Our survey revealed that therapeutic regimens for M. abscessus infection vary widely. Decontamination by 0.25% N-acetyl-L-cysteine and 1% NaOH (NALC-NaOH) is the preferred method. A three-drug regimen that includes isoniazid, rifampicin, and ethambutol was recommended in the 2007 Guideline [4]. Eur Respir J 2020; 56: The committee was chaired by C.D. There were, however, no significant differences in microbiologic recurrence rates or clinical improvement (which included both clinical symptoms and radiological findings). Remarks: There is in vitro evidence that macrolides and fluoroquinolones are active against M. xenopi, whereas rifampicin and ethambutol are inactive in vitro alone and in combinations [32]. Two studies in the 1980s found that treatment durations had an effect on outcomes (typically with isoniazid-rifampicin-ethambutol regimens). ALIS is currently approved by the United States Federal Drug Administration for treatment of refractory MAC pulmonary disease. Randomized controlled trials comparing shorter treatment regimens are currently lacking. There are no studies that have evaluated treatment outcomes of this regimen when given intermittently. Therefore, this guideline focuses on pulmonary disease in adults (without cystic fibrosis or human immunodeficiency virus [HIV] infection) caused by the most common NTM pathogens comprising Mycobacterium avium complex (MAC), Mycobacterium kansasii, and Mycobacterium xenopi among the slowly growing NTM and Mycobacterium abscessus among the rapidly growing NTM. In vitro data suggest that MIC values of fluoroquinolones are low for M. xenopi: in vitro activity of moxifloxacin is equal to that of clarithromycin [190]. Although there is good in vitro activity of the fluoroquinolones against M. kansasii, no randomized clinical trial or case series have been published in which a fluoroquinolone was used for the treatment of M. kansasii pulmonary disease. One patient (2.5%) recurred six months after completing treatment. Our series showed a wide range of treatment strategies for M. abscessus infection; most consisted of prolonged antimicrobial drug therapy. General information about Mycobacterium abscessus. Given the lack of evidence-based therapies, we hypothesized that treatment regimens have no clear pattern and that medication changes and toxicities occur frequently. Remarks: Because there are no randomized trials available and the small size of the single study that evaluated three times weekly therapy [26], the committee did not feel that they could recommend intermittent therapy in the setting of cavitary disease until more evidence was available. R. J. W. served as the director of a university clinical laboratory that does NTM identification, molecular strain comparison, and susceptibility testing; received research support from Insmed as mycobacterial reference laboratory for a trial of the inhaled liposomal amikacin. The panel members suggest that an expert in the management of patients with M. abscessus pulmonary disease be consulted. In one study that reported outcomes of patients who underwent video assisted thoracoscopic surgery (VATS), culture conversion occurred in 84% of the patients, postoperative complications occurred in 7% of patients, and there were no operative or postoperative deaths reported [216]. You will be subject to the destination website's privacy policy when you follow the link. For the current Guideline, no high-quality studies addressing the question were identified. Consisting of data provided by the authors to benefit the reader, the posted materials are not copyedited and are the sole responsibility of the authors, so questions or comments should be addressed to the corresponding author. This Guideline is dedicated to the memory of Won-Jung Koh, MD, whose passion, leadership, and work led to evidence that helped to support recommendations in this Guideline. massiliense develops mutational macrolide resistance with a mutation in the 23S rRNA gene, culture conversion is similar to that seen with subsp. Even so, surgical resection was associated with improved treatment outcomes and for most of the patients (85–100%), conversion of sputum cultures to negative was observed after surgery. All clinically relevant isolates of NTM should be identified by molecular methods, including follow-up isolates of patients undergoing NTM pulmonary disease treatment. For species of low pathogenicity such as M. gordonae, several repeated positive cultures over months, along with strong clinical and radiological evidence of disease, would be required to determine if it was causing disease, whereas a single positive culture for M. kansasii in the proper context may be enough evidence to initiate treatment [9]. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. For the remainder, subculture on solid media until the occurrence of visual growth is needed to obtain good MALDI-TOF results [79]. Limited retrospective observational data have failed to demonstrate that treatment of NTM pulmonary disease prolongs survival over watchful waiting [95, 96]. Although macrolides might still be useful for immunomodulatory effects or antimicrobial effects against other coinfecting organisms, they are not counted as an active drug against M. abscessus when inducible or mutational resistance is noted. For the full document, including tables and references, please visit the Oxford University Press website. Tuberc Respir Dis (Seoul). Reported side effects in these series ranged from 8 to 38% and included hoarseness, throat irritation, bitter taste, and thrush. One additional observational retrospective study suggested that multidrug therapy is associated with improved quality of life in M. abscessus patients, but this study did not compare outcomes according to different drug regimens [108]. The 2007 Guideline suggested a treatment duration of 12 months beyond culture conversion, acknowledging that the optimal duration was unknown [4]. There is not similar evidence to justify or support intermittent therapy for cavitary MAC pulmonary disease and it is not recommended. Only one study addressing this specific question was identified by the systematic review [213]. A study in France recorded 27% clinical and/or microbiological conversion with a median duration of treatment of five months in 122 patients [35]. A meta-analysis [57] of 9 studies [58–65] showed an increase in the sensitivity of culture for NTM of 15% if a solid medium was incubated alongside a liquid culture system. Unfortunately, there are no studies that have identified the optimum frequency or most cost-effective approach to monitoring for drug-related adverse reactions. In a systematic review of M. xenopipulmonary disease, data regarding parenteral therapy were found exclusively in retrospective series, and the data synthesis identified evidence against aminoglycosides [185]. Remarks: A priority in MAC pulmonary disease therapy is preventing the development of macrolide resistance. K. L. W. served on an advisory committee for Insmed, Johnson and Johnson, Paratek, Redhill Biopharma, and Spero; served as a consultant for Bayer Healthcare, Bristol-Myers Squibb, Horizon, Lilly, Pfizer, and RedHill Biopharma; received research support from Bristol-Myers Squibb, Cellestis, and Insmed; served on data safety and monitoring boards for Abbvie, Biomarin, Gilead, Roche, and UCB. Over watchful waiting ” may be a potential way to improve efficacy decrease! Disease be treated for at least 2–3 months recommendations were either “ strong or! Treatment outcomes in patients with cavitary pulmonary disease is often resistant to multiple antimicrobial drugs, overlapping toxicities! Individual regimens or medications but did not distinguish patients with nephrotoxicity reported in 1998 [ 164 ] on liquid... Diseases online component of management to conclude which regimen was best ( only 34 patients and two events ) ATS! 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