Guidelines for Diagnosis, Treatment, and Prevention of NTM Infections, Including MAC Infection
Treatment of Nontuberculous Mycobacterial Pulmonary Disease: An Official ATS/ERS/ESCMID/IDSA Clinical Practice Guideline, 2020 [27]
Guidelines for the prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: recommendations from the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America [26]
British Thoracic Society guidelines for the management of non-tuberculous mycobacterial pulmonary disease (NTM-PD) [33]
British Thoracic Society Guidelines for the Workup and Treatment of Nontuberculous Mycobacterial Pulmonary Disease
Workup
Sputum, induced sputum, bronchial washings, bronchoalveolar lavage, or transbronchial biopsy samples can be used to evaluate individuals suspected of having nontuberculous mycobacterial (NTM) pulmonary disease.
Whenever possible, less invasive sampling should be attempted first to minimize procedural risks.
Respiratory samples should be processed within 24 hours of collection (or refrigerated at 4°C if delays are anticipated).
Oropharyngeal swab culture or serology testing should not be used to diagnose NTM pulmonary infection.
If sputum cultures are negative but clinical suspicion of NTM infection is high, consider performing CT-directed bronchial washings to obtain targeted samples.
If individuals undergoing diagnostic evaluation for NTM infection are taking antibiotics that may impair NTM growth (eg, aminoglycosides, macrolides, tetracyclines, cotrimoxazole, linezolid), consider discontinuing these antibiotics 2 weeks before collecting samples.
A validated rapid method should be used to detect NTM in respiratory samples.
All respiratory samples should be stained using auramine-phenol after liquefaction and concentration and then examined by microscopy.
Respiratory tract samples should be cultured (following decontamination) on solid and liquid media in a ISO15189-accredited clinical laboratory for 8 weeks, extending to 12 weeks if necessary.
Routine use of non–culture-based detection methods is not recommended.
All NTM isolates from respiratory samples should be identified to at least species level using validated molecular or mass spectrometry techniques.
Isolates of M abscessus should be subspeciated using appropriate molecular techniques.
If person-to-person transmission of M abscessus is suspected, isolates should be typed, preferably using whole genome sequencing.
Drug susceptibility testing and reporting
Drug susceptibility testing and reporting should follow the Clinical Laboratory Standards Institute (CLSI) guidelines.
For M avium complex (MAC), clarithromycin and amikacin susceptibility testing should be performed on an isolate taken before initiation of treatment and on subsequent isolates if the patient fails to respond to treatment or recultures MAC after culture conversion.
Macrolide-resistant MAC isolates should be tested against a wider panel of antibiotics to guide, but not dictate, treatment regimens.
For M kansasii, rifampicin susceptibility testing should be performed on an isolate prior to initiation of treatment and on subsequent isolates if the patient fails to respond to treatment or recultures M kansasii after culture conversion.
Rifampicin-resistant M kansasii isolates should be tested against a wider panel of antibiotics to guide, but not dictate, treatment regimens.
Susceptibility testing for M abscessus should include at least clarithromycin, cefoxitin, and amikacin (and preferably also tigecycline, imipenem, minocycline, doxycycline, moxifloxacin, linezolid, co-trimoxazole, and clofazimine if a validated method is available) to guide, but not dictate, treatment regimens.
A minimum of 2 sputum samples collected on separate days should be sent for mycobacterial culture when investigating an individual suspected of having NTM pulmonary disease.
Individuals suspected of having NTM pulmonary disease whose sputum samples are consistently culture-negative for mycobacteria should have CT-directed bronchial washings sent for mycobacterial culture.
Individuals suspected of having NTM pulmonary disease who are unable to expectorate sputum should have CT-directed bronchial washings sent for mycobacterial culture.
Transbronchial biopsies should not be performed routinely in individuals suspected of having NTM pulmonary disease.
Treatment
Clarithromycin-sensitive MAC pulmonary disease should be treated with rifampicin, ethambutol, and clarithromycin or azithromycin using an intermittent (thrice weekly) or daily oral regimen. The choice of regimen should be based on disease severity and treatment tolerance.
An intermittent (thrice weekly) oral antibiotic regimen should not be used in individuals with severe MAC pulmonary disease or in individuals with a history of treatment failure.
An injectable aminoglycoside (amikacin or streptomycin) should be considered in individuals with severe MAC pulmonary disease.
Clarithromycin-resistant MAC pulmonary disease should be treated with rifampicin, ethambutol, and isoniazid or a quinolone, and consider an injectable aminoglycoside (amikacin or streptomycin).
Nebulized amikacin may be considered in place of an injectable aminoglycoside when intravenous/intramuscular administration is impractical or contraindicated or when longer-term treatment with an aminoglycoside is required for the treatment of MAC pulmonary disease.
Macrolide monotherapy or macrolide/quinolone dual therapy regimens should not be used for the treatment of MAC pulmonary disease.
Antibiotic treatment for MAC pulmonary disease should continue for a minimum of 12 months after culture conversion. [33]
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Thoracic CT scan in a 77-year-old woman who presented with chronic cough and sputum production, without a history of underlying pre-existing lung disease. Sputum culture grew Mycobacterium avium complex. The diagnosis was Lady Windermere syndrome.
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Thoracic CT scan in a 72-year-old woman who presented with chronic cough and sputum production, without a history of an underlying pre-existing lung disease. Sputum culture grew Mycobacterium avium complex (MAC). The diagnosis was Lady Windermere syndrome.
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Chest radiograph in a 67-year-old man who smokes and has a history of chronic obstructive pulmonary disease (COPD) and Mycobacterium avium complex (MAC) infection.
![Mycobacterium Avium Complex (MAC) (Mycobacterium Avium-Intracellulare [MAI])](https://img.medscapestatic.com/pi/meds/ckb/31/37331tn.jpg?interpolation=lanczos-none&resize=75:*)
