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Yamamoto H, Kuroda H, Hiramoto N, Hasuike T, Doi A, Nishioka H. Successful maintenance treatment of disseminated nocardiosis with cerebral abscess in a severely immunocompromised patient allergic to trimethoprim-sulfamethoxazole using moxifloxacin and high-dose minocycline: A case report. J Infect Chemother 2024:S1341-321X(24)00121-1. [PMID: 38670455 DOI: 10.1016/j.jiac.2024.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 03/08/2024] [Accepted: 04/18/2024] [Indexed: 04/28/2024]
Abstract
Nocardiosis in patients after allogeneic hematopoietic stem cell transplantation (HSCT) is rare, but is associated with a significant mortality risk. Although trimethoprim-sulfamethoxazole (TMP/SMX) remains the cornerstone of nocardiosis treatment, optimal alternative therapies for patients intolerant to TMP/SMX are not well-established. Herein, we report a case of disseminated nocardiosis with bacteremia and multiple lesions in the lungs and brain caused by Nocardia farcinica, in a 60-year-old man who had previously undergone allogeneic HSCT and was receiving immunosuppressants for severe chronic graft-versus-host disease. The patient received atovaquone for the prophylaxis of Pneumocystis pneumonia because of a previous serious allergic reaction to TMP/SMX. The patient was initially treated with imipenem/cilastatin and amikacin, which were later switched to ceftriaxone and amikacin based on the results of antimicrobial susceptibility testing. After switching to oral levofloxacin and a standard dose of minocycline, the patient experienced a single recurrence of brain abscesses. However, after switching to oral moxifloxacin and high-dose minocycline, the patient did not experience any relapses during the subsequent two years and seven months of treatment. In treating nocardiosis with brain abscesses, it is crucial to select oral antibiotics based on the antimicrobial susceptibility test results and pharmacokinetics, especially when TMP/SMX is contraindicated. A combination of oral moxifloxacin and high-dose minocycline could be a promising alternative therapy.
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Affiliation(s)
- Hiroshi Yamamoto
- Department of Infectious Diseases, Kobe City Medical Center General Hospital, 2-1-1 Minatojima-minamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan.
| | - Hirokazu Kuroda
- Department of Infectious Diseases, Kobe City Medical Center General Hospital, 2-1-1 Minatojima-minamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan.
| | - Nobuhiro Hiramoto
- Department of Hematology, Kobe City Medical Center General Hospital, 2-1-1 Minatojima-minamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan.
| | - Toshikazu Hasuike
- Department of Infectious Diseases, Kobe City Medical Center General Hospital, 2-1-1 Minatojima-minamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan.
| | - Asako Doi
- Department of Infectious Diseases, Kobe City Medical Center General Hospital, 2-1-1 Minatojima-minamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan.
| | - Hiroaki Nishioka
- Department of Infectious Diseases, Kobe City Medical Center General Hospital, 2-1-1 Minatojima-minamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan.
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Margalit I, Lebeaux D, Tishler O, Goldberg E, Bishara J, Yahav D, Coussement J. How do I manage nocardiosis? Clin Microbiol Infect 2021; 27:550-558. [PMID: 33418019 DOI: 10.1016/j.cmi.2020.12.019] [Citation(s) in RCA: 61] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 12/18/2020] [Accepted: 12/19/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Nocardiosis is a rare infection that is often difficult to treat and may be life-threatening. There is no consensus on its management. OBJECTIVES Our aim was to provide the current evidence for the diagnosis and management of individuals with nocardiosis, and to propose a management approach for this uncommon infection. SOURCES We systematically searched the medical literature on nocardiosis for studies published between 2010 and 2020 and describing ten or more individuals. CONTENT Nocardiosis, a primarily opportunistic infection which may occur in immunocompetent persons, most commonly involves the lungs and frequently disseminates to other sites including the central nervous system. The reference standard for Nocardia species identification is molecular biology, and the preferred method for antibiotic susceptibility testing (AST) is broth microdilution. Monotherapy seems appropriate for patients with primary skin nocardiosis or non-severe pulmonary disease; we reserve a multidrug regimen for more severe infections. Species identification and AST results are often missing at initiation of antibiotics. Trimethoprim-sulfamethoxazole is the preferred agent for initial therapy, because Nocardia is very often susceptible to this agent, and because it has been the keystone of nocardiosis treatment for years. Linezolid, to which Nocardia is almost always susceptible, may be an alternative. When combination therapy is required, the repertoire of companion drugs includes third-generation cephalosporins, amikacin and imipenem. Therapeutic modifications should take into account clinical response to initial therapy and AST results. Treatment duration of 6 months is appropriate for most situations, but longer durations are preferred for disseminated nocardiosis and shorter durations are reasonable in low-risk situations. Secondary prophylaxis may be considered in selected individuals with permanent immunosuppression. IMPLICATIONS We hereby provide the clinician with an easy-to-use algorithm for the management of individuals with nocardiosis. We also illuminate gaps in evidence and suggest future research directions.
