eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease
Nocardiosis: Treatment & Medication
Updated: Aug 28, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
- Sulfa-based therapy is recommended for nocardiosis. Trimethoprim-sulfamethoxazole (Bactrim) or a sulfonamide (sulfadiazine), given intravenously in high doses, is the treatment of choice.8
- Linezolid has a growing literature in support of its use in combination and even monotherapy for treatment of Nocardia infections. It has good CNS penetration, is available in an oral form, and is the only antibiotic known to be active against all strains of Nocardia.
- Additional concurrent therapy with an aminoglycoside (amikacin, gentamicin) plus ceftriaxone benefits patients with fulminant disease.
- Other medications for the pediatric age group include extended-spectrum cephalosporins, imipenem/meropenem, ampicillin, and amoxicillin-clavulanate. Tetracycline derivatives used in treatment include minocycline or doxycycline (in a child >8 y with sulfa hypersensitivity).
- Patients who are immunocompetent with lymphocutaneous disease are usually treated for 6-12 weeks. Therapy includes incision and drainage of abscesses. Patients with immunocompromising conditions are treated for at least 3 months after clinical cure (usually up to 1 y of therapy).
- Closely monitor patients with AIDS and CNS disease; relapse can occur years after therapy.
Surgical Care
- Surgical therapy to drain abscesses is usually helpful (and potentially diagnostic); however, brain abscesses may respond to antimicrobial treatment without surgery. The risks of an invasive neurosurgical procedure should be balanced against the benefits of a diagnostic biopsy or potentially therapeutic drainage.
Consultations
- A multidisciplinary team in a pediatric ICU setting should manage fulminant nocardiosis.
- Consultation with a pediatric infectious diseases specialist is also recommended.
- Neurosurgery or interventional radiology may need to be consulted to obtain biopsies.
Medication
Antibiotics
The mainstay of nocardiosis therapy are sulfa-based antibiotics (eg, trimethoprim-sulfamethoxazole) given intravenously in high doses. Trimethoprim-sulfamethoxazole has shown less efficacy as a single agent in some AIDS-related nocardial infections. The single best regimen for treatment has not been established, and antibiotic resistance testing is recommended to tailor therapies to the specific strain infecting the patient. Trimethoprim-sulfamethoxazole, amikacin, and either ceftriaxone or imipenem are a reasonable combination of drugs for an initial empiric therapy prior to the results of susceptibility testing.
The use of linezolid to treat resistant or severe infection has been documented and shows promise.9 Linezolid has been tested in vitro and has been shown to be the first antimicrobial agent to be active against all Nocardia species. It has good CNS penetration, does not require adjustment for renal or liver disease, has few drug interactions (especially with immunosuppressive medications), and has been shown to work as monotherapy against Nocardia. It is also available with excellent bioavailability in an oral form and may become a first-line therapy for Nocardia infection.
Trimethoprim-sulfamethoxazole (Bactrim, Septra)
Inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid. Doses are based on the trimethoprim component.
Adult
160 mg (trimethoprim) and 800 mg (sulfamethoxazole) PO bid (ie, 1 double-strength tab PO bid) for 6 mo
Immunocompromise: Duration of treatment lifelong if patient has AIDS
Pediatric
<6 weeks: Not recommended
>6 weeks: 15-20 mg/kg/d IV divided q6-8h; initial IV then PO for a total of 6-12 wk (lymphocutaneous disease)
Disseminated: Continue at least 3 mo after clinical cure is achieved; usually up to 1 y, especially with CNS involvement
May increase PT when used with warfarin (perform coagulation tests and adjust dose accordingly); coadministration with dapsone may increase blood levels of both drugs; coadministration of diuretics increases incidence of thrombocytopenia purpura in elderly persons; phenytoin levels may increase with coadministration; may potentiate effects of methotrexate in bone marrow depression; hypoglycemic response to sulfonylureas may increase with coadministration; may increase levels of zidovudine
Documented hypersensitivity; megaloblastic anemia caused by folate deficiency
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Avoid in pregnancy near term (risk of kernicterus in newborn); discontinue at first appearance of rash or sign of adverse reaction; frequently obtain CBC counts; discontinue therapy if significant hematologic changes occur; goiter, diuresis, and hypoglycemia may occur with sulfonamides; prolonged IV infusions or high doses may cause bone marrow depression (if signs occur, give 5-15 mg/d leucovorin); caution in folate deficiency (eg, chronic alcoholics, elderly persons, those receiving anticonvulsant therapy, or those with malabsorption syndrome); hemolysis may occur in individuals with G-6-PD deficiency; patients with AIDS may not tolerate or respond; caution in renal or hepatic impairment (perform urinalyses and renal function tests during therapy); give fluids to prevent crystalluria and stone formation
Imipenem and cilastatin (Primaxin)
Therapy with this alternative agent often is used in combination with amikacin. For CNS nocardiosis, consider the related drug, meropenem, instead.
