eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease
Atypical Mycobacterial Infection: Treatment & Medication
Updated: Sep 18, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
See Medication.
Surgical Care
Pediatric neck abscesses remain common problems that are sometimes difficult to manage.70 Surgical excision of infected nodes is recommended for immunocompetent children with suppurative adenitis secondary to M avium complex (MAC) and M scrofulaceum. The temptation is great to incise and drain the abscess cavity when fluctuant involvement is present. If this is done, a draining sinus usually persists until discharge of the involved lymph nodes beneath the skin has taken place over a period of months or years.22,7 Careful attention should be paid to avoid any injury to the mandibular branch of the facial nerve because it is often adherent to the tract.22
Consultations
Disseminated MAC disease is best treated in collaboration with a pediatric infectious disease specialist with experience in the treatment of pediatric HIV infection.
Diet
Diet should be individualized in the presence of gastrointestinal complications such as diarrhea and vomiting. Moderate and severe dehydration should be treated accordingly. Nutritional intervention such as nasogastric feeding and hyperalimentation through a central catheter, gastrostomy tube feeding, or jejunostomy tube feeding in the presence of gastroparesis should be considered. Oral feeding can be resumed when appropriate to improve the patient's quality of life.
Activity
Patients who are acutely or chronically ill may be weak and debilitated. Caloric loss and poor intake may restrict their daily activities. Pain relief treatment in the presence of recurrent abdominal pain is necessary to keep patients comfortable.
Medication
The treatment regimen for pediatric patients infected with HIV with disseminated M avium complex (MAC) disease includes at least 2 antimicrobials, one of which should be either clarithromycin or azithromycin.61,71 Many experts prefer ethambutol as the second drug. Some clinicians have added a third or fourth agent from the following list: clofazimine, rifabutin, ciprofloxacin, or amikacin.72,61,73,30 The choice of therapy should be based on sensitivity reports before the combination regimen is started. Antiretroviral agents should be initiated within 1-2 weeks of MAC treatment for patients who have not previously received or are not currently receiving antiretroviral drugs.
The possible benefits of administering ciprofloxacin to a child infected with HIV who has developed disseminated MAC infection frequently outweighs cautions regarding ciprofloxacin use in children younger than 13 years.72 Rifabutin induces CYP3A isoenzyme and, therefore, may reduce the plasma concentration of drugs metabolized by those enzymes (eg, itraconazole, clarithromycin, saquinavir).73 Drugs that inhibit CYP3A (eg, delavirdine, indinavir, nelfinavir, ritonavir) may significantly increase rifabutin plasma concentration. In such cases, the rifabutin dose should be reduced. Therapy should continue for the lifetime of the patient if clinical and microbiologic improvement is observed.72
Despite multiple drug combination therapy, disseminated MAC disease treatment in children infected with HIV is still a challenge. Multiple drug-resistant strains are always present, and sensitivity rarely exceeds 2 or 3 drugs.30 With prolonged survival time, children and adolescents develop resistance because of the duration of treatment. Clinical improvement, characterized by weight gain and absence of fever and diarrhea, may be present during the early treatment period; however, intolerance to medication, concurrent infections, and, sometimes, multiorgan failure, may impair the efficacy of a therapeutic regimen.
Therapy for disseminated MAC disease should be continued for life unless sustained immune recovery occurs with potent antiretroviral therapy.72 Discontinuation of MAC therapy did not show resurgence in clinical symptoms and the presence of MAC in subsequent blood cultures. Ongoing clinical studies may suggest that MAC therapy may not need to be indefinitely continued.53 In immunocompetent patients with lymphadenitis secondary to MAC, complete excision of major nodes is recommended. If excision is incomplete or disease recurs, clarithromycin or azithromycin plus ethambutol with rifampin should be used. That same regimen is recommended for pulmonary infections caused by MAC. However, management of MAC infection in HIV-negative patients without preexisting lung disease can be challenging.74,75
Excision of tissue is recommended in disseminated cutaneous infection caused by M fortuitum complex. Initial therapy is amikacin plus cefoxitin intravenously, followed by erythromycin, clarithromycin, doxycycline, or ciprofloxacin orally. Doxycycline is contraindicated in children younger than 8 years. Fluoroquinolones are contraindicated in children younger than 18 years. For catheter-related infections, the usual treatment is catheter removal combined with appropriate antibiotics (amikacin plus cefoxitin) for 6-12 weeks.3 Pulmonary infections and osteomyelitis caused by M kansasii are treated with rifampin plus ethambutol with isoniazid. Surgical debridement and prolonged antibiotic therapy may be necessary for patients with osteomyelitis.
