AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Moraxella catarrhalis is a gram-negative, aerobic, oxidase-positive diplococcus that was first described in 1896. The organism has also been known as Micrococcus catarrhalis, Neisseria catarrhalis, and Branhamella catarrhalis. For most of the 20th century, M catarrhalis was considered a saprophyte of the upper respiratory tract associated with no significant pathogenic consequences.

Although the commensal status of M catarrhalis in the nasopharynx is still accepted, the organism is a common cause of otitis media and sinusitis and an occasional cause of laryngitis. M catarrhalis causes bronchitis and pneumonia in children and adults with underlying chronic lung disease and is occasionally a cause of bacteremia and meningitis, especially in immunocompromised persons. Bacteremia can be complicated by local infections such as osteomyelitis or septic arthritis. M catarrhalis is also associated with nosocomial infections.

Pathophysiology

Different studies have shown that M catarrhalis colonizes the upper respiratory tract in 28-100% of humans in the first year of life. In adults, the colonization rate is 1-10.4%. Colonization appears to be an ongoing process with an elimination-colonization turnover of various strains. Transmission is believed to be due to direct contact with contaminated secretions by droplets.

The endotoxin of M catarrhalis, a lipopolysaccharide similar to those found in the Neisseria species, may play a role in the disease process. Some strains of M catarrhalis have pili or fimbriae, which may aid adherence to the respiratory epithelium. Some strains produce a protein that confers resistance to complement by interference with formation of the membrane attack complex. M catarrhalis also expresses specific proteins for iron uptake that act as receptors for transferrin and lactoferrin.

Humoral responses against M catarrhalis appear to be age-dependent, with the titer of immunoglobulin G (IgG) gradually increasing in children. Antibody responses to outer-membrane proteins have been obtained, predominantly in the IgG3 subclass.

Frequency

United States

M catarrhalis is the third most common cause of otitis media and sinusitis in children (following Streptococcus pneumoniae and Haemophilus influenzae). M catarrhalis is estimated to be responsible for 3-4 million cases of otitis media annually, with an associated health care cost (direct and indirect) of $2 billion each year.

Mortality/Morbidity

The most significant infections caused by M catarrhalis are upper respiratory tract infections, including otitis media and sinusitis in children and lower respiratory tract infections in adults. Infections with M catarrhalis in adults are more common if underlying conditions are present, especially in elderly persons. In a study of 42 cases of pneumonia with M catarrhalis isolated as single agent in sputum cultures, the mortality rate attributable to the underlying problems within 3 months of pneumonia was 45%.

Sex

In one study involving adult patients, the male-to-female ratio was 1.6:1.

Age

M catarrhalis infections may occur at any age. Although colonization is more common in children, only a small percentage of positive cultures findings have clinical significance in the pediatric population. In one study, 9% of cultures positive for M catarrhalis in children younger than 5 years and 33% of isolates from children aged 6-10 years were found to be clinically significant. However, all cultures positive for M catarrhalis had clinical importance in adults.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

