Tuesday, December 5, 2023
| Category | Site of diagnosis | Transplant recipient | Total, n = 268 | ||||||
|---|---|---|---|---|---|---|---|---|---|
| MN, n = 129 | AZ, n = 87 | FL, n = 52 | No, n = 186 | Yes, n = 82 | |||||
| Demographics | |||||||||
| Age, mean (SD) | 63.4 (16.3) | 65.9 (15.0) | 61.2 (11.7) | 66.1 (15.7) | 58.6 (12.4) | 63.8 (15.1) | |||
| Sex | |||||||||
| M | 61 (47.3) | 41 (47.1) | 37 (71.2) | 83 (44.6) | 56 (68.3) | 139 (51.9) | |||
| F | 68 (52.7) | 46 (52.9) | 15 (28.8) | 103 (55.4) | 26 (31.7) | 129 (48.1) | |||
| White | 121 (97.6) | 71 (84.5) | 39 (76.5) | 173 (96.6) | 58 (72.5) | 231 (89.2) | |||
| Hispanic | 0 (0.0) | 12 (14.0) | 3 (5.9) | 4 (2.2) | 11 (13.4) | 15 (5.7) | |||
| Coexisting conditions | |||||||||
| Diabetes | 7 (5.4) | 18 (20.7) | 23 (44.2) | 12 (6.5) | 36 (43.9) | 48 (17.9) | |||
| Liver failure | 4 (3.1) | 1 (1.1) | 2 (3.8) | 1 (0.5) | 6 (7.3) | 7 (2.6) | |||
| Renal failure/dialysis | 6 (4.7) | 4 (4.6) | 17 (32.7) | 2 (1.1) | 25 (30.5) | 27 (10.1) | |||
| Active malignancy | 16 (12.5) | 12 (13.8) | 13 (25.0) | 26 (14.0) | 15 (18.5) | 41 (15.4) | |||
| Rheumatologic conditions | 21 (16.4) | 5 (5.7) | 7 (13.5) | 28 (15.1) | 5 (6.2) | 33 (12.4) | |||
| Chronic lung disease | 95 (74.8) | 34 (39.1) | 27 (51.9) | 130 (69.9) | 26 (32.5) | 156 (58.6) | |||
| Transplant recipient | 14 (10.9) | 35 (40.2) | 33 (63.5) | NA | NA | 82 (30.6) | |||
| Transplanted organs | |||||||||
| Kidney | 2 (14.3) | 18 (51.4) | 13 (39.4) | NA | 33 (40.2) | 33 (40.2) | |||
| Liver | 2 (14.3) | 2 (5.7) | 1 (3.0) | NA | 5 (6.1) | 5 (6.1) | |||
| Pancreas | 1 (7.1) | 0 | 0 | NA | 1 (1.2) | 1 (1.2) | |||
| Lung | 1 (7.1) | 0† | 12 (36.4) | NA | 13 (15.9) | 13 (15.9) | |||
| Heart | 2 (14.3) | 9 (25.7) | 2 (6.1) | NA | 13 (15.9) | 13 (15.9) | |||
| Kidney and liver | 1 (7.1) | 0 | 1 (3.0) | NA | 2 (2.4) | 2 (2.4) | |||
| Kidney and pancreas | 0 | 0 | 3 (9.1) | NA | 3 (3.7) | 3 (3.7) | |||
| HSCT | 5 (35.7) | 6 (17.1) | 1 (3.0) | NA | 12 (14.6) | 12 (14.6) | |||
Table 1. Patient demographics and coexisting conditions by site of diagnosis and transplant status in study of invasive Nocardia infections across 3 distinct geographic regions, United States*
*Values are no. (%) patients except at indicated. AZ, Mayo Clinic Arizona, Phoenix/Scottsdale, Arizona, USA; FL, Mayo Clinic Florida, Jacksonville, Florida, USA; HSCT, hematopoietic stem cell transplant; MN, Mayo Clinic Rochester, Rochester, Minnesota, USA; NA, not applicable. †Lung transplantations not performed at Mayo Clinic Arizona during study period.
