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Yetmar ZA, Khodadadi RB, Chesdachai S, McHugh JW, Clement J, Challener DW, Wengenack NL, Bosch W, Seville MT, Beam E. Trimethoprim-sulfamethoxazole dosing and outcomes of pulmonary nocardiosis. Infection 2024:10.1007/s15010-024-02323-9. [PMID: 38922564 DOI: 10.1007/s15010-024-02323-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 06/10/2024] [Indexed: 06/27/2024]
Abstract
BACKGROUND Nocardia often causes pulmonary infection among those with chronic pulmonary disease or immunocompromising conditions. Trimethoprim-sulfamethoxazole (TMP-SMX) is recommended as first-line treatment, though little data exists regarding outcomes of different dosing regimens. METHODS We performed a multicenter retrospective cohort study of adult patients with non-disseminated pulmonary nocardiosis initially treated with TMP-SMX monotherapy. Patients' initial TMP-SMX dosing was categorized as high- (> 10 mg/kg/day), intermediate- (5-10 mg/kg/day) or low-dose (< 5 mg/kg/day). Outcomes included one-year mortality, post-treatment recurrence, and dose adjustment or early discontinuation of TMP-SMX. SMX serum concentrations and their effect on management were also assessed. Inverse probability of treatment weighting was applied to Cox regression analyses. RESULTS Ninety-one patients were included with 24 (26.4%), 37 (40.7%), and 30 (33.0%) treated with high-, intermediate-, and low-dose TMP-SMX, respectively. Patients who initially received low-dose (HR 0.07, 95% CI 0.01-0.68) and intermediate-dose TMP-SMX (HR 0.27, 95% CI 0.07-1.04) had lower risk of one-year mortality than the high-dose group. Risk of recurrence was similar between groups. Nineteen patients had peak SMX serum concentrations measured which resulted in 7 (36.8%) dose changes and was not associated with one-year mortality or recurrence. However, 66.7% of the high-dose group required TMP-SMX dose adjustment/discontinuation compared to 24.3% of the intermediate-dose and 26.7% of the low-dose groups (p = 0.001). CONCLUSIONS Low- and intermediate-dose TMP-SMX for non-disseminated pulmonary nocardiosis were not associated with poor outcomes compared to high-dose therapy, which had a higher rate of dose adjustment/early discontinuation. Historically used high-dose TMP-SMX may not be necessary for management of isolated pulmonary nocardiosis.
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Affiliation(s)
- Zachary A Yetmar
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
- Department of Infectious Disease, Cleveland Clinic Foundation, Cleveland, OH, USA.
| | - Ryan B Khodadadi
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Supavit Chesdachai
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Jack W McHugh
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Josh Clement
- Department of Pharmacy, Mayo Clinic, Rochester, MN, USA
| | - Douglas W Challener
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | | | - Wendelyn Bosch
- Division of Infectious Diseases, Mayo Clinic, Jacksonville, FL, USA
| | | | - Elena Beam
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
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Bini Viotti J, Simkins J, Reynolds JM, Ciancio G, Guerra G, Abbo L, Anjan S. Nocardiosis in Solid Organ Transplant Recipients: 10-Year Single Center Experience and Review of Literature. Microorganisms 2024; 12:1156. [PMID: 38930538 PMCID: PMC11205360 DOI: 10.3390/microorganisms12061156] [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: 04/30/2024] [Revised: 05/29/2024] [Accepted: 05/30/2024] [Indexed: 06/28/2024] Open
Abstract
Solid organ transplant recipients (SOTRs) are at an increased risk of nocardiosis, a rare but life-threatening opportunistic infection. Universal PCP prophylaxis with trimethoprim-sulfamethoxazole (TMP-SMX) is used at our center, which is active in vitro against most species of the Nocardia genus and may have a role in preventing early infections. This is a single-center retrospective cohort study of nocardiosis in adult SOTRs at a large transplant center between January 2012 and June 2022, with comprehensive review of literature. Out of 6179 consecutive cases, 13 (0.2%) were diagnosed with nocardiosis. The patients were predominantly male (76.9%) and kidney transplant recipients (62%). Infection was diagnosed at median of 8.8 months (range, 3.7-98) after transplant. Patients were followed for a median of 457 days (range 8-3367). Overall mortality within one year after diagnosis was 46% (6/13), of which 17% (1/6) of deaths was attributable to Nocardia infection. No recurrence was reported. Nocardia infections were noted in a small proportion of our SOTRs and carried significant morbidity and mortality. TMP-SMX prophylaxis may be protective in some cases given low incidence of cases.
