Andréjak C, Lescure F-X, Schmit J-L, Jounieaux V
Service de pneumologie et réanimation respiratoire, CHU d'Amiens, avenue Laënnec, Amiens cedex 1, France.
Rev Mal Respir. 2011 Dec;28(10):1293-309. doi: 10.1016/j.rmr.2011.02.016. Epub 2011 Nov 8.
Non tuberculous mycobacteria (NTM), unlike tuberculous mycobacteria, are not strictly human pathogens. The diagnosis of infection and the choice of treatment remain difficult.
Evidence of a NTM in a pulmonary sample is not synonymous with infection. The diagnosis depends on the association of clinical, radiological and microbiological factors. If a NTM is isolated from a respiratory sample, the probability of infection depends on the species. The main NTMs responsible for pulmonary infection in France are Mycobacterium avium intracellulare, Mycobacterium xenopi, Mycobacterium kansasi and Mycobacterium abscessus. Their management is difficult and poorly understood. Treatment is well established for M. avium intracellulare and M. kansasii, with combinations of clarithromycin-rifampicin-ethambutol and isoniazid-rifampicin-ethambutol respectively. For M. xenopi, the optimal treatment is not known and a combination of clarithromycin-rifampicin-ethambutol, with moxifloxacin as an alternative, is currently recommended. In general, treatment is prolonged and often associated with problems of tolerance.
The management of NTM infection, taking into account of the increase in patients "at risk", is an important issue. Further studies are needed to improve the criteria for infection and to find the optimal therapeutic combinations.
非结核分枝杆菌(NTM)与结核分枝杆菌不同,并非严格意义上的人类病原体。感染的诊断和治疗方案的选择仍然困难重重。
肺部样本中发现NTM并不等同于感染。诊断取决于临床、影像学和微生物学因素的综合判断。如果从呼吸道样本中分离出NTM,感染的可能性取决于菌种。在法国,导致肺部感染的主要NTM菌种为鸟分枝杆菌胞内分枝杆菌复合群、蟾分枝杆菌、堪萨斯分枝杆菌和脓肿分枝杆菌。对它们的治疗困难且了解不足。鸟分枝杆菌胞内分枝杆菌复合群和堪萨斯分枝杆菌的治疗方案已确立,分别采用克拉霉素-利福平-乙胺丁醇和异烟肼-利福平-乙胺丁醇联合用药。对于蟾分枝杆菌,最佳治疗方案尚不清楚,目前推荐使用克拉霉素-利福平-乙胺丁醇联合用药,莫西沙星可作为替代方案。总体而言,治疗疗程长,且常伴有耐受性问题。
鉴于“高危”患者数量增加,NTM感染的管理是一个重要问题。需要进一步研究以完善感染诊断标准并找到最佳治疗组合。