快樂小藥師 Im pharmacist nichts glücklich

MAC(Mycobacterium avium complex)來補充一些東西：
1.Mycobacterium avium complex是一群細菌的總稱，包含了M. avium, M. intracellul, M. intracellulare......一堆。
2.M. intracellulare比較根mycobacterial lung disease 有關。
3.M. avium免疫不好的病人必較常見。其實這一類感染只在免疫很差的病人才容易看見，例如AIDS, exogenous immunosuppression, SCID, IFN gamma or IL-12 pathway disorders....等等。超冷門....
4.治療藥物的使用上要用多久不清楚，通常是根據臨床反應給。一般要治療到18-24個月(含sputum culture陰性12個月)。
5.藥物治療選擇：
1)Severe or cavitary disease：用macrolide + ethambutol 15 mg/kg/day PO + rifampin 600 mg PO daily. 剛開始治療的前兩個月並不建議使用高劑量的EMB(ethambutol 25 mg/day )...EMB肝功能不好一般不用調，腎功能不好依熱病調。
2)Aminoglycoside用在refractory infections或是當作是adjunct treatment, Amikacin (15 mg/kg/dose, max 1 g, 3 times per wk IV)對MAI一般是首選，不然就是要用streptomycin 15 mg/kg/dose (max 1 g) 3 times per wk IM.
3)Macrolide resistant-MAI可以用aminoglycoside + ethambutol + rifampin(也可以試試 + isoniazid或是Moxifloxacin, 不過Fluoroquinolones似乎沒有文獻支持怎麼用最好)
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以下根據熱病40th
6.針對M. avium-intracellulare complex (MAC, MAI, or Battey bacillus), Immunocompromised病人的
預防策略：
首選：Azithro 1200 mg po weekly 或 Clarithromycin 500 mg po bid
替代：rifabutin 300 mg po q24h 或 Azithro 1200 mg po weekly + rifampin 300 mg po q24h
治療策略：
首選：(Clarithromycin 500 mg* po bid + ethambutol 15 mg/kg/day + rifabutin 300 mg po q24h 
* Higher doses of Clarithromycin (1000 mg bid) 可能跟mortality上升有關 (CID 29:125, 1999)
替代：azithromycin 500 mg po/day + ethambutol 15 mg/kg/day +/- rifabutin 300-450 mg po/day
7.rifabutin腎功能不好不用調。

abx guide的治療建議

Amikacin

Most active aminoglycoside against most MAC strains. Most common use is for macrolide resistant MAI. Azithromycin Clarithromycin may be modestly more active against MAI than azithromycin, but azithromycin has fewer clinically relevant drug-drug interactions. Specifically, azithromycin can be used safely with rifampin and rifabutin. Clarithromycin Clarithromycin may be modestly more effective than azithromycin, but generally less well-tolerated.

Clarithromycin

extended release (500mg XL tablet) 1000 mg/day is an alternative. Clarithromycin (substrate and inhibitor of CYP3A4) increases rifabutin levels approximately 50%, and clarithromycin levels are decreased approximately 50%. Azithromycin is alternative.

Rifabutin

No prospective studies comparing rifampin to rifabutin in macrolide-containing regimens for MAI lung disease in HIV-negative patients. Anecdotal reports suggest no therapeutic advantage to rifabutin. Given frequent adverse events with rifabutin (when combined with macrolide) and high cost of rifabutin, many experts use rifampin in macrolide-containing regimens for pulmonary MAI in HIV-negative persons.

Rifampin

No prospective studies comparing rifampin to rifabutin in macrolide-containing regimens for MAI lung disease in HIV-negative patients. Anecdotal reports suggest no therapeutic advantage to rifabutin. Given frequent adverse events with rifabutin (when combined with macrolide) and high cost of rifabutin, many experts use rifampin in macrolide-containing regimens for pulmonary MAI in HIV-negative persons.

Moxifloxacin

No prospective studies. Has good in vitro activity, but as with other agents for MAC disease, there may not be clear correlation between in vitro activity and in vivo activity. In mouse studies, appears to have less activity than predicted byin vitro studies. In situations of macrolide resistance, to avoid drug-drug interactions or drug allergy it may be useful.

Linezolid

Drug may have in vitro activity, but clinical experience is limited and side effects such as neuropathy and anemia with long-term treatment is high

Tigecycline

Glycycline drug that has in vitro activity and has been used in the treatment of some NTM infections such as M. abscessus; however, no clinical experience reported in MAI infections.

感謝bao yuan藥師提供資料