Adult learning online education:
Adult learning online education:
Adult learning online education:
About the example: Boolean searches were conducted on November 4, 2019; result numbers may vary at a later date. No additional database limiters were set to further narrow search returns.
Database strategies for targeted search results.
Most databases include limiters, or additional parameters, you may use to strategically focus search results. EBSCO databases, such as Education Research Complete & Academic Search Complete provide options to:
Keep in mind that these tools are defined as limiters for a reason; adding them to a search will limit the number of results returned. This can be a double-edged sword. How?
Use limiters with care. When starting a search, consider opting out of limiters until the initial literature screening is complete. The second or third time through your research may be the ideal time to focus on specific time periods or material (scholarly vs newspaper).
Expanding your search term at the root.
Truncating is often referred to as 'wildcard' searching. Databases may have their own specific wildcard elements however, the most commonly used are the asterisk (*) or question mark (?). When used within your search. they will expand returned results.
Using the asterisk wildcard will return varied spellings of the truncated word. In the following example, the search term education was truncated after the letter "t."
Original Search | |
adult education | adult educat* |
Results included: educate, education, educator, educators'/educators, educating, & educational |
Explore these database help pages for additional information on crafting search terms.
Tips for saving research directly to Google drive.
It is possible to save articles (PDF and HTML) and abstracts in EBSCOhost databases directly to Google drive. Select the Google Drive icon, authenticate using a Google account, and an EBSCO folder will be created in your account. This is a great option for managing your research. If documenting your research in a Google Doc, consider linking the information to actual articles saved in drive.
EBSCOHost Databases & Google Drive: Managing your Research
This video features an overview of how to use Google Drive with EBSCO databases to help manage your research. It presents information for connecting an active Google account to EBSCO and steps needed to provide permission for EBSCO to manage a folder in Drive.
About the Video: Closed captioning is available, select CC from the video menu. If you need to review a specific area on the video, view on YouTube and expand the video description for access to topic time stamps. A video transcript is provided below.
What is a literature review.
A definition from the Online Dictionary for Library and Information Sciences .
A literature review is "a comprehensive survey of the works published in a particular field of study or line of research, usually over a specific period of time, in the form of an in-depth, critical bibliographic essay or annotated list in which attention is drawn to the most significant works" (Reitz, 2014).
A systemic review is "a literature review focused on a specific research question, which uses explicit methods to minimize bias in the identification, appraisal, selection, and synthesis of all the high-quality evidence pertinent to the question" (Reitz, 2014).
EBSCO Connect [Discovery and Search]. (2022). Searching with boolean operators. Retrieved May, 3, 2022 from https://connect.ebsco.com/s/?language=en_US
EBSCO Connect [Discover and Search]. (2022). Searching with wildcards and truncation symbols. Retrieved May 3, 2022; https://connect.ebsco.com/s/?language=en_US
Machi, L.A. & McEvoy, B.T. (2009). The literature review . Thousand Oaks, CA: Corwin Press:
Reitz, J.M. (2014). Online dictionary for library and information science. ABC-CLIO, Libraries Unlimited . Retrieved from https://www.abc-clio.com/ODLIS/odlis_A.aspx
Ridley, D. (2008). The literature review: A step-by-step guide for students . Thousand Oaks, CA: Sage Publications, Inc.
Schedule an appointment.
Contact a librarian directly (email), or submit a request form. If you have worked with someone before, you can request them on the form.
A plain-language explainer (with examples).
By: Derek Jansen (MBA) & Kerryn Warren (PhD) | June 2020 (Updated May 2023)
If you’re faced with writing a dissertation or thesis, chances are you’ve encountered the term “literature review” . If you’re on this page, you’re probably not 100% what the literature review is all about. The good news is that you’ve come to the right place.
The word “literature review” can refer to two related things that are part of the broader literature review process. The first is the task of reviewing the literature – i.e. sourcing and reading through the existing research relating to your research topic. The second is the actual chapter that you write up in your dissertation, thesis or research project. Let’s look at each of them:
The first step of any literature review is to hunt down and read through the existing research that’s relevant to your research topic. To do this, you’ll use a combination of tools (we’ll discuss some of these later) to find journal articles, books, ebooks, research reports, dissertations, theses and any other credible sources of information that relate to your topic. You’ll then summarise and catalogue these for easy reference when you write up your literature review chapter.