• Common cold: In 29% of common-cold episodes due to bacterial pathogens (including M catarrhalis), affected children continued to be symptomatic 10 days after the first appearance of symptoms.¹
• Otitis media: A clinical history of acute otitis media and otitis media with effusion with symptoms includes otalgia, fever, and hearing loss. Otitis media is a very common condition, especially in children. Approximately 70% of children have at least one episode of otitis media during childhood. M catarrhalis has been isolated in 3-17.3% of middle ear exudates in children with otitis media.^{2, 3}
• Sinusitis: Clinical history commonly includes headache, pain in the maxillary or frontal area, fever, and cough. Young children present with persistent nasal discharge (lasting >2 wk) and cough, especially at night. M catarrhalis has been isolated in 22% of maxillary sinus aspirates in children as a single pathogen and in 72% of aspirates in combination with other organisms such as S pneumoniae and/or H influenzae.⁴
• Lower respiratory tract infections
• • Adult patients with a history of conditions such as chronic obstructive pulmonary disease (COPD), pneumoconiosis, asthma, malignancies, or immunosuppression, with findings characteristic of bronchitis or pneumonia or exacerbations of their underlying condition, may have an M catarrhalis infection. Lower respiratory tract infections with M catarrhalis were also associated with smoking in 77% of patients in a meta-analysis. M catarrhalis was isolated from sputum and transtracheal aspirate specimens at rates of 0.2-8.1%. In more than 30% of cases, H influenzae and/or S pneumoniae was isolated in addition to M catarrhalis.^{5, 6, 7, 8}
  • In children, lower respiratory tract infections have been associated with a history of recent respiratory syncytial virus or cytomegalovirus infection or with more debilitating conditions such as bronchopulmonary dysplasia, ventricular septal defect, leukemia, Arnold-Chiari syndrome, prematurity, or HIV infection.^{9, 10}
• Nosocomial infections: Outbreaks of infections with M catarrhalis have been reported, mostly involving pulmonary units or pediatric intensive care units.
• Bacteremia: No primary site of infection was found in 46% of patients with M catarrhalis bacteremia. Bacteremia is rare with M catarrhalis community-acquired pneumonia.¹¹ The following conditions have been found to predispose to M catarrhalis bacteremia:
• • Immunodeficiency or chronic respiratory conditions such as COPD, bronchiectasis, or cystic fibrosis^{9, 5, 6, 10, 7, 8}
  • Neutropenia, systemic lupus erythematosus, or leukemia
• Endocarditis: M catarrhalis endocarditis has been described in patients with previous history of valvular conditions or prosthesis, as well as in patients who were previously healthy. It has also been described as a complication of balloon angioplasty.^{12, 13}
• Sporadic cases of other infections with M catarrhalis include the following:
• • Meningitis
  • Neonatal ophthalmia
  • Septic arthritis
  • Keratitis
  • Urinary tract infection
  • Wound infection
  • Peritonitis in patients on dialysis
  • Conjunctivitis
  • Periorbital cellulitis¹⁴
  • Acute urethritis resembling gonorrhea¹⁵

Physical

Physical findings in M catarrhalis infections are similar to findings of infections with other organisms in the same location.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Otitis media
Otitis media with effusion
Bacteremia
Endocarditis
Acute bronchitis
Chronic bronchitis
Other primary infections of other etiology

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• CBC count: Increased WBC count with neutrophilia may be present in M catarrhalis infections.
• Gram stain: Gram-negative diplococci are found on cultures; strict adherence to the staining protocol is required.
• Confirmation of the diagnosis of M catarrhalis infection is based on isolation of the organism in culture.
• • Cultures can be taken from middle ear effusion, the nasopharynx, sputum, sinus aspirates, transtracheal or transbronchial aspirates, blood, peritoneal fluid, wounds, or urine.
  • Colonies are approximately 0.2 cm in diameter, opaque, and nonhemolytic after incubation on chocolate or blood agar for 48 hours.
  • Characteristically, colonies can be pushed along the surface of the agar like a hockey puck.
  • With standard methods of identification, M catarrhalis can be differentiated from Neisseria species by not using sucrose, glucose, maltose, and lactose. Because Neisseria cinerea exhibits the same reaction pattern, the superoxol test must be added.
  • For definitive identification, deoxyribonuclease (DNase) and nitrate reduction are performed; M catarrhalis produces DNase and reduces nitrate and nitrite levels.
  • Several rapid confirmatory tests are available to identify M catarrhalis, and they are all based on the ability of M catarrhalis to hydrolyze tributyrin. This provides immediate identification and separation from human Neisseria species, which do not hydrolyze tributyrin.
  • Serologic tests for infections with M catarrhalis are not widely used; cross-reactivity with Neisseria species in the detection of complement fixation antibodies by immunoelectrophoresis has been demonstrated. Serum antibodies to whole-cell proteins, to lipo-oligosaccharides, and to outer-membrane antigens have proved useful in the diagnosis of M catarrhalis infections. Other laboratory studies may be needed, depending on the site of infection and underlying conditions

Imaging Studies

• Imaging studies may be needed, depending of the site of infection.
• • Paranasal sinus radiography or CT scanning
  • Chest radiography
  • Abdominal radiography: Obtain a 3-way view if peritonitis is a possibility.

