British Thoracic Society guidelines for the management of non-tuberculous mycobacterial pulmonary disease (NTM-PD)

Abstract

of reCommendaTionS and good praCTiCe poinTS SeCTion 4: WhaT iS The evidenCe for TranSmiSSion of nTm BeTWeen individualS?recommendation ► Adequate infection control policies need to be implemented in both inpatient and outpatient settings to minimise risks of person-to-person transmission of Mycobacterium abscessus in individuals with cystic fibrosis (CF).(Grade B) SeCTion 5: hoW Should The lung diSeaSe aTTriBuTaBle To nTm infeCTion Be defined?recommendation ► In the absence of robust evidence to support an alternative definition and due to the clinical and research benefits of having a uniform definition, use of the American Thoracic Society/Infectious Diseases Society of America (ATS/IDSA) 2007 definition of non-tuberculous mycobacterial (NTM) pulmonary disease is recommended 1 (see Box 1).(Grade D) good practice point BTS guideline SeCTion 12a: WhaT anTiBioTiC regimen Should Be uSed To TreaT maC-pulmonary diSeaSe?recommendations ► Clarithromycin-sensitive MAC-pulmonary disease should be treated with rifampicin, ethambutol and clarithromycin or azithromycin using an intermittent (three times per week) or daily oral regimen.The choice of regimen should be based on the severity of disease (as defined in table 3) and treatment tolerance.(Grade D) ► An intermittent (three times per week) oral antibiotic regimen should not be used in individuals with severe MAC-pulmonary disease (as defined in table 3) or in individuals with a history of treatment failure.(Grade D) ► An injectable aminoglycoside (amikacin or streptomycin) should be considered in individuals with severe MAC-pulmonary disease (as defined in table 3).(Grade D) ► Clarithromycin-resistant MAC-pulmonary disease should be treated with rifampicin, ethambutol and isoniazid or a quinolone, and consider an injectable aminoglycoside (amikacin or streptomycin).(Grade D) ► Nebulised amikacin may be considered in place of an injectable aminoglycoside when intravenous/intramuscular administration is impractical, contraindicated or longer term treatment with an aminoglycoside is required for the treatment of MAC-pulmonary disease.(Grade D) ► Macrolide monotherapy or macrolide/quinolone dual therapy regimens should not be used for the treatment of MAC-pulmonary disease.(Grade D) ► Antibiotic treatment for MAC-pulmonary disease should continue for a minimum of 12 months after culture conversion.(Grade D) good practice points3 Individuals with clarithromycin-resistant MAC-pulmonary disease should be managed in collaboration with a physician experienced in managing NTM-pulmonary disease.3 Individuals with a history of treatment intolerance or treatment failure should be managed in collaboration with a physician experienced in managing NTM-pulmonary disease. SeCTion 12B: WhaT anTiBioTiC regimen Should Be uSed To TreaT M. kansasii-pulmonary diSeaSe? recommendations► Rifampicin-sensitive M. kansasii-pulmonary disease should be treated with rifampicin, ethambutol and isoniazid or a macrolide (clarithromycin or azithromycin) using a daily oral regimen.(Grade D) ► Rifampicin-resistant M. kansasii-pulmonary disease should be treated with a three-drug regimen guided, but not dictated by, drug susceptibility test results using a daily oral regimen.(Grade D) ► Antibiotic treatment for M. kansasii-pulmonary disease should continue for a minimum of 12 months after culture conversion.(Grade D) good practice points 3 Individuals with rifampicin-resistant M. kansasii-pulmonary disease should be managed in collaboration with a physician experienced in managing NTM-pulmonary disease.3 Individuals with a history of treatment intolerance or treatment failure should be managed in collaboration with a physician experienced in managing NTM-pulmonary disease. SeCTion 12C: WhaT anTiBioTiC regimen Should Be uSed To TreaT M. MalMoense-pulmonary diSeaSe? recommendations► M. malmoense-pulmonary disease should be treated with rifampicin, ethambutol and a macrolide (clarithromycin or azithromycin) using a daily oral regimen.(Grade D) ► An injectable aminoglycoside (amikacin or streptomycin) should be considered in individuals with severe M. malmoense-pulmonary disease (ie, acid-fast bacilli (AFB) smear-positive respiratory tract samples, radiological evidence of lung cavitation/severe infection or severe symptoms/signs of systemic illness).(Grade D) ► Nebulised amikacin may be considered in place of an injectable aminoglycoside when intravenous/intramuscular administration is impractical, contraindicated or longer term treatment with an aminoglycoside is required in the treatment of M. malmoense-pulmonary disease.(Grade D) ► Antibiotic treatment for M. malmoense-pulmonary disease should continue for a minimum of 12 months after culture conversion.(Grade D) good practice points 3 Individuals with a history of treatment intolerance or treatment failure should be managed in collaboration with a physician experienced in managing NTM-pulmonary disease.SeCTion 12d: WhaT anTiBioTiC regimen Should Be u