Minor cutaneous infections caused by M marinum do not require any treatment. Rifampin, trimethoprim-sulfamethoxazole, clarithromycin, or doxycycline is used for moderate diseases. Surgical debridement may be required for extensive lesions. Patients with otitis media caused by M abscessus should receive clarithromycin plus an initial course of amikacin plus cefoxitin. Surgical debridement may be required. Pulmonary infection in patients with CF should be treated based on susceptibility testing. Some experts recommend a 1-month course of intravenous imipenem or cefoxitin plus amikacin followed by oral clarithromycin plus ethambutol for at least 12 months after negativation.32 It may require surgical resection. Expert advice is recommended, and decisions should be made in consultation with a pediatric infectious disease specialist.
Dual therapy with rifampicin and streptomycin as well as surgical debridement is the standard treatment recommended for patients with Buruli ulcer.76 The combination of rifampicin and streptomycin results in a rapid onset of local cellular responses associated with phagocytosis of the extracellular M ulcerans. This may be related to declining levels of the macrolide toxin mycolactone in the tissue, thus leading to an enhanced chemotherapy-induced clearance of the infection.76
Indicated for treatment and prevention of disseminated MAC disease. The choice of therapy should be based on sensitivity reports before antimicrobial initiation. Regimens for treatment include 2 or more antimicrobials.
Azithromycin (Zithromax)
Macrolide that inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. It is used in combination with at least one other drug for treatment of disseminated MAC disease and as a primary prophylactic agent in patients who are severely immunocompromised based on their CD4+ lymphocyte count.
Adult
Treatment: 600 mg/d PO
Prophylaxis: 1200 mg PO qwk
Pediatric
Treatment: 10-12 mg/kg/d PO; not to exceed adult dose
Prophylaxis: 20 mg/kg PO qwk; not to exceed adult dose
Not affected by the CYP system; can be safely used in the presence of protease inhibitors and/or nonnucleoside reverse transcriptase inhibitors without concern of drug interactions; may increase toxicity of theophylline, warfarin, and digoxin; effects are reduced with coadministration of aluminum and/or magnesium antacids; nephrotoxicity and neurotoxicity may occur when coadministered with cyclosporine.
Toxicity increases when coadministered with fluconazole or pimozide; effects decrease and GI adverse effects may increase when coadministered with rifabutin or rifampin; may increase toxicity of anticoagulants, cyclosporine, tacrolimus, digoxin, carbamazepine, ergot alkaloids, triazolam, and HMG-CoA reductase inhibitors; benzodiazepine plasma levels may increase, prolonging CNS depression; arrhythmias and increases in QTc intervals occur with disopyramide; coadministration with omeprazole may increase plasma levels of both agents; decreases metabolism of repaglinide, thus increasing serum levels and effects
Documented hypersensitivity; hepatic impairment; coadministration with pimozide
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Site reactions can occur with IV route; bacterial or fungal overgrowth may result from prolonged antibiotic use; may increase hepatic enzymes and cholestatic jaundice; caution in patients with impaired hepatic function, prolonged QT intervals, or pneumonia; caution in hospitalized, geriatric, or debilitated patients
Clarithromycin (Biaxin)
Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest.
Adult
500 mg PO bid; alternatively, Biaxin XL 1 g/d PO
Pediatric
15-30 mg/kg/d PO divided q12h; not to exceed adult dose
Toxicity increases when coadministered with fluconazole or pimozide; effects decrease and GI adverse effects may increase when coadministered with rifabutin or rifampin; may increase toxicity of anticoagulants, cyclosporine, tacrolimus, digoxin, carbamazepine, ergot alkaloids, triazolam, and HMG-CoA reductase inhibitors
Benzodiazepine plasma levels may increase, prolonging CNS depression; arrhythmias and increases in QTc intervals occur with disopyramide; coadministration with omeprazole may increase plasma levels of both agents; decreases metabolism of repaglinide, thus increasing serum levels and effects
Protease inhibitors may increase clarithromycin levels, but no recommendation to adjust the dose of either clarithromycin or protease inhibitors can be made based on existing data; efavirenz can induce metabolism of clarithromycin, and this may result in reduced serum concentration of clarithromycin but increased concentration of 14-OH clarithromycin, an active metabolite of clarithromycin
Although the clinical significance of this interaction is not known, the efficacy of clarithromycin in MAC prophylaxis could be reduced because of this interaction
Documented hypersensitivity; coadministration of pimozide
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Teratogen in animals and should be used with caution during pregnancy; coadministration with ranitidine or bismuth citrate is not recommended with CrCl <25 mL/min; administer half dose or increase dosing interval if CrCl <30 mL/min; diarrhea may be sign of pseudomembranous colitis; superinfections may occur with prolonged or repeated antibiotic therapies
Erythromycin (EES, E-Mycin, Eryc, Ery-Tab)
Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes causing RNA-dependent protein synthesis to arrest. In children, infection severity determines proper dosage. When bid dosing is desired, half-total daily dose may be taken q12h. For more severe infections, double the dose.
