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Non-tuberculous mycobacterial pulmonary disease

Key sources
The following summarized guidelines for the evaluation and management of non-tuberculous mycobacterial pulmonary disease are prepared by our editorial team based on guidelines from the Infectious Diseases Society of America (IDSA/CDC/NIH/HIVMA 2023), the Infectious Diseases Society of America (IDSA/ERS/ATS/ESCMID 2020), and the British Thoracic Society (BTS 2017).
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Guidelines

1.Screening and diagnosis

Diagnostic criteria: use the following clinical, radiologic (both clinical and radiologic criteria required) and microbiologic criteria for the diagnosis of NTM-PD given other diagnoses are appropriately excluded:
Situation
Guidance
Clinical
Pulmonary or systemic symptoms
Radiologic
Nodular or cavitary opacities on CXR, or a HRCT scan showing bronchiectasis with multiple small nodules
Microbiologic (any)
Positive culture results from at least 2 separate expectorated sputum samples
Consider obtaining repeat sputum AFB smears and cultures if the results are nondiagnostic
Positive culture results from at least 1 bronchial wash or lavage
Transbronchial or other lung biopsy with mycobacterial histologic features (granulomatous inflammation or AFB) and positive culture for NTM or biopsy showing mycobacterial histologic features (granulomatous inflammation or AFB) and ≥ 1 culture positive sputum or bronchial washings
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2.Diagnostic investigations

Sample collection: consider collecting sputum, induced sputum, bronchial washings, BAL, or transbronchial biopsy samples to evaluate patients with suspected NTM-PD. Attempt to obtain less invasive sampling first to minimize procedural risks whenever possible.
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  • Microbiological testing

  • Susceptibility testing

  • Serologic testing

  • IGRA

  • Chest imaging

  • Skin testing

3.Diagnostic procedures

Lung biopsy: do not perform transbronchial biopsies routinely in patients with suspected NTM-PD.
D

4.Medical management

Setting of care: manage patients with NTM-PD in collaboration with a physician experienced in managing NTM-PD.
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  • Indications for treatment

  • Antimicrobial therapy (M. avium complex)

  • Antimicrobial therapy (M. kansasii)

  • Antimicrobial therapy (M. xenopi)

  • Antimicrobial therapy (M. abscessus)

  • Antimicrobial therapy (M. malmoense)

  • Duration of treatment

  • Adjuvant therapies

5.Surgical interventions

Surgical resection: as per ATS 2020 guidelines, consider performing surgical resection as an adjuvant to medical therapy after expert consultation in selected patients with NTM-PD.
C

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  • Lung transplantation

6.Specific circumstances

Patients with human immunodeficiency virus, primary prophylaxis: do not administer primary prophylaxis against M. avium complex in adult and adolescent patients immediately initiating ART.
D
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  • Patients with HIV (management of disseminated M. avium complex disease)

  • Patients with HIV (maintenance therapy)

  • Patients with HIV (adjuvant therapy)

7.Preventative measures

Infection control: implement adequate infection control policies in both inpatient and outpatient settings to minimize risks of person-to-person transmission of M. abscessus in patients with cystic fibrosis.
B

8.Follow-up and surveillance

Monitoring for medication adverse effects: monitor serum levels of aminoglycosides and creatinine in patients receiving aminoglycosides and adjust dosing according to local policies.
B
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  • Therapeutic drug monitoring

  • Serial clinical assessment

  • Serial laboratory assessment

  • Serial imaging assessment