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Drugs for MAC
- 1. Drugs for Mycobacterium Avium Complex S. Parasuraman, M.Pharm., Ph.D., Associate Professor, Faculty of Pharmacy, AIMST University
- 2. Mycobacterium avium complex (MAC) • Mycobacterium avium complex is a group of mycobacteria comprising Mycobacterium intracellulare and Mycobacterium avium causes pulmonary disease and multifocal disease in immunocompromized (HIV-AIDS) patients. • These bacteria are ubiquitous in the environment and can be encountered in water, food, and soil.
- 3. Pathogenic mycobacterial slow and rapid growers (Runyon classification) SLOW GROWERS Runyon I: Photochromogens • Mycobacterium kansasii • Mycobacterium marinum Runyon II: Scotochromogens • Mycobacterium scrofulaceum • Mycobacterium szulgai • Mycobacterium gordonae Runyon III: Nonchromogens • Mycobacterium avium complex • Mycobacterium haemophilum • Mycobacterium xenopi RAPID GROWERS • Runyon IV • Mycobacterium fortuitum complex • Mycobacterium smegmatis group • Mycobacterium abscessus
- 4. Therapy of MAC Pulmonary Infection • Mycobacterium avium complex is a group of mycobacteria comprising Mycobacterium intracellulare and Mycobacterium avium. • Eradication of MAC has not been achieved by any drug or regimen. • In newly diagnosed patients with MAC pneumonia, triple-drug therapy (rifamycin, ethambutol, and a macrolide) is recommended.
- 5. Therapy of Disseminated M. avium Complex • Disseminated MAC disease is caused by M. avium in 95% of patients. • This is a disease of the immunocompromised patient, especially with reduced cell-mediated immunity.
- 6. Prophylactic Therapy • The goals of prophylactic therapy are to prevent the development of disease during the time when a patient’s CD4 count is low. Monotherapy with either oral azithromycin 1200 mg once a week or clarithromycin 500 mg twice a day is started when patients present with a CD4 count below 50/mm3. • Once the CD4 count is greater than 100 per mm3 for 3 months or longer, MAC prophylaxis should be discontinued.
- 7. Definitive and Suppressive Therapy • In patients with disease due to MAC, the goals of therapy include suppression of symptoms. The infection itself is not completely eradicated until immune reconstitution. • Therapy is divided into initial therapy and chronic suppressive therapy. • Recommended therapy consists of a combination of clarithromycin 500 mg twice a day with ethambutol 15 mg/kg daily, administered orally. • Patients should be continued on suppressive therapy until all three of the following criteria are met – therapy duration of at least 12 months – CD4 count greater than 100/mm3 for at least 6 months – asymptomatic for MAC infection
- 8. Drugs active against atypical mycobacteria • Mycobacterium tuberculosis overshadows most other mycobacterial species, termed “atypical mycobacteria or Nontuberculous mycobacteria (NTM)”. Reference: Gentry C. Atypical Mycobacteria. Pharmacotherapy Self-Assessment Program 5th edition [Internet].
- 9. Drugs active against atypical mycobacteria • Atypical mycobacteria have caused many types of infections, including pneumonia, lung abscess, pleural space infection, lymphadenitis, skin and soft tissue infection (including postoperative wound infection), meningitis, gastrointestinal infection, joint space infection, osteomyelitis, disseminated infection, and even intravenous catheter-related infection.
- 10. Drugs active against atypical mycobacteria • NTM Medication: – Amikacin IV – Amikacin inhalation – Azithromycin – Bedaquiline – Clarithromycin – Cefoxitin – Ciprofloxacin – Clofazimine – Doxycycline – Ethambutol – Imipenem/cilastin Reference: Shulha JA, Escalante P, Wilson JW. Pharmacotherapy approaches in nontuberculous mycobacteria infections. InMayo Clinic Proceedings 2019 Jun 1. Elsevier. – Isoniazid – Levofloxacin – Linezolid – Minocycline – Moxifloxacin – Rifampin – Rifabutin – Tedizolid – Tigecycline – Tobramycin IV – Trimethoprim/sulfamethoxazole