Adult
250 mg erythromycin stearate/base (or 400 mg ethyl succinate) PO q6h 1 h ac or 500 mg q12h
Alternatively, 333 mg q8h; increase to 4 g/d depending on severity of infection
Pediatric
30-50 mg/kg/d (15-25 mg/lb/d) PO divided q6-8h; double dose for severe infection
Coadministration may increase toxicity of theophylline, digoxin, carbamazepine, and cyclosporine; may potentiate anticoagulant effects of warfarin; coadministration with lovastatin and simvastatin, increases risk of rhabdomyolysis; decreases metabolism of repaglinide, thus increasing serum levels and effects
Documented hypersensitivity; hepatic impairment
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in liver disease; estolate formulation may cause cholestatic jaundice; GI side effects are common (give dose pc); discontinue use if nausea, vomiting, malaise, abdominal colic, or fever occur
Ciprofloxacin (Cipro)
Fluoroquinolone with activity against pseudomonas, streptococci, MRSA, Staphylococcus epidermidis, most gram-negative organisms, and atypical mycobacteria, but no activity against anaerobes. Inhibits bacterial DNA synthesis and consequently growth.
Safety and effectiveness in pediatric patients and adolescents have not been established. Risks versus benefits should be outweighed in cases of disseminated MAC disease.
Adult
500-750 mg PO bid
Pediatric
<18 years: Not recommended
>18 years: Administer as in adults
Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; ciprofloxacin reduces therapeutic effects of phenytoin; probenecid may increase ciprofloxacin serum concentrations; may increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
In prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy
Cefoxitin (Mefoxin)
Second-generation cephalosporin indicated for gram-positive cocci and gram-negative rod infections. Used in combination with other antibiotics for infections due to rapid-growing atypical mycobacteria. Infections caused by cephalosporin- or penicillin-resistant gram-negative bacteria may respond to cefoxitin.
Combine with amikacin when used to treat M fortuitum complex.
Adult
1-2 g IV q6-8h
Pediatric
<3 months: Not established
Infants and children: 80-160 mg/kg/d IV divided q4-6h; higher doses for severe or serious infections; not to exceed 12 g/d
Probenecid may increase effects of cefoxitin; coadministration with aminoglycosides or furosemide may increase nephrotoxicity (closely monitor renal function)
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in severe renal insufficiency (high doses may cause CNS toxicity); superinfections and promotion of nonsusceptible organism may occur with prolonged use or repeated therapy
Doxycycline (Bio-Tab, Doryx, Doxy, Vibramycin, Vibra-Tabs)
Inhibits protein synthesis and thus bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria.
Adult
100 mg IV q12h with cefoxitin 2 g IV qid; continue treatment for at least 4 d and for at least 48 h after patient improves; follow by PO doxycycline (100 mg) bid for 10-14 d
Pediatric
<8 years: Not recommended
>8 years and <45 kg: 2-5 mg/kg/d PO qd or divided bid; not to exceed 200 mg/d
Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; tetracyclines can increase hypoprothrombinemic effects of anticoagulants; tetracyclines can decrease effects of PO contraceptives, causing breakthrough bleeding and increased risk of pregnancy
Documented hypersensitivity; severe hepatic dysfunction
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last one-half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines
Sulfamethoxazole-Trimethoprim (Bactrim, Septra)
Inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid.