The second step of the literature review is to write the actual literature review chapter (this is usually the second chapter in a typical dissertation or thesis structure ). At the simplest level, the literature review chapter is an overview of the key literature that’s relevant to your research topic. This chapter should provide a smooth-flowing discussion of what research has already been done, what is known, what is unknown and what is contested in relation to your research topic. So, you can think of it as an integrated review of the state of knowledge around your research topic.
The literature review chapter has a few important functions within your dissertation, thesis or research project. Let’s take a look at these:
The first function of the literature review chapter is, quite simply, to show the reader (or marker) that you know what you’re talking about . In other words, a good literature review chapter demonstrates that you’ve read the relevant existing research and understand what’s going on – who’s said what, what’s agreed upon, disagreed upon and so on. This needs to be more than just a summary of who said what – it needs to integrate the existing research to show how it all fits together and what’s missing (which leads us to purpose #2, next).
The second function of the literature review chapter is to show what’s currently missing from the existing research, to lay the foundation for your own research topic. In other words, your literature review chapter needs to show that there are currently “missing pieces” in terms of the bigger puzzle, and that your study will fill one of those research gaps . By doing this, you are showing that your research topic is original and will help contribute to the body of knowledge. In other words, the literature review helps justify your research topic.
The third function of the literature review is to form the basis for a conceptual framework . Not every research topic will necessarily have a conceptual framework, but if your topic does require one, it needs to be rooted in your literature review.
For example, let’s say your research aims to identify the drivers of a certain outcome – the factors which contribute to burnout in office workers. In this case, you’d likely develop a conceptual framework which details the potential factors (e.g. long hours, excessive stress, etc), as well as the outcome (burnout). Those factors would need to emerge from the literature review chapter – they can’t just come from your gut!
So, in this case, the literature review chapter would uncover each of the potential factors (based on previous studies about burnout), which would then be modelled into a framework.
The fourth function of the literature review is to inform the choice of methodology for your own research. As we’ve discussed on the Grad Coach blog , your choice of methodology will be heavily influenced by your research aims, objectives and questions . Given that you’ll be reviewing studies covering a topic close to yours, it makes sense that you could learn a lot from their (well-considered) methodologies.
So, when you’re reviewing the literature, you’ll need to pay close attention to the research design , methodology and methods used in similar studies, and use these to inform your methodology. Quite often, you’ll be able to “borrow” from previous studies . This is especially true for quantitative studies , as you can use previously tried and tested measures and scales.
Finding quality journal articles is essential to crafting a rock-solid literature review. As you probably already know, not all research is created equally, and so you need to make sure that your literature review is built on credible research .
We could write an entire post on how to find quality literature (actually, we have ), but a good starting point is Google Scholar . Google Scholar is essentially the academic equivalent of Google, using Google’s powerful search capabilities to find relevant journal articles and reports. It certainly doesn’t cover every possible resource, but it’s a very useful way to get started on your literature review journey, as it will very quickly give you a good indication of what the most popular pieces of research are in your field.
One downside of Google Scholar is that it’s merely a search engine – that is, it lists the articles, but oftentimes it doesn’t host the articles . So you’ll often hit a paywall when clicking through to journal websites.
Thankfully, your university should provide you with access to their library, so you can find the article titles using Google Scholar and then search for them by name in your university’s online library. Your university may also provide you with access to ResearchGate , which is another great source for existing research.
Remember, the correct search keywords will be super important to get the right information from the start. So, pay close attention to the keywords used in the journal articles you read and use those keywords to search for more articles. If you can’t find a spoon in the kitchen, you haven’t looked in the right drawer.
Unfortunately, there’s no generic universal answer for this one. The structure of your literature review will depend largely on your topic area and your research aims and objectives.
You could potentially structure your literature review chapter according to theme, group, variables , chronologically or per concepts in your field of research. We explain the main approaches to structuring your literature review here . You can also download a copy of our free literature review template to help you establish an initial structure.
In general, it’s also a good idea to start wide (i.e. the big-picture-level) and then narrow down, ending your literature review close to your research questions . However, there’s no universal one “right way” to structure your literature review. The most important thing is not to discuss your sources one after the other like a list – as we touched on earlier, your literature review needs to synthesise the research , not summarise it .
