Comprehensive Management Algorithm for Mycobacterium avium Complex Pulmonary Disease in the Real-World Setting

The management of Mycobacterium avium complex pulmonary disease (MAC-PD) is challenging because of limited efficacy and frequent adverse events associated with standard treatments. The 2020 guidelines from the American Thoracic Society, European Respiratory Society, European Society of Clinical Microbiology and Infectious Diseases, and Infectious Diseases Society of America provide recommendations, but real-world adherence is often hindered by these issues, leading many patients to be unable to complete standard therapy. 

This review proposes a comprehensive management algorithm for MAC-PD, emphasizing multidisciplinary approaches and integrating nonantimicrobial management before, during, and after drug treatment to enhance patient outcomes. When a patient presents with chronic respiratory symptoms suggestive of nontuberculous mycobacteria, clinicians should follow a guideline-based approach to diagnosis, as diagnostic delays are common because of nonspecific symptoms. Proper evaluation should determine the disease phenotype (existence of cavitary lesions), as it influences treatment choices. Airway clearance, nutritional support, and management of underlying conditions are essential nonantimicrobial components. Regular outpatient monitoring helps detect disease progression and optimize treatment. 

Treatment strategies vary based on disease severity. For noncavitary nodular bronchiectatic disease, a thrice-weekly regimen is preferred because of better tolerability. Severe cases or those with cavitary forms may require daily treatment with additional aminoglycosides. Amikacin liposome inhalation suspension is recommended for patients not responding to standard regimens after 6 months. Recent research addresses drug intolerance, suggesting alternatives such as a two drug regimen without rifamycin in certain cases. Consultation with nontuberculous mycobacteria specialists is advised for complex cases, particularly those with macrolide resistance or requiring surgical intervention. The algorithm emphasizes shared decision making, patient education, and family support to improve adherence and outcomes.

This content is free for users with an active ATS Membership.

Target Audience

Pulmonologists, critical care specialists, translational researchers, and clinicians

Learning Objectives

At the conclusion of this activity, learners should be able to:

  • Diagnose Mycobacterium avium complex (MAC) pulmonary disease
  • Identify which patients should be started on MAC treatment
  • Describe the importance of non-antimicrobial management in patient care
     
Course summary
Available credit: 
  • 1.00 AMA PRA Category 1 Credit(s)
    The American Thoracic Society designates this for a maximum of 1.00 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
  • 1.00 Participation
Publication Date: 
05/01/2025
Credit Expires: 
05/01/2027
Cost:
$25.00
Rating: 
0

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The American Thoracic Society is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Disclosure Declaration

Article Authorship Disclosures (as submitted to the ATS prior to article publication date)

Kozo Morimoto, M.D., (Respiratory Disease Center, and Division of Clinical Research, Fukujuji Hospital, Japan Anti-Tuberculosis Association, Tokyo, Japan; and Department of Clinical Mycobacteriosis, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan) reported funding in support of the manuscript from The Research Program on Emerging and Reemerging Infectious Diseases of the Japan Agency for Medical Research and Development (AMED). Dr. Morimoto also reported consulting fees from Insmed Incorporated, Boehringer Ingelheim, and MannKind as well as payment or honoraria from Insmed Incorporated and Boehringer Ingelheim. Finally, Dr. Morimoto reported participation on a Data Safety Monitoring Board or Advisory Board at the following companies: Insmed Incorporated, Boehringer Ingelheim, and MannKind. 

Charles L. Daley, M.D., (Department of Medicine, National Jewish Health, Denver, Colorado; and Department of Medicine, University of Colorado, Aurora, Colorado), reported grants or contracts from AN2, Insmed, Paratek, Bugworks, Juvabis, COPD Foundation, PCORI, FDA, Cystic Fibrosis Foundation, MannKind, Verona, and Renovion. Dr. Daley also reported consulting fees from AN2, Insmed, and Paratek. Dr. Daley is a participant on the data safety monitoring board of Otsuka, and Bill and Melinda Gates Foundation, and on the advisory board of the following companies: AN2, Hyfe, Insmed, MannKind, and Paratek. He holds leadership positions on the advisory board of Galapagos, Sanofi, and Spero. Finally, Dr. Daley holds stock in Nob Hill.

Off-Label Usage Disclosure

This educational activity will include discussion of off-label uses of azithromycin, clarithromycin, rifampin, ethambutol, streptomycin, and amikacin. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

Disclosures of AnnalsATS CME Planners

The Annals of the American Thoracic Society (AnnalsATS) original research, commentaries, reviews, and educational content of interest to clinicians and clinical investigators in pediatric and adult pulmonary and sleep medicine and medical critical care. The scope of the journal encompasses content that is applicable to clinical practice, the formative and continuing education of clinical specialists, and the advancement of public health.

The publication of articles that meet these goals by itself is only one step in a multi-step process for the translation of evidence-based improvements in are to clinical practice. Testing for CME credit is designed to function as a next step in the process. This is accomplished through a series of questions written by the author(s) to test that readers have the tools needed to translate recommendations for diagnostic and therapeutic clinical care into clinical practice. Members of the AnnalsATS editorial board review these questions and edit these questions for clarity, educational content, and the quality of the evidence supporting the response to the question.

AnnalsATS CME Planners

Margaret M. Hayes, M.D.
Harvard Medical School, Boston, MA, USA
Dr. Hayes reported receiving payments as an author for a chapter on heliox for UpToDate.
 
Caroline Okorie, M.D., M.P.H.
Stanford University School of Medicine, Stanford, CA, USA
Dr. Okorie reported no financial relationships with ineligible companies.

All relevant financial relationships have been reviewed and mitigated.

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Available Credit

  • 1.00 AMA PRA Category 1 Credit(s)
    The American Thoracic Society designates this for a maximum of 1.00 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
  • 1.00 Participation

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