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Mycobacterium avium complex Drug Recommendation

全身散佈型病例95%以上由 M.avium complex 鳥形分枝桿菌所引起。

為避免多重抗藥性，同時使用多種藥物是必須的。

引起頸部淋巴腺感染 ( MAC 或 M.scrofulaceum ) 的處理方式為將其完全切除，否則易變為慢性瘺管。

藥物的治療：Rifampicin 600 mg qd (或 Rifabutin 450-600mg qd )，Ethambutol 25mg/kg 2 個月之後改為 15 mg/kg，再加上 clarithromycin( 250mg) 2# bid (或 azithromycin 500 mg qd) 16。

若較嚴重的病患可加上 streptomycin 10-15mg/kg ( 或其它 aminoglycoside ) 2-3 個月。一般建議使用一年半到兩年，並在痰液陰轉後 12 個 月方可停藥。

若產生 clari-thromycin 抗藥的病患必須使用 Rifamycin ( Rif or rifabutin ) ，INAH，ethambutol，streptomycin，quinolone ( ciprofloxacin 750 mg bid ) ，clofazimine ( 100-200mg qd )，ethionamide 等 7 種藥物中選出至少四種藥物來治療，嚴重者必須配合手術治療。

進階抗生素治療：

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.