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British Thoracic Society guidelines for the management of non-tuberculous mycobacterial pulmonary disease (NTM-PD)
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  • Published on:
    Macrolides and Mycobacterium abscessus - time for a rethink?
    • Ross J Langley, Paediatric Respiratory Registrar Department of Paediatric Respiratory and Sleep Medicine, Royal Hospital for Sick Children, Edinburgh
    • Other Contributors:
      • Don Urquhart, Paediatric Respiratory Consultant
      • Stephen Bowhay, Paediatric Pharmacist
      • Christine Peters, Consultant Microbiologist


    We read with interest the latest BTS guideline for the management of non-tuberculous mycobacterial pulmonary disease (NTM-PD).1
    Of particular interest was the section relating to the treatment of Mycobacterium abscessus –pulmonary disease. The evidence for the treatment regimes remains poor (Grade D) and within paediatric population the experience of treatment strategies is based on both adult guidelines and clinical expertise. Questions remain about the rationale for the use of macrolides in organisms with inducible resistance. Table 8 in the article recommends the use of oral macrolides during both induction and continuation phase even if inducible macrolide resistance has been demonstrated in vitro. By definition, M. abscessus abscessus strains will possess a functional erm(41) gene, 2 and therefore we feel use of this drug may be inappropriate for this subspecies.

    Azithromycin is a bacteriostatic antibiotic, with intracellular penetration superior to that of the aminoglycosides. 3 M. abscessus complex can thrive within the intracellular environment. 4 Given the exposure of intracellular M. abscessus abscessus to a bacteriostatic agent we suggest this may induce not only resistance but also quiescence within the bacterium and therefore the bactericidal action of aminoglycosides would be significantly impaired given the lack of active protein synthesis. This quiescent state is likely given the difficulty in isolating this organism whilst the...

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    Conflict of Interest:
    None declared.