Treatment Regimen for Non-Mycobacterium Tuberculosis [NTM]

The suggested treatment regimen covering maximum non-Mycobacterium Tuberculosis (NTM) mainly Mycobacterium Avium Complex (MAC) is as follows: 

• Rifampicin (R) 450-600 mg OD
• Ethambutol (E) 800-1200 mg OD
• Clarithromycin (Clr) 1 gm OD (split into two doses)
• Add injection Amikacin (Am) 750 mg – 1 gm thrice weekly for the first 2-3 months

Intensive Phase (IP) is for 3 months and can be extended to a maximum of 6 months with all four drugs. 

Continuation Phase (CP) of treatment will be with the same drugs except for injectable. This should be continued for 12 months after sputum culture conversion. Drugs will be given as per the standard weight bands.

If the patient does not culture convert by end of 3 months, then species identification and Drug Susceptibility Testing (DST) are required for further management. 

Management of complicated/ invasive TB disease:

• Recommended initial regimen for most patients with nodular/ bronchiectatic MAC lung disease:
  • Thrice-weekly regimen including Clarithromycin 1000 mg or Azithromycin 500 mg, Ethambutol 25 mg/kg, and Rifampicin 600 mg administered three times per week.
• Recommended initial regimen for fibro-cavitary or severe nodular/ bronchiectatic MAC lung disease: 
• Clarithromycin 500-1000 mg/day or Azithromycin 250 mg/day, Ethambutol 15 mg/kg/day, and Rifampicin 10 mg/kg/day (maximum, 600 mg). 

Points to Note

• Intermittent drug therapy is not recommended for patients who have a cavitary disease, patients who have been previously treated, or patients who have moderate or severe disease.
• The primary microbiologic goal of therapy is 12 months of negative sputum cultures while on therapy; therefore, sputum must be collected from patients for Acid-fast Bacilli (AFB) examination throughout treatment on monthly basis in IP and quarterly basis in CP after culture conversion is achieved.
• Given these complexities, the treatment of NTM will be the prerogative of the Nodal Drug-resistant TB Centres (NDR-TBCs).

Resources

• Training Modules (1-4) for Programme Managers & Medical Officers (NTEP), 2020.
• British Thoracic Society Guidelines for the Management of Nontuberculous Mycobacterial Pulmonary Disease, 2017.
• Guidelines for Programmatic Management of Drug-resistant Tuberculosis in India, March 2021.

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