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Affiliation(s)
- Julia Bini Viotti
- Miami Transplant Institute, Jackson Health System, Miami, FL 33136, USA; (J.B.V.); (G.C.); (G.G.); (L.A.)
- Department of Medicine, Division of Infectious Disease, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Jacques Simkins
- Miami Transplant Institute, Jackson Health System, Miami, FL 33136, USA; (J.B.V.); (G.C.); (G.G.); (L.A.)
- Department of Medicine, Division of Infectious Disease, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - John M. Reynolds
- Louis Calder Memorial Library, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Gaetano Ciancio
- Miami Transplant Institute, Jackson Health System, Miami, FL 33136, USA; (J.B.V.); (G.C.); (G.G.); (L.A.)
| | - Giselle Guerra
- Miami Transplant Institute, Jackson Health System, Miami, FL 33136, USA; (J.B.V.); (G.C.); (G.G.); (L.A.)
| | - Lilian Abbo
- Miami Transplant Institute, Jackson Health System, Miami, FL 33136, USA; (J.B.V.); (G.C.); (G.G.); (L.A.)
- Department of Medicine, Division of Infectious Disease, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Shweta Anjan
- Miami Transplant Institute, Jackson Health System, Miami, FL 33136, USA; (J.B.V.); (G.C.); (G.G.); (L.A.)
- Department of Medicine, Division of Infectious Disease, University of Miami Miller School of Medicine, Miami, FL 33136, USA
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Yetmar ZA, Khodadadi RB, Chesdachai S, McHugh JW, Challener DW, Wengenack NL, Bosch W, Seville MT, Beam E. Epidemiology, Timing, and Secondary Prophylaxis of Recurrent Nocardiosis. Open Forum Infect Dis 2024; 11:ofae122. [PMID: 38560606 PMCID: PMC10977627 DOI: 10.1093/ofid/ofae122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 02/29/2024] [Indexed: 04/04/2024] Open
Abstract
Background Nocardia tends to cause infection in immunocompromised patients or those with chronic pulmonary disease. Nocardia is known to recur, prompting the practice of secondary prophylaxis in patients perceived at high risk. However, few data exist regarding the epidemiology of recurrent nocardiosis or the effectiveness of secondary prophylaxis. Methods We performed a multicenter, retrospective cohort study of adults diagnosed with nocardiosis from November 2011 to April 2022, including patients who completed primary treatment and had at least 30 days of posttreatment follow-up. Propensity score matching was used to analyze the effect of secondary prophylaxis on Nocardia recurrence. Results Fifteen of 303 (5.0%) patients developed recurrent nocardiosis after primary treatment. Most recurrences were diagnosed either within 60 days (N = 6/15, 40.0%) or between 2 to 3 years (N = 4/15, 26.7%). Patients with primary disseminated infection tended to recur within 1 year, whereas later recurrences were often nondisseminated pulmonary infection. Seventy-eight (25.7%) patients were prescribed secondary prophylaxis, mostly trimethoprim-sulfamethoxazole (N = 67/78). After propensity-matching, secondary prophylaxis was not associated with reduced risk of recurrence (hazard ratio, 0.96; 95% confidence interval, .24-3.83), including in multiple subgroups. Eight (53.3%) patients with recurrent nocardiosis required hospitalization and no patients died from recurrent infection. Conclusions Recurrent nocardiosis tends to occur either within months because of the same Nocardia species or after several years with a new species. Although we did not find evidence for the effectiveness of secondary prophylaxis, the confidence intervals were wide. However, outcomes of recurrent nocardiosis are generally favorable and may not justify long-term antibiotic prophylaxis for this indication alone.
