Nocardiosis: Treatment, Cost and Side Effects

Nocardiosis is an infectious bacterial disease caused by bacteria of the genus Nocardia mostly Nocardia asteroides or Nocardia brasiliensis. These bacteria are commonly found in soil and water, and it can cause infections in both humans and animals. Nocardiosis affects either the lungs causing a condition called pulmonary nocardiosis, or it affects the whole body. If so, this is known as systematic nocardiosis. Men are more likely to contract it, especially those who have a weakened immune system because of factors like HIV, cancer or even diabetes. Pulmonary nocardiosis is contracted by breathing in the bacteria usually suspended in the dust. This is the usual mode of transmission together with a traumatic introduction, especially in the jaw. Traumatic introduction causes the bacteria to get directly into the bloodstream thus the diseases progresses faster. The organisms may also get into an open wound, but this is less common. Those who are susceptible to nocardiosis are the ones with a weakened immune system and those with a low t-cell count.

Treatment for nocardiosis is taking a combination of antibiotics for quite some time ranging from several months to even a year. The treatment is done using Sulfonamides, that is sulfadiazine and sulfisoxazole. This has been the preferred choice of treatment for the past fifty years. Trimethoprim-sulfamethoxazole is the most commonly used sulfonamide. However, the benefit of the trimethoprim is not clear. This drug may, however, have adverse effects in its high doses such as hepatoxicity, myselosuppression, and even renal insufficiency. It is active and works in counter to Nocardia species. Nocardia otitidiscaviarum offers resistance as well. Substitute treatment for Nocardia includes imipenem, meropenem, ertapenem, amikanim, linezolid and tigecycline. Imipenem has proven to be effective than either ertapenem or eropenem. Linezolid is also a good option as it is effective against most Nocardia species and is also good in curing disseminated and central nervous system nocardiosis. It is however expensive and causes toxicities including: lactic acidosis and peripheral neuropathy. Initial combination of antibiotics is most suitable for most forms of nocardiosis, and it should continue until the state of the patient improves clinically, and the species causing the infection has been identified. Single-drug therapy should follow after that.

Once the patient goes to the hospital, a doctor takes samples from the specific part or the area of the body that is infected. This includes: the skin, brain tissue, mucus from the lower airways, or even the lungs. The doctor may use a bronchoscopy, a brain/lung/skin biopsy or a sputum culture. Laboratory tests are done to figure out which species caused the infection. Once the bacteria species is known then further tests, have to be conducted to find out which antibiotics the bacteria are resistant to so that treatment can start immediately with the appropriate drug. Doses of the drug Trimethoprim-sulfamethoxazole containing the trimeth-o-prim component may be prescribed to generate sulfonamide serum. Drugs are combined at first then single drug therapy follows afterward and the time taken to administer treatment is generally prolonged to reduce the possibility of the illness reoccurring in what is known as a relapse. Patients with pulmonary nocardiosis can be treated successfully within six to about twelve months. However, patients who have nocardiosis affecting the central nervous system especially if they are immunosuppressed should get not less than twelve months of medication with close monitoring. If abscesses or wounds develop, surgery may be required to remove them to prevent further complications.

The treatment for nocardiosis starts when a patient report to a hospital presenting signs and symptoms that are characteristic to nocardiosis. The signs and symptoms may be different depending on the type of nocardiosis one contracts thus determining which part of the body is affected. These are the signs:

1. Pulmonary Infection
• Chest pains, fever, cough and night sweats
• Progressive pneumonia
• They are harsher in immunocompromised patients
2. Neurological Infection: It may spread to the brain affecting the central nervous system, and the patient will experience:
• Weakness, confusion, headaches, and seizures.
• Abscesses on the brain
• Nocardial meningitis
3. Skin Infection occurs when the contaminated soil gets into open wounds or cuts. If infected, one develops:Skin ulcers and Nodules and the infection may spread to the lymph nodes.

The doctor thus asks for either Chest X-ray or a bronchoscopy or both for lungs infection, a biopsy for brain and skin infection. On the basis of the outcome of the result the cases of nocardiosis are then treated with long-term and low-dose antibiotics known as sulfonamides. In case an abscess develops there might be the need of a surgery.

Anyone who has tested positive for the nocardiosis is eligible for treatment. The only people who should not get treated for it are those who have the symptoms and still have not taken the required test to confirm it is a nocardiosis infection. This is mostly because nocardiosis is one of the great imitators. These are a group of medical conditions that have nonspecific signs and symptoms that are easily confused with many other illnesses.

There are various side effects of the nocardiosis treatment regimen and drugs. Some of the drugs used in its treatment such as Trimethoprim-sulfamethoxazole when used in high doses lead to adverse and frequent reactions such as hepatoxicity, myelosuppression, and renal insufficiency. In hepatoxicity, the liver is damaged by the chemicals in the drugs being administered whereas if the drugs cause myelosuppression the bone marrow is affected. Production of blood cells as such as leukocytes, erythrocytes, and even platelets is hindered. Renal insufficiency is a condition where there is poor function of the kidneys. This leads to more severe effects such as kidney failure, and the patient may require dialysis or kidney transplant.

After a patient has been successfully treated for nocardiosis, there is no specific and proven way or guidelines to prevent father infection. People with compromised immune systems will always be at risk of contracting it. However, they can reduce this risk by wearing protective clothing such as shoes and clothes covering the skin and any open wounds when they are working on the soil. This is to prevent skin infections. Those who have had organ or hematopoietic stem cell transplant should also be administered with antibiotics to prevent bacterial infections. This is because they receive immunosuppressive therapies to prevent their bodies from rejecting the transplanted organs.

Recovery time from nocardiosis depends on the part of the body that was affected, the overall health of the patient and the severity of the infection. On average, it requires at least six months for immunocompetent patients with pulmonary nocardiosis. Patients who are immunosuppressed and have nocardiosis affecting the central nervous system require more time to recover. These need more than 12 months of recovery time. Not all patients survive this disease. There is a 100% cure rate for those with skin infections, 90% cure rate for those with pulmonary infections but the rate falls to 66% for those with brain infection.

The treatment of nocardiosis is sure to be quite costly. The drugs used to treat it such as Linezolid are expensive and have to be taken for a long duration of time ranging from six months to twelve months. In India, it costs approximately 500 dollars for the doctor's consultations and tests to be done depending on the hospital one visits. There are additional costs of buying medicine and regular checkups. If one has a brain infection, they may need to be admitted into the hospital as close clinical monitoring is essential. Further costs are incurred if surgery has to be done to drain abscesses. It may cost a person more than 10000 to get treated in India.

Once one has been successfully treated for nocardiosis, the results of that treatment are not are not permanent. Nocardiosis has no specific ways to prevent its infection as it lacks a vaccine. If one is exposed to the bacteria causing the disease especially if their immune system is compromised, the infection will reoccur. One can only try their level best to avoid coming into contact with contaminated substances such as soil by wearing protective clothes. One can also prevent infection by maintaining their immune system by eating healthy foods, exercising regularly and seeking immediate medical attention when ill.

There is no alternative to treatment. Nocardia is a dangerous pathogen, and without treatment, it spreads throughout the body infecting more parts thus producing a serious and metastatic disease. Eventually, it leads to death. It is only possible to save the life of a patient if it is diagnosed early and the initiation of appropriate treatment is taken. It is especially crucial for patients who develop brain nocardiosis that causes brain abscesses that it is discovered in advance as their survival rate is meager. Therefore, a person ought to seek immediate medical care from a trusted medical practitioner immediately signs and symptoms which may signal to a nocardiosis infection manifest.