Seminars in respiratory and critical care medicine
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Semin Respir Crit Care Med · Jun 2018
ReviewSurgical Management of Pulmonary Mycobacterial Disease.
There is renewed interest in the use of adjuvant surgical resection in the treatment of pulmonary mycobacterial disease. For pulmonary Mycobacterium tuberculosis, the emergence of significant drug resistance has led clinicians to reconsider surgery in select cases, where a clear benefit in bacterial conversion and cure has been noted. ⋯ Resection is generally well tolerated, and may often be performed through a minimally invasive approach. While medical treatment clearly remains the mainstay of therapy, more research is needed regarding the use of adjuvant resection in this patient population.
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The diagnosis of pulmonary nontuberculous mycobacteria (NTM) disease may be challenging, as their presence alone does not necessarily indicate disease and diagnosis requires the integration of clinical, radiological, and microbiological findings. The first step is to suspect NTM disease; however, clinical manifestations of NTM are nonspecific and it may not be possible to separate them from those caused by underlying respiratory disease. The radiological appearance generally falls into two patterns, fibrocavitary disease and nodular-bronchiectatic disease; consolidation, infiltrates, and solitary nodules are also described. ⋯ If sputum is used, more than one isolate is required for diagnosis due to the propensity of NTM to contaminate clinical samples. The correct identification of NTM is vital, as their clinical relevance varies widely between species, and treatment is dictated by the identity of the isolated organism. This review covers the clinical presentation of NTM disease, the interpretation of radiological findings, and issues surrounding the isolation and identification of mycobacteria.
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Of the nontuberculous mycobacteria (NTMs) causing lung disease, members of the Mycobacterium abscessus complex (MABc) present a formidable obstacle to successful management. This challenge starts from a poorly understood pathogenesis, continues with complicated subspecies variation in treatment response, and extends to the multidrug-resistant nature of these organisms. ⋯ This disease also represents a frequent and unique problem in certain populations, including cystic fibrosis and lung transplant recipients, and providers who manage such patients should be familiar with how MABc disease influences management. Because of the rising prevalence of the MABc, especially in patients with complicated underlying pulmonary disease, it is increasingly necessary for infectious diseases and pulmonary medicine clinicians to understand the unique aspects of MABc management and understand when to obtain expert consultation in the care of these patients.
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Nontuberculous mycobacteria (NTM) can cause chronic pulmonary infection in susceptible hosts. Individuals with cystic fibrosis (CF), a multisystem disease predominated by progressive structural lung disease, are particularly vulnerable. Only recently have NTM been recognized for their potential to cause lung deterioration in CF patients. ⋯ In general, treatment regimens do not differ from the non-CF population but the clinician should be aware of potential interactions with other CF therapies. Recent population-level genomics has raised serious concern for indirect person-to-person transmission of several dominating NTM clones worldwide, raising awareness for increase prevention strategies when CF patients potentially congregate, such as clinic visits. Lung transplantation is controversial in those with NTM present in sputum culture but the available evidence suggests that this is not an absolute contraindication.
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Semin Respir Crit Care Med · Jun 2018
ReviewUpdates in the Treatment of Active and Latent Tuberculosis.
First-line therapy for active tuberculosis (TB) has remained unchanged for nearly 40 years. Isoniazid, rifampin, pyrazinamide, and ethambutol for the initial two-month phase followed by isoniazid and rifampin for 4 to 7 months is standard treatment for people at low risk for drug-resistant disease. Directly-observed therapy (DOT) remains the standard of care for pulmonary TB. ⋯ Newer studies are investigating even shorter LTBI treatment with durations of less than 2 months. Treatment of LTBI in people likely infected with multidrug resistant TB is very limited, but one observational study found that fluoroquinolones appear to be effective. The first randomized trials for treating LTBI in contacts to MDR-TB are currently enrolling.