Skolnik Kate, Kirkpatrick Gordon, Quon Bradley S
Department of Medicine, Division of Respirology, University of Calgary, Calgary, Alberta Canada ; Department of Medicine, Division of Respirology, University of British Columbia, Vancouver, BC Canada ; Rockyview General Hospital Respirology Offices, 7007 14th Street SW, Calgary, AB T2V 1P9 Canada.
Department of Medicine, Division of Respirology, University of British Columbia, Vancouver, BC Canada.
Curr Treat Options Infect Dis. 2016;8(4):259-274. doi: 10.1007/s40506-016-0092-6. Epub 2016 Oct 22.
Nontuberculous mycobacteria (NTM) are found in approximately 10 % of cystic fibrosis (CF) patients, but only a portion will develop NTM disease. The management of CF lung disease should be optimized, including antibiotic therapy targeted to the individual's usual airway bacteria, prior to considering treatment for NTM lung disease. Those who meet criteria for NTM lung disease may not necessarily require treatment and could be monitored expectantly if symptoms and radiographic findings are minimal. However, the presence of complex (MABSC), severe lung disease, and/or anticipated lung transplant should prompt NTM therapy initiation. For CF patients with complex (MAC), recommended treatment includes triple antibiotic therapy with a macrolide, rifampin, and ethambutol. Azithromycin is generally our preferred macrolide in CF as it is better tolerated and has fewer drug-drug interactions. MABSC treatment is more complex and requires an induction phase (oral macrolide and two IV agents including amikacin) as well as a maintenance phase (nebulized amikacin and two to three oral antibiotics including a macrolide). The induction phase may range from one to three months (depending on infection severity, treatment response, and medication tolerability). For both MAC and MABSC, treatment duration is extended 1-year post-culture conversion. However, in patients who do not achieve culture negative status but tolerate therapy, we consider ongoing treatment for mycobacterial suppression and prevention of disease progression.
非结核分枝杆菌（NTM）在约10%的囊性纤维化（CF）患者中被发现，但只有一部分会发展为NTM病。在考虑对NTM肺病进行治疗之前，应优化CF肺病的管理，包括针对个体常见气道细菌的抗生素治疗。符合NTM肺病标准的患者不一定需要治疗，如果症状和影像学表现轻微，可以进行观察监测。然而，存在复合（MABSC）、严重肺病和/或预期进行肺移植应促使开始NTM治疗。对于患有复合（MAC）的CF患者，推荐的治疗包括使用大环内酯类、利福平和乙胺丁醇的三联抗生素治疗。阿奇霉素通常是我们在CF中首选的大环内酯类药物，因为它耐受性更好且药物相互作用较少。MABSC治疗更为复杂，需要一个诱导期（口服大环内酯类药物和两种静脉用药，包括阿米卡星）以及一个维持期（雾化吸入阿米卡星和两到三种口服抗生素，包括一种大环内酯类药物）。诱导期可能为一到三个月（取决于感染严重程度、治疗反应和药物耐受性）。对于MAC和MABSC，治疗持续时间在培养转阴后延长1年。然而，对于未实现培养阴性状态但耐受治疗的患者，我们考虑持续治疗以抑制分枝杆菌并预防疾病进展。