Adult
250-500 mg IV q6h; not to exceed 3-4 g/d
Pediatric
60 mg/kg/d IV divided q6-8h; not to exceed 4 g/d for 6-12 wk (lymphocutaneous disease)
Disseminated: Continue at least 3 mo after clinical cure is achieved; usually up to 1 y
Coadministration with ganciclovir may result in generalized seizures; coadministration with cyclosporine, may increase CNS effects of both agents
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Give slowly via IV over 30-60 min; pruritus, urticaria, GI symptoms, seizures, dizziness, hypotension, elevated LFT findings, and blood dyscrasias can occur; adjust dose in renal insufficiency; nausea associated with infusion can be improved by slowing the infusion rate
Amikacin (Amikin)
Used in conjunction with trimethoprim-sulfamethoxazole or imipenem-cilastatin. Peak therapeutic levels are 20-30 mg/L, and trough levels are 5-10 mg/L.
Adult
15 mg/kg/d IV/IM divided bid/tid; not to exceed 1.5 g/d regardless of higher BW
Pediatric
15-22.5 mg/kg/d IV/IM divided q8h
Coadministration with other aminoglycosides, penicillins, cephalosporins, and amphotericin B increases nephrotoxicity; enhances effects of neuromuscular blocking agents; causes respiratory depression; irreversible hearing loss may occur with coadministration of loop diuretics
Documented hypersensitivity
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Not intended for long-term therapy; caution in patients with renal failure (not on dialysis), hypocalcemia, myasthenia gravis, and conditions that depress neuromuscular transmission
Minocycline (Dynacin, Minocin)
Another alternative drug both in PO and IV formulations for prolonged treatment. However, it is not recommended in children <8 y.
Adult
200 mg PO bid for 6 mo
Pediatric
<8 years: Not recommended
>8 years:
Loading dose: 4 mg/kg/dose PO/IV then, 2 mg/kg/dose q12h; not to exceed 400 mg/d for 6-12 wk (lymphocutaneous)
Disseminated: Continue at least 3 mo after clinical cure is achieved; usually up to 1 y
Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; can decrease effects of PO contraceptives, causing breakthrough bleeding and increased risk of pregnancy; tetracyclines can increase hypoprothrombinemic effects of anticoagulants
Documented hypersensitivity; severe hepatic dysfunction
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines
Amoxicillin and clavulanate (Augmentin)
Aminopenicillin with a beta-lactamase inhibitor. Doses are based on the amoxicillin component. This drug is used as a follow-up treatment PO agent for prolonged therapy following IV treatment with imipenem or meropenem/amikacin. (See trimethoprim-sulfamethoxazole for suggested treatment duration.)
Adult
500 mg q12h PO or 250 mg PO q8h
Pediatric
<40 kg: 20-40 mg/kg/d PO divided bid
>40 kg: Administer as in adults
Coadministration with warfarin or heparin, increases risk of bleeding
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
GI upset, rash, diarrhea may occur
Ampicillin (Marcillin, Omnipen)
Bactericidal activity against susceptible organisms. Alternative to amoxicillin when unable to take PO medication.
Adult
0.5-1 g IV q6h
Pediatric
200-400 mg/kg/d IV divided q6h
Probenecid and disulfiram elevate ampicillin levels; allopurinol decreases ampicillin effects and has additive effects on ampicillin rash; may decrease effects of PO contraceptives
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal failure; evaluate rash and differentiate from hypersensitivity reaction
Meropenem (Merrem IV)
Bactericidal broad-spectrum carbapenem antibiotic that inhibits cell-wall synthesis. Effective against most gram-positive and gram-negative bacteria.
Has slightly increased activity against gram-negative bacteria and slightly decreased activity against staphylococci and streptococci compared to imipenem. Not recommended for children.
Adult
1-2 g IV q8h
Pediatric
60 mg/kg/d IV divided q8h
Meningitis: 120 mg/kg/d IV divided q8h
Probenecid may inhibit renal excretion of meropenem, increasing meropenem levels
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Pseudomembranous colitis and thrombocytopenia may occur, requiring immediate discontinuation of medication
Doxycycline (Bio-Tab, Doryx, Vibramycin)
Inhibits protein synthesis and thus bacterial growth by binding to 30S and, possibly, 50S ribosomal subunits of susceptible bacteria.
