Mycobacterium abscessus medical therapy: Difference between revisions

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* [[Surgical debridement]]<ref name="pmid17277290">{{cite journal| author=Griffith DE, Aksamit T, Brown-Elliott BA, Catanzaro A, Daley C, Gordin F et al.| title=An official ATS/IDSA statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases. | journal=Am J Respir Crit Care Med | year= 2007 | volume= 175 | issue= 4 | pages= 367-416 | pmid=17277290 | doi=10.1164/rccm.200604-571ST | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17277290  }} </ref>
* [[Surgical debridement]]<ref name="pmid17277290">{{cite journal| author=Griffith DE, Aksamit T, Brown-Elliott BA, Catanzaro A, Daley C, Gordin F et al.| title=An official ATS/IDSA statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases. | journal=Am J Respir Crit Care Med | year= 2007 | volume= 175 | issue= 4 | pages= 367-416 | pmid=17277290 | doi=10.1164/rccm.200604-571ST | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17277290  }} </ref>
* Administration of combination of [[antibiotic]]s for a prolonged period of time ([[macrolide]] based regimen)<ref name="pmid17277290">{{cite journal| author=Griffith DE, Aksamit T, Brown-Elliott BA, Catanzaro A, Daley C, Gordin F et al.| title=An official ATS/IDSA statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases. | journal=Am J Respir Crit Care Med | year= 2007 | volume= 175 | issue= 4 | pages= 367-416 | pmid=17277290 | doi=10.1164/rccm.200604-571ST | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17277290  }} </ref>
* Administration of combination of [[antibiotic]]s for a prolonged period of time ([[macrolide]] based regimen)<ref name="pmid17277290">{{cite journal| author=Griffith DE, Aksamit T, Brown-Elliott BA, Catanzaro A, Daley C, Gordin F et al.| title=An official ATS/IDSA statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases. | journal=Am J Respir Crit Care Med | year= 2007 | volume= 175 | issue= 4 | pages= 367-416 | pmid=17277290 | doi=10.1164/rccm.200604-571ST | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17277290  }} </ref>
====Antibiotic Regimen====
In case of serious skin, soft tissues, and bones infection, a combination of [[antibiotic]]s need to be administered:<ref name="pmid17277290">{{cite journal| author=Griffith DE, Aksamit T, Brown-Elliott BA, Catanzaro A, Daley C, Gordin F et al.| title=An official ATS/IDSA statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases. | journal=Am J Respir Crit Care Med | year= 2007 | volume= 175 | issue= 4 | pages= 367-416 | pmid=17277290 | doi=10.1164/rccm.200604-571ST | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17277290  }} </ref>
* [[Macrolide]]: [[clarithromycin]] ''OR'' [[azithromycin]]
''PLUS''
* Parenteral antibiotics: [[amikacin]], [[cefoxitin]] ''OR'' [[imipenem]]
Note that, during the initial therapy, [[amikacin]] should be administered with [[cefoxitin]] up to two weeks or until the patient improves clinically.<ref name="pmid17277290">{{cite journal| author=Griffith DE, Aksamit T, Brown-Elliott BA, Catanzaro A, Daley C, Gordin F et al.| title=An official ATS/IDSA statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases. | journal=Am J Respir Crit Care Med | year= 2007 | volume= 175 | issue= 4 | pages= 367-416 | pmid=17277290 | doi=10.1164/rccm.200604-571ST | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17277290  }} </ref>
====Antibiotic Dosage====
{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |Antibiotic ||style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |Dosage