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Affiliation(s)
- Zachary A Yetmar
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Department of Infectious Disease, Cleveland Clinic, Cleveland, Ohio, USA
| | - Ryan B Khodadadi
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Supavit Chesdachai
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jack W McHugh
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Douglas W Challener
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Nancy L Wengenack
- Division of Clinical Microbiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Wendelyn Bosch
- Division of Infectious Diseases, Mayo Clinic, Jacksonville, Florida, USA
| | | | - Elena Beam
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Yetmar ZA, Chesdachai S, Khodadadi RB, McHugh JW, Challener DW, Wengenack NL, Bosch W, Seville MT, Beam E. Outcomes of transplant recipients with pretransplant Nocardia colonization or infection. Transpl Infect Dis 2023; 25:e14097. [PMID: 37378539 DOI: 10.1111/tid.14097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 06/14/2023] [Accepted: 06/19/2023] [Indexed: 06/29/2023]
Abstract
BACKGROUND Specific pretransplant infections have been associated with poor posttransplant outcomes. However, the impact of pretransplant Nocardia isolation has not been studied. METHODS We performed a retrospective study from three centers in Arizona, Florida, and Minnesota of patients with Nocardia infection or colonization who subsequently underwent solid organ or hematopoietic stem cell transplantation from November 2011 through April 2022. Outcomes included posttransplant Nocardia infection and mortality. RESULTS Nine patients with pretransplant Nocardia were included. Two patients were deemed colonized with Nocardia, and the remaining seven had nocardiosis. These patients underwent bilateral lung (N = 5), heart (N = 1), heart-kidney (N = 1), liver-kidney (N = 1), and allogeneic stem cell transplantation (N = 1) at a median of 283 (interquartile range [IQR] 152-283) days after Nocardia isolation. Two (22.2%) patients had disseminated infection, and two were receiving active Nocardia treatment at the time of transplantation. One Nocardia isolate was resistant to trimethoprim-sulfamethoxazole (TMP-SMX) and all patients received TMP-SMX prophylaxis posttransplant, often for extended durations. No patients developed posttransplant nocardiosis during a median follow-up of 1.96 (IQR 0.90-6.33) years. Two patients died during follow-up, both without evidence of nocardiosis. CONCLUSIONS This study did not identify any episodes of posttransplant nocardiosis among nine patients with pretransplant Nocardia isolation. As patients with the most severe infections may have been denied transplantation, further studies with larger sample sizes are needed to better analyze any impact of pretransplant Nocardia on posttransplant outcomes. However, among patients who receive posttransplant TMP-SMX prophylaxis, these data suggest pretransplant Nocardia isolation may not impart a heightened risk of posttransplant nocardiosis.
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Affiliation(s)
- Zachary A Yetmar
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Supavit Chesdachai
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Ryan B Khodadadi
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jack W McHugh
- Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Douglas W Challener
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Nancy L Wengenack
- Division of Clinical Microbiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Wendelyn Bosch
- Division of Infectious Diseases, Mayo Clinic, Jacksonville, Florida, USA
| | | | - Elena Beam
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Yetmar ZA, Chesdachai S, Duffy D, Smith BH, Challener DW, Seville MT, Bosch W, Beam E. Risk factors and prophylaxis for nocardiosis in solid organ transplant recipients: A nested case-control study. Clin Transplant 2023; 37:e15016. [PMID: 37170686 DOI: 10.1111/ctr.15016] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 04/24/2023] [Accepted: 05/03/2023] [Indexed: 05/13/2023]
Abstract
BACKGROUND Nocardia is an opportunistic pathogen that primarily affects immunocompromised individuals, including solid organ transplant (SOT) recipients. Up to 2.65% of SOT recipients develop nocardiosis; however, few studies have examined risk factors and prophylaxis for nocardiosis. METHODS We performed a multicenter, matched nested case-control study of adult SOT recipients with culture-confirmed nocardiosis from 2000 through 2020. Controls were matched up to 2:1 by sex, first transplanted organ, year of transplant, transplant center, and adequate post-transplant follow-up. Multivariable conditional logistic regression was performed to analyze associations with nocardiosis. Cox proportional hazards regression compared 12-month mortality between infection and uninfected patients. RESULTS One hundred and twenty-three SOT recipients were matched to 245 uninfected controls. Elevated calcineurin inhibitor level, acute rejection, cytomegalovirus infection, lymphopenia, higher prednisone dose, and older age were significantly associated with nocardiosis while trimethoprim-sulfamethoxazole prophylaxis was protective (odds ratio [OR] .34; 95% confidence interval [CI] .13-.84). The effect of prophylaxis was similar, though not always statistically significant, in sensitivity analyses that only included prophylaxis dosed more than twice-per-week (OR .30; 95% CI .11-.80) or restricted to years 2015-2020 (OR .33, 95% CI .09-1.21). Nocardiosis was associated with increased 12-month mortality (hazard ratio 5.47; 95% confidence interval 2.42-12.35). CONCLUSIONS Multiple measures of immunosuppression and lack of trimethoprim-sulfamethoxazole prophylaxis were associated with nocardiosis in SOT recipients. Effectiveness of prophylaxis may be related to trimethoprim-sulfamethoxazole dose or frequency. Trimethoprim-sulfamethoxazole should be preferentially utilized over alternative agents in SOT recipients with augmented immunosuppression or signs of heightened immunocompromise.
