Medical Care
Antibiotic therapy and appropriate surgical drainage are treatments of choice (see Medication).
For primary cutaneous nocardiosis, antibiotic therapy is usually recommended, although spontaneous resolution occurs in some cases without treatment. Recommendations regarding the duration of therapy range from 2-3 months for most cutaneous infections to 1 year for chronic cutaneous and systemic infections. Trimethoprim-sulfamethoxazole (TMP-SMZ) is used most frequently for nocardiosis.
If parenteral therapy is necessary, it need not be continued beyond a period of 3-6 weeks, even in patients with life-threatening systemic disease. With improving clinical status, most patients can be switched safely to oral medications, especially trimethoprim and sulfamethoxazole (TMP-SMZ).
Outpatient antibiotics are much more easily administered in oral form, and oral antibiotics have been shown to be just as effective as intravenous forms in patients with cutaneous disease.
Surgical Care
Surgical debridement or excision often is vital in the treatment of nocardiosis. Surgery is most helpful in abscesses and mycetomas, but it can also help resolve lymphocutaneous infection. In a review of nocardial lymphocutaneous syndrome published in 1999, [24] of 50 patients, 11 required surgery as a primary or secondary treatment.
Consultations
Consult a dermatologist regarding the diagnostic workup and optimization of therapy.
Consult an infectious disease specialist regarding the diagnostic workup and optimization of therapy.
Consultation with a general surgeon or orthopedic surgeon may be required if extensive surgical debridement is necessary.
Activity
Activity depends on the severity of illness and the location of the infection.
Long-Term Monitoring
Close outpatient follow-up care is vital to the success of therapy for cutaneous nocardiosis. Because of the long duration of therapy, relapse is possible. Although the optimal duration of therapy is uncertain, suggestions range from 6 weeks (in minor infections) to 1 year (severe systemic disease).
Frequent outpatient visits for the first 6 weeks are recommended, followed by less frequent visits if the patient does well clinically.
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Red nodules on a patient with disseminated nocardiosis.
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Ulcer on the arm of a patient with primary cutaneous nocardiosis.
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Gomori methenamine silver stain demonstrating black filamentous Nocardia species.
