Thursday, June 1, 2023
| Antimicrobial drug | This study | Case 1† | Case 2† | Case 3† | Case 4† | Case 5† | Case 6† | Case 7‡ |
|---|---|---|---|---|---|---|---|---|
| Amikacin | S | R | S | II | S | S | S | VSR or II |
| Amoxi-clav | R | R | II | S | R | R | R | R |
| Ceftriaxone | I | R | R | II | S | S | R | VSR or II |
| Ciprofloxacin | S | S | S | S | S | S | S | II |
| Clarithromycin | S | S | II | S | S | S | S | S |
| Doxycycline | R | R | II | II | II | R | R | II |
| Imipenem | R | R | R | R | II | R | R | VSR or II |
| Linezolid | S | S | S | II | II | S | S | S |
| Minocycline | R | R | II | II | M | R | R | II |
| Moxifloxacin | S | S | II | II | II | S | II | II |
| Tobramycin | S | II | II | II | II | II | II | II |
| TMP/SMX | S | R | R | II | S§ | R | S | S |
Reported susceptibility of Nocardia pseudobrasiliensis bacteria to antimicrobial drugs*
*Amoxi-clav, amoxicilline/clavulanic acid; I, intermediate; II, insufficient information; M, moderate; R, resistant; S, susceptible;
TMP/SMX, trimethoprim/sulfamethoxazole; VSR, variable susceptibility results.
†Veerappan Kandasamy et al. (2).
‡Wilson et al. (3).
§This specimen was susceptible to SMX only.
| Study | Age, y/sex | Nocardia species; positive culture site(s) | Days from SARS-CoV-2 diagnosis to Nocardia diagnosis | Site(s) of Nocardia infection | Predisposing factor | On MV? | Steroids before Nocardia diagnosis | Susceptibilities | Final therapy | Outcome |
|---|---|---|---|---|---|---|---|---|---|---|
| Colaneri et al. (5) | 45/F | N. cryarcigeorgica; subcutaneous lumps, lower respiratory tract sputum smear and culture | 5 d | Lung, skin, kidney | AIDS | No | Hydrocortisone for persistent fever | Susceptible: TMP/SMX, amikacin, linezolid; resistant: AMO/CLA, third-generation cephalosporins, quinolones | Tedizolid for 1 wk followed by 1 y TMP/SMX | Survived |
| Arif et al. (6) | 61/F | N. farcinica; Gram stain of pulmonary nodule biopsy | 10 d | Lung | Type 2 diabetes mellitus | No | Dexamethasone for COVID-19 | NA | TMP/SMX and linezolid | Survived |
| Atemnkeng et al. (7) | 63/M | N. asteroids; bronchial lavage culture | 50 d | Lung, brain | Type 2 diabetes mellitus | No | Dexamethasone for COVID-19 | Resistant: carbapenem | TMP/SMX and linezolid for 1 y | Survived |
| Kaur and Bhatti (8) | 80/F | N. farcinica; Gram stain and culture of brain abscess biopsy | >10 d, exact date unspecified | Brain | Advanced age | No | Dexamethasone for COVID-19 | NA | TMP/SMX, ceftriaxone, doxycycline | Not reported |
| Driscoll et al. 2022 (9) | 16/M | N. farcinica; lower airway samples | 9 d | Lung | Cystic fibrosis, bronchiectasis | Yes | Dexamethasone for COVID-19 | NA | Linezolid | Died |
| Cicero et. al. 2022 (10) | 79/M | N. otitidiscaviarum: sputum culture | 17 d | Lung | COPD, previous pulmonary tuberculosis, cirrhosis | No | Methylpredisolone for COVID-19 | Susceptible: ceftriaxone, amikacin, ciprofloxacin, meropenem, TMP/SMX | Not given | Died |
| Velickovic et al. 2022 (11) | 30/F | N. cyriacigeorgica; brain abscess | 200 d | Brain | Systemic lupus erythematosus, glucocorticoid therapy, CD4 count <100 | No | Prednisone for systemic lupus erythematosus | Susceptible: TMP/SMX, ceftriaxone, cefotaxime, imipenem, linezolid; resistant: ampicillin, AMO/CLA, fluoroquinolones | TMP/SMX | Survived |
