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David E. Griffith, Timothy Aksamit, Barbara A. Brown-Elliott, Antonino Catanzaro, Charles Daley, Fred Gordin, Steven M. Holland, Robert Horsburgh, Gwen Huitt, Michael F. Iademarco, Michael Iseman, Kenneth Olivier, Stephen Ruoss, C. Fordham von Reyn, Richard J. Wallace, Jr., and Kevin Winthrop An Official ATS/IDSA Statement: Diagnosis, Treatment, and Prevention of Nontuberculous Mycobacterial Diseases, American Journal of Respiratory and Critical Care Medicine, Vol. 175, No. 4 2007, pp. 367-416.
T his O fficial S tatement from the A merican T horacic S ociety ATS plus the I nfectious D iseases S ociety of A merica IDSA was adopted because of the ATS B oard O f D irectors, S eptember 2006, and from the IDSA B oard of D irectors, J anuary 2007
Collection, Digestion, Decontamination, and Staining of Specimens
Body Fluids, Abscesses, and Tissues
Skin, Soft Tissue, and Bone Disease
The minimum evaluation of the patient suspected of nontuberculous mycobacterial NTM lung disease will include the following: 1 chest radiograph or, inside absence of cavitation, chest high-resolution computed tomography HRCT scan; 2 three or higher sputum specimens for acid-fast bacilli AFB analysis; and 3 exclusion of other disorders, including tuberculosis TB. Clinical, radiographic, and microbiologic criteria are essential and all has to be met to have a diagnosis of NTM lung disease. The following criteria affect symptomatic patients with radiographic opacities, nodular or cavitary, or even an HRCT scan that shows multifocal bronchiectasis with multiple small nodules. These criteria fit best with Mycobacterium avium complex MAC, M. kansasii, and M. abscessus. There is not enough known about alot of NTM to be sure that these diagnostic criteria are universally applicable for those NTM respiratory pathogens.
Pulmonary symptoms, nodular or cavitary opacities on chest radiograph, or even an HRCT scan that shows multifocal bronchiectasis with multiple small nodules.
Appropriate exclusion of other diagnoses.
Positive culture is a result of at least two separate expectorated sputum samples. If the results through the initial sputum samples are nondiagnostic, consider repeat sputum AFB smears and cultures.
Positive culture is a result of at least one bronchial wash or lavage.
Transbronchial or another lung biopsy with mycobacterial histopathologic features granulomatous inflammation or AFB and positive culture for NTM or biopsy showing mycobacterial histopathologic features granulomatous inflammation or AFB and one or maybe more sputum or bronchial washings which can be culture positive for NTM.
Expert consultation ought to be obtained when NTM are recovered that happen to be either infrequently encountered or have a tendency to represent environmental contamination.
Patients who're suspected of experiencing NTM lung disease but who don't meet the diagnostic criteria needs to be followed before diagnosis is firmly established or excluded.
Making the carried out NTM lung disease will not, per se, necessitate the institution of therapy, that is a decision dependant on potential risks and benefits associated with therapy for individual patients.
The preferred staining procedure would be the fluorochrome method. Specimens ought to be cultured on both liquid and solid media. Species that need special growth conditions and/or lower incubation temperatures include M. haemophilum, M. genavense, and M. conspicuum. These species could potentially cause cutaneous and lymph node disease.
In general, NTM needs to be identified on the species level. Methods of rapid species identification include commercial DNA probes MAC, M. kansasii, and M. gordonae and high-performance liquid chromatography HPLC. For some NTM isolates, especially expanding as well mycobacterial RGM isolates M. fortuitum, M abscessus, and M. chelonae, other identification techniques could possibly be necessary including extended antibiotic in vitro susceptibility testing, DNA sequencing or polymerase incidents PCR restriction endonuclease assay PRA.
Routine susceptibility testing of MAC isolates is mandatory for clarithromycin only.
Routine susceptibility testing of M. kansasii isolates is suggested for rifampin only.
Routine susceptibility testing, for both taxonomic identification and therapy for RGM M. fortuitum, M abscessus, and M. chelonae ought to be with amikacin, imipenem M. fortuitum only, doxycycline, the fluorinated quinolones, a sulfonamide or trimethoprim-sulfamethoxazole, cefoxitin, clarithromycin, linezolid, and tobramycin M. chelonae only.
Prevention of health carerelated NTM infections makes it necessary that surgical wounds, injection sites, and intravenous catheters 't be exposed to regular water or tap waterderived fluids. Endoscopes cleaned in plain tap water and clinical specimens contaminated with plain tap water or ice can also be not acceptable.
Treatment of MAC pulmonary disease. For most patients with nodular/bronchiectatic disease, a three-times-weekly regimen of clarithromycin 1, 000 mg or azithromycin 500 mg, rifampin 600 mg, and ethambutol 25 mg/kg is mandatory. For patients with fibrocavitary MAC lung disease or severe nodular/bronchiectatic disease, a day-to-day regimen of clarithromycin 5001, 000 mg or azithromycin 250 mg, rifampin 600 mg or rifabutin 150300 mg, and ethambutol 15 mg/kg with deliberation over three-times-weekly amikacin or streptomycin at the beginning of therapy is suggested. Patients needs to be treated until culture negative on therapy for 12 months.
Treatment of disseminated MAC disease. Therapy will incorporate clarithromycin 1, 000 mg/d or azithromycin 250 mg/d and ethambutol 15 mg/kg/d with or without rifabutin 150350 mg/d. Therapy is usually discontinued with resolution of symptoms and reconstitution of cell-mediated immune function.
Prophylaxis of disseminated MAC disease. Prophylaxis really should be given to adults with acquired immunodeficiency syndrome AIDS with CD4
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