Successful Treatment of Nocardia Farcinica Prosthetic Valvular Endocarditis without Valvular Replacement

Abstract

We report a case of prosthetic valve nocardia endocarditis. A 43 year old farmer underwent aortic valve replacement with a bioprosthetic valve. The immediate post-operative course was uneventful but 2 weeks later he developed fever. A trans-oesophageal echocardiogram (TEE) showed a string like structure attached to the prosthetic valve. Blood cultures grew N. farcinica. He was initially treated with trimethoprim/sulfamethoxazole (TMP/SMZ), but due to eosinophilia and leucopenia his treatment was changed to imipenem and amikacin. He developed a rash, presumed to be due to imipenem, which was then substituted with linezolid. He completed a 6 week course of intravenous (i.v.) antibiotics. Desensitization with amoxicillin/clavulanic acid was successful and the patient received oral amoxicillin/clavulanic acid for 6 months. At present, 12 months from diagnosis, he is afebrile and TEE is normal. To our knowledge, this case is the fifth reported case of successful treatment of prosthetic valve nocardia endocarditis treated without surgery.

A Rare Case Report of Septic Embolism and Infective Endocarditis due to Nocardia farcinia from North India

“…16, 17 Empirical treatment with TMP-SMX along with carbapenems and Amoxiclav have been tried and resulted in successful outcomes in one such case series of 22 Nocardia cases. 18 Most of the Nocardia infections show susceptibility to TMP-SMX, moxifloxacin, linezolid, minocycline, and amikacin, and have variable susceptibility to ciprofloxacin and imipenem-cilastatin. 18, 19, 20 CNS infections require a longer course of antibiotics for even up to 8 to 12 months as the mortality rate in these cases is also very high over 55%.…”

“…18 Most of the Nocardia infections show susceptibility to TMP-SMX, moxifloxacin, linezolid, minocycline, and amikacin, and have variable susceptibility to ciprofloxacin and imipenem-cilastatin. 18, 19, 20 CNS infections require a longer course of antibiotics for even up to 8 to 12 months as the mortality rate in these cases is also very high over 55%. 19 Combination regimens with TMP-SMX and carbapenem or cephalosporins are usually recommended in severe infections.…”