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 viraemic on ART (drug resistant HIV with no option to achieve virologic control); exclude disseminated MAC disease before starting

  Drug / Dose (regimens listed are alternatives) 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

Treatment

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

For any treatment regimen, check for interactions with ARVs, see Drug-drug Interactions between ARVs or and Non-ARVs

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)

 

 

- 12 months, then secondary prophylaxis

 

 

- rifabutin especially indicated in case of severe disease, if resistance to macrolides or ethambutol is suspected or severe immunodeficiency (CD4 count < 50 cells/μL), high bacterial load (> 2*log of CFU/mL of blood), no ART

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

levofloxacin/moxifloxacin or amikacin can be considered as 4th drug for disseminated or severe/refractory disease (no data on additional benefit)
azithromycin
500 mg/day qd po
+ ethambutol
15-20 mg/kg/day po
Consider additional drugs as above

Mycobacterium kansasii

Preferred therapy

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 (regimens listed are alternatives)

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