Hintergrund und Fragestellung: Die Fortschritte in der mikrobiologischen Diagnostik ermöglichen zunehmend die Keimidentifikation auf Speziesniveau. Aktuell sind 17 Nokardienspezies bekannt. Klinische Präsentation, Resistenzspektrum gegen Antibiotika und geographische Verteilung unterscheiden sich speziesabhängig. Die Entdeckung einer neuen humanpathogenen Spezies verlangt nach einer klinischen und epidemiologischen Einordnung.
Patienten und Methoden: Ein Nokardienisolat aus multifokalen Hirnabszessen eines immunsupprimierten Patienten wurde mittels Analyse der zellulären Fettsäuren und Sequenzierung der 16S ribosomalen DNA identifiziert. Die Empfindlichkeitsprüfung gegen Antibiotika erfolgte quantitativ mit E-Tests.
Ergebnisse: Die Analyse der 16S ribosomalen DNA ergab eine 99 % Übereinstimmung mit Nocardia cyriacigeorgici. Es handelt sich somit um die Erstbeschreibung einer durch diesen Erreger verursachten invasiven Erkrankung beim Menschen. Der Keim wurde als sensibel für Meropenem, Amikacin, Ceftriaxon und Cotrimoxazol getestet. Die Therapie mit chirurgischer Drainage und insgesamt 13-monatiger Antibiotikagabe war erfolgreich.
Folgerungen: N. cyriacigeorgici vermag zumindest beim immunkompromittierten Patienten eine abszedierende Infektion zu bewirken. Der Vergleich mit dem in Europa häufigsten Erreger von invasiven Nokardienerkrankungen, N. asteroides, bezüglich klinischer Präsentation, Resistenzmuster gegenüber Antibiotika und Ansprechen auf die Therapie zeigt keine klinisch relevanten Unterschiede.
Background: Diagnostic laboratories increasingly offer bacterial identification to the species level. The 17 nocardia species known to date differ in their clinical presentation, antibiotic resistance patterns and geographic distribution. The discovery of a new species with pathogenicity for humans calls for the characterization of its clinical and epidemiological properties.
Patients and methods: Nocardia isolated from multifocal brain abscesses of an immunocompromised patient were further identified by the analysis of their cellular fatty acids and sequencing of the 16S ribosomal DNA. Quantitative antibiotic resistance testing was performed with E-tests.
Results: The 16S ribosomal DNA analysis showed a 99 % homology to Nocardia cyriacigeorgici. This is the first report of this species as an invasive human pathogen. N. cyriacigeorgici was found susceptible for meropenem, amikacin, ceftriaxon and cotrimoxazole. The combination of surgical drainage and antibiotic treatment for 13 months was curative.
Conclusions: N. cyriacigeorgici has the potential to cause invasive infections at least in immunocompromised patients. Comparing clinical and in vitro characteristics with N. asteroides, the main causative agent of nocardial infections in Europe, we found no clinically relevant differences.
Literatur
-
1
Beaman B L, Boiron P, Beaman L, Brownell G H, Schaal K, Gombert M E.
Nocardia and nocardiosis.
J Med Vet Mycol.
1992;
30
(Suppl 1)
317-31
-
2
Blumel J, Blumel E, Yassin A F, Schmidt-Rotte H, Schaal K P.
Typing of Nocardia farcinica by pulsed-field gel electrophoresis reveals an endemic strain as source of hospital infections.
J Clin Microbiol.
1998;
36
118-122
-
3
Boiron P, Provost F, Chevrier G, Dupont B.
Review of nocardial infections in France 1987 to 1990.
Eur J Clin Microbiol Infect Dis.
1992;
11
709-714
-
4
Curry W A.
Human nocardiosis: A clinical review with selected case reports.
Arch Intern Med.
1980;
140
818-826
-
5 David N, Gilbert R CMJ, Merle A, Sande. The Sanford Guide to Antimicrobial Therapy 2002. 32nd ed: Antimicrobial Therapy, Inc., Hyde Park, VT, USA 2002
-
6
Dominguez D C, Antony S J.
Actinomyces and nocardia infections in immunocompromised and nonimmunocompromised patients.
J Natl Med Assoc.
1999;
91
35-39
-
7
Farina C, Boiron P, Goglio A, Provost F. Northern Italy Collaborative Group on Nocardiosis .
Human nocardiosis in northern Italy from 1982 to 1992.
Scand J Infect Dis.
1995;
27
23-27
-
8
Feigin D S.
