Treatment of nocardiosis
- Denis Spelman, MBBS, FRACP, FRCPA, MPH
Denis Spelman, MBBS, FRACP, FRCPA, MPH
- Adjunct Professor, Monash University
- Alfred Hospital, Victoria, Australia
Nocardiosis is an uncommon gram-positive bacterial infection caused by aerobic actinomycetes in the genus Nocardia. Nocardia spp have the ability to cause localized or systemic suppurative disease in humans and animals [1-5]. Nocardiosis is typically regarded as an opportunistic infection, but approximately one-third of infected patients are immunocompetent .
Two characteristics of nocardiosis are its ability to disseminate to virtually any organ, particularly the central nervous system, and its tendency to relapse or progress despite appropriate therapy.
The treatment of nocardiosis will be reviewed here. The microbiology, epidemiology, pathogenesis, clinical manifestations, and diagnosis of nocardiosis are discussed separately. (See "Microbiology, epidemiology, and pathogenesis of nocardiosis" and "Clinical manifestations and diagnosis of nocardiosis".)
Reported antimicrobial susceptibility patterns have varied among different studies, countries, and Nocardia species. In a retrospective review of 765 isolates submitted voluntarily to the United States Centers for Disease Control and Prevention (CDC) between 1995 and 2004, 42 percent were resistant to trimethoprim-sulfamethoxazole (TMP-SMX) and 61 percent were resistant to sulfamethoxazole . This incidence of resistance is significantly higher than in other reports. There are limitations to this study, with the authors concluding that the presented data are probably not representative of all United States cases. As an example, patients who were not responding to treatment due to resistance may have been more likely to have had their isolates sent to the CDC than patients with susceptible isolates who were responding to treatment.
In contrast, in a study of 552 clinical isolates collected from six major medical referral centers in the United States between 2005 and 2011, which was prompted by the unexpected results of the CDC study, only 2 percent of isolates were resistant to TMP-SMX and/or sulfamethoxazole . Possible reasons for the discrepancy between these results and the results of the CDC study are that there might have been differences in the preparation of samples and/or the interpretation of results of in vitro susceptibility testing .
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- ANTIBIOTIC SUSCEPTIBILITY
- Approach to antimicrobial therapy
- - Trimethoprim-sulfamethoxazole
- - Other agents
- Cutaneous infection
- - Isolated cutaneous infection
- - Mycetoma
- - Duration of treatment
- Mild to moderate pulmonary disease
- Severe infection
- - Initial intravenous therapy
- - Switch to oral therapy
- - Sulfonamide resistance or allergy
- - Duration of treatment
- - Outcomes
- - Monitoring
- Treatment failures
- Patients on immunosuppressive therapy
- Maintenance suppressive therapy
- SUMMARY AND RECOMMENDATIONS