Table 13.18-1. Recommended treatment of nontuberculous mycobacterial disease1

Organism

Drugs

Duration

Mycobacterium avium complex lung disease (macrolide susceptible)

– Daily: clarithromycin 500 mg bid or azithromycin 250 mg; EMB 15 mg/kg (may use 25 mg/kg for initial 2 months); RMP (450-600 mg) or RBT (150-300 mg) ± aminoglycosides (SM or amikacin) intermittently (conditional recommendation, based on moderate evidence)

– Thrice weekly2 (may be considered for nonadvanced, nodular bronchiectatic pulmonary MAC): clarithromycin 500 mg bid or azithromycin 500 mg; EMB 25 mg/kg; RMP 600 mg (conditional recommendation, based on moderate evidence)

– Clofazimine and FQNs may be useful (conditional recommendation, based on moderate evidence)

12 months after culture conversion to negative (conditional recommendation, based on moderate evidence)

MAC lymphadenitis (macrolide susceptible)

If antibacterial therapy is being considered: daily or thrice weekly clarithromycin or azithromycin plus EMB ± RMP (conditional recommendation, based on very weak evidence)

3-9 months (conditional recommendation, based on very weak evidence)

M xenopi lung disease

– Azithromycin or clarithromycin plus RMP plus EMB

– Consider, in addition, moxifloxacin (or other FQNs), INH, SM, amikacin

(conditional recommendation, based on very weak evidence)

12 months after culture-negative (conditional recommendation, based on very weak evidence)

M abscessus complex lung disease

Clarithromycin or azithromycin + amikacin, cefoxitin or imipenem (± tigecycline, linezolid, clofazimine) (conditional recommendation, based on moderate evidence)

2-6 months of combination IV and PO therapy (conditional recommendation, based on weak evidence)

M kansasii lung disease

– Daily RMP, EMB, INH

– Consider clarithromycin or azithromycin, moxifloxacin, sulfamethoxazole, and aminoglycosides

(strong recommendation, based on moderate evidence)

12 months after culture-negative (conditional recommendation, based on weak evidence)

M fortuitum lung disease

Based on in-vitro sensitivity testing: azithromycin or clarithromycin and RMP or EMB (± doxycycline, amikacin, imipenem, FQNs, sulfonamides, cefoxitin) (conditional recommendation, based on very weak evidence)

12 months after culture-negative for lung disease (conditional recommendation, based on very weak evidence)

M fortuitum skin/soft tissue

Based on in-vitro sensitivity testing: azithromycin or clarithromycin and RMP or EMB (± doxycycline, amikacin, imipenem, FQNs, sulfonamides, cefoxitin) (conditional recommendation, based on very weak evidence)

4 months for skin/soft tissue (6 months for severe disease) (conditional recommendation, based on weak evidence)

M marinum skin/soft tissue

Clarithromycin, EMB ± RMP (conditional recommendation, based on weak evidence)

3-6 months (consider longer if deep structures involved) (conditional recommendation, based on weak evidence)

Disseminated MAC in HIV-infected patients

Treatment

Clarithromycin 500 mg PO daily + EMB 15 mg/kg PO daily ± RBT 300 mg PO daily3 (strong recommendation, based on very strong evidence)

Lifelong or until control of HIV viremia with rise of CD4 to >100 × 106/L for at least 6 months and 12 months after culture-negative (strong recommendation, based on strong evidence)

Disseminated MAC in HIV-infected patients

Prophylaxis

Patients with CD4 <50 × 106/L

Azithromycin 1200 mg weekly

or

RBT 300 mg a day

or

Clarithromycin 500 mg bid

(strong recommendation, based on very strong evidence)

Lifelong or until control of HIV viremia with rise of CD4 to >100 × 106/L for ≥6 months and 12 months after culture-negative (strong recommendation, based on strong evidence)

Suggested regimens for initial therapy of NTM disease should be modified, if needed, depending upon clinical circumstances such as drug intolerance, the presence of macrolide-resistant MAC, and lack of efficacy.

1 More detailed recommendations and treatment guidance regarding other NTM species may be found elsewhere.

2 Although directly observed therapy is recommended for intermittent therapy of TB, this is not so in NTM disease, because there is no public health consideration of contagion. Intermittent therapy for pulmonary NTM has been suggested to reduce toxic effects and sometimes costs of therapy and has been shown to be effective in many cases.

3 Doses may need to be adjusted according to interactions with concurrent antiretroviral therapy.

Source: ©All Rights Reserved. Canadian Tuberculosis Standards, 7th Edition. The Public Health Agency of Canada, The Lung Association, and the Canadian Thoracic Society, 2014. Adapted and reproduced with permission from the Minister of Health, 2016.

EMB; ethambutol; FQNs, fluoroquinolones; HIV, human immunodeficiency virus; INH, isoniazid; IV, intravenous; MAC, Mycobacterium avium complex; NTM, nontuberculous mycobacterium; PO, oral; RBT, rifabutin; RMP, rifampin (INN rifampicin); SM, streptomycin.