Adult
200 mg PO/IV on day 1, then 100-200 mg PO/IV qd
Pediatric
<8 years: Not recommended
>8 years: 2-4 mg/kg/d PO/IV qd
Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; tetracyclines can increase hypoprothrombinemic effects of anticoagulants; tetracyclines can decrease effects of PO contraceptives, causing breakthrough bleeding and increased risk of pregnancy
Documented hypersensitivity; severe hepatic dysfunction
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines
Sulfadiazine (Microsulfon)
Exerts bacteriostatic action by competitive antagonism of para-aminobenzoic acid (PABA). Microorganisms that require exogenous folic acid and do not synthesize folic acid are not susceptible to the action of sulfonamides.
Adult
Loading dose: 2-4 g PO once
Maintenance: 2-4 g/d PO divided q3-6h
Pediatric
120-150 mg/kg/d PO divided q6h
Increases effect of PO anticoagulants and PO hypoglycemic agents; sulfadiazine effects are decreased when concurrently administered with PABA or PABA metabolites of drugs such as proparacaine, tetracaine, sunscreens, and procaine
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Pregnancy category D near term (risk of kernicterus in newborn); caution in impaired renal, hepatic function, or G-6-PD deficiency; dose should be adjusted in renal insufficiency
Linezolid (Zyvox)
A synthetic antibiotic of the oxazolidinone class, which prevents the formation of functional 70S initiation complex. This is essential for the bacterial protein translation process. Although it seems to be bacteriostatic against Nocardia (as it is with most bacteria except pneumococci), it does seem to be a very effective therapy even as a monotherapy.
Adult
400-600 mg PO/IV q12h for 10-28 days
Pediatric
Preterm neonate <7 days: 10 mg/kg PO/IV q12h
Term neonates-12 years: 10 mg/kg PO/IV q8h
>12 years: Administer as in adults
Has mild MAOI properties and has potential to have same interactions as other MAOIs; caution with tyramine-containing foods and compounds; may cause hypertension when used concomitantly with adrenergic agents including pseudoephedrine, sympathomimetic agents, vasopressor or dopaminergic agents (reduce dose of dopamine or epinephrine if concurrent use required); serotonin syndrome may occur if used concomitantly with serotonergic agents including tricyclic antidepressants, meperidine, dextromethorphan, trazodone, venlafaxine, and selective serotonin reuptake; may cause myelosuppression (monitor blood counts when on chronic therapy) or pseudomembranous colitis
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in uncontrolled hypertension, pheochromocytoma, carcinoid syndrome, or untreated hyperthyroidism, and patients who are at increased risk for bleeding, have preexisting thrombocytopenia, receive concomitant medications that may decrease platelet count or function, or who may require >2 wk of therapy (monitor platelet counts); unnecessary use may lead to development of resistance to drug; may cause peripheral or optic neuropathy.
More on Nocardiosis |
| Overview: Nocardiosis |
| Differential Diagnoses & Workup: Nocardiosis |
 Treatment & Medication: Nocardiosis |
| Follow-up: Nocardiosis |
| Multimedia: Nocardiosis |
| References |
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References
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Further Reading
Keywords
nocardiosis, Nocardia, Nocardiaceae, Nocardia asteroides, Nocardia brasiliensis, Nocardia pseudobrasiliensis, Nocardia otitidis-caviarum, Nocardia caviae, Nocardia farcinica, Nocardia nova, Nocardia transvalensis, Nocardia carnea, Nocardia elegans, Nocardia paucivorans, Nocardia puris, Nocardia takedensis, chronic mycetoma, Nocardia abscessus, Nocardia africana, pneumonia, Nocardia ignorata, Nocardia cyriacigeorgica, cutaneous abscess, lymphocutaneous abscess, chronic granulomatous disease, human immunodeficiency virus, HIV, pulmonary alveolar proteinosis, tuberculosis, interleukin 12 deficiency, systemic lupus erythematosus, sepsis, subcutaneous abscesses, cervical adenitis, mycetoma, septic arthritis, anorexia, lymphoreticular neoplasms, respiratory distress, respiratory failure, bronchopneumonia, lobar pneumonia, necrotizing pneumonia, cerebral abscess, peritonitis, hematogenous endophthalmitis, sinusitis, aortitis, endocarditis, mediastinitis, treatment, diagnosis
