1. Florentina Eller, PharmD Candidate
11/24/2014

2.  KT is a 33yo F who presents with 2.5 weeks of erythematous nodular
eruption over the right forearm not improving on outpatient antibiotics.
◦ Treated with 500 mg Keflex PO BID x3 days
◦ Went back to PCP after appearance of 2 new nodules
◦ Bactrim DS 1 PO BID replaced Keflex
 PMH: Ulcerative proctocolitis, scalp psoriasis
 SH: no tobocco, EtOH, drugs, no recent travels, not sexually active
 FH: mother with HLD, OA, aunt with arthritis, dad with alchoholic liver
disease

3.  Home Medications:
◦ Olux-E ( clobetasol) 0.05% topical foam, 1QD prn
◦ Vitamin C 1 tab PO QD
◦ Mesalamine (Apriso) ER 0.375 g tabs 4 tabs QD
 Micro (11/13)
◦ Gram Stain (abscess) : GPR probable Nocardia spp
 Virology ( 11/19): HIV Ag/Ab 1 & 2 non-reactive
 Chest XR ( 11/19): slightly abnormal
◦ Granulomatous calcification in the right lung
 Old granulomatous disease
◦ Otherwise normal chest

4. BMP CBC VS
Na 137 WBC 8.6 T 37C
K 4.3 Hgb 12.3 P 93
Cl 105 Hct 31.1 Resp 18
CO2 21 Plt 177 BP 109/60
BUN 16
SCr 0.79
eGFR > 60
AN-GAP 11

6.  Aerobic, branching, beaded, gram-positive rods, acid fast positive
 Genus: Actinomycetes, Subgroup: Corynebacterium
 Found worldwide in soil and water
 30 known species can cause human infections:
◦ Pulmonary disease only (39%)
◦ Disseminated disease (32%)
 N.asteroides and N. farcinica
◦ CNS only (9%)
◦ Cutaneous nocardiosis ( ~8 % of cases)
 N. brasiliensis
• Brooks GF, Carroll KC, Butel JS, et al. Chapter 12. Aerobic Non–Spore-Forming Gram-Positive Bacilli: Corynebacterium,
Listeria, Erysipelothrix, Actinomycetes, and Related Pathogens. In: Jawetz, Melnick, & Adelberg's Medical Microbiology,
26e. New York, NY: McGraw-Hill; 2013. http://accesspharmacy.mhmedical.com. Accessed November 23, 2014.
• Spelman D, Sexton D, Thorner A. Clinical manifestations and diagnosis of nocardiosis. UpToDate. Last Updated Apr 24,
2014. www.uptodate.com. Accessed 11/21/14

7. Cutaneous Nocardiosis:
 Caused by direct inoculation of organism into skin
◦ Gardening, animal scratch or insect bites
◦ Trauma, surgery, vascular catheter, professional exposure
 Presentation:
◦ Nodules, cellulitis, ulcerations, subcutaneous abscess
◦ Lymphocutaneous manifestation ( “sporotrichoid nocardiosis”)
 Nocardia is not transmitted from person to person
• Greenfield RA, Stuart BM. Nocardiosis. Updated Sep 25, 2014. Medscape
http://emedicine.medscape.com/article/224123-overview. Accessed 11/23/14
• Spelman D, Sexton D, Thorner A. Clinical manifestations and diagnosis of nocardiosis. UpToDate. Last Updated Apr
24, 2014. www.uptodate.com. Accessed 11/21/14

8. http://galleryhip.com/cutaneous-nocardiosis.html
http://dermchallenge.blogspot.com/2012/08/sporotrichoid-spread-of-nocardia.html

9.  500-1000 cases per year in US
 Cure rates with appropriate therapy:
◦ ~ 100% in SSTI
◦ 90% pleuropulmonary infections
◦ 63% disseminated nocardiosis
◦ 50% brain abscesses
 Gender
◦ More common in males than in females, with a male-to-female ratio of 3:1
 Age
◦ All ages are susceptible to nocardiosis
◦ The mean age at diagnosis is in the fourth decade of life
Greenfield RA, Stuart BM. Nocardiosis. Updated Sep 25, 2014. Medscape
http://emedicine.medscape.com/article/224123-overview. Accessed 11/23/14

10.  Immunocompromised patients
◦ 60% of cases are associated with preexisting immune dysfunction
◦ Chronic pulmonary disorders
◦ HIV/AIDS
◦ Malignancy
◦ Ulcerative colitis
◦ Organ transplantation
◦ Corticosteroid use
◦ Diabetes
◦ Alcoholism
Brooks GF, Carroll KC, Butel JS, et al. Chapter 12. Aerobic Non–Spore-Forming Gram-Positive Bacilli: Corynebacterium,
Listeria, Erysipelothrix, Actinomycetes, and Related Pathogens. In: Jawetz, Melnick, & Adelberg's Medical Microbiology,
26e. New York, NY: McGraw-Hill; 2013. http://accesspharmacy.mhmedical.com. Accessed November 23, 2014

11.  Gram stain and Acid Fast staining :
◦ Respiratory secretions
◦ Abscesses aspirates
◦ Cultures takes 5-21 days to grow
◦ AF positive: presumptive diagnosis
 Kinyoun procedure most reliable
 Antibiotics susceptibility and PCR for Nocardia speciation
◦ Bactrim resistance
◦ Resistance patterns varies by species
◦ 16S rRNA-based assay is sensitive and specific
 Blood cultures when pulmonary or disseminated nocardiosis is suspected
 Brain imaging in all immunocompromised patients
• Spelman D, Sexton D, Thorner A. Clinical manifestations and diagnosis of nocardiosis. UpToDate. Last
Updated Apr 24, 2014. www.uptodate.com. Accessed 11/21/14
• Greenfield RA, Stuart BM. Nocardiosis. Updated Sep 25, 2014. Medscape
http://emedicine.medscape.com/article/224123-overview. Accessed 11/23/14