| Disease characteristics | Site of diagnosis | Transplant recipient | Total, n = 268 | ||||
|---|---|---|---|---|---|---|---|
| MN, n = 129 | AZ, n = 87 | FL, n = 52 | No, n = 186 | Yes, n = 82 | |||
| Diseased organ | |||||||
| Lung only | 106 (82.2) | 80 (92.0) | 31 (59.6) | 157 (84.4) | 60 (73.2) | 217 (81.0) | |
| Skin/soft tissue only | 8 (6.2) | 0 (0.0) | 10 (19.2) | 11 (5.9) | 7 (8.5) | 18 (6.7) | |
| Disseminated | 15 (11.6) | 7 (8.0) | 11 (21.2) | 18 (9.7) | 15 (18.3) | 33 (12.3) | |
| Any CNS involvement | 6 (4.7) | 5 (5.7) | 5 (9.6) | 6 (3.2) | 10 (12.2) | 16 (6.0) | |
| Nocardia spp. | |||||||
| N. abscessus | 13 (10.1) | 1 (1.1) | 3 (5.8) | 14 (7.5) | 3 (3.7) | 17 (6.3) | |
| N. brevicatena/N. paucivorans | 3 (2.3) | 2 (2.3) | 0 | 2 (1.1) | 3 (3.7) | 5 (1.9) | |
| N. cyriacigeorgica | 24 (18.6) | 36 (41.4) | 8 (15.4) | 52 (28.0) | 16 (19.5) | 68 (25.4) | |
| N. farcinica | 26 (20.2) | 13 (14.9) | 8 (15.4) | 30 (16.1) | 17 (20.7) | 47 (17.5) | |
| N. nova complex | 43 (33.3) | 2 (2.3) | 6 (11.5) | 44 (23.7) | 7 (8.5) | 51 (19.0) | |
| N. transvalensis complex | 1 (0.8) | 10 (11.5) | 1 (1.9) | 10 (5.4) | 2 (2.4) | 12 (4.5) | |
| N. brasiliensis | 2 (1.6) | 2 (2.3) | 9 (17.3) | 8 (4.3) | 5 (6.1) | 13 (4.9) | |
| N. wallacei | 0 | 12 (13.8) | 1 (1.9) | 7 (3.8) | 6 (7.3) | 13 (4.9) | |
| N. veterana | 1 (0.8) | 2 (2.3) | 2 (3.8) | 0 | 5 (6.1) | 5 (1.9) | |
| Other† | 16 (12.4) | 7 (8.0) | 14 (26.9) | 19 (10.2) | 18 (22.0) | 37 (13.8) | |
| Outcomes | |||||||
| Alive after 1 y | 108 (91.5) | 69 (83.1) | 44 (84.6) | 155 (90.6) | 66 (80.5) | 221 (87.4) | |
| Died within 1 y | 21 (8.5) | 18 (16.9) | 8 (15.4) | 31 (9.4) | 16 (19.5) | 47 (12.6) | |
Table 2. Disease characteristics and outcomes by site of diagnosis and transplant status in study of invasive Nocardia infections across 3 distinct geographic regions, United States*
*Values are no. (%) patients. AZ, Mayo Clinic Arizona, Phoenix/Scottsdale, Arizona, USA; CNS, central nervous system; FL, Mayo Clinic Florida, Jacksonville, Florida, USA; MN, Mayo Clinic Rochester, Rochester, Minnesota, USA. †Other species (n<5 each): N. amikacinitolerans (1), N. asiatica (1), N. asteroides (3), N. beijingensis (3), N. carnea (1), N. cerradoensis (1), N. exalbida (1), N. flavorosea (1), N. kruczakiae (1), N. niwae (2), N. otitidiscaviarum (1), N. pseudobrasiliensis (4), N. puris (1), N. takedensis (3), N. vermiculata (1), N. vinacea (1), N. yamanashiensis (1); no species identified (9).
