Mycobacterium abscessus medical therapy: Difference between revisions

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====Duration of the Antibiotic Regimen====
====Duration of the Antibiotic Regimen====
2-4 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 (2): [[Amikacin]] {{and}} [[Imipenem]] 500 mg IV q6-8h for two weeks until clinical improvement in severe cases
:* NOTE: 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 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
:* Alternative regimen(1): [[Tigecycline]] 100 mg IV load then 50 mg IV q12h could be substituted as one of the injectables
:* Alternative regimen(2): [[Linezolid]] 600 mg PO q12h or 600 mg PO OD {{and}} [[Clarithromycin]] could replace parental tx if not tolerated or feasible


==References==
==References==
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[[Category:Nontuberculous mycobacteria]]
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Revision as of 15:09, 2 July 2015

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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:

Antibiotic Regimen

In case of serious skin, soft tissues, and bones infection, a combination of antibiotics need to be administered:[1]

PLUS

Note that, during the initial therapy, amikacin should be administered with cefoxitin up to two weeks or until the patient improves clinically.[1]

Antibiotic Dosage

Antibiotic Dosage
Clarithromycin 1,000 mg/day[1]
Azithromycin 250 mg/day[1]
Amikacin

Once a day regimen
- Adults <50 years and normal renal function: 10-15 mg/kg
- Age >50 years and/or anticipated long term therapy for more than 3 weeks: 10 mg/kg


Three times per week regimen
- 25 mg/kg[1]

Cefoxitin High dose, up to 12 g/day, divided dose[1]
Imipenem 500 mg, 2-4 times/day[1]

Antibiotic Duration of Therapy

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]

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 antibiotics to be administered is:[1]

PLUS

PLUS

Note that, in case of macrolide resistance, the antibiotic therapy should be chosen based on the suscepibility profile of M. abscessus.

Duration of the Antibiotic Regimen

2-4 months

Treatment

Antimicrobial regimen

  • 1.Limited, localized extrapulmonary disease [2]
  • Preferred regimen: Clarithromycin 500 mg PO twice daily ± 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 (2): Amikacin AND Imipenem 500 mg IV q6-8h for two weeks until clinical improvement in severe cases
  • NOTE: 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 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 toClarithromycin 500 mg PO BID or 1000 mg XR OD OR Azithromycin 250 mg PO OD
  • Alternative regimen(1): Tigecycline 100 mg IV load then 50 mg IV q12h could be substituted as one of the injectables
  • Alternative regimen(2): Linezolid 600 mg PO q12h or 600 mg PO OD AND Clarithromycin could replace parental tx if not tolerated or feasible

References

  1. 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 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.

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