Institute for Epidemiology, University Medical Hospital Schleswig-Holstein, Kiel, Germany; Lung Clinic Grosshansdorf, Airway Research Center North, German Center for Lung Research, Grosshansdorf, Germany.
Institute for Health Service Research in Dermatology and Nursing, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Institution for Statutory Accident Insurance and Prevention in the Health and Welfare Services, Hamburg, Germany.
Chest. 2018 Apr;153(4):888-921. doi: 10.1016/j.chest.2018.01.024. Epub 2018 Feb 2.
Pulmonary disease (PD) caused by Mycobacterium avium complex (MAC) is increasing worldwide. We conducted a systematic review of studies that include microbiologic outcomes to evaluate current macrolide-based treatment regimens.
We searched literature published before April 2017 by using the MEDLINE, Cochrane, and Embase databases. Risk of bias in randomized trials was assessed using the Cochrane tool.
We retrieved 333 citations and evaluated 42 studies including 2,748 patients: 18 studies were retrospective chart reviews, 18 were prospective, and six were randomized. The weighted average proportion of sputum culture conversions in macrolide-containing regimens after subtracting posttreatment microbiologic recurrences was 52.3% (95% CI, 44.7%-59.9%). Using the triple-drug regimens recommended by the American Thoracic Society (ATS) achieved treatment success in 61.4% (95% CI, 49.7%-72.5%), which further increased to 65.7% (95% CI, 53.3%-77.4%) when drugs were taken for at least 1 year by patients who were macrolide susceptible and had previously untreated MAC. The overall risk of bias was low in five of the six randomized trials. However, selective outcome reporting because of a posteriori exclusion of initially included patients (14.0%), uncompleted treatment (17.6%), and inconsistent use of outcome parameters (17 definitions of treatment success) hampered the comparison of nonrandomized trials.
To date, randomized studies on treatment outcome in patients with MAC PD are scarce. Long-term treatments with ATS-recommended regimens for patients who are macrolide susceptible are superior to other macrolide-based therapies. A standardized definition of treatment success and genotypic distinction between reinfection and relapse by means of pretreatment and posttreatment identification of MAC species in cases of microbiologic recurrences may help to optimize evaluation of treatment regimens in the future.
由鸟分枝杆菌复合群（MAC）引起的肺部疾病（PD）在全球范围内呈上升趋势。我们对包括微生物学结果的研究进行了系统评价，以评估当前基于大环内酯类的治疗方案。
我们使用 MEDLINE、Cochrane 和 Embase 数据库检索了 2017 年 4 月前发表的文献。使用 Cochrane 工具评估随机试验的偏倚风险。
我们检索到 333 篇引文并评估了 42 项研究，共纳入 2748 名患者：18 项为回顾性病历回顾，18 项为前瞻性研究，6 项为随机对照试验。在扣除治疗后微生物学复发后，含大环内酯类药物方案的痰培养转化率的加权平均比例为 52.3%（95%CI，44.7%-59.9%）。使用美国胸科学会（ATS）推荐的三联药物方案，治疗成功率为 61.4%（95%CI，49.7%-72.5%），在对无大环内酯类药物耐药且之前未经治疗的 MAC 患者进行至少 1 年治疗时，成功率进一步提高至 65.7%（95%CI，53.3%-77.4%）。六项随机试验中有五项的整体偏倚风险较低。然而，由于事后排除最初纳入的患者（14.0%）、未完成治疗（17.6%）以及不一致使用结局参数（17 种治疗成功定义），选择性结局报告妨碍了非随机试验的比较。
迄今为止，MAC PD 患者治疗结局的随机研究较少。对于无大环内酯类药物耐药且之前未经治疗的 MAC 患者，采用 ATS 推荐的长期治疗方案优于其他基于大环内酯类的治疗方案。在出现微生物学复发的情况下，通过治疗前和治疗后鉴定 MAC 种来确定治疗成功的标准化定义以及复发与再感染的基因区分，可能有助于优化未来治疗方案的评估。
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