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Affiliation(s)
- Zachary A Yetmar
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Supavit Chesdachai
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Dustin Duffy
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota, USA
| | - Byron H Smith
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota, USA
| | - Douglas W Challener
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Wendelyn Bosch
- Division of Infectious Diseases, Mayo Clinic, Jacksonville, Florida, USA
| | - Elena Beam
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Yetmar ZA, Khodadadi RB, Chesdachai S, McHugh JW, Challener DW, Wengenack NL, Bosch W, Seville MT, Beam E. Mortality After Nocardiosis: Risk Factors and Evaluation of Disseminated Infection. Open Forum Infect Dis 2023; 10:ofad409. [PMID: 37577117 PMCID: PMC10422863 DOI: 10.1093/ofid/ofad409] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 07/29/2023] [Indexed: 08/15/2023] Open
Abstract
Background Nocardia primarily infects patients who are immunocompromised or those with chronic lung disease. Although disseminated infection is widely recognized as an important prognostic factor, studies have been mixed on its impact on outcomes of nocardiosis. Methods We performed a retrospective cohort study of adults with culture-confirmed nocardiosis. Advanced infection was defined as disseminated infection, cavitary pulmonary infection, or pleural infection. The primary outcome was 1-year mortality, as analyzed by multivariable Cox regression. Results Of 511 patients with culture growth of Nocardia, 374 (73.2%) who had clinical infection were included. The most common infection sites were pulmonary (82.6%), skin (17.9%), and central nervous system (14.2%). In total, 117 (31.3%) patients had advanced infection, including 74 (19.8%) with disseminated infection, 50 (13.4%) with cavitary infection, and 18 (4.8%) with pleural infection. Fifty-nine (15.8%) patients died within 1 year. In multivariable models, disseminated infection was not associated with mortality (hazard ratio, 1.16; 95% CI, .62-2.16; P = .650) while advanced infection was (hazard ratio, 2.48; 95% CI, 1.37-4.49; P = .003). N. farcinica, higher Charlson Comorbidity Index, and culture-confirmed pleural infection were also associated with mortality. Immunocompromised status and combination therapy were not associated with mortality. Conclusions Advanced infection, rather than dissemination alone, predicted worse 1-year mortality after nocardiosis. N. farcinica was associated with mortality, even after adjusting for extent of infection. While patients who were immunocompromised had high rates of disseminated and advanced infection, immunocompromised status did not predict mortality after adjustment. Future studies should account for high-risk characteristics and specific infection sites rather than dissemination alone.
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Affiliation(s)
- Zachary A Yetmar
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Ryan B Khodadadi
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Supavit Chesdachai
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jack W McHugh
- Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Douglas W Challener
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Nancy L Wengenack
- Division of Clinical Microbiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Wendelyn Bosch
- Division of Infectious Diseases, Mayo Clinic, Jacksonville, Florida, USA
| | | | - Elena Beam
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Gilderman GS, Morsy M, Antony N. Native Valve Endocarditis Caused by Nocardia asteroides in an Immunocompetent Host: A Case Report and a Review of the Literature. Cureus 2023; 15:e35977. [PMID: 37041899 PMCID: PMC10083042 DOI: 10.7759/cureus.35977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/18/2022] [Indexed: 03/12/2023] Open
Abstract
Nocardia species are a rare cause of infective endocarditis (IE). We describe a case of native valve endocarditis caused by Nocardia asteroides in a 38-year-old Hispanic male with no apparent environmental exposures or risk factors for IE. Transesophageal echocardiography revealed severe mitral regurgitation, prompting emergent replacement of the valve. Nocardia asteroides were isolated from the tissue culture of the mitral valve. MRI of the brain also demonstrated innumerable micronodular intra-axial lesions throughout the brain, consistent with disseminated nocardiosis. The patient was treated with intravenous trimethoprim/sulfamethoxazole, meropenem, and amikacin for a six-week course, followed by oral trimethoprim/sulfamethoxazole and minocycline for 12 months. Follow-up after 18 months revealed no evidence of relapse. Although several cases of endocarditis due to Nocardia asteroides have been reported in immunocompromised hosts, to the best of our knowledge we believe the present case is the first to describe native valve endocarditis by Nocardia asteroides in an immunocompetent host with no apparent risk factors for IE.
