From the Guidelines
The treatment for non-tuberculous mycobacterium (NTM) infections typically involves a multidrug antibiotic regimen tailored to the specific mycobacterial species and infection site, with the most recent guidelines recommending a daily oral antibiotic regimen containing a macrolide, rifampin, and ethambutol for MAC pulmonary disease 1.
Key Considerations
- For Mycobacterium avium complex (MAC), the most common NTM infection, treatment usually consists of a macrolide (clarithromycin 500mg twice daily or azithromycin 250-500mg daily) combined with ethambutol (15mg/kg daily) and often rifampin (600mg daily) or rifabutin (300mg daily) 1.
- For M. abscessus, treatment may include a combination of intravenous antibiotics (amikacin, imipenem, tigecycline) for several weeks followed by oral macrolides with additional agents 1.
- M. kansasii infections generally respond well to rifampin, ethambutol, and isoniazid 1.
- Treatment duration is lengthy, ranging from 12-24 months depending on the species and disease severity 1.
- Surgical intervention may be necessary for localized disease or when drug therapy fails 1.
- Drug susceptibility testing is crucial as resistance patterns vary widely among NTM species 1.
- Side effects must be monitored closely, including hepatotoxicity, vision changes with ethambutol, and hearing loss with aminoglycosides 1.
Monitoring and Follow-up
- Patients should be treated until culture negative on therapy for 1 year 1.
- Sputum culture conversion to negative is a key indicator of treatment success 1.
- Regular monitoring of liver function, renal function, and hearing is essential to minimize the risk of adverse effects 1.
Recent Guidelines
- The 2020 ATS/ERS/ESCMID/IDSA clinical practice guideline recommends a daily oral antibiotic regimen containing a macrolide, rifampin, and ethambutol for MAC pulmonary disease 1.
- The guideline also recommends against the use of monotherapy with a macrolide or other antimicrobial agent for the treatment of NTM pulmonary disease 1.
From the Research
Treatment for Non-Tuberculoid Mycobacterium (NTM) Infections
- The treatment for NTM infections typically involves a combination of antibiotics, such as rifampicin, ethambutol, and clarithromycin 2.
- A study published in 2021 found that the combination of rifampicin, ethambutol, and clarithromycin (REC) provided relatively good clinical results for the treatment of hand MAC, but recurrences were observed even after completion of REC 2.
- Another study published in 2014 found that treatment with clarithromycin and ethambutol was not inferior to treatment with clarithromycin, ethambutol, and rifampicin for Mycobacterium avium complex lung disease 3.
- A study published in 1998 compared azithromycin plus ethambutol with clarithromycin plus ethambutol in the treatment of disseminated MAC infection in HIV-infected patients, and found that clarithromycin plus ethambutol was more effective at sterilizing blood cultures after 16 weeks of therapy 4.
Principles of Treatment
- The treatment of NTM-PD should be guided by the principles of patient-centered care and pathogen-directed therapy 5.
- The choice of antibiotics and the duration of treatment should be individualized based on the specific NTM species, the severity of the disease, and the patient's response to treatment.
- Combination therapy is often necessary to prevent the selection of resistant mutant strains and to achieve optimal clinical outcomes.
Antibiotic Combinations
- A study published in 1996 found that the combination of rifabutin, clarithromycin, and ethambutol had significant activity against M. avium in human macrophages, and suggested that this combination may be useful in the treatment of disseminated MAC infection 6.
- Other antibiotic combinations, such as azithromycin plus ethambutol, and clarithromycin plus ethambutol, have also been studied and found to be effective in the treatment of NTM infections 3, 4.