Nocardia Infections In Solid Organ Transplantation
Publication Date: February 28, 2019
Last Updated: March 14, 2022
GUIDELINES
DIAGNOSTIC STRATEGIES
Nocardia commonly affects the lung, brain, and skin and may cause disseminated infection. (, )
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Early recognition of nocardiosis is critical to achieving good outcomes. (, )
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The diagnosis should be considered in patients with nodular or cavitating lung lesions or brain lesions and appropriate cultures and biopsies obtained. (High, Strong)
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We recommend brain imaging for patients with pulmonary and disseminated nocardiosis to evaluate for CNS involvement. (Moderate, Strong)
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We recommend prolonged incubation of diagnostic specimens in suspected cases of Nocardia infection, use of selective media such as Thayer‐Martin agar with antibiotics, and communication with clinical microbiology laboratory personnel to alert them to the possibility of nocardiosis. (Low, Strong)
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We recommend obtaining speciation of clinical Nocardia isolates to help guide antimicrobial therapy. (Moderate, Strong)
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Traditional phenotypic methods for identifying Nocardia species are inadequate, and isolates should be speciated at qualified laboratories by molecular methods. (Low, Weak)
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TREATMENT
Nocardia spp vary in susceptibility to antimicrobial agents and susceptibility testing of isolates should be performed by a lab with expertise in Nocardia susceptibility testing. (High, Strong)
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We recommend TMP‐SMX as first‐line treatment of Nocardia infections. (Moderate, Strong)
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Monotherapy may be adequate for localized skin infection or stable patients with pneumonia. (Moderate, Strong)
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Imipenem, ceftriaxone, or linezolid are options for first‐line treatment of Nocardia infections in those with sulfa allergy. (Moderate, Strong)
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For severe pulmonary infection, CNS involvement or disseminated disease, at least two agents (imipenem + amikacin or TMPSMX) should be used for initial therapy. (Moderate, Weak)
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The use of three drugs for life‐threatening disease can be considered. (Very Low, Weak)
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Duration of therapy should be prolonged and will depend on the site and extent of infection, to avoid relapse. (Moderate, Strong)
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Surgical debridement may be used when necessary. (Low, Weak)
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Duration of therapy should be extended if there is augmentation of immunosuppression. (Moderate, Weak)
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Monitoring should continue for up to 1 year after the discontinuation of therapy. (Very Low, Weak)
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PREVENTION
TMP‐SMX prophylaxis may be helpful in preventing primary Nocardia infection or relapse after treatment, although infections can occur despite prophylaxis. (Very Low, Weak)
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Non‐TMP‐SMX antimicrobials used as alternatives for Pneumocystis jiroveci prophylaxis may provide inadequate protection against nocardiosis. (Very Low, Weak)
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There are no definitive data on the dose and duration of prophylaxis. (, )
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The use of TMP‐SMX at a dose of one double‐strength tablet daily (dose‐adjusted for renal function) for secondary prophylaxis after an episode of nocardiosis can be considered. (Very Low, Weak)
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Recommendation Grading
Disclaimer
Overview
Title
Nocardia Infections In Solid Organ Transplantation
Authoring Organization
American Society of Transplantation
Publication Month/Year
February 28, 2019
Last Updated Month/Year
June 12, 2023
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Document Objectives
These updated guidelines from the Infectious Diseases Community of Practice of the American Society of Transplantation review the diagnosis, prevention, and management of Nocardia infections after solid organ transplantation (SOT).
Target Patient Population
Patients after solid organ transplantation
Inclusion Criteria
Female, Male, Adolescent, Adult, Older adult
Health Care Settings
Ambulatory, Hospital, Operating and recovery room, Outpatient
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Diagnosis, Prevention, Management
Diseases/Conditions (MeSH)
D014180 - Transplantation, D019737 - Transplants, D009617 - Nocardia Infections
Keywords
infection prevention, infection, solid organ transplant, nocardia infection