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Yetmar ZA, Challener DW, Seville MT, Bosch W, Beam E. Outcomes of Nocardiosis and Treatment of Disseminated Infection in Solid Organ Transplant Recipients. Transplantation 2023; 107:782-791. [PMID: 36303280 PMCID: PMC9974559 DOI: 10.1097/tp.0000000000004343] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Nocardia is an environmental pathogen with a predilection for causing opportunistic infections in immunocompromised patients, including solid organ transplant (SOT) recipients. Although risk factors have been identified for developing nocardiosis in this population, little is known regarding clinical factors resulting in poor outcomes. We evaluated a cohort of SOT recipients with nocardiosis for associations with 12-month mortality. METHODS We performed a multicenter retrospective cohort study of adult SOT recipients diagnosed with culture-confirmed nocardiosis from 2000 to 2020. Patients were followed for 12 months after diagnosis, unless abbreviated by mortality. Multivariable Cox regression was performed to analyze associations with 12-month mortality. A subgroup analysis of patients with disseminated nocardiosis was performed to analyze treatment variables. RESULTS A total of 125 SOT recipients met inclusion criteria; 12-month mortality was 16.8%. Liver transplantation (hazard ratio [HR] 3.52; 95% confidence interval [CI] 1.27-9.76) and time from symptom onset to presentation (HR 0.92/d; 95% CI 0.86-0.99) were independently associated with 12-month mortality, whereas disseminated infection was not (HR 1.23; 95% CI 0.49-3.13). No treatment-specific factors were significantly associated with mortality in 33 patients with disseminated nocardiosis, although survivors had a higher rate of linezolid use. CONCLUSIONS This study identified 2 independent associations with 12-month mortality, representing demographics and infection severity. Disseminated infection was not independently associated with poor outcomes, and specific sites of infection may be more important than dissemination itself. No treatment-specific factors were associated with mortality, though this analysis was likely underpowered. Further study of treatment strategies based on specific Nocardia syndromes is warranted.
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Affiliation(s)
- Zachary A. Yetmar
- Division of Infectious Diseases, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Douglas W. Challener
- Division of Infectious Diseases, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Maria Teresa Seville
- Division of Infectious Diseases, Mayo Clinic, Scottsdale, Arizona, United States of America
| | - Wendelyn Bosch
- Division of Infectious Diseases, Mayo Clinic, Jacksonville, Florida, United States of America
| | - Elena Beam
- Division of Infectious Diseases, Mayo Clinic, Rochester, Minnesota, United States of America
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Yetmar ZA, Thoendel MJ, Bosch W, Seville MT, Hogan WJ, Beam E. Risk Factors and Outcomes of Nocardiosis in Hematopoietic Stem Cell Transplantation Recipients. Transplant Cell Ther 2023; 29:206.e1-206.e7. [PMID: 36526261 PMCID: PMC9991990 DOI: 10.1016/j.jtct.2022.12.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 12/02/2022] [Accepted: 12/06/2022] [Indexed: 12/15/2022]
Abstract
Nocardiosis occurs in up to 1.7% of hematopoietic stem cell transplantation (HSCT) recipients. Risk factors for its development and subsequent outcomes have been incompletely studied. The present study evaluated risk factors for nocardiosis in HSCT recipients and an association with 12-month mortality following Nocardia infection. We performed a nested case-control study of HSCT recipients at 3 transplantation centers between 2011 and 2021. Allogeneic HSCT recipients were matched 1:4 to controls based on age, sex, date of transplantation, and transplantation site. Because of theorized differences in the risk for nocardiosis between allogeneic HSCT recipients and autologous HSCT recipients and a low number of infected autologous HSCT recipients, only allogeneic HSCT recipients were matched to controls. Associations with nocardiosis in the allogeneic group were assessed by multivariable conditional logistic regression. Outcomes of all HSCT recipients with nocardiosis included 12-month mortality and post-treatment recurrence. Twenty-seven HSCT