Ultimately, you need to craft your literature review so that it conveys the most important information effectively – it needs to tell a logical story in a digestible way. It’s no use starting off with highly technical terms and then only explaining what these terms mean later. Always assume your reader is not a subject matter expert and hold their hand through a journe y of the literature while keeping the functions of the literature review chapter (which we discussed earlier) front of mind.
In the video below, we walk you through a high-quality literature review from a dissertation that earned full distinction. This will give you a clearer view of what a strong literature review looks like in practice and hopefully provide some inspiration for your own.
In this post, we’ve (hopefully) answered the question, “ what is a literature review? “. We’ve also considered the purpose and functions of the literature review, as well as how to find literature and how to structure the literature review chapter. If you’re keen to learn more, check out the literature review section of the Grad Coach blog , as well as our detailed video post covering how to write a literature review .
This post is an extract from our bestselling short course, Literature Review Bootcamp . If you want to work smart, you don't want to miss this .
Thanks for this review. It narrates what’s not been taught as tutors are always in a early to finish their classes.
Thanks for the kind words, Becky. Good luck with your literature review 🙂
This website is amazing, it really helps break everything down. Thank you, I would have been lost without it.
This is review is amazing. I benefited from it a lot and hope others visiting this website will benefit too.
Timothy T. Chol [email protected]
Thank you very much for the guiding in literature review I learn and benefited a lot this make my journey smooth I’ll recommend this site to my friends
This was so useful. Thank you so much.
Hi, Concept was explained nicely by both of you. Thanks a lot for sharing it. It will surely help research scholars to start their Research Journey.
The review is really helpful to me especially during this period of covid-19 pandemic when most universities in my country only offer online classes. Great stuff
Great Brief Explanation, thanks
So helpful to me as a student
GradCoach is a fantastic site with brilliant and modern minds behind it.. I spent weeks decoding the substantial academic Jargon and grounding my initial steps on the research process, which could be shortened to a couple of days through the Gradcoach. Thanks again!
This is an amazing talk. I paved way for myself as a researcher. Thank you GradCoach!
Well-presented overview of the literature!
This was brilliant. So clear. Thank you
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Reference management. Clean and simple.
The purpose of a literature review, how to write a literature review, the format of a literature review, general formatting rules, the length of a literature review, literature review examples, frequently asked questions about literature reviews, related articles.
A literature review is an assessment of the sources in a chosen topic of research.
In a literature review, you’re expected to report on the existing scholarly conversation, without adding new contributions.
If you are currently writing one, you've come to the right place. In the following paragraphs, we will explain:
Tip: It’s not always mandatory to add a literature review in a paper. Theses and dissertations often include them, whereas research papers may not. Make sure to consult with your instructor for exact requirements.
The four main objectives of a literature review are:
Ultimately, the main goal of a literature review is to provide the researcher with sufficient knowledge about the topic in question so that they can eventually make an intervention.
The format of a literature review is fairly standard. It includes an:
➡️ Take a look at our guide on how to write a literature review to learn more about how to structure a literature review.
First of all, a literature review should have its own labeled section. You should indicate clearly in the table of contents where the literature can be found, and you should label this section as “Literature Review.”
➡️ For more information on writing a thesis, visit our guide on how to structure a thesis .
There is no set amount of words for a literature review, so the length depends on the research. If you are working with a large amount of sources, it will be long. If your paper does not depend entirely on references, it will be short.
Take a look at these three theses featuring great literature reviews:
Literature reviews are most commonly found in theses and dissertations. However, you find them in research papers as well.
There is no set amount of words for a literature review, so the length depends on the research. If you are working with a large amount of sources, then it will be long. If your paper does not depend entirely on references, then it will be short.
No. A literature review should have its own independent section. You should indicate clearly in the table of contents where the literature review can be found, and label this section as “Literature Review.”
The main goal of a literature review is to provide the researcher with sufficient knowledge about the topic in question so that they can eventually make an intervention.
This blog is about what not to include in your literature review. In short, the literature review is a snapshot of the current state of research on your topic, including research on study variables and major concepts or theories of your study. The literature review also helps to support your research problem and rationalize why your study is necessary by identifying gaps in the literature and methodological weaknesses of previous studies. Below is what not to include in your literature review.
