higher risk of dissemination . The treatment for N. farcinica
is complicated by its resistance to most b-lactam anti-
microbials, tobramycin, and tetracyclines [12, 34]. The treat-
ment of choice is TMP-SMX . However, side effects such as
skin reactions may necessitate alternative therapy [6,24,36]. In
addition, as many as 50% of isolates demonstrate TMP-SMX
resistance, emphasizing the need for antibiotic susceptibility
testing of clinical isolates [13,37,38].
N. farcinica is susceptible to TMP-SMX, minocycline, linezolid,
moxiﬂoxacin, and amikacin and demonstrates variable suscep-
tible to imipenem-cilastatin and ciproﬂoxacin [20, 39-43]. It is
recommended that immunocompetent patients be treated for at
least six months . If the central nervous system is involved, 12
months of therapy is recommended . Therapy for N. farcinica
has become more aggressive, with increasing administration of
multiple antimicrobials. In this review, 74.6% of patients (n = 50)
received TMP-SMX as part of their treatment. Carbapenems
(n = 25; 37.3%), amikacin (n = 16; 23.9%), and ceftriaxone (n = 12;
17.9%) also were used commonly (see Table 1). A previous
review found TMP-SMX was administered in 54% of patients
infected with N. farcinica, whereas amikacin with imipenem-
cilastatin and amoxicillin/clavulanic acid were used in only 7%
. Nevertheless, the death rate was 31% with TMP-SMX and
38.8% with carbapenems and amikacin .
The patient described here was unusual in that he was
immunocompetent. Although the primary origin of his in-
fection is not documented, it is tempting to speculate that the
prior febrile episode and infected cyst of three years earlier
was his initial encounter with the organism. Subsequent re-
activation with dissemination may have been prompted by
unknown factors and perhaps facilitated by the local steroid
injection. The distribution of his infection was pulmonary and
musculoskeletal (limited to the right knee) with no radiologic
or post-mortem evidence of central nervous system involve-
ment. Despite therapy, the patient died from Nocardia sepsis,
attesting to the virulence N. farcinica.
JMB is a trainee of the National Institutes of Health Medical
Scientist Training Program (Grant GM07281) at the University
Author Disclosure Statement
No conﬂicting ﬁnancial interests exist.
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