Nocardia Infections In Solid Organ Transplantation

Publication Date: February 28, 2019

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

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Overview

Title

Nocardia Infections In Solid Organ Transplantation

Authoring Organization

Publication Month/Year

February 28, 2019

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