Do not include purely historical or informational material, such as information from websites. Information from reputable web sites, such as government and state sites, can be useful. But such information is typically more suitable for background or introductory sections of the dissertation. If it is necessary to include historical or informational material in your literature review, do so sparingly.
Aligning theoretical framework, gathering articles, synthesizing gaps, articulating a clear methodology and data plan, and writing about the theoretical and practical implications of your research are part of our comprehensive dissertation editing services.
Also, be cautious about the use of books in literature reviews. Although manuscripts of academic books are often sent to external reviewers, it is difficult to be certain whether a book manuscript was peer reviewed. Different publishers have different approaches, and there are no review standards for book manuscripts. Some schools and professors allow books in literature reviews; however, a general rule of thumb is that books should be used sparingly and with a degree of caution.
Do not include extended quotations, and use direct quotes sparingly, if at all. The literature review is a synthesis and analysis of research on your topic in your own words. Most ideas can be and should be paraphrased. Professors sometimes perceive undue reliance on quotations as intellectual laziness. However, if you feel it necessary to use quotations, use them sparingly.
One caveat to the above suggestions is the theoretical framework. If you have a theoretical foundation or framework section in your literature review, it may be necessary to use books and older foundational articles to explain and support theories. Theories are developed over time; consequently, it takes longer to publish on theories compared to studies. Discussion and development of theories often appear in books. However, do not use material from websites to support your theoretical framework.
How to write a lit review.
Examples of lit reviews, additional resources.
What is a literature review?
The organization of your lit review should be determined based on what you'd like to highlight from your research. Here are a few suggestions:
Your literature review should:
BMC Pulmonary Medicine volume 24 , Article number: 440 ( 2024 ) Cite this article
Metrics details
Recurrent respiratory infections are a leading cause of morbidity and mortality in persons with Cystic Fibrosis (pwCF). Recently, the emergence of Nocardia species as a potential pathogen in CF has raised questions about its role and management, as its clinical significance and the optimal patient management remain unclear in current clinical practice. This review explores the clinical implications of Nocardia species in patients with Cystic Fibrosis (pwCF) through a comprehensive literature review. Key objectives include assessing its impact on lung function, identifying colonization risk factors, and evaluating an appropriate treatment.
The literature review, conducted until June 30, 2023, from databases like MEDLINE, PubMed, Embase, and Cochrane, included 16 articles involving 89 pwCF with Nocardia species isolation according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guideline recommendations. Articles reporting Nocardia prevalence and symptoms based on original data in adult and paediatric pwCF were included. All the retrieved studies were observational ones, thus, they were categorized by study type as case report and case series.
Overall 89 pwCF and Nocardia species isolation were included: 42 children and 47 adults. Where reported, we found these main following bacterial species: Nocardia asteroides (35%, 23/64), Nocardia farcinica (21%, 14/64), Nocardia tranvalensis (13%, 8/64) and Nocardia cyriacigeorgica (11%, 7/64). A co-infection was reported in 85% of patients (61/72). Of patients whose lung function was reported before and after Nocardia isolation, 23% (16/68) showed a decline in FEV 1 . Above all, 82 patients were treated at least once after isolation of Nocardia strain. In 93% (77/82) of cases, treatment was started immediately upon isolation. Antibiotic treatment was performed per o s or intravenously depending on the clinical condition of the individual patient. Nocardia eradication was attempted in only 32 cases out of 82, and 78% (25/32) of these patients were successfully eradicated after one or more courses of antibiotics. Death was reported in 3 patients, 2 of which were children.
In general the isolation of the bacteria does not necessarily imply therapy, but patients need to be monitored closely to assess the possible occurrence of active infection. The treatment seems to be indicated in patients showing lung involvement with the possible appearance of pneumonia, pleural effusion, fever, cough, or a decrease in FEV 1 , as in the case that we described, or in patients undergoing pulmonary transplantation.
• A strength of this study is that it provides an updated systematic review on the management of Nocardia ’s isolation in patients with Cystic Fibrosis. By synthesising findings across all included studies we propose a therapeutic management algorithm.
• This systematic review protocol follows the Joanna Briggs Institute, mixed-method systematic review protocol.
• Limitations of the study is the paucity of randomised controlled trials and the heterogeneity among available publications.
