Treatment of Slowly Growing Mycobacteria

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Key points

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    The treatment of slow-growing mycobacteria requires a multidrug regimen and a long course of therapy, typically 12 to 18 months.

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    The only drugs for which in vitro susceptibilities correlate with an in vivo response in MAC lung disease are macrolides and amikacin.

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    Patients with macrolide-resistant MAC and patients who do not respond to standard therapy require early referral and treatment at a specialized center.

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    Inhaled amikacin may provide an adjunct therapy for the treatment of MAC lung disease,

Patient evaluation overview

Slowly growing NTM lung disease, especially caused by MAC, is broadly associated with 2 distinct radiographic forms of disease. The first to be described involves upper lobe fibrocavitary densities resembling pulmonary tuberculosis and occurs primarily in men with underlying obstructive lung disease (Fig. 1A). The second radiographic manifestation involves nodules and bronchiectasis and occurs primarily in women without underlying pulmonary disease other than bronchiectasis and in the United

Mycobacterium avium Complex

There are multiple impediments to successful MAC lung disease therapy that are pertinent, at least to some degree, to other slowly growing NTM pathogens. It is all too familiar to clinicians that treatment outcomes for MAC lung disease are in general less successful than treatment outcomes for tuberculosis. The explanation(s) for this observation are likely multiple and not readily apparent but are the subject of intense investigation.

Perhaps the most frustrating aspect of NTM lung disease

Nonpharmacologic treatment options

Mounting evidence suggests that household sources of NTM exposure, specifically household plumbing and water sources, are important for contracting NTM pathogens. The recent evidence of likely NTM recurrence after successful NTM therapy in bronchiectasis suggests an ongoing host vulnerability, which seems to suggest the necessity for efforts to limit environmental NTM exposure.25 However, it is still unknown how much of a risk NTM in municipal water and household plumbing presents for most

Treatment resistance/complications

An additional critical element in the management of patients with MAC lung disease is prevention of the emergence of macrolide resistance. Although the role of in vitro susceptibility for most other agents remains controversial, it is clear that the development of macrolide resistance in a MAC isolate (MIC >16 μg/mL) is strongly associated with treatment failure and increased mortality.31 The most important risk factors for developing macrolide-resistant MAC are macrolide monotherapy and the

Evaluation of outcome and long-term recommendations

Long-term follow-up is essential in NTM lung disease. We recommend monthly sputum sampling for AFB as well as routine culture while patients are taking antibiotic therapy and every 1 to 2 months thereafter after cessation of therapy, at the least for the first year after stopping antimicrobials. Although there are no established guidelines, we obtain imaging by chest radiograph and high-resolution computed tomography (CT) of the chest before starting therapy for NTM. Repeat radiographs, usually

Summary

Slowly growing mycobacteria cause most NTM lung disease in the United States, with MAC the most frequent and important NTM pulmonary pathogen. Treatment of MAC is usually successful, although not as often successful as treatment of tuberculosis. Guideline-based therapy is effective, although for unclear reasons, it is not embraced for many patients with MAC lung disease. The consequence of inadequate MAC therapy can be the emergence of macrolide-resistant MAC, which is associated with high

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    Disclosure: Dr. Philley served on an advisory board for Insmed Pharmaceuticals in 2014.

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