Objectives: Combination therapy including amikacin is recommended for the treatment of severe Nocardia infections. Use of amikacin in SOT is difficult due to renal dysfunction and concomitant use of other nephrotoxic drugs. LZD has excellent in vitro activity against Nocardia and its use in the initial therapy is attractive. We sought to describe our experience with LZD for the treatment of nocardiosis in SOT.

Methods: Single-center, retrospective review of Nocardia infection in SOT from 2006 to 2012.

Results: 19 SOT with nocardiosis were identified. Mean age was 60, 74% were male. Types of transplant were lung in 74%, intestinal/multivisceral in 11%, heart/lung in 5%, heart in 5% and liver in 5%. 79% had received alemtuzumab. All were on a tacrolimus-based regimen. 68% were on trimethoprim-sulfamethaxole (TMP-SMX) prophylaxis. Median CrCl at baseline was 55.4 ml/min (19 – 116). The most common species were N. nova in 32%, followed by N. asteroides in 26%. 79% of patients (pts) had pulmonary disease and 16% had disseminated disease. 42% of pts were admitted to the ICU at the time of diagnosis and 37% required mechanical ventilation. Initial therapy included TMP-SMX in 17 (89%), LZD in 15 (79%), imipenem in 12 (63%) and amikacin in 2 (11%) pts. 93% of pts received LZD and TMP-SMX combination. LZD was given for a median duration of 21 days (7-56). 12/13 isolates tested were sensitive to LZD. Thrombocytopenia occurred in 93% of pts on LZD vs 50% not on LZD (p=0.09) and anemia on 60% of pts on LZD vs 25% not on LZD (p=0.3). LZD had to be discontinued in 64% of pts. LZD-induced neutropenia, lactic acidosis and neuropathy were not observed. LZD was not used for definitive therapy, even after susceptibilities were known. Mortality at 6 months was 32%, 11% of deaths were due to Nocardia. Mortality did not differ between pts on and not on LZD.

Conclusions: LZD-associated thrombocytopenia was common, precluding its long-term use. However, it can be useful while antimicrobial susceptibility results are pending. Mortality attributable to nocardiosis was lower than previously described. LZD should be considered as an option in the initial treatment of Nocardia in SOT, particularly when renal dysfunction is a concern.

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