Chest
Volume 146, Issue 2, August 2014, Pages 276-282
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Original Research
Chest Infections
Macrolide/Azalide Therapy for Nodular/Bronchiectatic Mycobacterium avium Complex Lung Disease

https://doi.org/10.1378/chest.13-2538Get rights and content

BACKGROUND

There is no large study validating the appropriateness of current treatment guidelines for Mycobacterium avium complex (MAC) lung disease. This is a retrospective single-center review evaluating the efficacy of macrolide/azalide-containing regimens for nodular/bronchiectatic (NB) MAC lung disease.

METHODS

Patients were treated according to contemporary guidelines with evaluation of microbiologic responses. Macrolide susceptibility of MAC isolates was done at initiation of therapy, 6 to 12 months during therapy, and on the first microbiologic recurrence isolate. Microbiologic recurrence isolates also underwent genotyping for comparison with the original isolates.

RESULTS

One hundred eighty patients completed > 12 months of macrolide/azalide multidrug therapy. Sputum conversion to culture negative occurred in 154 of 180 patients (86%). There were no differences in response between clarithromycin or azithromycin regimens. Treatment regimen modification occurred more frequently with daily (24 of 30 [80%]) vs intermittent (2 of 180 [1%]) therapy (P = .0001). No patient developed macrolide resistance during treatment. Microbiologic recurrences during therapy occurred in 14% of patients: 73% with reinfection MAC isolates, 27% with true relapse isolates (P = .03). Overall, treatment success (ie, sputum conversion without true microbiologic relapse) was achieved in 84% of patients. Microbiologic recurrences occurred in 74 of 155 patients (48%) after completion of therapy: 75% reinfection isolates, 25% true relapse isolates.

CONCLUSIONS

Current guidelines for macrolide/azalide-based therapies for NB MAC lung disease result in favorable microbiologic outcomes for most patients without promotion of macrolide resistance. Intermittent therapy is effective and significantly better tolerated than daily therapy. Microbiologic recurrences during or after therapy are common and most often due to reinfection MAC genotypes.

Section snippets

Materials and Methods

Patients treated at The University of Texas Health Science Center, Tyler, (UTHSCT), Texas, for NB MAC lung disease not previously reported are included in this report. The clinical treatment outcome studies, retrospective chart reviews, and maintenance of a database were approved by the Institutional Review Board of UTHSCT (Institutional Review Board #760, #11-009).

Daily therapy consisted of rifampin 600 mg or rifabutin 150 mg, ethambutol 15 mg/kg, clarithromycin 1,000 mg in divided doses or 15

Results

Two hundred seven consecutively treated patients were started on MAC therapy for NB MAC lung disease during the study period. Twenty-seven patients were excluded from the main analysis because they did not receive at least 12 months of macrolide/azalide-based therapy, leaving 180 patients who met the inclusion criteria for analysis. Fifty-five of 180 patients (31%) received > 6 months macrolide-based therapy prior to treatment at our facility. Twenty-one patients (15%) received either

Discussion

Patients with macrolide-susceptible NB MAC lung disease had a high rate of sputum conversion to AFB culture negative (86%) with macrolide/azalide-based regimens. There were no significant differences in microbiologic responses between clarithromycin and azithromycin treatment regimens. Overall treatment success was achieved in 84% of patients. Consistent with prior reports, our findings support currently recommended macrolide/azalide treatment regimens for NB MAC lung disease.4, 5, 11, 20, 23

Acknowledgments

Author contributions: R. J. W. is guarantor of the manuscript. R. J. W., B. A. B.-E., S. M., J. V. P., J. K., R. W. W., D. S. Y., S. S., and D. E. G. contributed to conception and design; data acquisition, analysis, and interpretation; drafting and critical revision of the submitted article for important intellectual content; final approval of the version to be published; and accountability for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part

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    Data included in this manuscript were presented in part at the American Thoracic Society Annual Meeting, May 14-19, 2010, New Orleans, LA.

    FUNDING/SUPPORT: This manuscript was supported in part by institutional funds from the University of Texas Health Science Center, Tyler and the Carter Foundation (Dr Wallace) and the Moncrief Foundation (Dr Griffith).

    Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.

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