outcomes and those with favorable outcomes. This
is further compounded by the fact that macrolide
drug levels in lung tissue are higher than in plasma
and hence the significance of low plasma levels
is unclear; however, it is postulated that achieving higher drug levels could in fact lead to better
clinical outcomes. Pending specific well-designed
prospective randomized controlled trials, routine
therapeutic drug monitoring is not currently recommended.
With the overall 5-year mortality for MAC pulmonary disease being approximately 28% in a retrospective analysis, especially in cavitary disease,55
surgery is an option in selected cases as part of
adjunctive therapy along with anti-MAC therapy
based on mycobacterial sensitivity. Surgery is
used as either a curative approach or a “
debulk-ing” measure. 9 When present, clearly localized disease, especially in the upper lobe, lends itself best
to surgical intervention. Surgical resection of a solitary pulmonary nodule due to MAC in addition to
concomitant medical treatment is recommended.
Surgical intervention should be considered early in
the course of the disease because it may provide
a cure without the prolonged treatment and its associated problems, and this approach may lead to
early sputum conversion. Surgery should also be
considered in patients with macrolide-resistant or
multidrug-resistant MAC or in those who cannot
tolerate the side effects of therapy, provided that
the disease is focal and limited. Patients with poor
preoperative lung function have poorer outcomes
than those with good lung function, and postoperative complications arising from treatment, especially with a right-sided pneumonectomy, tend to occur
more frequently in these patients.35,36,56
CASE 2 CONCLUSION
The patient is restarted on therapy with
clarithromycin, rifampin, and moxifloxacin
and has a good clinical response.
NTM is ubiquitous in the environment, and NTM
infection has variable manifestations, especially
in patients with no recognizable immune impairments. Management strategies must be individualized based on degree of involvement, goal of
therapy, and risk-benefit ratio. In diffuse pulmonary
disease, drug treatment remains difficult due to
medication side effects and high failure rates.
When a localized source of infection is identified,
especially in RGM disease, surgical treatment may
be needed. The importance of appropriately determining which patients require close surveillance
and no specific antimicrobial therapy or specific
treatment with recognition of comorbidity and relapses cannot be overemphasized.
1. Tobin-D’Angelo MJ, Blass MA, del Rio C, et al. Hospital
water as a source of Mycobacterium avium complex
(MAC) isolates in respiratory specimens. J Infect Dis
2. Marras TK, Daley CL. Epidemiology of human pulmonary
infection with non-tuberculous mycobacteria. Clin Chest
3. Marras TK, Chedore P, Ying AM, Jamieson F. Isolation
prevalence of pulmonary nontuberculous mycobacteria in
Ontario, 1997–2003. Thorax 2007;62:661–6.
4. Prevots DR, Shaw PA, Strickland D, et al. Nontuberculous
mycobacterial lung disease prevalence at four integrated
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