What are the recommended treatments for nontuberculous mycobacterial (NTM) infections in children, including cervical lymphadenitis and pulmonary disease?

Treatment of Nontuberculous Mycobacterial (NTM) Infections in Children

For NTM cervical lymphadenitis in children, complete surgical excision without chemotherapy is the definitive treatment with a 95% cure rate, while pulmonary NTM disease requires macrolide-based multidrug antibiotic regimens tailored to the specific species and susceptibility patterns. 1

NTM Cervical Lymphadenitis (Most Common Pediatric Presentation)

Primary Treatment Approach

Complete excisional surgery without chemotherapy is the gold standard for children with NTM cervical lymphadenitis, achieving approximately 95% cure rates. 1 This applies to disease caused by MAC (Mycobacterium avium complex) and M. scrofulaceum, which account for the majority of cases in children under 3 years of age. 1

Critical Pitfalls to Avoid

• Never perform incisional biopsy alone or use anti-TB drugs without a macrolide, as this frequently leads to persistent disease, sinus tract formation, and chronic drainage. 1
• Fine needle aspiration for diagnosis followed by complete excision is acceptable. 1

Alternative Treatment Options

When surgery is not feasible or for recurrent disease:

• Clarithromycin-based multidrug regimen (same as used for pulmonary MAC disease) is the alternative. 1
• This approach is particularly appropriate when surgical risk is high, such as preauricular nodes with facial nerve involvement risk. 1
• Recent evidence shows that observation ("wait and see") or antibiotics alone achieve 70-73% cure rates, though significantly lower than complete excision (98%). 2

Important consideration: Complete excision carries a 10% risk of facial nerve palsy (2% permanent), which must be weighed against the higher cure rate. 2

Special Clinical Scenario

If a child has granulomatous disease on excised lymph nodes AND a strongly positive PPD (≥15 mm):

• Start anti-TB therapy while awaiting culture results, especially with TB risk factors (positive family history, foreign-born child). 1
• Discontinue anti-TB therapy if cultures are negative for mycobacteria and no significant TB risk factors exist. 1

Pulmonary NTM Disease in Children

MAC Pulmonary Disease

For children with MAC pulmonary disease, treatment mirrors adult regimens but requires careful dosing:

Daily regimen for severe or fibrocavitary disease:

• Clarithromycin (dose adjusted for weight) or azithromycin
• Rifampin or rifabutin
• Ethambutol (15 mg/kg/day)
• Consider adding amikacin or streptomycin three times weekly early in therapy 1

Duration: Continue treatment until culture-negative for 1 year. 1

M. abscessus Pulmonary Disease

M. abscessus represents the most challenging NTM to treat in children. The 2020 ATS/ERS/ESCMID/IDSA guidelines provide the most current approach:

• Macrolide susceptibility testing is mandatory, including detection of functional/nonfunctional erm(41) gene. 3
• For macrolide-susceptible strains: Use a macrolide-containing regimen with at least 3 active drugs guided by in vitro susceptibility. 3
• For strains with inducible or mutational macrolide resistance: Macrolides may still be used for immunomodulatory properties but don't count as an active drug. 3

Critical point: There are no drug regimens of proven or predictable efficacy for M. abscessus lung disease. 1 Multidrug clarithromycin-based regimens may cause symptomatic improvement, but surgical resection of localized disease combined with multidrug therapy offers the best chance for cure. 1

Duration Considerations for M. abscessus

The optimal duration remains controversial and should be individualized based on:

• Nodular/bronchiectatic versus cavitary disease
• M. abscessus subspecies
• Macrolide and amikacin susceptibility
• Expert consultation is strongly recommended 3

Intrathoracic NTM in Otherwise Healthy Children

Recent evidence shows that pulmonary NTM can occur in immunocompetent young children (12 months to 2.5 years) presenting with:

• Refractory wheezing or stridor failing bronchodilator therapy
• Endobronchial lesions and/or hilar lymph nodes causing bronchial obstruction 4

Treatment: Anti-mycobacterial therapy with or without surgery has been successful, without identified immunologic abnormalities or CFTR mutations. 4

Disseminated MAC Disease

For children with AIDS and disseminated MAC:

• Clarithromycin or azithromycin
• Ethambutol (15 mg/kg/day)
• With or without rifabutin
• Dual approach required: Treat both mycobacterial infection AND HIV to improve underlying immunosuppression 1

Key Principles Across All Pediatric NTM Treatment

1. Species identification is mandatory to guide appropriate therapy
2. Macrolide-based regimens are the cornerstone for most NTM infections requiring antibiotics
3. Surgical intervention plays a critical role in both lymphadenitis (primary treatment) and pulmonary disease (adjunctive for localized disease)
4. Expert consultation is essential for complex cases, particularly M. abscessus infections 3
5. Recent data shows increasing incidence of pediatric NTM adenitis, with M. avium as the predominant species 5