• There is potential for heterogeneity of published data, which may limit the conclusions that can be drawn from this study.
Peer Review reports
Cystic fibrosis (CF) is a common autosomal recessive disorder resulting from variants in the CF transmembrane conductance regulator ( CFTR ) gene. Multiple systems are affected, however, respiratory tract infections are one leading cause of morbidity and mortality [ 1 ].
The adaption of 16s rDNA community sequencing technologies and more extensive culturing approaches [ 2 ] have enabled the identification of bacterial strains in the pulmonary microbiota only recently considered to potentially have a pathogenic role including members of the genera Bacteroides , Gemella , Prevotella , Sphingobacterium and Nocardia spp [ 9 , 10 , 11 , 12 , 13 , 14 , 15 ].
Specifically for Nocardia , a large number of species have been recognized with different geographic prevalences, pathogenic traits, and antimicrobial susceptibility patterns [ 5 ]. Therefore, the identification of Nocardia isolates to the species level might provide physicians with useful information but only limited laboratories have the necessary facilities [ 5 ]. Nocardia spp are a gram-positive aerobic filamentous bacteria, ubiquitous in soil and aquatic habitats and worldwide spread. Transmission occurs mainly by inhalation of organisms contained in the dust, but also, more rarely, by skin inoculation directly through a wound [ 3 , 4 , 5 , 6 ].
Nocardial infection may be associated to lung or skin disease and, especially in immunocompromised patients, it may disseminate and virtually involve any body site, including the central nervous system (CNS) where brain abscesses may occur, while meningitis is rarely seen [ 4 , 6 ].
Pulmonary nocardiosis can manifest as acute, subacute, or chronic disease. Symptoms of nocardiosis are unspecific and may include fever, dyspnea, chest pain, increased respiratory secretions and night sweats [ 4 , 6 ]. X-ray shows multiple lung infiltrates, rarely associated with necrotizing pneumonia. Chest radiograph can demonstrate areas of consolidation, mild diffuse infiltrates, reticulonodular patterns, or cavitation [ 6 ]. According to some experts“opinion, if Nocardia species are identified in CF sputum, his clinical significance and the optimal patient management remain unclear [ 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 ]. Determining the difference between Nocardia infection versus colonization is extremely challenging in CF patients due to several reasons: the inconsistency of patient’s clinical symptoms, the absence of pathognomonic radiological features, the difficulty in identifying this slow-growing microorganism on common culture media (although nowadays the use of non-culture methods such as NGS (Next-Generation Sequencing) and PCR (Polymerase Chain Reaction), where applicable, have resolved this issue), the lack of understanding of its role in the microbiota of the lung in a patient with CF. Furthermore, Nocardia species are often found alongside other microorganisms. Moreover, to complicate the picture, adverse events to antibiotic therapy may occur and appropriate duration of therapy in these patients is under debate [ 8 , 9 , 10 , 15 ].
With this systematic review, our aim is to examine the current understanding of the clinical implications of Nocardia species in individuals with CF, starting from the presentation of a clinical case. Moreover, a systematic literature review was performed in order to evaluate the management of Nocardia isolation and outcomes in patients with CF. Finally, we attempt to address some of the questions that clinicians might face when encountering this unconventional bacterium in the respiratory tracts of pwCF.
Do nocardia species have a pathogenic role in patients with cf.
What are the risk factors for nocardiosis in pwCF?
Does Nocardia affect lung function in pwCF?
Should pwCF with Nocardia -positive sputum always be treated?
What antibiotic regimen should be used in pwCF?
How long should the antibiotic treatment for Nocardia last in pwCF?
Articles reporting Nocardia prevalence and symptoms based on original data in adult and paediatric pwCF were included. Commentaries, editorials and letters to the author with no original data were excluded as well as studies concerning Nocardia ’s infection in persons who did not have CF. No restrictions on language of publication were applied.
We performed a systematic review of the literature, according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guideline recommendations.
We searched the MEDLINE by PubMed, Embase and Cochrane databases for articles available up to 30 June 2023. Search terms for the MEDLINE and EMBASE database were: (“Nocardiosis” [All Fields] OR “Cystic Fibrosis” [All Fields] OR “Nocardiosis isolation” [All Fields] OR “Nocardiosis treatment” [All Fields] OR “Nocardiosis prognosis” [All Fields] OR “Infections in pwCF” [All Fields].