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |[[Clarithromycin]]||style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |1,000 mg/day<ref name="pmid17277290">{{cite journal| author=Griffith DE, Aksamit T, Brown-Elliott BA, Catanzaro A, Daley C, Gordin F et al.| title=An official ATS/IDSA statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases. | journal=Am J Respir Crit Care Med | year= 2007 | volume= 175 | issue= 4 | pages= 367-416 | pmid=17277290 | doi=10.1164/rccm.200604-571ST | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17277290  }} </ref>
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |[[Azithromycin]]||style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | 250 mg/day<ref name="pmid17277290">{{cite journal| author=Griffith DE, Aksamit T, Brown-Elliott BA, Catanzaro A, Daley C, Gordin F et al.| title=An official ATS/IDSA statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases. | journal=Am J Respir Crit Care Med | year= 2007 | volume= 175 | issue= 4 | pages= 367-416 | pmid=17277290 | doi=10.1164/rccm.200604-571ST | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17277290  }} </ref>
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |[[Amikacin]]||style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |
''Once a day regimen'' <br>
- Adults <50 years and normal renal function: 10-15 mg/kg <br>
- Age >50 years and/or anticipated long term therapy for more than 3 weeks: 10 mg/kg <br>
''Three times per week regimen'' <br>
- 25 mg/kg<ref name="pmid17277290">{{cite journal| author=Griffith DE, Aksamit T, Brown-Elliott BA, Catanzaro A, Daley C, Gordin F et al.| title=An official ATS/IDSA statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases. | journal=Am J Respir Crit Care Med | year= 2007 | volume= 175 | issue= 4 | pages= 367-416 | pmid=17277290 | doi=10.1164/rccm.200604-571ST | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17277290  }} </ref>
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |[[Cefoxitin]]||style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | High dose, up to 12 g/day, divided dose<ref name="pmid17277290">{{cite journal| author=Griffith DE, Aksamit T, Brown-Elliott BA, Catanzaro A, Daley C, Gordin F et al.| title=An official ATS/IDSA statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases. | journal=Am J Respir Crit Care Med | year= 2007 | volume= 175 | issue= 4 | pages= 367-416 | pmid=17277290 | doi=10.1164/rccm.200604-571ST | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17277290  }} </ref>
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |[[Imipenem]]||style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | 500 mg, 2-4 times/day<ref name="pmid17277290">{{cite journal| author=Griffith DE, Aksamit T, Brown-Elliott BA, Catanzaro A, Daley C, Gordin F et al.| title=An official ATS/IDSA statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases. | journal=Am J Respir Crit Care Med | year= 2007 | volume= 175 | issue= 4 | pages= 367-416 | pmid=17277290 | doi=10.1164/rccm.200604-571ST | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17277290  }} </ref>
|-
|}
====Antibiotic Duration of Therapy====
* [[Skin or soft tissue infection]]: At least 4 months<ref name="pmid17277290">{{cite journal| author=Griffith DE, Aksamit T, Brown-Elliott BA, Catanzaro A, Daley C, Gordin F et al.| title=An official ATS/IDSA statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases. | journal=Am J Respir Crit Care Med | year= 2007 | volume= 175 | issue= 4 | pages= 367-416 | pmid=17277290 | doi=10.1164/rccm.200604-571ST | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17277290  }} </ref>
* [[Bone]] infection: 6 months<ref name="pmid17277290">{{cite journal| author=Griffith DE, Aksamit T, Brown-Elliott BA, Catanzaro A, Daley C, Gordin F et al.| title=An official ATS/IDSA statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases. | journal=Am J Respir Crit Care Med | year= 2007 | volume= 175 | issue= 4 | pages= 367-416 | pmid=17277290 | doi=10.1164/rccm.200604-571ST | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17277290  }} </ref>


