Non-Tuberculous Mycobacteria (NTM)

M. avium complex, M. genavense, M. kansasii

Primary Prophylaxis

Prophylaxis is not recommended if ART is started

Prophylaxis may be considered for persons with CD4 counts < 50 cells/μL who remain viremic on ART (drug resistant HIV with no option to achieve virologic control); exclude disseminated MAC disease before starting

	Drug / Dose	Comments
Regimens listed are alternatives	azithromycin 1200-1250 mg/week po	Check for interactions with ARVs, see Drug-drug Interactions between ARVs or and Non-ARVs
OR clarithromycin 500 mg bid po
OR rifabutin 300 mg qd po	Check for interactions with ARVs, see Drug-drug Interactions between ARVs or and Non-ARVs Active TB should be ruled out before starting rifabutin

Drug / Dose

Comments

Regimens listed are alternatives

azithromycin
1200-1250 mg/week po

Check for interactions with ARVs, see Drug-drug Interactions between ARVs or and Non-ARVs

OR
clarithromycin
500 mg bid po

OR
rifabutin
300 mg qd po

Check for interactions with ARVs, see Drug-drug Interactions between ARVs or and Non-ARVs

Active TB should be ruled out before starting rifabutin

Diagnosis and treatment

Diagnosis:
clinical appearance and cultures of blood, lymph nodes, bone marrow or other usually sterile specimen.

Notes on treatment:
for any treatment regimen, check interactions with ARVs, see Drug-drug Interactions between ARVs and Non-ARVs and Anti-infective and ART interactions table

Active TB should be ruled out before starting anti-TB drugs (rifampicin, rifabutin, ethambutol, isoniazid)

	Drug / Dose	Comments
Mycobacterium avium-intracellulare complex (MAC) Preferred therapy	clarithromycin 500 mg bid po + ethambutol 15-20 mg/kg qd po ± rifabutin 300 mg qd po (or 150 mg qd if PI/b) rifabutin can be replaced by: + levofloxacin/moxifloxacin 500 mg qd po/400 mg qd po OR + amikacin 10-15 mg/kg qd iv	- 12 months, then secondary prophylaxis In case of drug interactions or intolerance, azithromycin 500 mg qd po may be used in place of clarithromycin - rifabutin can be considered in case of severe disease, if resistance to macrolides or ethambutol is suspected, or in case of high bacterial load (> 2log of CFU/mL of blood). Rifabutin* is indicated if ART is not given levofloxacin/moxifloxacin or amikacin can be considered as 4th drug for disseminated or severe/refractory disease (no data on additional benefit)
Mycobacterium kansasii	rifampicin 600 mg qd po (OR rifabutin 300 mg qd po) + isoniazid 300 mg qd po + ethambutol 15-20 mg/kg qd po	12 months after negative culture
OR rifampicin 600 mg qd po (OR rifabutin 300 mg qd po) + clarithromycin 500 mg bid po + ethambutol 15-20 mg/day qd po

Drug / Dose

Comments

Mycobacterium avium-intracellulare complex (MAC)

Preferred therapy

clarithromycin
500 mg bid po
+ ethambutol
15-20 mg/kg qd po
± rifabutin
300 mg qd po (or 150 mg qd if PI/b)

rifabutin can be replaced by:
+ levofloxacin/moxifloxacin
500 mg qd po/400 mg qd po
OR
+ amikacin
10-15 mg/kg qd iv

- 12 months, then secondary prophylaxis

In case of drug interactions or intolerance, azithromycin 500 mg qd po may be used in place of clarithromycin

- rifabutin can be considered in case of severe disease, if resistance to macrolides or ethambutol is suspected, or in case of high bacterial load (> 2*log of CFU/mL of blood). Rifabutin is indicated if ART is not given

levofloxacin/moxifloxacin or amikacin can be considered as 4th drug for disseminated or severe/refractory disease (no data on additional benefit)

Mycobacterium kansasii

rifampicin
600 mg qd po
(OR rifabutin
300 mg qd po)
+ isoniazid
300 mg qd po
+ ethambutol
15-20 mg/kg qd po

12 months after negative culture

OR
rifampicin
600 mg qd po
(OR rifabutin
300 mg qd po)
+ clarithromycin
500 mg bid po
+ ethambutol
15-20 mg/day qd po

Secondary Prophylaxis / Maintenance Therapy

MAC infection

Stop: if CD4 count > 100 cells/μL and HIV-VL undetectable over 6 months and MAC treatment for at least 12 months

	Drug / Dose
Mycobacterium avium (MAC) Regimens listed are alternatives	clarithromycin 500 mg bid po + ethambutol 15-20 mg/kg qd po
OR azithromycin 500 mg qd po + ethambutol 15-20 mg/kg qd po

Drug / Dose

Mycobacterium avium (MAC)

Regimens listed are alternatives

clarithromycin
500 mg bid po
+ ethambutol
15-20 mg/kg qd po

OR
azithromycin
500 mg qd po
+ ethambutol
15-20 mg/kg qd po