At first, we screened titles and abstracts to discover eligible studies, and then we analyzed all full texts for the final evaluation. Two investigators (TB, AC) independently reviewed and evaluated every study. Studies were limited to human participants and of any follow-up duration and timepoints. The quality of the eligible studies was evaluated by two authors independently (TB, AC), using different methods according to the study design: The Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Case Reports [ 16 ] and the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Case Series [ 17 ]. We planned to use the Newcastle-Ottawa Quality Assessment Form for the analytic observational studies [ 18 ], however, we did not identify articles that properly fitted this definition.
From each study, we selected information regarding study design, date of publication, country of origin, age at first Nocardia ’s isolation, Nocardia ’s species, co-infections, reported symptoms, deaths related to Nocardiosis , patients for whom FEV1 has worsened, type of treatment and the number of eradicated patients. All key extracted data were reviewed and quality checked at the end of the data extraction phase by the same two researchers. All the retrieved studies were observational ones, thus, they were categorized by study type as case report and case series.
Included studies.
The process of selecting included studies is shown in the Fig. 1 .
flow chart of the study selection
Overall, 41 articles were initially retrieved; a total of 16 articles were eligible according to our criteria and were included in the review: 9 case reports and 7 case series.
Characteristics of the included studies are reported in Table 1 .
The quality assessment of the studies is reported in Figs. 2 and 3 .
Quality assessment of the included studies. Figure 2 : The Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Case Reports; Fig. 3 : The Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Case Series.
Quality assessment of the included studies: the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Case Reports
Quality assessment of the included studies: the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Case Series
Overall, 89 pwCF and Nocardia species isolation were included: 42 children and 47 adults. Among the 71 patients whose sex was specified, 32 were female (45%) and 39 were male (55%). Where reported, we found the following bacterial species: Nocardia asteroides (35%, 23/64), Nocardia farcinica (21%, 14/64), Nocardia tranvalensis (13%, 8/64), Nocardia cyriacigeorgica (11%, 7/64), Nocardia abscessus (5%, 3/64), Nocardia veterana (3%, 2/64), Nocardia wallacei (3%, 2/64), Nocardia miyunesis (1%, 1/64), Nocardia pneumoniae (1%, 1/64), Nocardia asiatica (1%, 1/64), Nocardia elegans (1%, 1/64), Nocardia otitidiscavarium (1%, 1/64). A co-infection was reported in 85% of patients (61/72). In 17 patients the possible presence of other microorganisms in sputum was not mentioned.
Of patients whose lung function was reported before and after Nocardia isolation, 23% (16/68) showed a decline in FEV 1 .
Above all, 82 patients were treated at least once after isolation of Nocardia strain. In 93% (77/82) of cases, treatment was started immediately upon isolation.
Antibiotic treatment was performed per o s or intravenously depending on the clinical condition of the individual patient. The following antibiotics were prescribed in the 16 selected articles: trimethoprim-sulfamethoxazole (52/82, 63%), ciprofloxacin (17/82, 20%), penicillins (16/82, 18%), aminoglycosides (12/82, 14%), cephalosporins (11/82, 13%), carbapenems (10/82, 12%), tetracyclines (8/82, 10%), linezolid (7/82, 9%). For 30 out of 89 patients (33%), hospitalization and intravenous antibiotic therapy were required. Death was reported in 3 patients, 2 of which were children, with severe lung disease or Pa and Mycobacterium avium complex co-infection.
Nocardia eradication was attempted in only 32 cases out of 82, and 78% (25/32) of these patients were successfully eradicated from Nocardia after one or more courses of antibiotics.
The results of the studies have been reported in the Table 1 .
The pathogenic role of Nocardia in pwCF is still unclear [ 10 , 15 ]. In 2002, Lumb et al., in a retrospective study on 3 pwCF, firstly discussed the role of Nocardia as a possible pathogen in CF, concluding that the isolation of this bacteria does not always mean active infection. Therefore, the treatment must be considered in the clinical context of each patient and a careful follow-up is mandatory, particularly in patients in therapy with steroids due to their immunosuppressive effect [ 8 ]. This view was confirmed by subsequent studies. In 2009 Thorn et al., in a retrospective study on 17 pwCF, concluded that Nocardia frequently acts as a colonizer, not resulting in active infection with symptoms or impaired respiratory function [ 10 ]. Our study confirms this variability in the pathogenicity of Nocardia across various studies and suggests a clinically guided approach based on imaging and lung function.