===Pulmonary Infection===
===Pulmonary Infection===
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* Surgical resection of the localized disease<ref name="pmid17277290">{{cite journal| author=Griffith DE, Aksamit T, Brown-Elliott BA, Catanzaro A, Daley C, Gordin F et al.| title=An official ATS/IDSA statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases. | journal=Am J Respir Crit Care Med | year= 2007 | volume= 175 | issue= 4 | pages= 367-416 | pmid=17277290 | doi=10.1164/rccm.200604-571ST | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17277290  }} </ref>
* Surgical resection of the localized disease<ref name="pmid17277290">{{cite journal| author=Griffith DE, Aksamit T, Brown-Elliott BA, Catanzaro A, Daley C, Gordin F et al.| title=An official ATS/IDSA statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases. | journal=Am J Respir Crit Care Med | year= 2007 | volume= 175 | issue= 4 | pages= 367-416 | pmid=17277290 | doi=10.1164/rccm.200604-571ST | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17277290  }} </ref>


====Antibiotic Regimen====
There is no optimal multidrug regimen for the treatment of pulmonary ''M. abscessus'' infection. A successful treatment is defined by 12 months of negative sputum culture.  In the majority of cases, pulmonary ''M. abscessus'' infection is chronic and incurable.


The suggested combination of [[antibiotic]]s to be administered is:<ref name="pmid17277290">{{cite journal| author=Griffith DE, Aksamit T, Brown-Elliott BA, Catanzaro A, Daley C, Gordin F et al.| title=An official ATS/IDSA statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases. | journal=Am J Respir Crit Care Med | year= 2007 | volume= 175 | issue= 4 | pages= 367-416 | pmid=17277290 | doi=10.1164/rccm.200604-571ST | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17277290  }} </ref>
==Treatment==
* [[Macrolide]]: [[clarithromycin]] ''OR'' [[azithromycin]]
''PLUS''
* [[Amikacin]]
''PLUS''
* [[Cefoxitin]] ''OR'' [[imipenem]]


Note that, in case of [[macrolide]] resistance, the antibiotic therapy should be chosen based on the suscepibility profile of ''M. abscessus''.
*1.'''Limited, localized extrapulmonary disease ''' <ref>{{cite book | last = Bartlett | first = John | title = Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases | publisher = Jones and Bartlett Learning | location = Burlington, MA | year = 2012 | isbn = 978-1449625580 }}</ref>


====Duration of the Antibiotic Regimen====
:* Preferred regimen: [[Clarithromycin]] 500 mg PO bid {{withorwithout}} [[Amikacin]] 10-15 mg/kg/day IV or 25 mg/kg three times weekly for 4 months  
2-4 months
 
==Treatment==
===Antimicrobial regimen===
*1.'''Limited, localized extrapulmonary disease ''' <ref>{{cite book | last = Bartlett | first = John | title = Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases | publisher = Jones and Bartlett Learning | location = Burlington, MA | year = 2012 | isbn = 978-1449625580 }}</ref>
:* Preferred regimen: [[Clarithromycin]] 500 mg PO twice daily {{withorwithout}} [[Amikacin]] 10-15 mg/kg/day IV or 25 mg/kg three times weekly for 4 months  


:* Alternative regimen (1): [[Amikacin]] {{and}} [[Cefoxitin]] 12 g/day typically for two weeks until clinical improvement in severe cases
:* Alternative regimen (1): [[Amikacin]] {{and}} [[Cefoxitin]] 12 g/day PO for two weeks  
:* Note: until clinical improvement in severe cases


:* Alternative regimen (2): [[Amikacin]] {{and}} [[Imipenem]] 500 mg IV q6-8h for two weeks until clinical improvement in severe cases
:* Alternative regimen (2): [[Amikacin]] {{and}} [[Imipenem]] 500 mg IV q6-8h for two weeks  
:* NOTE: Osteomyelitis should be treated for as least 6 months; Infected foreign bodies should be removed
:* Note(1): Until clinical improvement in severe cases
:* Note(2): Osteomyelitis should be treated for as least 6 months; Infected foreign bodies should be removed


