This protocol applies to immunocompetent patients with mild, nondisseminated pulmonary nocardiosis and underlying chronic pulmonary disease whose initial treatment with trimethoprim-sulfamethoxazole (TMP-SMX) monotherapy has not achieved the expected clinical or radiographic response.
First-line therapy consisted of single-agent trimethoprim-sulfamethoxazole (TMP-SMX) for mild pulmonary nocardiosis. The required treatment goals — signs of clinical improvement and radiographic response on follow-up chest imaging — were not reached, triggering escalation to this protocol.
The patient is immunocompetent and has mild nondisseminated pulmonary nocardiosis with concurrent chronic pulmonary disease. No evidence of disseminated infection is present. Although no validated severity grading system exists for nocardiosis, patients in this category typically follow a chronic course to diagnosis and are often managed in the outpatient setting.
The approach involves transitioning to a different active monotherapy, with agent selection guided by antimicrobial susceptibility results. Full regimen details and management guidance are available in the complete protocol.
Signs of clinical improvement of pulmonary nocardiosis and radiographic response on follow-up chest imaging.
DOI: 10.1093/cid/ciae643
Although no validated grading system for Nocardia severity exists, patients with mild nocardiosis are often managed in the outpatient setting, have a chronic course leading to diagnosis, and have nondisseminated infection.
Additionally, select immunocompetent patients with mild pulmonary nocardiosis (typically those with chronic pulmonary disease) can be closely monitored until susceptibility results are available.
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.
Patients with pulmonary or CNS disease should undergo follow-up chest or brain imaging, respectively, to evaluate for response to treatment.
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