Adult
160 mg TMP/800 mg SMZ (ie, 1 double-strength tab) PO q12h for 10-14 d
Pediatric
<2 months: Contraindicated
>2 months: 10-20 mg (based on trimethoprim component)/kg/d PO/IV divided q6-8h
May increase PT when used with warfarin (perform coagulation tests and adjust dose accordingly); coadministration with dapsone may increase blood levels of both drugs; coadministration of diuretics increases frequency of thrombocytopenia purpura in elderly; phenytoin levels may increase with coadministration; may potentiate effects of methotrexate in bone marrow depression; hypoglycemic response to sulfonylureas may increase with coadministration; may increase levels of zidovudine
Documented hypersensitivity; megaloblastic anemia due to folate deficiency; age <2 months
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Do not use during last trimester of pregnancy due to potential toxicity to newborn (eg, jaundice, hemolytic anemia, kernicterus)
Discontinue at first appearance of skin rash or sign of adverse reaction; obtain CBC counts frequently; discontinue therapy if significant hematologic changes occur; goiter, diuresis, and hypoglycemia may occur with sulfonamides; prolonged IV infusions or high doses may cause bone marrow depression (if signs occur, give leucovorin 5-15 mg/d); caution in folate deficiency (eg, those with chronic alcoholism, elderly, those receiving anticonvulsant therapy, or those with malabsorption syndrome); hemolysis may occur in G-6-PD deficient individuals; patients with AIDS may not tolerate or respond to TMP-SMZ; caution in renal or hepatic impairment (perform urinalyses and renal function tests during therapy); give fluids to prevent crystalluria and stone formation
Rifampin (Rifadin)
Inhibits RNA synthesis in bacteria by binding to beta subunit of DNA-dependent RNA polymerase, which, in turn, blocks RNA transcription.
Adult
10 mg/kg/d mg PO/IV qd; not to exceed 600 mg/d
Pediatric
10-20 mg/kg/d mg PO/IV qd; not to exceed 600 mg/d
Induces microsomal enzymes, which may decrease effects of acetaminophen, PO anticoagulants, barbiturates, benzodiazepines, beta-blockers, chloramphenicol, PO contraceptives, corticosteroids, mexiletine, cyclosporine, digitoxin, disopyramide, estrogens, hydantoins, methadone, clofibrate, quinidine, dapsone, tazobactam, sulfonylureas, theophyllines, tocainide, and digoxin; blood pressure may increase with coadministration of enalapril; coadministration with isoniazid or pyrazinamide may result in higher rate of hepatotoxicity than with either agent alone (discontinue one or both agents if alterations in LFTs occur)
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Obtain CBC counts and baseline clinical chemistries prior to and throughout therapy; in liver disease, weigh benefits against risk of further liver damage; interruption of therapy and high-dose intermittent therapy are associated with thrombocytopenia that is reversible if therapy is discontinued as soon as purpura occurs; if treatment is continued or resumed after appearance of purpura, cerebral hemorrhage or death may occur
Rifabutin (Mycobutin)
Ansamycin antibiotic derived from rifamycin S. Inhibits DNA-dependent RNA polymerase, preventing chain initiation in susceptible strains of Escherichia coli and Bacillus subtilis but not in mammalian cells. If GI upset occurs, administer dose bid with food. Liquid formulation suitable for children is not currently available in the United States.
Adult
300 mg/d PO
Pediatric
<6 years: Not established
>6 years: 5-10 mg/kg/d PO; not to exceed adult dose
Decreases plasma concentration of methadone, verapamil, cyclosporine, digoxin, corticosteroids, PO anticoagulants, barbiturates, theophylline, quinidine, halothane, PO contraceptives, ketoconazole, and chloramphenicol; toxicity of rifabutin increases when administered concurrently with indinavir, ketoconazole, itraconazole, and erythromycin.
Drugs that inhibit CYP3A (eg, delavirdine, indinavir, nelfinavir, ritonavir) may significantly increase rifabutin plasma concentration (decrease rifabutin dose)
Documented hypersensitivity; WBC count <1,000/μL or platelet count <50,000/μL
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Limited experience in pregnant women; do not administer to patients with active tuberculosis; no evidence rifabutin is effective in prophylaxis against M tuberculosis; may administer isoniazid and rifabutin concurrently in patients requiring prophylaxis against both M tuberculosis and MAC; periodically perform hematologic studies in patients receiving prophylaxis because of association with neutropenia and more rarely thrombocytopenia
Ethambutol (Myambutol)
Diffuses into actively growing mycobacterial cells, such as tubercle bacilli. Impairs cell metabolism by inhibiting synthesis of one or more metabolites, which in turn causes cell death. No cross-resistance demonstrated. Mycobacterial resistance is frequent with previous therapy. Use in these patients in combination with second-line drugs that have not been previously administered.
