Successful Treatment of Disseminated Nocardiosis Complicated by Cerebral Abscess with Ceftriaxone and Amikacin: Case Report

Abstract

We report the case of an 85-year-old female patient who suffered from disseminated Nocardia asteroides infection complicated by a cerebral abscess. Treatment with amikacin for 2 weeks and ceftriaxone for 6 weeks led to complete recovery, and there was no recurrence of disease over a follow-up period of 12 months after therapy. The use ofceftriaxone in combination with amikacin might significantly shorten the duration of treatment for patients with disseminated nocardiosis. This combination of antibiotics merits further investigation with use of a larger sample of patients.Sulfonamides or trimethoprim-sulfamethoxazole is given as standard therapy for disseminated nocardiosis [1][2][3]. However, primary resistance to sulfonamides is well known [1,4,5], late relapses are frequent [4,6], and prolonged treatment is often required. Therefore, therapeutic alternatives are needed. In view of their good in vitro activity against species of Nocardia. ceftriaxone and cefuroxime seem especially promising [5,7]. Amikacin is another drug with excellent efficacy in vitro [5], in animal models [8], and in treatment of human disease [4,9]. Good clinical results have been observed with the synergistic combination of cefuroxime and amikacin [4].We report the case of a patient with disseminated nocardiosis complicated by cerebral abscess who was successfully treated with ceftriaxone for 6 weeks and amikacin for 2 weeks.An 85-year-old female patient was admitted to the hospital because of arthralgias and multiple skin lesions. On admission, the patient was afebrile; physical examination revealed multiple nodular reddish lesions on the left thigh and the lower abdomen that were painful and measured up to 1.5 em.Laboratory analysis revealed mild leukocytosis (white blood cell count, 15.1 X 10 9 /L) with 40% neutrophils and a relative lymphopenia of 10%. lesions appeared and signs of peritoneal irritation were observed. A repeated puncture of a cutaneous lesion revealed delicate, beaded, branching gram-positive filaments. Microscopic examination of the sputum showed the same microorganisms.A presumptive clinical diagnosis of actinomycosis was made, and 20 million units of iv penicillin G were administered daily. Because of generalized seizures that were assumed to be due to CNS toxicity associated with the use of penicillin, the treatment was changed to amoxicillin. On day 8 of treatment, a left-sided hemiparesis appeared. The computed tomography (CT) scan revealed a right-sided ring-enhancing hemispheric lesion suggestive of an abscess (figure 1). The lumbar puncture showed a normal cell count and a slightly elevated level of protein (56.8 mg/dL).In the meantime, culture of a sample obtained by cutaneous aspiration revealed N. asteroides that was resistant to trimethoprim-sulfamethoxazole and produced penicillinase. Antibiotic treatment was changed to iv amikacin (MIC, 0.12 JLg/mL) and iv ceftriaxone (MIC, 8 JLg/mL) (for microdilution method, see [10]). In vitro testing showed that the combination ofceftriaxone and amikacin did not ha...

In Vitro Activities of Linezolid against Multiple Nocardia Species

“…The MIC at which 50% of the strains are inhibited (MIC 50 ) and MIC 90 for all species other than Nocardia farcinica were 2 and 4 g/ml. Linezolid is the first antimicrobial agent demonstrated to be active against all Nocardia species.Treatment of Nocardia infections continues to be difficult, especially with central nervous system or disseminated disease (1,6,7,9,10) and species, such as Nocardia farcinica, that are highly drug resistant (22). Most recent antimicrobial therapy of complicated cases has involved the use of a sulfonamide or trimethoprim-sulfamethoxazole plus the injectable agents amikacin and imipenem or ceftriaxone (6,10,16,18 E-143, 1998.).…”

“…Most recent antimicrobial therapy of complicated cases has involved the use of a sulfonamide or trimethoprim-sulfamethoxazole plus the injectable agents amikacin and imipenem or ceftriaxone (6,10,16,18 E-143, 1998.). We studied the new oxazolidinone compound linezolid against all clinically important species of Nocardia including drug-resistant species, such as N. farcinica and Nocardia transvalensis (22,23).…”

“…The sulfonamides or trimethoprim-sulfamethoxazole is active against most clinical isolates (21), but patients with central nervous system disease and severe disease do poorly with sulfonamide therapy only (7), and hypersensitivity reactions to sulfonamides are common. Other agents active against most strains and species are injectable agents, including amikacin, imipenem, and ceftriaxone (6,7,9,10,12,(16)(17)(18)21). These agents work well alone or in combination with a sulfonamide but are limited by the need for intravenous administration, high cost, and significant toxicity.…”

Nocardiosis: Clinical and Pathological Aspects

“…Alternatives to sulfonamides include amikacin, imipenem, meropenem, ceftriaxone, cefotaxime, minocycline, moxifloxacin, levofloxacin, linezolid, tigecycline, and amoxicillinclavulanic acid 47,48 .…”

Nocardia Infection in Lung Transplantation

“…Other beta-lactam antibiotics such as the third-generation cephalosporins ceftriaxone or cefotaxime, due to their good CNS penetration, may be combined with other antimicrobials for treatment of intracranial infections with good results, depending on the species of Nocardia, since some may be intrinsically resistant (Garlando et al, 1992;Durmaz et al, 2001). …”