Risk Factors, Clinical Characteristics, and Outcome of Nocardia Infection in Organ Transplant Recipients: A Matched Case-Control Study

• Published in: Clinical infectious diseases Vol. 44; no. 10; pp. 1307 - 1314
• Main Authors: Peleg, Anton Y., Husain, Shahid, Qureshi, Zubair A., Silveira, Fernanda P., Sarumi, Molade, Shutt, Kathleen A., Kwak, Eun J., Paterson, David L.
• Format: Journal Article
• Language: English
• Published: Chicago, IL The University of Chicago Press 15.05.2007; University of Chicago Press; Oxford University Press
• Subjects: Adult; Aged; Articles and Commentaries; Bacterial diseases; Biological and medical sciences; Calcineurin Inhibitors; Case-Control Studies; Clinical outcomes; Cytomegalovirus; Enzyme Inhibitors - administration & dosage; Enzyme Inhibitors - adverse effects; Epidemiology; Female; Graft Rejection - microbiology; Gram-positive bacteria; Heart; Human bacterial diseases; Human subjects; Humans; Infections; Infectious diseases; Kidneys; Logistic Models; Lungs; Male; Medical sciences; Middle Aged; Miscellaneous; Nocardia; Nocardia asteroides; Nocardia brasiliensis; Nocardia farcinica; Nocardia infections; Nocardia Infections - epidemiology; Nocardia Infections - etiology; Nocardia Infections - immunology; Nocardia nova; Pennsylvania - epidemiology; Pneumocystis; Predisposing factors; Prednisone - administration & dosage; Prednisone - adverse effects; Regression analysis; Risk Factors; Transplantation; Transplantation - adverse effects; Transplantation - methods; Transplantation Immunology; Transplants & implants; Pennsylvania; Prognosis; Actinomycosis; Transplantation; Case control study; Homotransplantation; Infection; Nocardiosis; Symptomatology; Treatment; Surgery; Risk factor; Bacteriosis; Graft
• ISSN: 1058-4838; 1537-6591; 1537-6591
• DOI: 10.1086/514340

Background.Risk factors for Nocardia infection in organ transplant recipients have not been formally assessed in the current era of transplantation. Methods.We performed a matched case-control study (1 : 2 ratio) between January 1995 and December 2005. Control subjects were matched for transplant type and timing. Univariate matched odds ratios were determined and conditional logistic regression was performed to identify independent risk factors. Clinical and microbiological characteristics of all case patients were reviewed. Results.Among 5126 organ transplant recipients, 35 (0.6%) were identified as having cases of Nocardia infection. The highest frequency was among recipients of lung transplants (18 [3.5%] of 521 patients), followed by recipients of heart (10 [2.5%] of 392), intestinal (2 [1.3%] of 155), kidney (3 [0.2%] of 1717), and liver (2 [0.1%] of 1840) transplants. In a comparison of case patients with 70 matched control subjects, receipt of high-dose steroids (odds ratio, 27; 95% confidence interval, 3.2–235; P = .003) and cytomegalovirus disease (odds ratio, 6.9; 95% confidence interval, 1.02–46; P = .047) in the preceding 6 months and a high median calcineurin inhibitor level in the preceding 30 days (odds ratio, 5.8; 95% confidence interval, 1.5–22; P = .012) were found to be independent risk factors for Nocardia infection. The majority of case patients (27 [77%] of 35) had pulmonary disease only. Seven transplant recipients (20%) had disseminated disease. Nocardia nova was the most common species (found in 17 [49%] of the patients), followed by Nocardia farcinica (9 [28%]), Nocardia asteroides (8 [23%]), and Nocardia brasiliensis (1 [3%]). Of the 35 case patients, 24 (69%) were receiving trimethoprim-sulfamethoxazole for Pneumocystis jirovecii pneumonia prophylaxis. Thirty-one case patients (89%) experienced cure of their Nocardia infection. Conclusions.Receipt of high-dose steroids, history of cytomegalovirus disease, and high levels of calcineurin inhibitors are independent risk factors for Nocardia infection in organ transplant recipients. Our study provides insights into the epidemiology of Nocardia infection in the current era, a period in which immunosuppressive and prophylactic regimens have greatly evolved.