We wish to comment further on the recent correspondence by Carradice and Szer relating to Nocardia infections post allogeneic stem cell transplantation. 1 Two cases of pulmonary Nocardia have occurred in allogeneic transplant recipients within our unit in the last 12 months. Both patients suffered steroid-refractory chronic graft versus host disease. In one case, similar to Carradice and Szer's report, nebulized pentamadine was being used in place of co-trimoxazole for prophylaxis against Pneumocystis. However, in the second case, the patient was receiving (and taking) co-trimoxazole (1 double-strength tablet b.i.d. twice per week) for Pneumocystis prophylaxis before developing Nocardia. Interestingly, the Nocardia species isolated in this second case remained sensitive to sulphonamides.Our experience is similar to published series of Nocardia infection in bone marrow transplant recipients, where 16-40% of infections have been reported to occur in patients receiving co-trimoxazole as prophylaxis against Pneumocystis. 2-4 Although co-trimoxazole appears to reduce the incidence of Nocardia infection after allogeneic stem cell transplantation, the magnitude of this risk reduction is not known, and Nocardia infections in this group of patients still occur despite use of co-trimoxazole for Pneumocystis prophylaxis. 2-4 As such, we caution physicians not to exclude the possibility of Nocardia infection in transplant patients simply on the basis of concurrent use of cotrimoxazole for prophylaxis against Pneumocystis.

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