In the previously mentioned study by Lumb et al., the authors associate nocardiosis with cell-mediated immunosuppression, potentially facilitated by corticosteroid oral treatment or a history of transplantation [ 8 , 9 , 13 , 19 ]. Others link nocardiosis to the co-colonization of Nocardia species and Pa [ 10 ], although this observation is strictly clinical and contradicted by other case series studies [ 15 , 22 ], or highlight a history of bronchopulmonary aspergillosis (ABPA) as a high risk to develop lung disease in CF patients with Nocardia species [ 21 ]. Similarly, Nocardia can be damaging in patients undergoing lung transplantation, resulting in rapid failure of respiratory function, as described by Chacon et al. in 2014 [ 19 ]. Some authors correlate the subspecies of Nocardia transvalensis with a greater symptom burden than the more prevalent Nocardia asteroides subspecies [ 20 ]. Nocardia isolations are typically uncommon in the general pediatric population, and advanced age is recognized as a risk factor for nocardia’s infections. However, our analysis reveals that children contract these infections at a similar rate to adults. These findings might indicate that, in addition to age, CF should be regarded as an additional risk factor [ 15 ]. Finally, a recent case report link necrotizing pneumonia to co-infection of Nocardia and Covid-19 in pwCF [ 25 ].
In 2015, a longitudinal study examined pulmonary function tests (PFT) in pwCF before and after Nocardia isolation not reporting statistically significant difference between patients with a single episode and those with recurrent isolation, nor between patients that underwent antibiotic therapy and those who did not receive treatment. However, pwCF affected by nocardiosis showed a small trend to faster decline in PFTs compared to similar status CF patients without isolation of this microorganism in their sputum [ 11 , 22 ]. Other authors noticed Nocardia species positive sputum culture may be followed by lung function deterioration and may promote the onset of other infections [ 21 ]. Our review demonstrates that only a few patients exhibit a deterioration in lung function following the isolation of Nocardia . However, data on lung function trends in these patients are weak in the literature and deserve further investigation.
At the present there are no guidelines for treatment of Nocardia in pwCF and the most prudent strategy seems to be the one suggested by Barrio et al. in a retrospective study in 2008: the isolation of Nocardia does not necessarily imply therapy and patients need to be monitored closely to assess the possible occurrence of active infection and subjects to be treated should be selected on an individual basis [ 10 ].
A proposal for a therapeutic management algorithm is reported in Supplemental Figure S1 . Antibiotic treatment should always be administered when Nocardia species are isolated in patients before undergoing lung transplantation [ 13 , 15 , 19 ]. Otherwise the majority of authors agree to treat Nocardia species when, even though initially categorized as a colonizer, they are isolated in presence of : worsening of clinical status, radiological features or lung function or in cases where there is a concurrent infection with more common bacterial species in pwCF, such as Pa, and the patient does not improve despite broad antibiotic coverage [ 8 , 10 , 14 , 15 , 20 , 21 ]. However, the eradication of Nocardia species is difficult to obtain [ 19 ]. In any case, most studies performed so far describe few cases of Nocardia infection in pwCF, and it is possible that the occurrence of such infection is underestimated due to its limited recognition and research in laboratories [ 9 , 15 , 23 ].
In conclusion, our study shows that, although in a few cases the isolation of Nocardia is directly associated with a deterioration in lung function, various cystic fibrosis centers around the world prefer to treat it immediately.
Antibiogram should drive the selection of the most effective therapy [ 11 , 23 ]. Interestingly, the species that more frequently infect pwCF seem to not show difference in the pattern of susceptibility [ 15 , 23 ] even if the identification of the species is rather difficult using conventional cultural and biochemical methods, and misclassifications may occur [ 4 ]. In most studies, trimethoprim-sulfamethoxazole was used as first-line treatment, followed by minocycline or amikacin in more severe forms [ 7 , 8 , 9 , 10 , 11 , 12 , 14 , 15 , 19 , 21 , 23 ]. Linezolid, to which Nocardia is almost always susceptible, may be an alternative [ 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 ]. In case of worsening general clinical conditions, hospitalization is necessary along with the initiation of intravenous antibiotic therapy using at least two antibiotics chosen based on the antibiogram [ 14 , 15 , 21 ]. When combination therapy is required, drugs included can be third- generation cephalosporins, amikacin and imipenem [ 12 , 13 , 15 , 19 , 20 , 21 , 22 , 23 ].