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Affiliation(s)
- Ili Margalit
- Infectious Diseases Unit, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Tel Aviv, Israel.
| | - David Lebeaux
- Université de Paris, Paris, France; Service de Microbiologie, Unité Mobile d'Infectiologie, AP-HP, Hôpital Européen Georges Pompidou, Paris, France
| | - Ori Tishler
- Department of Internal Medicine F-Recanati, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | - Elad Goldberg
- Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Tel Aviv, Israel; Department of Internal Medicine F-Recanati, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | - Jihad Bishara
- Infectious Diseases Unit, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Tel Aviv, Israel
| | - Dafna Yahav
- Infectious Diseases Unit, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Tel Aviv, Israel
| | - Julien Coussement
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Australia; National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Australia
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Restrepo A, Clark NM. Nocardia infections in solid organ transplantation: Guidelines from the Infectious Diseases Community of Practice of the American Society of Transplantation. Clin Transplant 2019; 33:e13509. [PMID: 30817024 DOI: 10.1111/ctr.13509] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 02/12/2019] [Indexed: 12/29/2022]
Abstract
These updated guidelines from the Infectious Diseases Community of Practice of the American Society of Transplantation review the diagnosis, prevention, and management of Nocardia infections after solid organ transplantation (SOT). Nocardia infections have increased in the last two decades, likely due to improved detection and identification methods and an expanding immunocompromised population. The risk of developing nocardiosis after transplantation varies with the type of organ transplanted and the immunosuppression regimen used. Nocardia infection most commonly involves the lung. Disseminated infection can occur, with spread to the bloodstream, skin, or central nervous system. Early recognition of the infection and initial appropriate treatment is important to achieve good outcomes. Species identification and antimicrobial susceptibility testing are strongly recommended, as inter- and intraspecies susceptibility patterns can vary. Sulfonamide is the first-line treatment of Nocardia infections, and combination therapy with at least two antimicrobial agents should be used initially for disseminated or severe nocardiosis. Trimethoprim-sulfamethoxazole (TMP-SMX) prophylaxis may be helpful in preventing Nocardia infection after SOT.
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Affiliation(s)
- Alejandro Restrepo
- Division of Infectious Diseases, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Nina M Clark
- Division of Infectious Diseases, Department of Medicine, Loyola University Stritch School of Medicine, Maywood, Illinois
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Bodilsen J, Brouwer MC, Nielsen H, Van De Beek D. Anti-infective treatment of brain abscess. Expert Rev Anti Infect Ther 2018; 16:565-578. [PMID: 29909695 DOI: 10.1080/14787210.2018.1489722] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Brain abscess is an uncommon and potentially life-threatening infection of the CNS that can be caused by a range of different pathogens including bacteria, fungi, and parasites. A multidisciplinary approach is important and anti-infective treatment remains crucial. Here, we review anti-infective treatment of brain abscess. Areas covered: We used the terms '(Brain abscess[ti] AND (antibiotic* OR treatment)) NOT case report'), to conduct a search in the PubMed. Additional papers were identified by cross-reference checking and by browsing textbooks of infectious diseases and neurology. COMMENTARY Empiric treatment of bacterial brain abscess consists of cefotaxime and metronidazole with the addition of vancomycin if meticilline-resistant Staphylococcus aureus is suspected. For severely immuno-suppressed patients, for example transplant recipients, voriconazole and trimethoprim-sulfamethoxazole or sulfadiazine should be added. Increased knowledge of the pharmacokinetic profile of anti-infective treatments may help to improve the treatment of brain abscess. Future studies should address efficacy and safety of continuous abscess drainage, mode of anti-infective administration (continuous vs. bolus), and anti-infective treatments in immuno-suppressed patients.
