Shorter vs. standard-duration antibiotic therapy for nocardiosis: a multi-center retrospective cohort study

Purpose: The prolonged treatment recommended for nocardiosis does not rely on strong evidence. Consequently, some clinicians opt shorter therapy in certain circumstances. We assessed the effectiveness of shorter therapy. Methods: A multi-center retrospective cohort study comprising individuals diagnosed with nocardiosis between 2007 and 2022. We classified all patients who survived 90 days into three groups according to treatment duration: short (≤ 90 days), intermediate (91–180 days), and prolonged (> 180 days). We compared baseline characteristics (comorbidities, immune status) and nocardiosis manifestations across the unadjusted treatment groups, one-year all-cause mortality, disease relapse, and antibiotic-related adverse events to identify patients who may safely receive the short course. Results: We detected 176 patients with nocardiosis, their median age was 65 years; 74 (42%) were women. Forty-three (24%) patients died within 90 days. Of the remaining 133, 37 (28%) patients received short therapy, 40 (30%) intermediate, and 56 (42%) prolonged treatment duration. Longer courses were more likely to be administered to patients with immunosuppression, disseminated nocardiosis, and N. farcinica infection. Within a year, 20 (15%) individuals died and 2 (2%) relapsed. Treatment duration was not associated with either mortality (p = 0.945) or relapse (p = 0.509). Nocardiosis was the cause of death in only one patient, receiving a prolonged course. Of 73 patients with solitary pulmonary nocardiosis, 20 (27%) received short duration. None relapsed and 2 (10%) died, both immunocompromised. The rate of AE was similar across the groups. Conclusions: With clinically guided case-by-case patient selection nocardiosis can be safely treated for durations significantly shorter than traditionally recommended.