TRIP

Nocardiosis (Treatment)

eMedicine Pediatrics, 2011

Trimethoprim-sulfamethoxazole (Bactrim) or a sulfonamide (sulfadiazine), given intravenously in high doses, is the treatment of choice.
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 with immunocompromising conditions are treated for at least 3 months after clinical cure (usually up to 1 y of 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.
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.