Nocardiosis of the lung: chest radiographic findings in 21 cases.
Radiology.
1986;
159
9-14
-
9
Fleetwood I G, Embil J M, Ross I B.
Nocardia asteroides cerebral abscess in immunocompetent hosts: report of three cases and review of surgical recommendations.
Surg Neurol.
2000;
53
605-610
-
10
Goldstein F W, Hautefort B, Acar J F.
Amikacin-containing regimens for treatment of nocardiosis in immunocompromised patients.
Eur J Clin Microbiol.
1987;
6
198-200
-
11
Gombert M E, Aulicino T M.
Synergism of imipenem and amikacin in combination with other antibiotics against Nocardia asteroides.
Antimicrob Agents Chemother.
1983;
24
810-811
-
12
Kayacan S M, Turkmen A, Alis H, Imer M, Barlas O, Ecder S T, Yildiz A, Aydin A E, Eldegez U, Sever M S.
Successful therapy combined with surgery for severe post-transplant nocardiosis.
J Nephrol.
2001;
14
304-306
-
13
Kim J, Minamoto G Y, Grieco M H.
Nocardial infection as a complication of AIDS: report of six cases and review.
Rev Infect Dis.
1991;
13
624-629
-
14
Lerner P I.
Nocardiosis.
Clin Infect Dis.
1996;
22
891-903
-
15
Loeffler J M, Bodmer T, Zimmerli W, Leib S L.
Nocardial brain abscess: observation of treatment strategies and outcome in Switzerland from 1992 to 1999.
Infection.
2001;
29
337-341
-
16
Mamelak A N, Obana W G, Flaherty J F, Rosenblum M L.
Nocardial brain abscess: treatment strategies and factors influencing outcome.
Neurosurgery.
1994;
35
622-31
-
17
Mari B, Monton C, Mariscal D, Lujan M, Sala M, Domingo C.
Pulmonary nocardiosis: clinical experience in ten cases.
Respiration.
2001;
68
382-388
-
18
Overkamp D, Waldmann B, Lins T, Lingenfelser T, Petersen D, Eggstein M.
Successful treatment of brain abscess caused by Nocardia in an immunocompromised patient after failure of co-trimoxazole.
Infection.
1992;
20
365-366
-
19
Palmer D L, Harvey R L, Wheeler J K.
Diagnostic and therapeutic considerations in Nocardia asteroides infection.
Medicine (Baltimore).
1974;
53
391-401
-
20 Sorell T C IJ, Mitchell D H. Nocardia Species. Philadelphia: Churchill Livingstone In: Mandell GL BJ, Dolin R, ed. Mandell, Douglas and Bennett’s Principles and Practice of Infectious Diseases. edn 5 ed 2000: 2637-2645
-
21
Stamm A M, McFall D W, Dismukes W E.
Failure of sulfonamides and trimethoprim in the treatment of nocardiosis.
Arch Intern Med.
1983;
143
383-385
-
22
Uttamchandani R B, Daikos G L, Reyes R R, Fischl M A, Dickinson G M, Yamaguchi E, Kramer M R.
Nocardiosis in 30 patients with advanced human immunodeficiency virus infection: clinical features and outcome.
Clin Infect Dis.
1994;
18
348-353
-
23
van Burik J A, Hackman R C, Nadeem S Q, Hiemenz J W, White M H, Flowers M E, Bowden R A.
Nocardiosis after bone marrow transplantation: a retrospective study.
Clin Infect Dis.
1997;
24
1154-1160
-
24
Wallace R J, Septimus E J, Williams T W, Conklin R H, Satterwhite T K, Bushby M B, Hollowell D C.
Use of trimethoprim-sulfamethoxazole for treatment of infections due to Nocardia.
Rev Infect Dis.
1982;
4
315-325
-
25 Wayne P. Susceptibility Testing of Mycobacteria, Nocardia, and Other Aerobic Actinomycetes. National Committee for Clinical Laboratory Standards Tentative standard M24-T2. National Committee for Clinical Laboratory Standards. 2nd ed 2000
-
26
Yassin A F, Rainey F A, Steiner U.
Nocardia cyriacigeorgici sp. nov.
Int J Syst Evol Microbiol.
2001;
51
1419-1423
Prof. Dr. med. Stephen Leib
Institut für Infektionskrankheiten
Friedbühlstrasse 51
Postfach 61
CH-3010 Bern
Phone: 0041/31/6324949
Fax: 0041/31/6323550
Email: stephen.leib@ifik.unibe.ch