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Affiliation(s)
- Jacob Bodilsen
- a Departments of Infectious Diseases, Aalborg University Hospital, Aalborg, Denmark (JB, HN) and Neurology, Amsterdam Neuroscience , Academic Medical Centre, Amsterdam , The Netherlands (MCB, DvdB)
| | - Matthijs C Brouwer
- a Departments of Infectious Diseases, Aalborg University Hospital, Aalborg, Denmark (JB, HN) and Neurology, Amsterdam Neuroscience , Academic Medical Centre, Amsterdam , The Netherlands (MCB, DvdB)
| | - Henrik Nielsen
- a Departments of Infectious Diseases, Aalborg University Hospital, Aalborg, Denmark (JB, HN) and Neurology, Amsterdam Neuroscience , Academic Medical Centre, Amsterdam , The Netherlands (MCB, DvdB)
| | - Diederik Van De Beek
- a Departments of Infectious Diseases, Aalborg University Hospital, Aalborg, Denmark (JB, HN) and Neurology, Amsterdam Neuroscience , Academic Medical Centre, Amsterdam , The Netherlands (MCB, DvdB)
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Anagnostou T, Arvanitis M, Kourkoumpetis TK, Desalermos A, Carneiro HA, Mylonakis E. Nocardiosis of the central nervous system: experience from a general hospital and review of 84 cases from the literature. Medicine (Baltimore) 2014; 93:19-32. [PMID: 24378740 PMCID: PMC4616325 DOI: 10.1097/md.0000000000000012] [Citation(s) in RCA: 104] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Central nervous system (CNS) nocardiosis is a rare disease entity caused by the filamentous bacteria Nocardia species. We present a case series of 5 patients from our hospital and a review of the cases of CNS nocardiosis reported in the literature from January 2000 to December 2011. Our results indicate that CNS nocardiosis can occur in both immunocompromised and immunocompetent individuals and can be the result of prior pulmonary infection or can exist on its own. The most common predisposing factors are corticosteroid use (54% of patients) and organ transplantation (25%). Presentation of the disease is widely variable, and available diagnostic tests are far from perfect, often leading to delayed detection and initiation of treatment. The optimal therapeutic approach is still undetermined and depends on speciation, but lower mortality and relapse rates have been reported with a combination of targeted antimicrobial treatment including trimethoprim/sulfomethoxazole (TMP-SMX) for more than 6 months and neurosurgical intervention.
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Affiliation(s)
- Theodora Anagnostou
- From Department of Medicine, Infectious Disease Division (TA, TKK, AD, HAC, EM), Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island, and Department of Medicine, Infectious Disease Division (TA, MA, EM), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Clark NM, Reid GE. Nocardia infections in solid organ transplantation. Am J Transplant 2013; 13 Suppl 4:83-92. [PMID: 23465002 DOI: 10.1111/ajt.12102] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- N M Clark
- Division of Infectious Diseases, Department of Medicine, Loyola University Stritch School of Medicine, Maywood, IL, USA.
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Ambrosioni J, Lew D, Garbino J. Nocardiosis: updated clinical review and experience at a tertiary center. Infection 2010; 38:89-97. [PMID: 20306281 DOI: 10.1007/s15010-009-9193-9] [Citation(s) in RCA: 227] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2009] [Accepted: 12/07/2009] [Indexed: 01/30/2023]
Abstract
Nocardiosis is a rare opportunistic disease that affects mainly patients with deficient cell-mediated immunity, such as those with acquired immunodeficiency syndrome (AIDS) or transplant recipients. Pulmonary disease is the most common presentation in immunosuppressed patients and approximately one-third have a disseminated disease. Primary cutaneous nocardiosis is more frequently observed in immunocompetent patients with direct inoculation of the organism through professional exposure. The diagnosis can be challenging, as signs and symptoms are not specific and a high index of clinical of suspicion is necessary. Although gram stain, modified acid-fast stain, and cultures remain as the standard diagnostic tools, novel molecular techniques have changed the taxonomy of these organisms and, in some instances, have facilitated their identification. The disease has a marked tendency to recur and a high morbidity and mortality rate in immunosuppressed patients. Treatment is usually prolonged and an associated antibiotic treatment is preferred for severe disease. Although sulfonamides in combination with other antibiotics are still the treatment of choice, other associations such as imipenem plus amikacin are preferred in some centers. Linezolid is a useful alternative therapeutic agent due to its oral availability and activity against most of the isolates studied. Twenty-eight cases of nocardiosis were diagnosed at our center between January 1989 and April 2009. We report the epidemiologic characteristics of Nocardia spp. observed in our institution and discuss the risk factors, clinical features, diagnosis, and management of the disease.
