Sections

Nocardiosis

Treatment

Medical Care

Protracted specific antimicrobial therapy is the mainstay of medical care for nocardiosis. Therapy is generally recommended for at least 6 months, and at least 12 months for CNS infections.^{[1, 16]}

In patients who require immunosuppressive therapy, such therapy can generally be continued while appropriate specific therapy for nocardiosis is administered.

Surgical Care

For lesions outside the CNS, surgical management is the same as standard recommendations for other infections; that is, localized abscesses generally require prompt surgical therapy. Pericarditis complicating pulmonary infection may be fatal and requires surgical drainage^[31].

In patients with nocardial brain abscesses, surgery should be performed if the lesions are large, readily accessible, or progressing beyond 2 weeks of antimicrobial therapy.^[14]

Consultations

An infectious diseases specialist is recommended for coordinating protracted antimicrobial therapy. Depending on the infection site(s), consultation with a pulmonologist, thoracic surgeon, general surgeon, and/or neurosurgeon may be appropriate.

Diet

No specific dietary recommendations are warranted.

Activity

Activity can be as tolerated by the patient.

Prevention

Primary prevention is not routinely recommended for immunosuppressed individuals.

Patients at risk of Nocardia infection should be evaluated for reduction or cessation of immunosuppressive therapy. In patients with prior nocardiosis infections on immunosuppressive therapy which cannot be discontinued, secondary prophylaxis may be considered with daily double-strength trimethoprim-sulfamethoxazole (TMP-SMX).^{[38, 39]}

While lower dose regimens of TMP-SMX are effective in preventing other opportunistic infections, such as Pneumocystis jiroveci pneumonia (PJP) (See the Medscape Reference article Preventing Opportunistic Infections in Patients With HIV) in immunocompromised patients, bi-and tri-weekly TMP-SMX regimens have not been sufficient in preventing Nocardia in high-risk patients.^{[38, 40]}

Long-Term Monitoring

Antimicrobial therapy for pulmonary or disseminated nocardiosis should be continued for 6-12 months and at least 1 month following resolution of all evidence of infection. Patients should undergo follow-up monthly after discharge from the hospital and during antimicrobial therapy to ensure an appropriate response to therapy and monitor for medication adverse effects with laboratory studies. These patients require at least 12 months of monitoring after the completion of therapy to detect possible late relapses.

Follow-up radiographic studies should be obtained roughly every three months to monitor treatment. Examples include chest radiographs and CT-scans for patients with pulmonary disease and CT-brain or MRI for CNS disease. Radiographic studies are required after antimicrobial therapy has concluded to to ensure there is not evidence of relpase on imaging.

Medication

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Media Gallery

High-power microscopic appearance of Nocardia. Image courtesy of CDC.
Photomicrograph of tissue biopsy stained with Gomori methenamine silver demonstrating acute inflammatory response and organisms compatible with Nocardia.
Plain chest radiograph in a patient with nocardiosis. Image courtesy of Applied Radiology, Anderson Publishing, LTD.
Chest CT scan in a patient with pleuropulmonary nocardiosis. Image courtesy of Applied Radiology, Anderson Publishing, LTD.
Brain CT scan in a patient with nocardial brain abscess. Image courtesy of Applied Radiology, Anderson Publishing, LTD.

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Author

Shirin A Mazumder, MD, FIDSA Associate Professor of Medicine, Director of Infectious Disease Fellowship Program, Division of Infectious Diseases, Department of Internal Medicine, University of Tennessee Health Science Center College of Medicine, University of Tennessee Methodist Physicians

Shirin A Mazumder, MD, FIDSA is a member of the following medical societies: American Academy of HIV Medicine, American College of Physicians, American Medical Association, HIV Medicine Association, Infectious Diseases Society of America, Memphis Medical Society, Society for Healthcare Epidemiology of America, Tennessee Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Rachel E Gibbs MD Candidate, Ben Gurion University Medical School for International Health, Israel

Rachel E Gibbs is a member of the following medical societies: American College of Physicians, HIV Medicine Association, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

John W King, MD Professor of Medicine, Chief, Section of Infectious Diseases, Director, Viral Therapeutics Clinics for Hepatitis, Louisiana State University School of Medicine in Shreveport; Consultant in Infectious Diseases, Overton Brooks Veterans Affairs Medical Center

John W King, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Federation for Medical Research, American Society for Microbiology, Association of Subspecialty Professors, Infectious Diseases Society of America, Sigma Xi, The Scientific Research Honor Society

Disclosure: Nothing to disclose.

Chief Editor

Michael Stuart Bronze, MD David Ross Boyd Professor and Chairman, Department of Medicine, Stewart G Wolf Endowed Chair in Internal Medicine, Department of Medicine, University of Oklahoma Health Science Center; Master of the American College of Physicians; Fellow, Infectious Diseases Society of America; Fellow of the Royal College of Physicians, London

Michael Stuart Bronze, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Medical Association, Association of Professors of Medicine, Infectious Diseases Society of America, Oklahoma State Medical Association, Southern Society for Clinical Investigation

Disclosure: Nothing to disclose.

Additional Contributors

Thomas J Marrie, MD Dean of Faculty of Medicine, Dalhousie University Faculty of Medicine, Canada

Thomas J Marrie, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Society for Microbiology, Association of Medical Microbiology and Infectious Disease Canada, Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

George Kurdgelashvili, MD Clinical Associate Professor of Medicine, Department of Medicine, University of Oklahoma College of Medicine; Assistant Chief of Medical Service, Director of Diagnostic Center Clinic, Chair of Infection Prevention and Control Committee, Attending Physician, Infectious Diseases Section, Oklahoma City Veterans Affairs Medical Center

George Kurdgelashvili, MD is a member of the following medical societies: Infectious Diseases Society of America, HIV Medicine Association, Veterans Affairs Society of Practitioners in Infectious Diseases

Disclosure: Nothing to disclose.

Nocardiosis Treatment & Management

Medical Care

Surgical Care

Consultations

Diet

Activity

Prevention

Long-Term Monitoring

References

Tables

Contributor Information and Disclosures

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