| DiMeglio et al. 2022 (12) | 70/M | N. farcinica: spinal cord abscess | 48 d | Brain and spinal cord | Diabetes mellitus, advanced age, glucocorticoid therapy | No | Dexamethasone for COVID-19 | NR | TMP/SMX, linezolid | Died |
| Laplace et al. 2022 (13) | 83/M | N. cyriacigeorgica: sputum culture | 4 d | Lung | Advanced age | No | Dexamethasone for COVID-19 | NR | Imipenem, cotrimoxazole | Died |
| This study | 52/M | N. pseudobrasiliensis: sputum gram stain | 7 d | Lung | Bronchiectasis, sarcoidosis, immunosuppressive therapy, type 2 diabetes mellitus | No | Dexamethasone for COVID-19 | Susceptible: amikacin, ciprofloxacin, clarithromycin, linezolid, moxifloxacin, tobramycin, TMP/SMX; resistant: AMO/CLA, doxycycline, imipenem, minocycline | Linezolid, ciprofloxacin | Survived |
Nocardiosis infections reported during or shortly after COVID-19 infection, 2021*
*AMO/CLA, amoxicillin/clavulanic acid; COPD, chronic obstructive pulmonary disease; MV, mechanical ventilation; NA, not available; NR, not reported; TMP/SMX, trimethoprim/sulfamethoxazole.
Physicians - maximum of 1.00 AMA PRA Category 1 Credit(s)™
ABIM Diplomates - maximum of 1.00 ABIM MOC points
This activity is intended for infectious disease clinicians, pulmonologists, internists, intensivists, and other clinicians caring for patients with pneumonia who may have coinfection with SARS-CoV-2 and Nocardia.
The goal of this activity is for learners to be better able to describe clinical features, course, treatment, and predisposing factors for nocardiosis and COVID-19 coinfection, based on a case report of SARS-CoV-2 coinfection with pulmonary Nocardia pseudobrasiliensis and a literature review.
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CME / ABIM MOC Released: 3/22/2023
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During the SARS-CoV-2 pandemic, few cases of Nocardia spp. co-infection have been reported during or after a COVID-19 infection. Nocardia spp. are gram-positive aerobic actinomycetes that stain partially acid-fast, can infect immunocompromised patients, and may cause disseminated disease. We report the case of a 52-year-old immunocompromised man who had Nocardia pseudobrasiliensis pneumonia develop after a SARS-CoV-2 infection. We also summarize the literature for nocardiosis and SARS-CoV-2 co-infections. Nocardia spp. infection should remain a part of the differential diagnosis for pneumonia in immunocompromised hosts, regardless of other co-infections. Sulfonamide/carbapenem combinations are used as empiric therapy for nocardiosis; species identification and susceptibility testing are required to select the optimal treatment for each patient.
Nocardia pseudobrasiliensis are gram-positive aerobic actinomycetes; stains of N. pseudobrasiliensis are partially acid fast (1). As with other Nocardia species, N. pseudobrasiliensis can infect immunocompromised patients and may cause disseminated disease (2). Risk factors for nocardiosis include immunosuppression caused by solid organ or hematopoietic cell transplantation, glucocorticoid therapy, chronic lung disease, diabetes, AIDS, and malignancy (3,4). Infection by other pathogens during or after SARS-CoV-2 infection is a known but relatively uncommon occurrence. Nocardiosis co-infection with SARS-CoV-2 is rarely reported. We describe a case of SARS-CoV-2 co-infection with pulmonary Nocardia pseudobrasiliensis and summarize the literature on nocardiosis and COVID-19 co-infection.
