No abstract

The full guideline for the management of non-tuberculous mycobacterial pulmonary disease is published in Thorax. The following is a summary of the recommendations and good practice points. The sections referred to in the summary refer to the full guideline.

Background: The mainstays of treatment for pulmonary disease caused by opportunist mycobacteria are rifampicin (R) and ethambutol (E). The role of macrolides, quinolones and immunotherapy with Mycobacterium vaccae is not clear. A trial was undertaken to compare clarithromycin (Clari) and ciprofloxacin (Cipro) as third drugs added after 2 years of treatment with R and E for pulmonary disease caused by M avium-intracellulare (MAC), M malmoense and M xenopi (REClari and RECipro). An optional comparison of immunotherapy with M vaccae vs no immunotherapy was also performed. Methods: Progress was monitored annually during the 2 years of treatment and for 3 years thereafter. If the patient was not improving at 1 year the regimen was supplemented by the addition of the drug not received in the original allocation of treatment. Results: 371 patients (186 REClari, 185 RECipro) entered the study (170 MAC, 167 M malmoense, 34 M xenopi). All-cause mortality was high for both groups (44% REClari, 43% RECipro); for MAC it was higher with REClari than with RECipro (48% vs 29%) but for M malmoense (42% vs 56%) and M xenopi (29% vs 47%) it was higher with RECipro (p = 0.006). 3% died from their mycobacterial disease (REClari = RECipro). At the end of treatment, 4% of REClari and 10% of RECipro patients still had positive cultures. Among those with negative cultures at the end of treatment, 6% of the REClari group and 4% of the RECipro group had relapsed. At 5 years 30% of the REClari group were known to have completed treatment as allocated and to be alive and cured compared with 21% of the RECipro group (p = 0.04), but this difference was principally due to those with M malmoense (REClari 38%, RECipro 20%). Patients with MAC or M xenopi were more likely to have a poor outcome than those with M malmoense (p = 0.004), with no difference between REClari and RECipro. Overall, 20% in each group were unable to tolerate the regimen allocated, Cipro being associated with more unwanted effects than Clari (16% vs 9%, p = 0.05). No significant differences in outcomes were found between M vaccae-treated patients and those not treated with M vaccae immunotherapy. Conclusion: Considering all three species together, there were no differences in outcome between the REClari and RECipro groups. Immunotherapy did not improve outcome. New therapies, optimised management of comorbid conditions and a more holistic approach must be explored in the hope of improving outcome.

No abstract

ABsTRAcr Forty seven patients (82 % male) with pulmonary infection caused by Mycobacterium xenopi have been reviewed. Pre-existing lung disease was present in 35 (75 %). In 21 patients the disease was characterised by a subacute illness developing over a period of two to four months, while in another 20 patients there was a longer history of chronic respiratory problems often associated with slowly progressive changes evident from chest radiographs. Response to treatment was poor and unpredictable, and was not related to the results of in vitro sensitivity tests, pre-existing lung disease, or mode of onset of symptoms. Eleven patients (23 %) were cured with chemotherapy. The best drug regimen appeared to be rifampicin and isoniazid combined with either streptomycin or ethambutol. Another 12 (26%) showed favourable responses to drug treatment initially, but eventually relapsed. Four patients had progressive disease while receiving prolonged courses of chemotherapy. Resection was performed in five patients with resultant cure in four. Since the prognosis with drug treatment alone is so unpredictable it is suggested that resection might be part of first line treatment, and that it should usually be performed if patients fail to respond to initial chemotherapy or if they relapse.Published reports have suggested that pulmonary infection with Mycobacterium xenopi responds to antituberculous chemotherapy and carries a relatively good prognosis for cure.'3 Much of the information on which these views are based, however, has been obtained from small series or case reports on individual patients. Moreover, with the exception of a recent paper by Smith and Citron,4 follow up periods have been either short or not documented.'-3 S-9 It has not therefore been possible to assess accurately the effect of chemotherapy or surgery on the long term prognosis of patients with this condition. We have studied 47 patients with M xenopi infection presenting over a 10 year period in an attempt to assess their response to treatment and prognosis for cure and to identify the forms of treatment most likely to lead to successful outcome. MethodsThe names of 90 patients whose sputa had yielded