Treatment of Cutaneous Nocardiosis in Disseminated Nocardiosis When Empiric Combination Therapy Has Not Achieved Clinical Improvement
Patients with severe or disseminated nocardiosis typically require hospitalisation and follow a more rapid clinical course from onset to diagnosis. When initial empiric multi-agent therapy does not produce sufficient signs of clinical improvement, a defined next-line approach is indicated.
Clinical Scenario
This protocol applies to cutaneous nocardiosis presenting in the context of severe nocardiosis or disseminated nocardiosis. These are forms in which 2 or 3 agents are typically initiated empirically, and where the pace and severity of disease make timely therapeutic decisions particularly critical.
When the Prior Step Was Not Sufficient
The previous approach — empiric combination therapy with agents from those most Nocardia isolates are susceptible to (amikacin, imipenem, linezolid, and/or trimethoprim-sulfamethoxazole) — did not achieve the required target: signs of clinical improvement sufficient to allow narrowing to monotherapy. This protocol describes the next step taken after that failure.
Next-Step Approach (Partial Overview)
The next-line strategy centres on transitioning to an alternative therapeutic approach, with agent selection informed by Nocardia species identification and antimicrobial susceptibility results. The complete regimen, sequencing, and selection criteria are contained in the full structured protocol.
References
DOI: 10.1093/cid/ciae643
In contrast, patients with severe nocardiosis are typically hospitalized and have a more rapid course from onset to diagnosis.
This is particularly crucial in severe forms of nocardiosis (eg, disseminated or progressive pulmonary infection), where 2 or 3 different agents are typically initiated empirically.
Patients with TMP-SMX toxicity and yet-to-improve severe infection may be better served transitioning to alternative therapy, as patients with severe nocardiosis are underrepresented in the available data.
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