Management

New Guideline for Treatment of Adults With Nontuberculous Mycobacterial Pulmonary Disease

The American Thoracic Society, European Respiratory Society, European Society of Clinical Microbiology and Infectious Diseases, and Infectious Diseases Society of America have developed a new guideline for the treatment of adults with nontuberculous mycobacterial (NTM) pulmonary disease. Included are 31 evidence-based recommendations.

The guideline focuses on the treatment of adults without cystic fibrosis or HIV infection who have pulmonary disease caused by the most common NTM pathogens. Included among the slowly growing NTM are Mycobacterium avium complex (MAC), Mycobacterium kansasii, and Mycobacterium xenopi. Included among the rapidly growing NTM is Mycobacterium abscessus.

For each NTM that is addressed, the recommendations are organized by the medications that should be included in the regimen, the frequency of administration, and the duration of therapy. Among the strong recommendations are:

  • Instead of a standard oral regimen, add amikacin liposome inhalation suspension to the treatment regimen for patients with MAC pulmonary disease who have failed therapy after at least 6 months of guideline-based therapy.
  • Consider a macrolide-containing multidrug treatment regimen for patients with M abscessus pulmonary disease caused by strains without inducible or mutational resistance.
  • Consider a 3-drug regimen that includes a macrolide over a 3-drug regimen without a macrolide for patients with macrolide-susceptible MAC pulmonary disease.

 

Other conditional recommendations include:

  • Instead of watchfully waiting, initiate treatment for patients who meet the diagnostic criteria for NTM pulmonary disease, especially in the context of positive acid-fast bacilli sputum smears and/or cavitary lung disease.
  • Consider susceptibility-based treatment for macrolides and amikacin over empiric therapy for patients with MAC pulmonary disease.
  • Consider a regimen of rifampicin, ethambutol, and either isoniazid or macrolide for patients with rifampicin-susceptible M kansasii pulmonary disease.
  • Consider using a multidrug treatment regimen that includes moxifloxacin or macrolide among patients with M xenopi pulmonary disease.

 

The guideline panel comprised specialists in pulmonary medicine, infectious diseases and clinical microbiology, laboratory medicine, and patient advocacy.

According to the authors, many research gaps in the treatment of NTM pulmonary disease were identified during the guideline’s development. The panel suggests that future research priorities focus on the need for new medications, treatment regimens, shorter regimens, and better-tolerated regimens.

—Colleen Murphy

Reference:

Daley CL, Iaccarino Jr JM, Lange C, et al. Treatment of nontuberculous mycobacterial pulmonary disease: an official ATS/ERS/ESCMID/IDSA clinical practice guideline: executive summary. Clin Infect Dis. Published online July 6, 2020. doi:10.1093/cid/ciaa241