Tuberc Respir Dis.  2019 Jan;82(1):15-26. 10.4046/trd.2018.0060.

Treatment of Mycobacterium avium Complex Pulmonary Disease

• Kwon YS
• Koh WJ
• Daley CL

• KMID: 2441726
• DOI: http://doi.org/10.4046/trd.2018.0060

Abstract

The pathogen Mycobacterium avium complex (MAC) is the most common cause of nontuberculous mycobacterial pulmonary disease worldwide. The decision to initiate long-term antibiotic treatment is difficult for the physician due to inconsistent disease progression and adverse effects associated with the antibiotic treatment. The prognostic factors for the progression of MAC pulmonary disease are low body mass index, poor nutritional status, presence of cavitary lesion(s), extensive disease, and a positive acid-fast bacilli smear. A regimen consisting of macrolides (clarithromycin or azithromycin) with rifampin and ethambutol has been recommended; this regimen significantly improves the treatment of MAC pulmonary disease and should be maintained for at least 12 months after negative sputum culture conversion. However, the rates of default and disease recurrence after treatment completion are still high. Moreover, treatment failure or macrolide resistance can occur, although in some refractory cases, surgical lung resection can improve treatment outcomes. However, surgical resection should be carefully performed in a well-equipped center and be based on a rigorous risk-benefit analysis in a multidisciplinary setting. New therapies, including clofazimine, inhaled amikacin, and bedaquiline, have shown promising results for the treatment of MAC pulmonary disease, especially in patients with treatment failure or macrolide-resistant MAC pulmonary disease. However, further evidence of the efficacy and safety of these new treatment regimens is needed. Also, a new consensus is needed for treatment outcome definitions as widespread use of these definitions could increase the quality of evidence for the treatment of MAC pulmonary disease.

Keyword

Nontuberculous Mycobacteria; Mycobacterium avium Complex; Mycobacterium avium; Mycobacterium intracellulare; Treatment

MeSH Terms

Amikacin
Body Mass Index
Clofazimine
Consensus
Disease Progression
Ethambutol
Humans
Lung
Lung Diseases
Macrolides
Mycobacterium avium Complex*
Mycobacterium avium*
Mycobacterium*
Nontuberculous Mycobacteria
Nutritional Status
Recurrence
Rifampin
Sputum
Treatment Failure
Treatment Outcome
Amikacin
Clofazimine
Ethambutol
Macrolides
Rifampin

Figure

• 

  Figure 1 Treatment initiation algorithm for treatment naïve MAC-PD. Treatment should be considered when patients have risk factors for disease progression, including cavitary lesion(s), low body mass index, poor nutritional status, extensive disease, and AFB smear-positive sputum. If patients have mild disease and no risk factors for progression, treatment should be initiated when patients exhibit disease progression. MAC-PD: Mycobacterium avium complex pulmonary disease; HRCT: high-resolution computed tomography; AFB: acid-fast bacilli.

• 

  Figure 2 Fibrocavitary form of Mycobacterium intracellulare pulmonary disease in a 57-year-old male patient. (A) Chest high-resolution computed tomography (HRCT) shows a large, thick-walled cavity in the right upper lobe. (B) After 12 months of daily azithromycin, ethambutol, and rifampin treatment in combination with streptomycin injection for the initial 3 months, chest HRCT showed improvement of the cavitary lesion.

• 

  Figure 3 Cavitary nodular bronchiectatic form of Mycobacterium avium pulmonary disease in a 61-year-old female patient. (A) Chest high-resolution computed tomography (HRCT) shows severe bronchiectasis in the lingular segment of the left upper lobe. Note the cavity and multiple nodules suggesting bronchiolitis in the left lower lobe. (B) After 12 months of daily azithromycin, ethambutol, and rifampin treatment, chest HRCT showed improvement of cavitary and nodular lesions.

• 

  Figure 4 Non-cavitary nodular bronchiectatic form of pulmonary disease caused by Mycobacterium intracellulare in a 57-year-old female patient. (A) Chest high-resolution computed tomography (HRCT) shows severe bronchiectasis in the right middle lobe and the lingular segment of the left upper lobe. Note the peribronchiectatic consolidation, the multiple, small nodules, and tree-in-bud appearances suggesting bronchiolitis in both lungs. (B) After 12 months of three-times-weekly antibiotic therapy that included azithromycin, ethambutol, and rifampin, chest HRCT showed a decreased extent of bilateral consolidation and improvement of bronchiolitis.

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