A 56-year-old male with poorly controlled diabetes presents to the clinic for evaluation of a draining facial wound. He rarely follows with physicians but recently did require 3 dental extractions for periapical abscess. His wound lies just anterior to right ear, near where his dental extractions occurred.
He states that approximately 4 weeks after the dental work his wound opened and began to drain. The dental surgeon prescribed 2 weeks of amoxicillin/clavulanate, which resulted in temporary improvement. However, his wound recurred following the discontinuation of antibiotics.
On exam you unroof a sinus tract, with minimal surrounding erythema, draining thin purulent fluid which you gram stained below.
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Correct Answer: Start Penicillin V for 3 month course
This describes a case of cervicofacial actinomyces which is best treated with high dose oral penicillin V or oral amoxicillin. In severe cases, patients may require a course of parenteral therapy prior to oral therapy.
Cervicofacial actinomycosis often occurs indolently in patients who have a history of dental or orofacial trauma.
This is a classic presentation- involving a wound that developed chronically, opening a sinus tract, and partially improved on antibiotics. Question stems may also include mention of sulfur granules, which are small yellow granules that are actually conglomerations of bacteria. Targeted amoxicillin or penicillin are preferred therapy and generally require prolonged course of at least 3 months, may be extended to 6 based off response to therapy and individual risk factors.
Distractor answer choices
- When parenteral antibiotics are required, IV penicillin and ampicillin are preferred, broad coverage of pip-tazo is unnecessary
- Amoxicillin is reasonable choice but wouldn’t need broader coverage of amox-clav and generally would treat for longer duration
- Trimethoprim-Sulfamethoxazole is not active against Actinomycosis. This would treat Nocardia, which is not a common cause of orofacial infections such as this but may have similar gram stain appearance.
- Clindamycin is active against some causes of Actinomycosis, however there is evidence of resistance. This is not considered a reliable agent for this disease.
Question written by Nathan Nolan at Washington University in St. Louis
Picture credit CDC PHIL #22293 & #2856
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This question was uploaded on 3/29/22
Picture credit CDC PHIL #2856 (top)
Picture credit CDC PHIL #22293 (Bottom)