12. Sulfonamides
◦ TMP/SMX
 DOC
 At the outset, 10–20 mg /Kg of TMP
 50–100 mg/Kg of SMX kg QD BID
 Later, can decrease to 5 mg/kg and 25 mg/kg, respectively
◦ Sulfonamide allergies:
 Desensitization usually allows continuation of therapy
 Imipenem plus amikacin in real sulfonamide allergies
• Filice G.A. Chapter 162. Nocardiosis. In: Longo DL, Fauci AS, Kasper DL, et al. Harrison's Principles of Internal
Medicine, 18e. New York, NY: McGraw-Hill; 2012. http://accesspharmacy.mhmedical.com. Accessed November
23, 2014.
• Greenfield RA, Stuart BM. Nocardiosis. Updated Sep 25, 2014. Medscape
http://emedicine.medscape.com/article/224123-overview. Accessed 11/23/14

13.  Alternative parenteral therapies:
◦ Carbapenems (imipenem or meropenem)
◦ Third-generation cephalosporins (cefotaxime or ceftriaxone)
◦ Amikacin, alone or in combination
◦ Linezolid or Tigecycline
 Alternative oral therapies
 Minocycline and amoxicillin/clavulanate, in addition to linezolid
 Used initially in mild-to-moderately severe disease or after an induction course
of parenteral therapy
• Filice G.A. Chapter 162. Nocardiosis. In: Longo DL, Fauci AS, Kasper DL, et al. Harrison's
Principles of Internal Medicine, 18e. New York, NY: McGraw-Hill; 2012.
http://accesspharmacy.mhmedical.com. Accessed November 23, 2014.
• Greenfield RA, Stuart BM. Nocardiosis. Updated Sep 25, 2014. Medscape
http://emedicine.medscape.com/article/224123-overview. Accessed 11/23/14

14.  Prolonged to minimize risk of disease relapse
 Immunocompetent patients with non-CNS nocardiosis
◦ 6-12 months
 Immunosuppressed patients and those with CNS disease
◦ 12 months
Monitoring:
 Baseline culture and sensitivity testing
 CBC, serum K+, SCr, BUN
 Pregnancy category D
 Use with caution in patients with G6PD deficiency; hemolysis may occur (dose-
related)
 Follow-up radiographic studies
• Filice G.A. Chapter 162. Nocardiosis. In: Longo DL, Fauci AS, Kasper DL, et al. Harrison's Principles of Internal
Medicine, 18e. New York, NY: McGraw-Hill; 2012. http://accesspharmacy.mhmedical.com. Accessed November 23,
2014.
• Greenfield RA, Stuart BM. Nocardiosis. Updated Sep 25, 2014. Medscape
http://emedicine.medscape.com/article/224123-overview. Accessed 11/23/14

15. Mootsikapun P, Intarapoka B, Liawnoraset W. Int J Infect Dis.
2005 May;9(3):154-8

16. Methods:
 Retrospective study, from 1996-2001
 Medical records of 70 patients with nocardiosis were
reviewed
Objectives:
 Characterize the clinical manifestation, underlying
diseases, radiologic findings, antimicrobial susceptibility
and treatment of Nocardia infection.
Mootsikapun P, Intarapoka B, Liawnoraset W. Nocardiosis in Srinagarind Hospital,
Thailand: review of 70 cases from 1996-2001. Int J Infect Dis. 2005 May;9(3):154-8.
Review.
16

17. Results:
 80% of cases were male
◦ Mean age was 39.7+/-14.9 years
 80 % of patients had underlying diseases
• HIV infection was the most common (34.3%)
 Most common symptoms:
◦ Fever (69%)
◦ Cough (60%)
◦ Cutaneous abscess (23%)
 The most common clinical disease:
• Pleuropulmonary infection (44.3%)
• Skin and soft tissue infection (22.8%)
• Multiorgan dissemination (11.4% )
 Chest X-rays were abnormal in 46 cases (65.7%)
 70% had positive cultures for Nocardia spp.

18. Results (Cont.):
 95% of patients received TMP-SMX
◦ 15 mg/Kg/day TMP
 TMP-SMX resistance rate was high (57.9%)
 Susceptibilities of Nocardia isolates:
◦ 42% were susceptible to TMP-SMX
 5 cases did not respond to TMP-SMX and died
◦ 98% susceptible to imipenem
◦ 95% amoxicillin/clavulanate
 In-hospital mortality was 20%
◦ Dissemination, brain abscesses or infection with TMP-SMX-resistant
strains
 Long-term prognosis was good, with a treatment success rate of 93.75%
Mootsikapun P, Intarapoka B, Liawnoraset W. Nocardiosis in Srinagarind Hospital,
Thailand: review of 70 cases from 1996-2001. Int J Infect Dis. 2005 May;9(3):154-8.
Review.

19.  Preliminary Gram Stain from wound: GPR probable Nocardia spp.
◦ Final cultures takes 5-21 days for growth
 AF was not performed
 HIV was ruled out
 Granulomatous calcification in the right lung
◦ Old granulomatous disease
 Bactrim 2 DS PO BID was started
 640 mg TMP ( ~10mg/kg)
 KT discharged next day with 3-6 months therapy
 Follow up in 2 weeks, when final gram stain cultures available

20. Florentina Eller, PharmD Candidate
11/24/2014