*2.'''Pulmonary or serious extrapulmonary disease'''
*2.'''Pulmonary or serious extrapulmonary disease'''
:* Preferred regimen: [[Clarithromycin]] 500 mg PO twice daily {{and}} [[Amikacin]] 15 mg/kg/day IV {{and}} [[Cefoxitin]] 2g q4h IV {{or}} [[Imipenem]] 1g q6h IV for at least 2-4 months, if limited by adverse effects, then switch to[[Clarithromycin]] 500 mg PO BID or 1000 mg XR OD {{or}} [[Azithromycin]] 250 mg PO OD
:* Preferred regimen: [[Clarithromycin]] 500 mg PO bid {{and}} [[Amikacin]] 15 mg/kg/day IV {{and}} [[Cefoxitin]] 2g IV q4h {{or}} [[Imipenem]] 1g IV q6h for at least 2-4 months  
:* Alternative regimen(1): [[Tigecycline]] 100 mg IV load then 50 mg IV q12h could be substituted as one of the injectables  
:* Note: If limited by adverse effects {{then}} [[Clarithromycin]] 500 mg PO bid or 1000 mg XR qd {{or}} [[Azithromycin]] 250 mg PO qd
:* Alternative regimen(2): [[Linezolid]] 600 mg PO q12h or 600 mg PO OD {{and}} [[Clarithromycin]] could replace parental tx if not tolerated or feasible
:* Alternative regimen(1): [[Tigecycline]] 100 mg IV loading dose {{then}} 50 mg IV q12h  
 
:* Note: could be substituted as one of the injectables  
:* Alternative regimen(2): [[Linezolid]] 600 mg PO bid or 600 mg PO qd {{and}} [[Clarithromycin]]  
:* Note: Could replace parental tx if not tolerated or feasible
==References==
==References==
{{Reflist|2}}
{{Reflist|2}}
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Latest revision as of 18:08, 18 September 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rim Halaby, M.D. [2]

Overview

The treatment of Mycobacterium abscessus (M. abscessus) skin and soft tissue infection includes draining collections of pus, surgical debridement, and administration of combination of antibiotics. M. abscessus has a variable in vitro drug susceptibilities profile; therefore, antibiotic susceptibility testing is required. The treatment of pulmonary M. abscessus infection includes a combination of antibiotics and surgical resection of the localized disease. M. abscessus infection is treated by a macrolide-based multidrug antibiotic regimen. The duration of the antibiotic regimen depends on the site of infection: 2-4 months in pulmonary infection, at least 4 months in skin and soft tissue infection, and 6 months for bone infection.

Medical Therapy

Skin and Soft Tissue Infections

The treatment of M. abscessus includes the following:

Pulmonary Infection

The treatment of pulmonary M. abscessus infection includes:

  • Administration of combination of antibiotics for a prolonged period of time (macrolide based regimen)[1]
  • Surgical resection of the localized disease[1]


Treatment

  • 1.Limited, localized extrapulmonary disease [2]
  • Preferred regimen: Clarithromycin 500 mg PO bid ± Amikacin 10-15 mg/kg/day IV or 25 mg/kg three times weekly for 4 months
  • Alternative regimen (1): Amikacin AND Cefoxitin 12 g/day PO for two weeks
  • Note: until clinical improvement in severe cases
  • Alternative regimen (2): Amikacin AND Imipenem 500 mg IV q6-8h for two weeks
  • Note(1): Until clinical improvement in severe cases
  • Note(2): Osteomyelitis should be treated for as least 6 months; Infected foreign bodies should be removed
  • 2.Pulmonary or serious extrapulmonary disease
  • Preferred regimen: Clarithromycin 500 mg PO bid AND Amikacin 15 mg/kg/day IV AND Cefoxitin 2g IV q4h OR Imipenem 1g IV q6h for at least 2-4 months
  • Note: If limited by adverse effects THEN Clarithromycin 500 mg PO bid or 1000 mg XR qd OR Azithromycin 250 mg PO qd
  • Alternative regimen(1): Tigecycline 100 mg IV loading dose THEN 50 mg IV q12h
  • Note: could be substituted as one of the injectables
  • Alternative regimen(2): Linezolid 600 mg PO bid or 600 mg PO qd AND Clarithromycin
  • Note: Could replace parental tx if not tolerated or feasible

References

  1. 1.0 1.1 1.2 1.3 Griffith DE, Aksamit T, Brown-Elliott BA, Catanzaro A, Daley C, Gordin F; et al. (2007). "An official ATS/IDSA statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases". Am J Respir Crit Care Med. 175 (4): 367–416. doi:10.1164/rccm.200604-571ST. PMID 17277290.
  2. Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.