Nocardia prophylaxis, treatment, and outcomes of infection in lung transplant recipients: A matched case‐control study

Abstract

Background Lung transplant recipients are at heightened risk for nocardiosis compared to other solid organ transplant recipients, with incidence rates as high as 9% and up to 30% associated mortality. No controlled studies assessing risk factors for nocardiosis in this high‐risk population have been reported. Methods Patients undergoing lung transplantation at a single center between 2012 and 2018 and diagnosed with nocardiosis post‐transplant were matched 1:2 to uninfected control subjects on the basis of age, transplant date, and sex. Results The incidence of nocardiosis in this lung transplant population was 3.4% (20/586), occurring a median of 9.4 months (range 4.4‐55.2) post‐transplant. In multivariable analysis, consistent use of trimethoprim/sulfamethoxazole (TMP/SMX) in the 12 weeks prior to diagnosis was independently associated with protection against nocardiosis (OR 0.038; 95% CI 0.01‐0.29; P = .002). Augmented immunosuppression in the 6 months prior to diagnosis was independently associated with the development of nocardiosis (OR 9.94; 95% CI 1.62‐ 61.00; P = .013). Six case patients (30%) had disseminated disease; all‐cause 6‐month mortality was 25%. The most common species was Nocardia farcinica (7/17 isolates), which was associated with dissemination and mortality. The most active antibiotics were TMP/SMX (100%), linezolid (100%), and amikacin (76%). Imipenem was only active against 4/17 isolates (24% susceptibility), with two isolates becoming non‐susceptible later in therapy. Conclusions Trimethoprim/sulfamethoxazole prophylaxis was shown to be protective against nocardiosis in lung transplant recipients, while augmented immunosuppression conferred increased risk. Institutional epidemiologic data are needed to best guide empiric therapy for Nocardia, as historical in vitro data may not predict local susceptibilities.

Recurrent nocardiosis in solid organ transplant recipients: An evaluation of secondary prophylaxis

“…Out of four lung transplant recipients who received TMP‐SMX DS weekly, two experienced recurrent infection while on prophylaxis suggesting such dosing was not protective. This is similar to findings in a recent study evaluating primary prophylaxis in lung transplant recipients found TMP‐SMX as compared to either no or inconsistent use of TMP‐SMX, which was found to be protective against Nocardia infection with an odds ratio of 0.038 24 . However, other studies in mixed SOT populations have shown inconsistent results 5,6,13 .…”

“…found to be protective against Nocardia infection with an odds ratio of 0.038. 24 However, other studies in mixed SOT populations have shown inconsistent results. 5,6,13 As lung transplant recipients appear to be at higher risk for primary and recurrent nocardiosis, this group may derive more benefit from consistently dosed primary or secondary prophylaxis.…”

Nodular Cutaneous Lesions in Immune-Compromised Hosts as a Clue for the Diagnosis of Disseminated Nocardiosis: From Bedside to Microbiological Identification

“…The only two TMP/SMX-resistant strains were MDR, according to the criteria of Magiorakos et al [ 34 ]. In recent work by Goodlet et al [ 35 ], previous TMP/SMX prophylaxis in lung transplant patients has been found to be an independent protective factor for nocardiosis; nonetheless, one of our patients who received TMP/SMX prophylaxis developed an infection sustained by a resistant strain.…”

Lung and Cerebral Nocardiosis Caused by <i>Nocardia elegans</i> in a Lung Transplant Recipient: A Case Report and Literature Review

“…In patients with lung transplantation, infections caused by Nocardia species, such as N. farcinica, N. nova, and N. asteroids, have been reported (3)(4)(5)(6)(7). However, to our knowledge, there have been no reports of N. elegans infection in lung transplant recipients.…”