Management of nontuberculous mycobacterial Pulmonary disease refractory to guideline-based therapy: A systematic review.
Diana Moreira-Sousa, Beatriz Martins, Ana Aguiar et al.
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In 30 seconds
This systematic review examined management strategies for nontuberculous mycobacterial pulmonary disease (NTM-PD) that does not respond to guideline-based therapy. It included 25 studies, mostly retrospective and observational, focused mainly on Mycobacterium avium complex and Mycobacterium abscessus; substantial heterogeneity meant findings were synthesised qualitatively. Severe baseline radiological findings and multiple prior regimen modifications were associated with lower treatment success. The review found no standardised management approach and highlighted species-specific treatment intensification, symptom control, supportive care, and emerging therapies, while noting that evidence for many strategies remains limited.
Key findings
- Twenty-five studies met inclusion criteria; most were retrospective and observational, and heterogeneity precluded quantitative synthesis.
- Severe baseline radiological findings and multiple prior regimen modifications were associated with lower treatment success.
- Intermittent intravenous antibiotics may help control symptoms; evidence for additional antibiotics and supportive interventions remains limited.
- Surgical resection may be considered for localised disease, but recurrence risk remains substantial, particularly with positive preoperative cultures.
Why it matters
Refractory NTM-PD presents complex decisions about treatment escalation, symptom relief, and potential surgery. The review highlights the need to consider clinical, microbiological, and radiological factors—including resistance or pathogen shifts—before changing therapy. Its findings also show that many proposed interventions are supported mainly by observational evidence, underscoring important gaps in the evidence base.
What to keep in mind
The evidence was substantially heterogeneous and mostly retrospective and observational, limiting quantitative synthesis and the strength of conclusions.