321.4 📋 章末速記 Summary

321.4.1 🔑 一句話總結

NTM (non-tuberculous mycobacteria) = TB + leprosy 以外的 200+ 種 mycobacteria；main pulmonary pathogens：(1) MAC (M. avium complex) 最常見；(2) M. abscessus complex 最棘手；(3) M. kansasii TB-like；(4) M. xenopi、M. malmoense；環境傳播（water, soil, showers, hot tubs）— 不是人傳人；diagnosis (ATS/IDSA 2020)：clinical + radiographic (nodular bronchiectatic or fibrocavitary) + microbiologic (≥ 2 sputum OR 1 BAL OR 1 tissue biopsy)；MAC treatment：azithromycin + ethambutol + rifampin × 12 months after culture conversion（總約 18-24 months）；refractory → ALIS (inhaled liposomal amikacin, CONVERT 2018, FDA 2018)；M. abscessus：IV (amikacin + imipenem/cefoxitin + macrolide if susceptible + tigecycline/linezolid) → oral (macrolide + clofazimine + bedaquiline)；≥ 12 months；cure 30-50%；M. kansasii: rifampin + isoniazid + ethambutol × 9-12 months (TB-like, curable)；Lady Windermere syndrome：tall thin elderly women + RML/lingula bronchiectasis + MAC；disseminated MAC in HIV CD4 < 50 → macrolide + ethambutol + rifabutin + ART；prophylaxis with azithromycin if HIV + CD4 < 50。

321.4.2 💊 治療精要

  • MAC pulmonary：azithromycin 250-500 mg daily + ethambutol 15 mg/kg + rifampin 10 mg/kg × 12 mo after sputum culture conversion
  • MAC refractory：add ALIS (Arikayce) 590 mg inhaled daily (CONVERT 2018, FDA 2018)
  • M. abscessus IV phase：amikacin + imipenem-cilastatin or cefoxitin + macrolide (if subsp. massiliense or low erm[41]) + tigecycline/linezolid × 2-3 months
  • M. abscessus oral continuation：macrolide + clofazimine + bedaquiline (emerging) + others × ≥ 12 months
  • M. kansasii：rifampin + isoniazid + ethambutol × 9-12 months (± macrolide)
  • M. xenopi / M. malmoense：macrolide + ethambutol + rifampin × 12 months after conversion
  • Disseminated MAC (HIV)：macrolide + ethambutol + rifabutin (less drug interaction with HIV ART)
  • HIV prophylaxis：azithromycin 1200 mg weekly if CD4 < 50

321.4.3 🎯 盧醫師的考前提醒

  1. NTM 不傳人（unlike TB）— 環境暴露（water, soil, showers, hot tubs）；M. chimaera 從 cardiac surgery heater-cooler unit
  2. ATS/IDSA 2020 diagnostic criteria：clinical + radiographic + microbiologic (2 sputum OR 1 BAL OR 1 tissue)；single positive sputum 不算 — 需要 confirmation
  3. MAC subspecies：M. avium + M. intracellulare + M. chimaera；最常見 pulmonary NTM
  4. M. abscessus complex 三亞種：abscessus + bolletii = inducible macrolide resistance (erm[41])，massiliense = macrolide-susceptible；erm(41) gene testing 重要
  5. Lady Windermere syndrome：tall thin elderly women + right middle lobe + lingula bronchiectasis + MAC infection（cough suppression hypothesis）
  6. MAC treatment duration：12 months after culture conversion（不只 12 個月 total）；total 約 18-24 個月
  7. CONVERT 2018 + ALIS (Arikayce) FDA 2018：refractory MAC pulmonary disease (failed standard ≥ 6 mo) → add inhaled liposomal amikacin → ↑ culture conversion 29% vs 9% 在 standard
  8. M. kansasii most TB-like + curable：rifampin + isoniazid + ethambutol × 9-12 months；95%+ cure rate
  9. disseminated MAC in HIV (CD4 < 50)：bone marrow + multi-organ；treatment macrolide + ethambutol + rifabutin (NOT rifampin, less drug interaction with HIV ART)；ART critical
  10. HIV prophylaxis azithromycin 1200 mg weekly for CD4 < 50；discontinue if CD4 > 100 × 3 months on ART