RISK FACTORS
β’ Most cases occur as opportunistic infection of immunocompromised
hosts or hosts with predisposing
pulmonary abnormalities
β’ Solid organ transplantation, chronic granulomatous
disease of childhood, dysgammaglobulinemias, pemphigus
RISK FACTORS
β’ Most cases occur as opportunistic infection of immunocompromised hosts or hosts with predisposing
pulmonary abnormalities
β’ Solid organ transplantation, chronic granulomatous disease of childhood, dysgammaglobulinemias, pemphigus, Cushing disease, hemochromatosis, cirrhosis, bronchiectasis, tuberculosis, sarcoidosis, anthrasilicosis, pulmonary alveolar proteinosis, lymphoma, leukemia, glucocorticoid and cytotoxic therapy, solid
malignancies, and AIDS.
β’ Immunologically normal individuals can develop primary cutaneous disease days to weeks after receiving a
wound contaminated with soil
APPROPRIATE HEALTH CARE Patients with moderate or severe illness generally require hospitalization
GENERAL MEASURES Respiratory support is often necessary in such hospitalized patients
SURGICAL MEASURES Surgical drainage of abscesses other than intrapulmonary abscesses is generally indicated if technically feasible
ACTIVITY Acute phase usually requires bedrest. Increase activity as condition improves.
DIET No special diet
PATIENT EDUCATION
β’ Not a contagious disease
β’ Advise patients of the need for long-term antimicrobial therapy to reduce the likelihood of relapse
DRUG(S) OF CHOICE
β’ Survival may be improved if a sulfa-containing regimen is used. Some prefer sulfadiazine because of possibly
better CNS penetration. Sulfadiazine should be given as 4-8 gm po per day in 4 divided doses. Dosage
should be adjusted to maintain sulfonamide serum levels in the range of 8-16 mg/dL.
β’ Some prefer to use trimethoprim-sulfamethoxazole. This agent must be used if parenteral sulfonamide
therapy is required. Initial dose based on trimethoprim component: 640 mg trimethoprim daily. Base subsequent
doses on sulfamethoxazole level. Dosage should provide equivalent sulfonamide dosing and levels as when a sulfonamide is used alone.
β’ Duration of therapy is usually 3 months for immunocompetent hosts and 6 months for those who are
immunocompromised
ALTERNATIVE DRUGS
β’ Alternatives for sulfonamide allergic patients include doxycycline or minocycline, ampicillin plus erythromycin,
amikacin, imipenem, Γ-lactam/Γ-lactamase inhibitor combinations, and cefotaxime or ceftriaxone. Clinical
experience with these alternative regimens is limited.
β’ Species specific trends in susceptibility have been identified
β’ For acutely ill, cefotaxime 1-2 gm IV every 8 hours plus imipenem 500 mg IV every 6 hours
β’ Selection of combination oral therapy should be based on microbiologic sensitivity testing
PATIENT MONITORING Patients on high dose sulfonamide therapy should have a complete blood count and assessment of hepatic and renal function performed at least every other week
POSSIBLE COMPLICATIONS
β’ Central nervous system infection (brain abscess or meningitis) (16%)
β’ Secondary cutaneous nocardiosis (13%)
β’ Septic arthritis (2%)
β’ Hematogenous osteomyelitis (1%)
β’ Other focal manifestations of disseminated infection (13%)
EXPECTED COURSE/PROGNOSIS
Overall modern mortality is 7-44%. In renal transplant recipients: overall mortality 25%, 0% mortality with isolated cutaneous involvement, 29% mortality with localized pleuropulmonary disease, 42% mortality with central nervous system involvement. In patients with the acquired immunodefi ciency syndrome, mortality is 30%