| Species | No. isolates |
Susceptibility | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| AM/CL | CEF | CTX | IMP | CIP | MOX | CLA | AMI | TOB | DOX | MIN | TMP/SMX | LIN | ||
| N. abscessus | 17 | 82 | 82 | 94 | 59 | 0 | 14 | 41 | 100 | 94 | 88 | 88 | 94 | 100 |
| N. brevicatena/N. paucivorans | 5 | 50 | 75 | 100 | 100 | 100 | 100 | 100 | 100 | 100 | 100 | 100 | 100 | 100 |
| N. cyriacigeorgica | 68 | 6 | 28 | 60 | 97 | 2 | 3 | 2 | 99 | 99 | 6 | 9 | 100 | 100 |
| N. farcinica | 47 | 96 | 4 | 4 | 87 | 57 | 88 | 4 | 100 | 0 | 0 | 6 | 100 | 100 |
| N. nova complex | 51 | 4 | 51 | 12 | 98 | 4 | 7 | 100 | 98 | 6 | 2 | 18 | 100 | 100 |
| N. transvalensis complex | 12 | 92 | 17 | 58 | 8 | 58 | 100 | 0 | 8 | 0 | 0 | 17 | 100 | 100 |
| N. brasiliensis | 13 | 100 | 0 | 0 | 15 | 0 | 46 | 0 | 100 | 100 | 8 | 0 | 100 | 100 |
| N. wallacei | 13 | 92 | 8 | 67 | 0 | 58 | 100 | 0 | 25 | 0 | 17 | 50 | 100 | 100 |
| N. veterana | 5 | 0 | 60 | 20 | 100 | 0 | 0 | 100 | 100 | 20 | 0 | 20 | 100 | 100 |
| Other† | 37 | 11 | 44 | 61 | 78 | 42 | 61 | 50 | 94 | 86 | 47 | 67 | 92 | 97 |
| Total | 268 | 40 | 33 | 40 | 78 | 24 | 40 | 33 | 91 | 51 | 17 | 27 | 99 | 100 |
Table 3. Antimicrobial susceptibilities based on Nocardia spp. in study of invasive Nocardia infections across 3 distinct geographic regions, United States*
*AM/CL, amoxicillin/clavulanic acid; CEF, cefepime; CTX, ceftriaxone; IMP, imipenem; CIP, ciprofloxacin; MOX, moxifloxacin; CLA, clarithromycin; AMI, amikacin; TOB, tobramycin; DOX, doxycycline; MIN, minocycline; TMP/SMX, trimethoprim/sulfamethoxazole; LIN, linezolid †Other species (n<5 each): N. amikacinitolerans (1), N. asiatica (1), N. asteroides complex (3), N. beijingensis (3), N. carnea (1), N. cerradoensis (1), N. exalbida (1), N. flavorosea (1), N. kruczakiae (1), N. niwae (2), N. otitidiscaviarum (1), N. pseudobrasiliensis (4), N. puris (1), N. takedensis (3), N. vermiculata (1), N. vinacea (1), and N. yamanashiensis (1); no species identified (9)
| Initial treatment | No. (%) | Treatment after species confirmation and antimicrobial susceptibility testing results | ||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| AM/ CL |
CEF | CTX | IMP | CIP | MOX | CLA | AMI | TOB | DOX | MIN | TMP/ SMX |
LIN | SUL | Other† | ||
| AM/CL | 7 (2.6) | 57 | 0 | 0 | 14 | 14 | 14 | 14 | 0 | 0 | 0 | 0 | 57 | 0 | 0 | 0 |
| CEF | 3 (1.1) | 0 | 100 | 0 | 0 | 0 | 0 | 0 | 0 | 33 | 33 | 0 | 67 | 0 | 0 | 0 |
| CTX | 22 (8.2) | 14 | 0 | 27 | 5 | 5 | 18 | 9 | 5 | 0 | 9 | 14 | 45 | 5 | 9 | 5 |
| IMP | 49 (18.3) | 16 | 0 | 8 | 22 | 0 | 22 | 8 | 2 | 0 | 4 | 31 | 69 | 0 | 4 | 2 |
