肺非結核性抗酸菌症治療：ATS/ERS/ESCMID/IDSA 公式臨床実践ガイドライン

日本の医療行政から見放されてる疾患の一つについてのガイドライン

Treatment of nontuberculous mycobacterial pulmonary disease: an official ATS/ERS/ESCMID/IDSA clinical practice guideline
Charles L. Daley, et al.
European Respiratory Journal 2020 56: 2000535;
DOI: 10.1183/13993003.00535-2020
https://erj.ersjournals.com/content/56/1/2000535
https://erj.ersjournals.com/content/erj/56/1/2000535.full.pdf


Remarks: The decision to initiate antimicrobial therapy for NTM pulmonary disease should be individualized based on a combination of clinical factors, the infecting species, and individual patient priorities. Any treatment decision should include a discussion with the patient that outlines the potential side effects of antimicrobial therapy, the uncertainties surrounding the benefits of antimicrobial therapy, and the potential for recurrence including reinfection ( particularly in the setting of nodular/bronchiectatic disease) .

Question II: Should patients with NTM pulmonary disease be treated empirically or based on in vitro drug susceptibility test results?
Recommendations

1) In patients with MAC pulmonary disease, we suggest susceptibility-based treatment for macrolides and amikacin over empiric therapy (conditional recommendation, very low certainty in estimates of effect).
2) In patients with M. kansasii pulmonary disease, we suggest susceptibility-based treatment for rifampicin over empiric therapy (conditional recommendation, very low certainty in estimates of effect).
3) In patients with M. xenopi pulmonary disease, the panel members felt there is insufficient evidence to make a recommendation for or against susceptibility-based treatment.
4) In patients with M. abscessus pulmonary disease we suggest susceptibility-based treatment for macrolides and amikacin over empiric therapy (conditional recommendation, very low certainty in estimates of effect). For macrolides, a 14-day incubation and/or sequencing of the erm(41) gene is required in order to evaluate for potential inducible macrolide resistance. 

Remark: Although in vitro-in vivo correlations have not yet been proven for all major antimycobacterial drugs, baseline susceptibility testing to specific drugs is recommended according to the Clinical and Laboratory Standards Institute (CLSI) guidelines for NTM isolates from patients with definite disease.
Testing of other drugs may be useful, but there is insufficient data to make specific recommendations.

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MACもAbscessusもマクロライドとアミカシンの感受性試験を重要視すべき

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Question III: Should patients with macrolide-susceptible MAC pulmonary disease be treated with a 3-drug regimen with a macrolide or without a macrolide? 

Recommendation
1) In patients with macrolide-susceptible MAC pulmonary disease, we recommend a 3-drug regimen that includes a macrolide over a 3-drug regimen without a macrolide (strong recommendation, very low certainty in estimates of effect). 

Remarks: Although no well-designed randomized trials of macrolide therapy have been performed, macrolide susceptibility has been a consistent predictor of treatment success for pulmonary MAC . Loss of the macrolide from the treatment regimen is associated with a markedly reduced rate of conversion of sputum cultures to negative and higher mortality . Therefore, the panel members felt strongly that a macrolide should be included in the regimen.


といいつつ、MAC治療ではマクロライドを含む治療を勧めている

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Question IV: In patients with newly diagnosed macrolide-susceptible MAC pulmonary disease, should an azithromycin-based regimen or a clarithromycin-based regimen be used?

Recommendation 1) In patients with macrolide-susceptible MAC pulmonary disease we suggest azithromycin-based treatment regimens rather than clarithromycin-based regimens (conditional recommendation, very low certainty in estimates of effect). 

Remarks: The panel felt that azithromycin was preferred over clarithromycin because of better tolerance, less drug interactions, lower pill burden, single daily dosing, and equal efficacy. However, when azithromycin is not available or not tolerated, clarithromycin is an acceptable alternative.


アジスロマイシン主体だが、日本では保険適応の関係でクラリスロマイシンベースが主体という現状


ジスロマック６００ｍｇ錠

【効能・効果】
＜適応菌種＞
マイコバクテリウム・アビウムコンプレックス（MAC）
＜適応症＞
後天性免疫不全症候群（エイズ）に伴う播種性マイコバクテリウ
ム・アビウムコンプレックス（MAC）症の発症抑制及び治療

HIV＆MAC症しか使えない

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abscessusはさらに悲惨

Mycobacterium abscessus (Questions XIX–XXI) Question XIX: In patients with M. abscessus pulmonary disease, should a macrolide-based regimen or a regimen without a macrolide be used for treatment?

Recommendations

1) In patients with M. abscessus pulmonary disease caused by strains without inducible or mutational resistance, we recommend a macrolide-containing multidrug treatment regimen (strong recommendation, very low certainty in estimates of effect).
2) In patients with M. abscessus pulmonary disease caused by strains with inducible or mutational macrolide resistance, we suggest a macrolide-containing regimen if the drug is being used for its immunomodulatory properties although the macrolide is not counted as an active drug in the multidrug regimen (conditional recommendation, very low certainty in estimates of effect). 

Remarks: M. abscessus infections can be life-threatening, and the use of macrolides is potentially of great benefit. Macrolides are very active in vitro against M. abscessus strains without a functional erm(41) gene, and evidence supports use of macrolides in patients with disease caused by macrolide-susceptible M. abscessus [38, 39]. It is important to perform in vitro macrolide susceptibility testing including detection of a functional or nonfunctional erm(41) gene [40–42]