- gram positive bacilli that form weakly acid-fast beaded branching filaments
- found worldwide in soil and some form part of healthy oral flora
- usually transmitted by inhalation or traumatic innoculation
- disease of the immunocompromised – esp T-cell mediated immunity (AIDS, SCID, immunosuppresant therapy)
- pneumonia + brain abscess
- spinal cord
- granulomatous disease
- sample graunlomas
- gram stain
- lung biopsy
- co-trimoxazole (first line agent)
- ceftriaxone (second line agent)
- Expert advice recommended.
- Empiric therapy:
trimethoprim-sulfamethoxazole 320+1600 mg (child more than 2 months: 8+40 mg/kg up to 320+1600 mg) IV or orally, 12-hourly
imipenem 500 mg (child: 12.5 mg/kg up to 500 mg) IV, 6-hourly
meropenem 2 g (child: 40 mg/kg up to 2 g) IV, 8-hourly (meropenem has a lower risk of seizures than imipenem, but there is less published data to support its use)
amikacin (adult and child) 15 mg/kg IV, daily or amikacin (adult and child) 7.5 mg/kg IV, 12-hourly
- Subsequent therapy should be guided by species identification and susceptibility results.
— Ceftriaxone 4 g (child: 100 mg/kg up to 4 g) IV, once daily (or in 2 divided doses) can replace the carbapenem and/or amikacin if the organism is susceptible.
— trimethoprim-sulfamethoxazole up to 320+1600 mg (child more than 2 months: 8+40 mg/kg up to 320+1600 mg) orally, 12-hourly for up to a further 12 months.
— amoxycillin+clavulanate, minocycline, linezolid and moxifloxacin have also been successful in small numbers of cases, particularly for some of the more unusual species.
— Initial parenteral therapy should be continued for 3 to 6 weeks.
— Oral therapy is continued for up to a further 12 months.
Prophylaxis in lung transplant patients
- low-dose trimethoprim/sulfamethoxazole prophylaxis to protect against Pneumocystis jiroveci pneumonia, toxoplasmosis and nocardial infection.
References and Links
Brown-Elliott BA, Brown JM, Conville PS, Wallace RJ Jr. Clinical and laboratory features of the Nocardia spp. based on current molecular taxonomy. Clin Microbiol Rev. 2006 Apr;19(2):259-82. Review. PubMed PMID: 16614249; PubMed Central PMCID: PMC1471991
Leis JA, Bunce PE, Lee TC, Gold WL. Brain and lung lesions in an immunocompromised man. CMAJ. 2011 Mar 22;183(5):573-6. doi: 10.1503/cmaj.100477. Epub 2010 Sep 27. PubMed PMID: 20876264; PubMed Central PMCID: PMC3060186