| CIP | 7 (2.6) | 14 | 0 | 0 | 0 | 86 | 0 | 0 | 0 | 0 | 0 | 14 | 43 | 14 | 0 | 29 |
| MOX | 19 (7.1) | 11 | 0 | 11 | 16 | 0 | 74 | 11 | 0 | 0 | 5 | 16 | 37 | 0 | 0 | 0 |
| CLA | 10 (3.7) | 0 | 0 | 0 | 0 | 10 | 20 | 80 | 10 | 0 | 0 | 10 | 20 | 0 | 0 | 10 |
| AMI | 8 (3.0) | 25 | 0 | 0 | 0 | 13 | 13 | 25 | 13 | 0 | 0 | 13 | 75 | 0 | 13 | 0 |
| TOB | 2 (0.8) | 0 | 50 | 0 | 0 | 0 | 0 | 0 | 0 | 50 | 0 | 0 | 50 | 0 | 0 | 0 |
| DOX | 15 (5.6) | 20 | 7 | 0 | 20 | 7 | 13 | 0 | 0 | 0 | 33 | 0 | 73 | 0 | 7 | 0 |
| MIN | 27 (10.1) | 11 | 0 | 7 | 7 | 4 | 30 | 7 | 0 | 0 | 4 | 37 | 52 | 0 | 0 | 0 |
| TMP/SMX | 153 (57.1) | 6 | 1 | 7 | 5 | 5 | 5 | 17 | 3 | 1 | 4 | 10 | 82 | 2 | 3 | 3 |
| LIN | 21 (7.8) | 19 | 0 | 10 | 19 | 5 | 33 | 5 | 0 | 0 | 5 | 38 | 57 | 5 | 10 | 0 |
| SUL | 4 (1.5) | 25 | 0 | 50 | 0 | 25 | 0 | 0 | 0 | 0 | 25 | 0 | 0 | 75 | 0 | |
| Other | 15 (5.6) | 7 | 0 | 7 | 7 | 13 | 0 | 0 | 0 | 0 | 13 | 13 | 60 | 0 | 0 | 13 |
Table 4. Choice of initial/empiric antimicrobials and subsequent antimicrobials after susceptibilities were reported in study of invasive Nocardia infections across 3 distinct geographic regions, United States*
*Gray shaded cells show percentages of patients in which initial antimicrobial was retained as part of subsequent therapy. AM/CL, amoxicillin/clavulanic acid; CEF, cefepime; CTX, ceftriaxone; IMP, imipenem; CIP, ciprofloxacin; MOX, moxifloxacin; CLA, clarithromycin; AMI, amikacin; TOB, tobramycin; DOX, doxycycline; MIN, minocycline; TMP/SMX, trimethoprim/sulfamethoxazole; LIN, linezolid, SUL, sulfadiazine †Other species (n<5 each): N. amikacinitolerans (1), N. asiatica (1), N. asteroides complex (3), N. beijingensis (3), N. carnea (1), N. cerradoensis (1), N. exalbida (1), N. flavorosea (1), N. kruczakiae (1), N. niwae (2), N. otitidiscaviarum (1), N. pseudobrasiliensis (4), N. puris (1), N. takedensis (3), N. vermiculata (1), N. vinacea (1), and N. yamanashiensis (1); no species identified (9).
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 primary care clinicians, infectious disease specialists, and other healthcare professionals who treat and manage patients with Nocardia infection.
The goal of this activity is for members of the healthcare team to be better able to assess patterns of infection and outcomes of Nocardia infection.
Upon completion of this activity, participants will:
Medscape, LLC requires every individual in a position to control educational content to disclose all financial relationships with ineligible companies that have occurred within the past 24 months. Ineligible companies are organizations whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.
