Sandbox sc

Mycobacterium terrae

• Mycobacterium terrae

• 1. In vitro susceptibility

• All six of the isolates from a single center and 90% or more of an additional 22 isolates of M. terrae complex were susceptible to Ciprofloxacin and Sulfonamides. Recently, 11 isolates of M. terrae complex were also shown to be susceptible to Linezolid

• 2. Antimicrobial therapy

• Preferred regimen: Macrolide AND Ethambutol or other agent based on in vitro susceptibility results

Mycobacterium szulgai

• Mycobacterium szulgai

• 1. in vitro susceptibility

• M. szulgai is susceptible in vitro to most antituberculous drugs including Quinolones and newer Macrolides.

• 2. Pulmonary infection

• Preferred regimen: three- or four-drug regimen based on susceptibility that includes 12 months of negative sputum cultures while on therapy

• 3. Extrapulmonary infection

• Preferred regimen: combination anti-tuberculous medications based on in vitro susceptibilities for 4 to 6 months

Mycobacterium smegmatis

• Mycobacterium smegmatis

• 1. Mild disease

• Preferred regimen: Doxycycline PO AND Trimethoprim sulfamethoxazole PO

• 2. Severe disease

• Preferred regimen: Amikacin IV OR Imipenem IV

Mycobacterium mucogenicum

• Mycobacterium mucogenicum

• In vitro susceptible agents: Aminoglycosides, Cefoxitin, Clarithromycin, Minocycline, Doxycycline, Quinolones, Trimethoprim/sulfamethoxazole, and Imipenem

Mycobacterium malmoense

• Mycobacterium malmoense

• in vitro

• Susceptible: Ethambutol, Ethionamide, Kanamycin, and Cycloserine
• Resistant: INH, Streptomycin, Rifampin, and Capreomycin

• Pulmonary M. malmoense infection

• Preferred regimen: INH AND Rifampin AND Ethambutol ± Quinolones AND Macrolides

Mycobacterium immunogenum

• Mycobacterium immunogenum

• In vitro

• susceptible: Amikacin AND Clarithromycin but
• resistant: Ciprofloxacin, Doxycycline, Cefoxitin, Tobramycin, and Sulfamethoxazole
• NOTE: The optimal therapy for this organism is unknown; however, successful therapy is likely difficult due to the extensive antibiotic resistance of the organism

Mycobacterium leprae

• Mycobacterium leprae

• 1. Multibacillary Leprosy (Skin smear positive)

• Preferred regimen: Dapsone 100 mg/day PO AND Rifampin 600 mg PO 4 times per week AND Clofazimine 50 mg/day PO supplemented by Clofazimine 300 mg PO loading dose monthly
• Pediatric regimen: Dapsone 1-2 mg/kg/day PO AND Rifampin 450 mg PO <35 kg, 300 mg PO <20 kg, 150 mg PO <12 kg
• Length of treatment: 12-24 months

• 2. Paucibacillary Leprosy (Skin Smear negative)

• Preferred regimen: Rifampin 600 mg PO once a month for 6 months AND Dapsone 100 mg/day PO for 6 months

• 3. Erythema Nodosum Leprosum (ENL)

• Continue anti-leprosy drugs throughout
• 3.1 Mild

• Preferred regimen: Rest affect limb, analgesics, follow-up twice a week, check for iridocyclitis; Chloroquine OR Aspirin may be useful

• 3.2 Severe (numerous nodules + fever, ulcerating/pustular ENL, visceral involvement, nodules + neuritis, recurrent ENL)

• Preferred regimen: Prednisolone 30-40 mg/day PO (not to exceed 1 mg/kg) for 1-2 weeks, then taper over 12 weeks
• Alternative regimen (1): (If unresponsive to corticosteroids or if risk of corticosteroids prevent administration) Start Clofazimine 100 mg PO TID for maximum of 12 weeks, taper the dose to 100 mg PO BID for 12 weeks and then 100 mg qd for 12-24 weeks
• Alternative regimen (2): (if not contraindicated) Thalidomide 200-400 mg/day PO, reduced to 50-100 mg/day after 1-2 weeks

• 4. Reversal Reaction

• Preferred regimen: Prednisolone start with 40 mg/day PO then taper by 10 mg twice a week for 12 weeks

Mycobacterium xenopi

• Mycobacterium xenopi

• 1. The cornerstone of therapy for M. xenopi

• Preferred regimen: A combination of Clarithromycin AND Rifampin AND Ethambutol. Therapy should be continued until the patient has maintained negative sputum cultures while on therapy for 12 months

• 2. Pulmonary disease

• Preferred regimen: INH AND Rifabutin OR Rifampin AND Ethambutol AND Clarithromycin ± an initial course of Streptomycin. A quinolone, preferably Moxifloxacin, could be substituted for one of the antituberculous drugs

• 3. Extrapulmonary disease

• Therapy for extrapulmonary disease would include the same agents as for pulmonary disease