Correspondence

Into the Woods

N Engl J Med 2007; 356:2429-2430June 7, 2007

Article

To the Editor:

The Clinical Problem-Solving article by Safdar et al. (March 1 issue)1 concerns an immunocompromised woman who received the diagnosis of pulmonary nocardiosis. The authors recommended that if the patient still required immunosuppression after completion of therapy, prophylaxis with trimethoprim–sulfamethoxazole (TMP-SMX) should be given. A role of TMP-SMX prophylaxis has been well established for Pneumocystis carinii pneumonia, but there is no clear evidence that it will prevent patients from acquiring nocardia infections. In two case series, TMP-SMX prophylaxis did not show a benefit in immunocompromised patients with nocardia infection.2,3 In our experience with lung-transplant recipients, all patients with nocardia infection were receiving TMP-SMX prophylaxis. The only data supporting a role for TMP-SMX prophylaxis in nocardia infections comes from a case series of patients with human immunodeficiency virus infection.4 It would be extremely difficult to make an assumption that TMP-SMX prophylaxis in doses that are routinely prescribed will prevent the development of nocardia infection. The possibility of either using a higher dose for prophylaxis or increasing the frequency of administration of the drug needs to be elucidated.

Babar A. Khan, M.D
Indiana University Medical Center, Indianapolis, IN 46202
bakhan@iupui.edu

Irina Gubina, M.D.
St. Vincent Physicians Network, Indianapolis, IN 46268

4 References

1. 1

   Safdar N, Kaul DR, Saint S. Into the woods. N Engl J Med 2007;356:943-947
   Full Text | Web of Science | Medline

2. 2

   Husain S, McCurry K, Dauber J, Singh N, Kusne S. Nocardia infection in lung transplant recipients. J Heart Lung Transplant 2002;21:354-359
   CrossRef | Web of Science | Medline

3. 3

   Roberts SA, Franklin JC, Mijch A, Spelman D. Nocardia infection in heart-lung transplant recipients at Alfred Hospital, Melbourne, Australia, 1989-1998. Clin Infect Dis 2000;31:968-972
   CrossRef | Web of Science | Medline

4. 4

   Walensky RP, Moore RD. A case series of 59 patients with nocardiosis. Infect Dis Clin Pract 2001;10:249-254
   CrossRef

Author/Editor Response

We agree with Khan and Gubina that breakthrough nocardia infections have been reported in patients receiving TMP-SMX prophylaxis for pneumocystis pneumonia. However, a single-center review of the incidence of nocardia infections in heart-transplant recipients showed an association between the use of TMP-SMX for pneumocystis pneumonia prophylaxis and a reduction in the number of nocardia infections.1 Many clinicians continue secondary prophylaxis with TMP-SMX indefinitely in immunosuppressed patients with nocardia, but we agree that there is little evidence to support this approach.

Nasia Safdar, M.D.
University of Wisconsin Medical School, Madison, WI 53792
ns2@medicine.wisc.edu

Daniel Kaul, M.D.
University of Michigan Medical School, Ann Arbor, MI 48109

Sanjay Saint, M.D., M.P.H.
Ann Arbor Veterans Affairs Medical Center, Ann Arbor, MI 48105

1 References

1. 1

   Montoya JG, Giraldo LF, Efron B. Infectious complications among 620 consecutive heart transplant patients at Stanford University Medical Center. Clin Infect Dis 2001;33:629-640
   CrossRef | Web of Science | Medline