Dermatologic Manifestations of Nocardiosis Medication

  • Author: Brent A Shook, MD; Chief Editor: Dirk M Elston, MD   more...
 
Updated: Jan 11, 2012
 

Medication Summary

Sulfonamides have been the antimicrobial agents of choice for more than 50 years and are recommended based on accumulated clinical experience because results from in vitro studies have been less than impressive. TMP-SMZ is used most commonly. Other sulfonamides used include (1) sulfadiazine, which is not recommended as first-line therapy because of significant risk of oliguria, azotemia, and crystalluria in patients who do not maintain a high fluid intake, and (2) sulfisoxazole, which is as equally effective as sulfadiazine and much less likely to cause oliguria, although no parenteral form is available (2 g PO q6h in adults).

Potassium iodide is an older therapy active against lymphocutaneous nocardiosis and is not recommended for severe infections or systemic disease.

Newer antimicrobials such as linezolid have been used successfully in combination with more traditional agents in more resistant or severe cases of nocardiosis.[17] Linezolid is the only antimicrobial that has been shown to be active against all Nocardia species in vitro.[18]

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Antibiotics

Class Summary

Empiric antimicrobial therapy must be comprehensive and cover all likely pathogens in the clinical setting. Imipenem is consistently active in vitro, although 18-36% of Nocardia farcinica strains are not susceptible and 70% of Nocardia brasiliensis strains are resistant. Because most primary cutaneous nocardiosis is caused by N brasiliensis, imipenem is mostly used to treat systemic disease. The parenteral drug of choice for initial therapy in persons with systemic disease is amikacin in combination with imipenem. Tobramycin is an aminoglycoside to which many nocardial strains are resistant, especially N farcinica.

A case report demonstrated successful use of oral minocycline in a patient who did not respond to intravenous cephalosporin therapy for primary cutaneous nocardiosis caused by N brasiliensis.[19]

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Trimethoprim/sulfamethoxazole (Bactrim DS; Septra DS)

 

First-line treatment for both cutaneous and systemic nocardiosis. Inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid. Has maximal efficacy against N brasiliensis. More than 90% of N asteroides and N transvalensis isolates are sensitive. Not effective against N otitidiscaviarum.

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Minocycline (Dynacin, Minocin)

 

Second DOC because of excellent in vitro activity against most pathogenic nocardial species. Especially effective in pulmonary nocardiosis and N farcinica (4% resistance). Only Nocardia transvalensis isolates are significantly resistant (46%). A case report demonstrated successful use of PO minocycline in a patient who did not respond to IV cephalosporin therapy for primary cutaneous nocardiosis caused by N brasiliensis.

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Amikacin (Amikin)

 

Irreversibly binds to 30S subunit of bacterial ribosomes; blocks recognition step in protein synthesis; causes growth inhibition. Along with imipenem, amikacin is currently the most active parenteral drug in vitro against nocardiosis (90-95% of all strains). N transvalensis has up to an 18% resistance. Extremely effective against N farcinica (0% resistance) and in immunocompromised patients. Unfortunately, potential adverse effects may limit usefulness for the long courses needed for cure.

Check peak (20-35 mcg/mL) and trough (< 5 mcg/mL).

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Cefotaxime (Claforan)

 

Arrests bacterial cell wall synthesis, which, in turn, inhibits bacterial growth. Third-generation cephalosporin with gram-negative spectrum. Lower efficacy against gram-positive organisms. High levels of resistance are seen against third-generation cephalosporins by N farcinica. Recommended in combination with amikacin or imipenem in acutely ill patients.

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Contributor Information and Disclosures
Author

Brent A Shook, MD  Director, The Woodlands Skin Surgery Center, The Woodlands, Texas

Brent A Shook, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Mohs Micrographic Surgery and Cutaneous Oncology, American Medical Association, American Society for Dermatologic Surgery, American Society for Laser Medicine and Surgery, American Society for MOHS Surgery, Christian Medical & Dental Society, and Texas Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Ronald P Rapini, MD  Josey Professor and Chair, Department of Dermatology, Professor of Pathology, University of Texas Medical School at Houston and MD Anderson Cancer Center

Ronald P Rapini, MD is a member of the following medical societies: American Academy of Dermatology, American Dermatological Association, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Society for Investigative Dermatology, and Texas Medical Association

Disclosure: Elsevier publishers Royalty Independent contractor

Specialty Editor Board

Daniel Mark Siegel, MD, MS  Director, Procedural Dermatology Fellowship Program, Clinical Professor of Dermatology, Department of Dermatology, State University of New York Downstate

Daniel Mark Siegel, MD, MS is a member of the following medical societies: American Academy of Dermatology, American College of Mohs Micrographic Surgery and Cutaneous Oncology, American College of Physician Executives, American Society for Dermatologic Surgery, American Society for MOHS Surgery, and International Society for Dermatologic Surgery

Disclosure: Nothing to disclose.

Richard P Vinson, MD  Assistant Clinical Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine; Consulting Staff, Mountain View Dermatology, PA

Richard P Vinson, MD is a member of the following medical societies: American Academy of Dermatology, Association of Military Dermatologists, Texas Dermatological Society, and Texas Medical Association

Disclosure: Nothing to disclose.

Lester F Libow, MD  Dermatopathologist, South Texas Dermatopathology Laboratory

Lester F Libow, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, and Texas Medical Association

Disclosure: Nothing to disclose.

Catherine M Quirk, MD  Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania

Catherine M Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD  Director, Ackerman Academy of Dermatopathology, New York

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

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Red nodules on a patient with disseminated nocardiosis.
Ulcer on the arm of a patient with primary cutaneous nocardiosis.
Gomori methenamine silver stain demonstrating black filamentous Nocardia species.
 
 
 
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