It should be continued based on the severity of the pulmonary condition and the progression of antimicrobial susceptibility [ 3 , 14 , 15 , 20 , 21 ]. In the literature, treatments from 6 to 12 months are recommended for serious lung infections or in patients with strong immunosuppression. If symptoms are few, treatment could be reduced to 1–3 months [ 15 ].
Nocardia species are a complex group of organisms which can be isolated in pwCF. Of the validly described species, not all strains have been shown to be pathogenic in humans. Several species have been implicated as the cause of serious infections, especially in immunocompromised patients such as pwCF, but the identification of the specific Nocardia spp complex and expensive techniques available only in few laboratories. The picture is further complicated by the fact that Nocardia is not included in dedicated CF registries, so the care of these patients relies on individual experiences reported by centers located around the world and related reviews.
Several studies suggest that Nocardia acts mainly as a colonizer rather than a pathogen, not resulting in active infection, while other studies illustrate how Nocardia species could cause lung deterioration and promote the onset of other bacterial infections. In particular, patients with history of ABPA, those undergone lung transplantation or in therapy with steroids or immunosuppressor, are at a higher risk of clinically active Nocardiosis.
Management of nocardia isolation has no protocols validated by evidence-based medicine approach and under these circumstances our center, as well as others reported in this review, has chosen a pro-active approach and attempted eradication in the absence of symptoms as is done with other pathogens in pwCF.
In general the isolation of the bacteria does not necessarily imply therapy, but patients need to be monitored closely to assess the possible occurrence of active infection. On the contrary, the treatment is indicated in patients showing lung involvement with the possible appearance of pneumonia, pleural effusion, fever, cough, or a decrease in FEV 1 , or in patients undergoing pulmonary transplantation. However, the eradication of Nocardia is difficult to obtain. The complexity of Nocardia’s role in pwCF underscores the importance of individualized patient care and ongoing clinical monitoring.
Further research is needed to refine treatment strategies, identify definitive risk factors, and elucidate its impact on lung function, as well as defining the role of the lung microbiota on the risk of infection or the impact of new CFTR modulators. The possibility of improvement in CFTR function resulting in enhanced ability to clear pathogens, has attracted considerable attention and literature, in particular for P. Aeruginosa and A. Fumigatus [ 24 , 25 ], and this possibility could radically change the prognosis of these patients witch Nocardiosis .
All data generated or analysed during this study are included in this published article.
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Department of Paediatric Medicine, IRCCS, Cystic Fibrosis Regional Reference Center, Meyer Children’s Hospital, Florence, Italy
Vito Terlizzi, Daniela Dolce, Silvia Campana & Giovanni Taccetti
Department of Health Sciences, Pediatric resident, Meyer Children’s University Hospital IRCCS, University of Florence, Florence, Italy
Tommaso Ballerini & Alice Castaldo
SC di Pneumologia e UTSIR, AORN Santobono-Pausilipon, Naples, Italy
Alice Castaldo
Infectious Diseases Unit, Meyer Children’s Hospital IRCCS, Florence, Italy
Elena Chiappini
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All authors contributed to the concept and design of the systematic review for which this protocol has been written. TB and AC wrote the first draft of the manuscript. EC, VT, DD, SC and GT contributed to subsequent drafts. All authors reviewed and approved the final manuscript before submission.
Correspondence to Elena Chiappini .
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Terlizzi, V., Ballerini, T., Castaldo, A. et al. Clinical features and outcomes of persons with cystic fibrosis and nocardia isolation: a systematic review. BMC Pulm Med 24 , 440 (2024). https://doi.org/10.1186/s12890-024-03217-0
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Background Recurrent respiratory infections are a leading cause of morbidity and mortality in persons with Cystic Fibrosis (pwCF). Recently, the emergence of Nocardia species as a potential pathogen in CF has raised questions about its role and management, as its clinical significance and the optimal patient management remain unclear in current clinical practice. This review explores the ...