Procedures

• Various procedures may be needed, depending on the site of the infection and underlying conditions.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical Care

Medical care of M catarrhalis infection depends on the infection site, age of the patient, underlying condition(s), and severity of the disease.

Consultations

• Consultation with an ear, nose, and throat specialist may be indicated in recurrent cases of otitis or sinusitis.
• Consultation with an infectious disease specialist is recommended for infections that do not respond to antibiotic treatment, infections in patients with underlying debilitating conditions, systemic infections with M catarrhalis, or infections in unusual locations.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Approximately 95% of M catarrhalis strains isolated in the United States produce beta-lactamase. Antibiotics such as penicillin, amoxicillin, and ampicillin are only effective against strains that do not produce beta-lactamase.

Topical ciprofloxacin/dexamethasone treatment for acute otitis media with otorrhea via tympanostomy tubes was found to have similar efficacy to that of topical ofloxacin in M catarrhalis infections.¹⁶

Treatment with oral azithromycin 500 mg once daily for 3 days was found comparable with a 10-day regimen of oral clarithromycin 500 mg twice daily in the treatment of acute exacerbation of chronic bronchitis.¹⁷

Telithromycin, a ketolide derivative of erythromycin A, demonstrated good in vitro activity against M catarrhalis in acute exacerbation of chronic bronchitis.¹⁸ However, severe liver disease associated with telithromycin use has been recently reported.¹⁹

The below antimicrobial drugs may be used in M catarrhalis infections, depending on the need for use of oral or parenteral medication, patient's age, underlying condition, sensitivity of the organism, and desired spectrum of coverage.

Drug Category: Antimicrobials

Therapy should cover likely pathogens in the context of this clinical setting. Nearly all M catarrhalis strains are beta-lactamase producers.

Amoxicillin-clavulanate, second- and third-generation oral cephalosporins, and trimethoprim-sulfamethoxazole (TMP-SMX) are the most recommended agents. Alternatively, azithromycin, clarithromycin, or dirithromycin can be used. All other agents listed below are also effective.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Outpatient Care

• Follow-up care with the patient's primary care physician is highly recommended.
• Worsening symptoms warrant a return visit to the primary care physician.

Deterrence/Prevention

• Universal precautions, good hand-washing technique, and sterilization of instruments and tubes used in intubations, aspiration, or invasive procedures may reduce or prevent the nosocomial infections caused by M catarrhalis.
• Research is under way to create a vaccine to prevent M catarrhalis infections. Clinical trials are planned for the near future.^{20, 21}
• Cessation of smoking and prevention of passive smoking may reduce M catarrhalis infections.

Complications

• Recurrence
• Bacteremia/sepsis
• Meningitis
• Mastoiditis
• Hearing loss
• Pleural effusion
• Shock
• Death

Prognosis

• The prognosis of M catarrhalis infection is poor in hospitalized patients with underlying conditions, especially the following:
• • Patients hospitalized for prolonged periods
  • Patients in pulmonary units or pediatric intensive care units
  • Patients of advanced age

Patient Education

• Hand washing, smoking cessation, and good health habits (eg, proper rest, exercise, diet) are helpful both in the treatment process and in prevention of any infection.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Treating patients who are extremely young or extremely old, patients with debilitating conditions, or patients with immunosuppression with supportive care only or with antibiotics that may not cover M catarrhalis infections
• Failure to recognize antibiotic-resistant strains
• Failure to consider M catarrhalis as cause of infection
• Failure to provide follow-up care for patients

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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37. Pérez JL, Pulido A, Pantozzi F, et al. Butyrate esterase (4-methylumbelliferyl butyrate) spot test, a simple method for immediate identification of Moraxella (Branhamella) catarrhalis [corrected]. J Clin Microbiol. Oct 1990;28(10):2347-8. [Medline].
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Article Last Updated: Jul 2, 2008