St John's Institute of Dermatology, Guy's and St Thomas' Trust, London, United Kingdom.
J Am Acad Dermatol. 2010 Feb;62(2):239-46. doi: 10.1016/j.jaad.2009.06.043. Epub 2009 Dec 11.
Actinomycetomas are chronic, granulomatous, subcutaneous infections caused by actinomycetes bacteria. Despite prolonged high-dose and combination antibiotic therapies, some cases remain resistant with risks of bone and visceral involvement.
We sought to evaluate the efficacy and safety of imipenem monotherapy, and in combination with amikacin for the treatment of severe and refractory disease, and to identify the disease characteristics that might predict therapy failure with first-line sulfonamides.
A retrospective study was performed of all microbiologically confirmed cases of actinomycetomas treated since 1995 at a tertiary center for mycology. Eleven patients (Nocardia, n = 10) were treated with sulfonamide combinations (trimethoprim/sulfamethoxazole and dapsone). Eight patients (Nocardia, n = 7) refractory to previous therapies including sulfonamides received a 3-week course of either parenteral imipenem monotherapy (1.5 g daily, n = 3) or combination therapy with amikacin (1 g daily, n = 5), which was repeated at 6-month intervals.
Eleven patients with limited disease and mean disease duration of 1.7 years responded successfully to sulfonamides after a mean treatment period of 15 months (range 6-48 months). Patients receiving imipenem had mean disease duration of 10 years, with visceral and bone involvement in 4 patients. Imipenem treatment was well tolerated, and 4 patients achieved clinical and microbiological cure after one to two courses of treatment, the others demonstrating greater than 75% clinical improvement and negative culture results.
Patient cohorts in this study were small because strict criteria for inclusion included species identification and adequate follow-up periods. The efficacy data for imipenem +/- amikacin therapy cannot be extrapolated to all Nocardia mycetomas, as the cohort treated in this study had particularly refractory infection.
Sulfonamides are effective for limited disease of relatively short duration. Imipenem monotherapy or in combination with amikacin is well tolerated and demonstrates efficacy in severe disease refractory to sulfonamides.
放线菌病是一种由放线菌引起的慢性、肉芽肿性、皮下感染。尽管采用了长时间、大剂量联合抗生素治疗，但仍有部分病例耐药，存在骨和内脏受累的风险。
我们旨在评估亚胺培南单药治疗以及联合阿米卡星治疗严重和难治性疾病的疗效和安全性，并确定可能预测磺胺类药物一线治疗失败的疾病特征。
对 1995 年以来在一个真菌学三级中心经微生物学确诊的放线菌病患者进行了回顾性研究。11 例患者（诺卡菌，n=10）接受磺胺类药物联合治疗（甲氧苄啶/磺胺甲恶唑和氨苯砜）。8 例（诺卡菌，n=7）对包括磺胺类药物在内的既往治疗耐药的患者接受了 3 周的亚胺培南单药治疗（1.5 g/天，n=3）或联合阿米卡星治疗（1 g/天，n=5），每 6 个月重复一次。
11 例局限性疾病患者的平均病程为 1.7 年，在接受磺胺类药物治疗后 15 个月（6-48 个月）成功缓解，平均治疗时间为 15 个月。接受亚胺培南治疗的患者平均病程为 10 年，4 例患者有内脏和骨骼受累。亚胺培南治疗耐受性良好，4 例患者在 1-2 个疗程后达到临床和微生物学治愈，其余患者的临床改善程度大于 75%，且培养结果为阴性。
本研究的患者队列较小，因为纳入的严格标准包括物种鉴定和足够的随访期。亚胺培南 +/-阿米卡星治疗的疗效数据不能外推至所有诺卡菌放线菌病，因为本研究中治疗的患者具有特别难治性感染。
磺胺类药物对病程较短的局限性疾病有效。亚胺培南单药治疗或联合阿米卡星治疗耐受性良好，对磺胺类药物耐药的严重疾病有效。
