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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

• 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

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

• 3. Extrapulmonary infection

• Combination anti-tuberculous medications based on in vitro susceptibilities for 4-6 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
• 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 for 12-24 months
• NOTE: Clofazimine should be supplemented by loading dose 300 mg PO monthly
• Pediatric regimen:

• <35 kg

• Preferred regimen: Dapsone 1-2 mg/kg/day PO AND Rifampin 450 mg PO for 12-24 months

• <20 kg

• Preferred regimen: Dapsone 1-2 mg/kg/day PO AND Rifampin 300 mg PO for 12-24 months

• <12 kg

• Preferred regimen: Dapsone 1-2 mg/kg/day PO AND Rifampin 150 mg PO for 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)

• 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: Clarithromycin AND Rifampin AND Ethambutol.
• NOTE: 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 ± Streptomycin
• NOTE: A quinolone, preferably Moxifloxacin, could be substituted for one of the antituberculous drugs

• 3. Extrapulmonary disease

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

Mycobacterium ulcerans

• Mycobacterium ulcerans

• 1. Preulcerative lesions

• Excision and primary closure, Rifampin monotherapy, or heat therapy

• 2. Established ulcers

• Most antimycobacterial agents are ineffective for the treatment of the ulcer; Surgical debridement combined with skin grafting is the usual treatment of choice

• 3. Control complications of the ulcer

• Preferred regimen: Clarithromycin AND Rifampin

Swine influenza

• Swine influenza

• 1. Condition1: Patients who have severe or progressive clinical illness

• Preferred regimen: Oseltamivir 150 mg PO bid
• NOTE(1): Treatment duration depends on clinical response
• NOTE(2): Where the clinical course remains severe or progressive, despite 5 or more days of antiviral treatment, monitoring of virus replication and shedding, and antiviral drug susceptibility testing is desirable
• NOTE(3): Antiviral treatment should be maintained without a break until virus infection is resolved or there is satisfactory clinical improvement
• NOTE(4): Patients who have severe or progressive clinical illness, but who are unable to take oral medication may be treated with Oseltamivir administered by nasogastric or orogastric tube

• 2. Condition2: In situations where oseltamivir is not available, or not possible to use, patients who have severe or progressive clinical illness

• Preferred regimen: Zanamivir inhaled
• NOTE: Zanamivir IV should be considered where available and is recommended for those with serious or progressive illness. If not available, Peramivir IV may be considered

• 3. Condition3: Severely immunosuppressed patients

• Antiviral chemoprophylaxis would be considered by using Oseltamivir OR Zanamivir

Mycobacterium simiae

• Mycobacterium simiae

• Preferred regimen: Clarithromycin AND Moxifloxacin AND Trimethoprim/sulfamethoxazole

Mycobacterium foruitum

• Mycobacterium foruitum

• 1. M. fortuitum isolates

• Susceptible agents: Amikacin (100%), Ciprofloxacin and Ofloxacin (100%), Sulfonamides (100%), Cefoxitin (50%), Imipenem (100%), Clarithromycin (80%), and Doxycycline (50%)

• 2. M. fortuitum lung disease

• At least two agents with in vitro activity against the clinical isolate should be given for at least 12 months of negative sputum cultures

• 3. Serious skin, bone, and soft tissue M fortuitum disease

• At least two agents with in vitro activity against the clinical isolate should be given for a minimum of 4 months; For bone infections, 6 months of therapy is recommended

Mycobacterium scrofulaceum

• Mycobacterium scrofulaceum

• Susceptibility data are lacking and standard treatment regimens for M. scrofulaceum are controversial, emphasizing the need to perform susceptibility testing on confirmed disease-producing isolates of M. scrofulaceum

Mycobacterium marinum

• Mycobacterium marinum

• 1. M. marinum isolates

• Susceptible: Rifampin, Rifabutin, Ethambutol, Clarithromycin, Sulfonamides, and Trimethoprim sulfamethoxazole

• Intermediately susceptible: Streptomycin, Doxycycline, and Minocycline

• Resistant: Isoniazid and Pyrazinamide
• NOTE: Two active agents for 1 to 2 months after resolution of symptoms, typically 3 to 4 months in total

• 2. skin and soft tissue infections

• Preferred regimen (1): Clarithromycin AND Ethambutol
• Preferred regimen (2): Ethambutol AND Rifampin
• NTOE: Azithromycin can replace Clarithromycin

• 3. osteomyelitis or deep structure infection

• Preferred regimen (1): Clarithromycin AND Ethambutol AND Rifampin

Mycobacterium kansasii

• Mycobacterium kansasii

• 1. pulmonary disease

• Preferred regimen: Rifampin 10 mg/kg/day (maximum, 600 mg) PO AND Ethambutol 15 mg/kg/ day PO AND Isoniazid 5 mg/kg/day (maximum 300 mg) PO AND Pyridoxine 50 mg/day PO
• NOTE: Treatment duration for M. kansasii lung disease should include 12 months of negative sputum cultures

• 2. Rifampin-resistant M. kansasii disease

• Preferred regimen: Clarithromycin OR Azithromycin OR Moxifloxacin OR Ethambutol OR Sulfamethoxazole OR Streptomycin
• NOTE(1): Use three-drug regimen
• NOTE(2): Patients undergoing therapy for M. kansasii lung disease should have close clinical monitoring with frequent sputum examinations for mycobacterial culture throughout therapy

• 3. Disseminated M. kansasii disease

• NOTE: The treatment regimen for disseminated disease should be the same as for pulmonary disease

Mycobacterium gordonae

• Mycobacterium gordonae

• Preferred regimen: Ethambutol OR Rifabutin OR Clarithromycin OR Linezolid OR Fluoroquinolones

Mycobacterium genavense

• Mycobacterium genavense

• Susceptibility: Amikacin, Rifamycin, Fluoroquinolones, Streptomycin, and Macrolides
• NOTE(1): Ethambutol has limited activity
• NOTE(2): Optimal therapy is not determined, but multidrug therapies including Clarithromycin appear to be more effective than those without Clarithromycin

Mycobacterium haemophilum

• Mycobacterium haemophilum

• 1. In vitro

• Susceptible: Amikacin, Clarithromycin, Ciprofloxacin, Rifampin, and Rifabutin
• Less susceptible: Doxycycline and Sulfonamides

• 2. Disseminated disease

• Preferred regimen: Clarithromycin AND Rifampin AND Rifabutin AND Ciprofloxacin

Mycobacterium chelonae

• Mycobacterium chelonae
• 1. Localized infections

• Preferred regimen: Clarithromycin 500 mg PO bid
• Alternative regimen: Azithromycin

• 2. Disseminated or extensive disease

• 2.1 monotherapy

• Preferred regimen: Clarithromycin 500 mg PO bid for 6 months

• 2.2 multidrug therapy

• preferred regimen: Clarithromycin 500 mg PO bid AND Tobramycin 5 mg IV/kg/day PO OR Imipenem 0.5-1 g IV q6h OR Linezolid 600 mg IV/PO bid for 4-8 weeks
• Alternative regimen: Moxifloxacin 400 mg PO qd AND Linezolid 600 mg PO bid
• NTOE(1): During initial treatment, multidrug therapy may prevent development of acquired resistance
• NOTE(2): Total treatment duration is 6 months

• 3. Keratitis (LASIK-related)

• Preferred regimen: Clarithromycin 500 mg PO bid AND topicals (Tobramycin 0.3%, 2 gtts q4h AND Gatifloxacin 0.3%, 1 gtt q4h OR Moxifloxacin 0.5%, 1 gtt q4h