All relevant financial relationships for anyone with the ability to control the content of this educational activity are listed below and have been mitigated. Others involved in the planning of this activity have no relevant financial relationships.
Medscape, LLC designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™ . Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 1.0 MOC points in the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit. Aggregate participant data will be shared with commercial supporters of this activity.
For questions regarding the content of this activity, contact the accredited provider for this CME/CE activity noted above. For technical assistance, contact [email protected]
There are no fees for participating in or receiving credit for this online educational activity. For information on applicability
and acceptance of continuing education credit for this activity, please consult your professional licensing board.
This activity is designed to be completed within the time designated on the title page; physicians should claim only those
credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the
activity online during the valid credit period that is noted on the title page. To receive AMA PRA Category 1 Credit™, you must receive a minimum score of 70% on the post-test.
Follow these steps to earn CME/CE credit*:
You may now view or print the certificate from your CME/CE Tracker. You may print the certificate, but you cannot alter it.
Credits will be tallied in your CME/CE Tracker and archived for 6 years; at any point within this time period, you can print
out the tally as well as the certificates from the CME/CE Tracker.
*The credit that you receive is based on your user profile.
CME / ABIM MOC Released: 11/17/2023
Valid for credit through: 11/17/2024, 11:59 PM EST
processing....
We reviewed invasive Nocardia infections in 3 noncontiguous geographic areas in the United States during 2011–2018. Among 268 patients with invasive nocardiosis, 48.2% were from Minnesota, 32.4% from Arizona, and 19.4% from Florida. Predominant species were N. nova complex in Minnesota (33.4%), N. cyriacigeorgica in Arizona (41.4%), and N. brasiliensis in Florida (17.3%). Transplant recipients accounted for 82/268 (30.6%) patients overall: 14 (10.9%) in Minnesota, 35 (40.2%) in Arizona, and 33 (63.5%) in Florida. Manifestations included isolated pulmonary nocardiosis among 73.2% of transplant and 84.4% of non–transplant patients and central nervous system involvement among 12.2% of transplant and 3.2% of non–transplant patients. N. farcinica (20.7%) and N. cyriacigeorgica (19.5%) were the most common isolates among transplant recipients and N. cyriacigeorgica (38.0%), N. nova complex (23.7%), and N. farcinica (16.1%) among non–transplant patients. Overall antimicrobial susceptibilities were similar across the 3 study sites.
Nocardia is a genus of aerobic, filamentous, beaded, gram-positive bacteria ubiquitous in the environment, especially in soil, decomposing organic matter, and water. Nocardia spp. are opportunistic pathogens in immunocompromised hosts and immunocompetent persons with chronic lung disease[1]. The Centers for Disease Control and Prevention has estimated that the United States sees 500–1,000 new cases of Nocardia infection annually[2,3]. Pulmonary infections acquired by inhaling aerosolized organisms account for most Nocardia-associated illness[4]. Direct inoculation, which causes cutaneous infections, constitutes the second most common route of exposure[3,5]. Patients with defects in cell-mediated immunity are at highest risk for infection[6,7]. Other risk factors include systemic corticosteroid use, solid organ or hematopoietic stem cell transplantation, HIV infection, diabetes mellitus, and underlying malignancy being treated with chemotherapy[8]. The brain, skin, and soft tissues, and to a lesser degree bones and joints or other organs, comprise the most common sites of extrapulmonary dissemination[6,9].
Geographic distribution of various Nocardia spp. and their effect on human disease has not been described. Although N. cyriacigeorgica (formerly N. asteroides drug pattern type VI)[10,11] and N. farcinica are distributed evenly throughout the United States, distribution of other Nocardia spp. varies by geographic location. N. brasiliensis is associated with tropical and subtropical environments and has a higher prevalence in the southwestern and southeastern regions of the United States[4,12]. Because Mayo Clinic, headquartered in Rochester, Minnesota, USA, operates tertiary locations in the midwestern, southeastern, and southwestern United States, we had a unique opportunity to study Nocardia infections in those 3 distinct noncontiguous geographic areas.
