Nontuberculous Mycobacterial Infection in Cystic Fibrosis: Treatment Recommendations

A multidisciplinary team discussed exploring the management options for nontuberculous mycobacterial (NTM) infection during the 32nd Annual North American Cystic Fibrosis (CF) Conference, held October 18-20, 2018 in Denver, Colorado. The discussion was summarized and published in a 2019 edition of Pediatric Pulmonology.

A clinical challenge posited by the audience and discussed with the panel included managing newly acquired NTM infection. The audience and panel agreed that treatment discontinuation should be recommended once NTM is identified in patients on 3 times weekly azithromycin. In addition, clinicians may wish to recommend discontinuation of chronic inhaled tobramycin in an effort to reduce the risk for NTM aminoglycoside resistance.

They also discussed the uncertainty regarding whether CF transmembrane conductance regulator (CFTR) modulator use affects the prevalence and outcomes of NTM infection. The panel recommended evaluating the response to CFTR modulators before diagnosing NTM pulmonary disease in patients with a new NTM infection in whom CFTR modulators were recently initiated.

In terms of the preferred treatment regimens, the panel recommended a treatment plan targeting the species recovered in cultures. Clinicians should adjust NTM treatment options for any concomitant therapies the patient may be receiving to reduce the risk for drug-drug interactions, such as the possible interaction between rifamycins and ivacaftor. Counseling and educating patients about potential drug toxicities and anticipated side effects are also important components in therapy monitoring.

To determine a treatment end point, the panel recommended cultures be monitored each month during therapy in an expectorating patient. Current standard of care is to continue therapy for 12 months beyond the date of conversion to negative cultures in patients with NTM pulmonary disease.

The investigators concluded that the most important part of managing a patient with NTM “through all phases is a well‐organized and closely monitored management plan that is mutually agreed upon by the provider, CF care team, and patient.”

Disclosure: Several study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.

Reference

Martiniano SL, Esther CR, Haworth CS, Kasperbauer SH, Zemanick ET, Caverly LJ. Challenging scenarios in nontuberculous mycobacterial infection in cystic fibrosis [published online December 10, 2019]. Pediatr Pulmonol. doi:10.1002/ppul.24604