Infectious Diseases Unit, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Tel Aviv, Israel.
Université de Paris, Paris, France; Service de Microbiologie, Unité Mobile d'Infectiologie, AP-HP, Hôpital Européen Georges Pompidou, Paris, France.
Clin Microbiol Infect. 2021 Apr;27(4):550-558. doi: 10.1016/j.cmi.2020.12.019. Epub 2021 Jan 5.
Nocardiosis is a rare infection that is often difficult to treat and may be life-threatening. There is no consensus on its management.
Our aim was to provide the current evidence for the diagnosis and management of individuals with nocardiosis, and to propose a management approach for this uncommon infection.
We systematically searched the medical literature on nocardiosis for studies published between 2010 and 2020 and describing ten or more individuals.
Nocardiosis, a primarily opportunistic infection which may occur in immunocompetent persons, most commonly involves the lungs and frequently disseminates to other sites including the central nervous system. The reference standard for Nocardia species identification is molecular biology, and the preferred method for antibiotic susceptibility testing (AST) is broth microdilution. Monotherapy seems appropriate for patients with primary skin nocardiosis or non-severe pulmonary disease; we reserve a multidrug regimen for more severe infections. Species identification and AST results are often missing at initiation of antibiotics. Trimethoprim-sulfamethoxazole is the preferred agent for initial therapy, because Nocardia is very often susceptible to this agent, and because it has been the keystone of nocardiosis treatment for years. Linezolid, to which Nocardia is almost always susceptible, may be an alternative. When combination therapy is required, the repertoire of companion drugs includes third-generation cephalosporins, amikacin and imipenem. Therapeutic modifications should take into account clinical response to initial therapy and AST results. Treatment duration of 6 months is appropriate for most situations, but longer durations are preferred for disseminated nocardiosis and shorter durations are reasonable in low-risk situations. Secondary prophylaxis may be considered in selected individuals with permanent immunosuppression.
We hereby provide the clinician with an easy-to-use algorithm for the management of individuals with nocardiosis. We also illuminate gaps in evidence and suggest future research directions.
诺卡氏菌病是一种罕见的感染，通常难以治疗，可能危及生命。目前对其治疗方法尚未达成共识。
旨在为诺卡氏菌病患者的诊断和治疗提供最新证据，并为这种罕见感染提出一种治疗方法。
我们系统地检索了 2010 年至 2020 年期间发表的关于诺卡氏菌病的医学文献，并描述了十例或更多的病例。
诺卡氏菌病是一种主要的机会性感染，可发生于免疫功能正常者，最常累及肺部，常播散至其他部位，包括中枢神经系统。诺卡氏菌属鉴定的参考标准是分子生物学，抗生素药敏试验（AST）的首选方法是肉汤微量稀释法。单一药物治疗似乎适用于原发性皮肤诺卡氏菌病或非严重肺部疾病的患者；我们保留多药治疗方案用于更严重的感染。在开始使用抗生素时，通常缺乏种属鉴定和 AST 结果。复方磺胺甲噁唑是初始治疗的首选药物，因为诺卡氏菌通常对该药物敏感，并且多年来一直是诺卡氏菌病治疗的基石。几乎对所有诺卡氏菌都敏感的利奈唑胺可能是另一种选择。如果需要联合治疗，可选择的药物包括第三代头孢菌素、阿米卡星和亚胺培南。治疗方案的调整应考虑到初始治疗的临床反应和 AST 结果。大多数情况下，6 个月的治疗时间是合适的，但对于播散性诺卡氏菌病，需要延长治疗时间，而在低风险情况下，较短的治疗时间是合理的。在某些永久性免疫抑制的个体中，可考虑进行二级预防。
我们为临床医生提供了一种易于使用的诺卡氏菌病患者管理算法。我们还阐明了证据中的空白，并提出了未来的研究方向。
