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Classification -
ECOLOGY EPIDEMIOLOGY
Ubiqiotous environmental saprophytes, occurring in soil, organic matter, water
N asteroides species complex now changed to individual species names with advent of
molecular characterization
CLINICAL EPIDEMIOLOGY
Most cases are in those with immunocompromised. Very strong risk factor
Presentation
1994 literature review of 1050 cases of nocardiosis
• Pulmonary (only) – 39 percent
• Systemic (≥2 sites involved) – 32 percent;
• 44% CNS involvement
• Single-site extrapulmonary (eg, eyes, bone) – 12
percent
• CNS (only) – 9 percent
• Cutaneous or lymphocutaneous – 8 percent
CLINICAL MANIFESTATIONS
PULMONARY
50 percent of all pulmonary cases disseminate to sites outside the lungs, most
commonly the brain
CNS INVOLVEMENT
NEOPLASIA mimic:
Infections of the brain by Nocardia spp are often insidious in
onset and difficult to diagnose and treat successfully.
Systemic Nocardiosis
Pathogenesis:
site:
any anatomic location can be involved, but most common sites
to be infected during dissemination are CNS, cutaneous and
subcutaneous tissues, eyes (esp retina), kidneys, bones, joints,
and heart.
morphology:
hallmark of disseminated nocardial lesions is abscess
formation, with polymorphs representing dominant cell type in
early stages of infection.
In advanced stages, host cell reponse becomes mixed.
Laboratory Diagnosis
TREATMENT
Susecptibility testing:
Antimicrobial susceptibilities should be performed on all Nocardia isolates as
a guide to therapy.
Choice of drug
Sulfonamides have been considered the standard of therapy for more than 50
years, despite the lack of controlled comparative data. This consensus is
based in part upon the results of a few retrospective reviews in which there
was a trend toward increased survival in nocardiosis with the use of
sulfonamide-containing regimens
Other agents
Severe infection
Severe nocardiosis includes some cases of pulmonary disease, and all cases
of disseminated disease or central nervous system disease, as well as all
infections involving more than one site in immunocompromised patients.
Despite the lack of data to support the superiority of combination therapy over
single drug regimens, most infectious diseases specialists initially treat severe
nocardial infection with two intravenous drugs prior to the availability of
susceptibility results (table 1) [1,2]. However, in cases of life-threatening
infection, we suggest using three intravenous drugs
Initial Treatment
Initial treatment (ie, induction therapy) should be administered intravenously
for at least three to six weeks and/or until clinical improvement is documented.
We favor at least two intravenous agents during this phase of therapy for all
patients with severe disease. Patients initially on three intravenous drugs who
both improve on initial intravenous combination therapy and are proven to
have susceptible isolates may be switched to two intravenous drugs to
complete the induction phase of therapy. The results of susceptibility testing
should be used to tailor the regimen. As an example, if the isolate is
susceptible to the third-generation cephalosporins (ceftriaxone, cefotaxime),
imipenem can be switched to one of these agents.
Duration
The optimal duration of antimicrobial treatment for severe disease has not
been determined, but most recommend a prolonged course because of the
relapsing nature of Nocardia infection. We usually treat for a duration of three
to six months for isolated cutaneous infection in immunocompetent patients,
but for 6 to 12 months in immunocompromised patients. Serious pulmonary
infection is treated for 6 to 12 months or longer. All immunocompromised
patients (except those with isolated cutaneous infection) as well as patients
with CNS involvement should be treated for at least one year [2], and some
suggest indefinite suppressive therapy in immunocompromised patients.
Within these ranges, the total duration of therapy (IV followed by oral) is based
upon the severity and extent of disease and the clinical and radiographic
response to treatment.
Resistance