Administer q24h until permanent bacteriologic conversion and maximal clinical improvement is observed. Absorption is not significantly altered by food.
Used in combination with azithromycin or clarithromycin for MAC treatment or secondary prophylaxis.
Adult
No previous antituberculous therapy: 15 mg/kg/d (7 mg/lb) PO
Previous antituberculous therapy: 25 mg/kg/d (11 mg/lb) PO
Pediatric
15-25 mg/kg/d PO
Aluminum salts may delay and reduce absorption (allow several hours before or after ethambutol dose)
Documented hypersensitivity; optic neuritis (unless clinically indicated)
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Reduce dose in impaired renal function; may have reversible visual adverse effects if promptly discontinued
Isoniazid (Nydrazid)
Best combination of effectiveness, low cost, and minor side effects. First-line drug unless known resistance or another contraindication exists. Therapeutic regimens of <6 mo demonstrate unacceptably high relapse rate. Coadministration of pyridoxine is recommended if peripheral neuropathies secondary to isoniazid therapy develop. Prophylactic doses of 6-50 mg of pyridoxine daily are recommended.
Adult
5 mg/kg/d PO (usually 300 mg/d) and 10 mg/kg/d in 1-2 divided doses in patients with disseminated disease; not to exceed 300 mg/d
Directly observed therapy: 15 mg/kg twice weekly; not to exceed 900 mg/d
Pediatric
10-20 mg/kg PO qd or divided bid; not to exceed 300 mg/d
Higher frequency of isoniazid-related hepatitis can occur with alcohol ingestion on daily basis; aluminum salts may decrease isoniazid serum levels (administer 1-2 h before taking aluminum salts); may increase anticoagulants effects with coadministration; may inhibit metabolic clearance of benzodiazepines
Carbamazepine toxicity or isoniazid hepatotoxicity may result from concurrent use (monitor carbamazepine concentrations and liver function); coadministration with cycloserine may increase CNS side effects (eg, dizziness); acute behavioral and coordination changes may occur with coadministration of disulfiram; coadministration with rifampin after halothane anesthesia may result in hepatotoxicity and hepatic encephalopathy; may inhibit hepatic microsomal enzymes and increase toxicity of hydantoin
Documented hypersensitivity; previous isoniazid-associated hepatic injury or other severe adverse reactions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Monitor patients with active chronic liver disease or severe renal dysfunction; periodic ophthalmologic examinations during isoniazid therapy are recommended even when visual symptoms do not occur
Clofazimine (Lamprene)
Inhibits mycobacterial growth, binds preferentially to mycobacterial DNA. Has antimicrobial properties, but mechanism of action is unknown.
Always use with other antitubercular agents. Because of severe toxicities, clofazimine should be considered only if no other effective antimycobacterial agent can be used based on resistance testing.
Adult
100 mg/d PO
Pediatric
1-2 mg/kg/d PO
Dapsone may inhibit anti-inflammatory activity of clofazimine
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Severe abdominal symptoms may require exploratory laparotomies; caution in patients with GI problems (eg, abdominal pain, diarrhea); skin discoloration caused by drug is severe enough that depression and suicide have been reported; apply oil to skin for dryness and ichthyosis
More on Atypical Mycobacterial Infection |
| Overview: Atypical Mycobacterial Infection |
| Differential Diagnoses & Workup: Atypical Mycobacterial Infection |
 Treatment & Medication: Atypical Mycobacterial Infection |
| Follow-up: Atypical Mycobacterial Infection |
| References |
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Further Reading
Keywords
atypical mycobacteria, mycobacterial disease, mycobacterial infection, Mycobacterium tuberculosis, M tuberculous, nontuberculous mycobacteria, NTM, lymphadenitis, Mycobacterium avium complex infection, disseminated MAC disease, MAC infection, HIV-associated infections, human immunodeficiency virus, highly active antiretroviral therapy, HAART, interferon-gamma, IFN-gamma, opportunistic infections, Buruli ulcer, IFN-gamma receptor ligand-binding deficiency, Mycobacterium phlei, Mycobacterium aurum, Mycobacterium flavescens, Mycobacterium vaccae, Mycobacterium neoaurum, Mycobacterium thermoresistible, Mycobacterium smegmatis, Mycobacterium scrofulaceum, Bacillus Calmette-Guérin, AIDS, pulmonary disease, Mycobacterium ulcerans, Buruli ulcer, cystic fibrosis, CF
