Approach Considerations

A diagnosis of nontuberculous mycobacteria (NTM) lung disease does not necessitate prompt initiation of antibiotic therapy. This decision should be made based on the potential risks and benefits of a prolonged course of treatment with multiple antibiotics. Initiation of NTM treatment should be individualized based on disease type, comorbid conditions, and patient age.^[4]

Therapy of skin and soft-tissue NTM infections varies depending on the causative organism.^[84]Initial empiric treatment with clarithromycin can be considered while awaiting culture and sensitivity results in patients with high suspicion and clinical presentations suggestive of cutaneous NTM infection. The optimal treatment regimen and length are not well established. As a general rule, deeper infections may require 6 or more months of treatment.

Patients with atypical mycobacteria infections can be treated as outpatients after appropriate surgery has been performed.

Medical Care

Infections with atypical mycobacteria can be treated with a variety of antibiotics. It is important to note that the choice of the regimen reflects more the personal experience and preference of the physician. Since most of the nontuberculous mycobacteria (NTM) species demonstrate strong resistance to multiple antimicrobial agents, treatment of NTM infections and establishment of an effective regimen remain challenging.^[85]In specific cases, the results of susceptibility tests help guide the decision.

M avium complex lung disease

American Thoracic Society/Infectious Diseases Society of America (ATS/IDSA) clinical guidelines recommend an initial regimen of three drugs: a macrolide (clarithromycin or azithromycin), ethambutol, and rifampin. The ideal duration of treatment is 12 months after achieving culture conversion.^[4]

M avium complex prevention of disseminated infection in HIV-infected patients

Recommended therapy is azithromycin at 1200 mg orally weekly. Alternatives are clarithromycin at 500 mL orally twice daily or rifabutin at 300 mg orally daily.

M kansasii infection

In rifampin-susceptible strains, a four-drug regimen is recommended, including rifampin, ethambutol, isoniazid, and pyridoxine. The ideal duration is 12 months after achieving culture conversion.

In rifampin-resistant strains, a three-drug regimen is recommended, combining in higher doses clarithromycin or azithromycin, moxifloxacin, isoniazid, ethambutol, sulfamethoxazole, or streptomycin.

M marinum infection

This organism is susceptible to clarithromycin, minocycline, trimethoprim-sulfamethoxazole, rifampin, rifabutin, and ethambutol. It is resistant to isoniazid and pyrazinamide.

Excellent outcomes in deep infections have been reported with clarithromycin plus rifampin or ethambutol.^[67]

M ulcerans infection

Medical therapy for M ulcerans infection has been disappointing. Rifampin in combination with clarithromycin for at least 6-8 weeks may be the best choice for controlling complications of the ulcer.

M haemophilum infection

Currently, there exists no standardized susceptibility test for M haemophilum. Even though there is no optimal therapy, multidrug regimens including clarithromycin, rifampin, rifabutin, ciprofloxacin, or amikacin have proven to be efficacious.

M scrofulaceum

There is no standard treatment regimen, but the most effective proven regimen is the combination of isoniazid with clarithromycin or rifampin.

Rapidly growing mycobacteria infections (M fortuitum, M chelonae, M abscessus)

M fortuitum is susceptible to ciprofloxacin and ofloxacin, amikacin, sulfonamides, imipenem, clarithromycin, cefoxitin, and doxycycline. For serious infections, use at least two agents.

M chelonae can be treated with clarithromycin and a second agent chosen from linezolid, imipenem, tobramycin, or amikacin.

M abscessus complex group bacteria are the most difficult rapidly growing mycobacteria to treat, owing to their resistance to multiple standard antituberculous drugs. Treatment options include clarithromycin or azithromycin, with the addition of amikacin, cefoxitin, or imipenem for serious and complicated infections.

Surgical Care

A combined therapeutic approach, including surgical drainage, debridement, excision, and a prolonged (>3 mo) treatment with combined antimicrobial agents, remains a mainstream in some cases of atypical mycobacteria infection.

A 2019 retrospective study in Taiwan concluded that surgical resection of nontuberculous mycobacteria (NTM) solitary pulmonary nodules is curative in asymptomatic patients without positive culture of the same NTM species from respiratory specimens and a history of NTM pulmonary disease. Further medical treatment for NTM will probably not be necessary.^[86]

Selective cervical lymphadenectomy leads to a quick resolution of NTM cervicofacial lymphadenitis in children.^[87]

Split-thickness skin grafting has been successfully used to cover large wounds. Grafting did not appear to foster recurrent infection.

Consultations

Consultations with infectious disease specialists, surgeons, dermatologists, clinical microbiologists, and pulmonary specialists may be necessary.

Prevention

Patients should avoid contaminant material and injections with contaminated materials. Patients should also avoid contaminated water.

Long-Term Monitoring

Patients must be aware of the needed prolonged courses of antibiotics and the importance of compliance. Lack of the compliance results in treatment failure and higher resistance and a more prolonged course of further therapy.

Medication

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Mycobacterium marinum is an atypical mycobacteria found in water with a wide range of temperatures and salinities

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Author

Erisa Alia, MD Clinical Trials Research Fellow, Department of Dermatology, University of Connecticut School of Medicine

Erisa Alia, MD is a member of the following medical societies: Albanian Society of Dermatology and Venereology, European Academy of Dermatology and Venereology

Disclosure: Nothing to disclose.

Coauthor(s)

Jun Lu, MD, FAAD Associate Professor, Director of Clinical Trial Unit, Director of Connective Tissue Disease Multispecialty Clinic, Farmington Site Director of Dermatology Residency Program, Department of Dermatology, University of Connecticut Health Center

Jun Lu, MD, FAAD is a member of the following medical societies: American Academy of Dermatology, American Telemedicine Association, Connecticut Society of Dermatology and Dermatologic Surgery, New England Dermatological Society, Rheumatologic Dermatology Society

Disclosure: Nothing to disclose.

Specialty Editor Board

David F Butler, MD Former Section Chief of Dermatology, Central Texas Veterans Healthcare System; Professor of Dermatology, Texas A&M University College of Medicine; Founding Chair, Department of Dermatology, Scott and White Clinic

David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, Association of Military Dermatologists, Phi Beta Kappa, Texas Dermatological Society

Disclosure: Nothing to disclose.

Jeffrey P Callen, MD Professor of Medicine (Dermatology), Chief, Division of Dermatology, University of Louisville School of Medicine

Jeffrey P Callen, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, American College of Rheumatology

Disclosure: Received income in an amount equal to or greater than $250 from: Biogen US (Adjudicator for study entry cutaneous lupus erythematosus); Priovant (Adjudicator for entry into a dermatomyositis study); IQVIA (Serono - adjudicator for a study of cutaneous LE) <br/>Received honoraria from UpToDate for author/editor; Received royalty from Elsevier for book author/editor; Received dividends from trust accounts, but I do not control these accounts, and have directed our managers to divest pharmaceutical stocks as is fiscally prudent from Stock holdings in various trust accounts include some pharmaceutical companies and device makers for these trust accounts for: Stocks held in various trust accounts: Allergen; Amgen; Pfizer; 3M; Johnson and Johnson; Merck; Abbott Laboratories; AbbVie; Procter and Gamble;; Celgene; Gilead; CVS; Walgreens; Bristol-Myers Squibb.

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

Takeji Nishikawa, MD Emeritus Professor, Department of Dermatology, Keio University School of Medicine; Director, Samoncho Dermatology Clinic; Managing Director, The Waksman Foundation of Japan Inc

Disclosure: Nothing to disclose.