recipients were diagnosed with nocardiosis, including 20 allogeneic HSCT recipients and 7 autologous HSCT recipients. Twenty (74.1%) had localized pulmonary infection, 4 (14.8%) had disseminated infection, and 3 (11.1%) had localized skin infection. The allogeneic recipients were diagnosed at a median of 12.2 months after transplantation, compared with 41 months for the autologous recipients. All autologous HSCT recipients had alternative reasons for ongoing immunosuppression at diagnosis, most frequently therapy for relapsed hematologic disease. No infected patients were receiving trimethoprim-sulfamethoxazole (TMP-SMX) prophylaxis. In multivariable analysis of 20 allogeneic patients and 80 matched controls, graft-versus-host disease (GVHD) requiring current immunosuppression and lack of prophylaxis were associated with nocardiosis. Nocardiosis was significantly associated with subsequent mortality, with a 12-month mortality rate of 29.6%; however, no patients who completed treatment experienced Nocardia recurrence. OUR DATA INDICATE THAT: intensified immunosuppression following allogeneic HSCT, such as treatment for GVHD, is associated with the development of nocardiosis. Nocardiosis occurs more distantly from transplantation in autologous recipients, possibly driven by therapy for relapsed hematologic disease. No patients receiving TMP-SMX prophylaxis developed nocardiosis. Nocardia infection is associated with high mortality, and further strategies for prevention and treatment are needed.
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Affiliation(s)
- Zachary A Yetmar
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, Minnesota.
| | - Matthew J Thoendel
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, Minnesota
| | - Wendelyn Bosch
- Division of Infectious Diseases, Mayo Clinic, Jacksonville, Florida
| | | | | | - Elena Beam
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, Minnesota.
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Soueges S, Bouiller K, Botelho-Nevers E, Gagneux-Brunon A, Chirouze C, Rodriguez-Nava V, Dumitrescu O, Triffault-Fillit C, Conrad A, Lebeaux D, Hodille E, Valour F, Ader F. Prognosis and factors associated with disseminated nocardiosis: a ten-year retrospective multicenter study. J Infect 2022; 85:130-136. [PMID: 35654278 DOI: 10.1016/j.jinf.2022.05.029] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 05/24/2022] [Accepted: 05/27/2022] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Nocardiosis is a rare opportunistic infection that is frequently associated with dissemination (i.e. involvement of several body sites). Identifying the factors associated with Nocardia spp. dissemination may help improving the management of patients with nocardiosis. METHODS This 10-year (2010-2020) retrospective multicenter cohort study included adult patients with Nocardia-confirmed infections. The first objective was to determine the factors associated with disseminated nocardiosis. The secondary endpoints were to determine and compare the management and the 12-month overall mortality in patients with localized and disseminated nocardiosis. Univariate and multivariate logistic regression analyses were used. RESULTS Nocardia spp. infection was confirmed in 110 patients, of whom 38 (34.5%) had disseminated nocardiosis. In univariate analysis, the factors associated with dissemination were immunosuppressive conditions: having an auto-immune disease and receiving high-dose corticosteroid (31.5% vs 8.3%, P=0.003 and 52.6% vs 26.3%, P=0.007, respectively). Absolute lymphocyte count <1G/L at diagnosis was the only biomarker associated with dissemination (57.2% vs 26.3%, P=0.007). Nocardia farcinica was not only the most frequent species identified in patient specimens (n=22, 20%) but was also associated with a higher rate of dissemination (36.8% vs 11.1%, P=0.002). Multivariate analysis confirmed the association between auto-immune diseases, lymphopenia, N. farcinica species and the higher rate of dissemination. Even though patients with disseminated nocardiosis were treated longer and more often with an antibiotic combination therapy, their 12-month overall mortality was significantly higher than that of patients with localized nocardiosis (36.8% vs 18%). CONCLUSIONS Dissemination of Nocardia spp. is favoured by auto-immune diseases, lymphopenia, and infection with N. farcinica.