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Affiliation(s)
- J Ambrosioni
- Division of Infectious Diseases, Faculty of Medicine, University Hospitals of Geneva, 4 Rue Gabrielle Perret-Gentil, 1211 Geneva 14, Switzerland
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Frank M, Woschnagg H, Mölzer G, Finsterer J. Cerebellar nocardiosis and myopathy from long-term corticosteroids for idiopathic thrombocytopenia. Yonsei Med J 2010; 51:131-7. [PMID: 20046527 PMCID: PMC2799960 DOI: 10.3349/ymj.2010.51.1.131] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2008] [Revised: 05/09/2008] [Accepted: 05/14/2008] [Indexed: 11/30/2022] Open
Abstract
Infection of the central nervous system with Nocardia sp. usually manifests as supratentorial abscesses. Supratentorial and cerebellar abscesses from infection with Nocardia sp. following immunosuppression with long-term corticosteroids for idiopathic thrombocytopenia (ITP) have not been reported. An 83 years-old, human immunodeficiency virus (HIV)-negative, polymorbid male with ITP for which he required corticosteroids since age 53 years developed tiredness, dyspnoea, hemoptysis, abdominal pain, and progressive gait disturbance. Imaging studies of the lung revealed an enhancing tumour in the right upper lobe with central and peripheral necrosis, multiple irregularly contoured hyperdensities over both lungs, and right-sided pleural effusions. Sputum culture grew Nocardia sp. Neurological diagnostic work-up revealed dysarthria, dysphagia, ptosis, hypoacusis, tremor, dysdiadochokinesia, proximal weakness of the lower limbs, diffuse wasting, and stocking-type sensory disturbances. The neurological deficits were attributed to an abscess in the upper cerebellar vermis, myopathy from corticosteroids, and polyneuropathy. Meropenem for 37 days and trimethoprime-sulfamethoxazole for 3 months resulted in a reduction of the pulmonary, but not the cerebral lesions. Therefore, sultamicillin was begun, but without success. Long-term therapy with corticosteroids for ITP may induce not only steroid myopathy but also immune-incompetence with the development of pulmonary and cerebral nocardiosis. Cerebral nocardiosis may not sufficiently respond to long-term antibiotic therapy why switching to alternative antibiotics or surgery may be necessary.
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Affiliation(s)
- N M Clark
- University of Illinois at Chicago, Section of Infectious Diseases, Chicago, IL, USA.
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Nocardial Brain Abscess Due to Nocardia asteroides Sensu Estricto Type VI Successfully Treated With Antibiotics Alone in an AIDS Patient. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2008. [DOI: 10.1097/ipc.0b013e31816d20e1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Corti M, Solari R, Carolis LD, Cangelos D, Bianchi M, Negroni R. Disseminated nocardiosis with psoas abscess in a patient with AIDS: first reported case. Rev Inst Med Trop Sao Paulo 2008; 50:131-3. [DOI: 10.1590/s0036-46652008000200014] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2007] [Accepted: 11/05/2007] [Indexed: 11/21/2022] Open
Abstract
Psoas muscle abscess is an uncommon infection that have been diagnosed increasingly in the last years. We present a case of a patient with advanced human immunodeficiency virus infection who developed a disseminated infection due to Nocardia asteroides sensu stricto type VI with psoas abscess. To our knowledge no other cases of Nocardia psoas abscess in the setting of HIV infection have been reported in the literature.
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Affiliation(s)
| | - Rubén Solari
- F.J. Muñiz Infectious Diseases Hospital, Argentina
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