Diagnostic modalities for pre-transplant NTM pulmonary disease |
Chest CT scan and sputum culture are suggested for NTM screening in LTx candidates. |
Bronchial washing AFB smear and culture are suggested for NTM screening in donor lung before LTx. |
Sputum/BAL fluid cultures should be sent to reference labs for NTM identification and susceptibility testing. |
Transplant listing criteria in patients with NTM pulmonary disease |
Experts have different opinions about patients with MAC infection who are currently on treatment and sputum culture-negative. Some suggest LTx without further waiting, others recommend culture negativity for the past 6 or 12 months. Experts did not agree that LTx is contraindicated irrespective of culture status. |
Patients with M. abscessus infection who are currently on treatment and sputum culture-negative can be listed for lung transplant if the sputum culture has been negative for the past 12 months. |
Patients with M. kansasii infection who are currently on treatment and sputum culture-negative can be listed for lung transplant if the sputum culture has been negative for the past 6–12 months. |
Patients with a history of treated MAC and M. abscessus infection currently not on treatment and sputum culture-negative should be listed for lung transplant if treated 12 months ago, and 6 months ago in the patients with M. kansasii. |
In patients with past history of M. abscessus infection and currently negative sputum culture who are candidates for single LTx, to prevent NTM infection in allograft perform bilateral LTx. |
Pre-transplant management of NTM pulmonary disease |
Azithromycin, rifampin, amikacin and rifabutin are suggested as empiric antibiotic regimen in NTM non-cavitary disease pending speciation. |
The preferred antibiotic regimens in non-cavitary MAC include: ethambutol, rifampin, azithromycin and clarithromycin. |
The preferred antibiotic regimens in non-cavitary M. abscessus include: azithromycin and amikacin. |
The preferred antibiotic regimens in non-cavitary M. kansasii include: azithromycin, ethambutol and rifampin. |
The recommended frequency of antibiotic therapy for MAC and M. abscessus is daily treatment. |
Post-transplant surveillance for NTM pulmonary disease |
AFB smear, culture, PCR and liver function tests can be used for surveillance while treating NTM in LTx recipients. |
Patients with M. abscessus and M. kansasii infections currently on treatment and negative sputum culture require surveillance sputum cultures with every surveillance bronchoscopy. |
Post-transplant management of NTM pulmonary disease |
Clarithromycin and azithromycin are the most commonly preferred empiric antibiotic regimens (no identification yet) in non-cavitary disease. Some panellists suggest no empiric treatment. |
The preferred antibiotic regimens in non-cavitary MAC include: ethambutol, rifampin, azithromycin and clarithromycin. In macrolide resistant patients, rifabutin and ethambutol are recommended. |
The preferred antibiotic regimens in non-cavitary M. abscessus include: azithromycin, amikacin and imipenem. |
The preferred antibiotic regimen in non-cavitary M. kansasii is rifabutin. |
In the post-transplant stage, a dose reduction of immunosuppressive treatment is recommended if M. abscessus is isolated. |