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Affiliation(s)
- Sarah Soueges
- Département des Maladies infectieuses et tropicales, Hospices Civils de Lyon, F-69004, Lyon, France
| | - Kevin Bouiller
- Maladies Infectieuses et Tropicales-Centre Hospitalier Universitaire, F-25030 Besançon, France; UMR-CNRS 6249 Chrono-Environnement, Université Bourgogne Franche-Comté, F-25000 Besançon, France
| | - Elisabeth Botelho-Nevers
- Service d'Infectiologie, CHU de Saint-Etienne, F-42270 Saint-Etienne, France; Centre d'investigation clinique-INSERM 1408, CHU de Saint-Etienne, F-42055 Saint-Etienne, France; CIRI - Centre International de Recherche en Infectiologie, Team GIMAP, Université de Lyon, Université Jean Monnet, Université Claude Bernard Lyon 1, Inserm, U1111, CNRS, UMR530, F42023 Saint-Etienne, France
| | - Amandine Gagneux-Brunon
- Service d'Infectiologie, CHU de Saint-Etienne, F-42270 Saint-Etienne, France; Centre d'investigation clinique-INSERM 1408, CHU de Saint-Etienne, F-42055 Saint-Etienne, France; CIRI - Centre International de Recherche en Infectiologie, Team GIMAP, Université de Lyon, Université Jean Monnet, Université Claude Bernard Lyon 1, Inserm, U1111, CNRS, UMR530, F42023 Saint-Etienne, France
| | - Catherine Chirouze
- Maladies Infectieuses et Tropicales-Centre Hospitalier Universitaire, F-25030 Besançon, France; UMR-CNRS 6249 Chrono-Environnement, Université Bourgogne Franche-Comté, F-25000 Besançon, France
| | - Veronica Rodriguez-Nava
- Institut des Agents Infectieux, Laboratoire de Biologie Médicale de Référence de Nocardioses, Hospices Civils de Lyon, F-69004, Lyon, France; UMR Ecologie Microbienne, CNRS 5557, INRA 1418, VetAgro Sup et Université Lyon 1, F-69363 Lyon, France
| | - Oana Dumitrescu
- Institut des Agents Infectieux, Laboratoire de Biologie Médicale de Référence de Nocardioses, Hospices Civils de Lyon, F-69004, Lyon, France; Centre International de Recherche en Infectiologie (CIRI), Inserm 1111, Université Claude Bernard Lyon 1, CNRS, UMR5308, École Normale Supérieure de Lyon, Univ Lyon, F-69007, France
| | - Claire Triffault-Fillit
- Département des Maladies infectieuses et tropicales, Hospices Civils de Lyon, F-69004, Lyon, France
| | - Anne Conrad
- Département des Maladies infectieuses et tropicales, Hospices Civils de Lyon, F-69004, Lyon, France; Centre International de Recherche en Infectiologie (CIRI), Inserm 1111, Université Claude Bernard Lyon 1, CNRS, UMR5308, École Normale Supérieure de Lyon, Univ Lyon, F-69007, France
| | - David Lebeaux
- Service de Microbiologie, Unité Mobile D'Infectiologie, AP-HP, Hôpital Européen Georges Pompidou, F-75015, Paris, France; Université de Paris, 75006, Paris, France
| | - Elisabeth Hodille
- Institut des Agents Infectieux, Laboratoire de Biologie Médicale de Référence de Nocardioses, Hospices Civils de Lyon, F-69004, Lyon, France
| | - Florent Valour
- Département des Maladies infectieuses et tropicales, Hospices Civils de Lyon, F-69004, Lyon, France; Centre International de Recherche en Infectiologie (CIRI), Inserm 1111, Université Claude Bernard Lyon 1, CNRS, UMR5308, École Normale Supérieure de Lyon, Univ Lyon, F-69007, France
| | - Florence Ader
- Département des Maladies infectieuses et tropicales, Hospices Civils de Lyon, F-69004, Lyon, France; Centre International de Recherche en Infectiologie (CIRI), Inserm 1111, Université Claude Bernard Lyon 1, CNRS, UMR5308, École Normale Supérieure de Lyon, Univ Lyon, F-69007, France.
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