 30 microL propolis extract per well. Propolis extract was more active than the ethanol (P < 0.001). By 30 microL extract per well, mean inhibitory diameters of the clostridia, other Gram-positive- and Gram-negative anaerobes were 11.5, 13.1, and 11.3 mm, and those by 90 microL were 16, 18.1 and 15.4 mm, respectively. Mean inhibitory diameters of all strains by 30 and 90 microL ethanol were only 8.4 and 9.5 mm. By 30 microL propolis extract per well, inhibitory diameters of 15 mm or more were more common in Gram-positive (32%) than in Gram-negative bacteria (13.6%, P < 0.05). Moist propolis disks inhibited more strains (89.4%) than dried disks (68.1%, P < 0.001). Most (81.8%) Bacteroides fragilis group strains and 75% of clostridial strains were inhibited by moist EEP disks. CONCLUSION: Bulgarian propolis was active against most anaerobic strains of different genera. In addition to oral pathogens, an activity of propolis against Clostridium, Bacteroides and Propionibacterium species was observed. The results could motivate a higher medical interest and further trials for evaluating the use of bee glue for prophylaxis or treatment of some anaerobic infections such as oral, skin and wound diseases.