Nontuberculous Mycobacterial Disease Management Principles

Abstract

The management of patients with nontuberculous mycobacterial (NTM) disease, especially pulmonary disease (PD), is neither intuitive nor simple. As is often lamented, treatment of NTM PD is typically more complicated and difficult than the treatment of tuberculosis (TB). Complexity begins with the requirement to select patients that meet established diagnostic criteria and who would benefit from therapy. Essentially all patients with NTM PD have respiratory comorbidities, typically bronchiectasis and/or chronic obstructive lung disease which also requires evaluation and treatment. Management of these comorbidities in the presence of NTM PD is critical but presents additional challenges such as symptomatic overlap with NTM PD that obfuscates NTM treatment responses. Likewise, the decision to begin a multidrug mycobacterial regimen must always involve careful risk-benefit assessment on an individual patient basis. In those instances that treatment for NTM PD is not started, continued monitoring and follow-up of patients are essential. For successful treatment outcomes, clinicians managing NTM PD patients must be familiar with the characteristics of individual NTM PD pathogens and especially the nuances and peculiarities of drug susceptibility patterns. For selected pathogens and antibiotics, the avoidance of acquired mutational drug resistance is imperative. Management requires close and ongoing patient monitoring to assess treatment response and drug toxicity. There are multiple impediments to successful NTM PD therapy so that even with optimal management strategies, treatment success can be elusive. In that context, however, adherence to basic management principles will maximize the chances for a successful treatment outcome. Specific recommendations for comprehensive NTM disease management are offered in this chapter.