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Nontuberculous Myobacterial Pulmonary Disease

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3 Treatment Systematic reviews were conducted around each of 22 PICO (Population, Intervention, Comparator, Outcome) questions and the guidelines provide evidence- based recommendations that have been developed using GR ADE (Grading of Recommendations, Assessment, Development, and Evaluation) methodolog y. GR ADE involves structured literature review, systematic reviews and meta-analyses of combined data, and expert discussion to assess the certainty in the evidence and determine the strength of each recommendation. (See Table 7) Treatment of NTM Pulmonary Disease (Table 3) ➤ In patients who meet the diagnostic criteria for NTM pulmonary disease (Table 1), we suggest initiation of treatment rather than watchful waiting, especially in the context of positive acid-fast bacilli sputum smears and/or cavitary lung disease (conditional recommendation, very low certainty in estimates of effect). ➤ In patients with MAC pulmonary disease, we suggest susceptibility- based treatment for macrolides and amikacin over empiric therapy (conditional recommendation, very low certainty in estimates of effect). ➤ In patients with M. kansasii pulmonary disease, we suggest susceptibility-based treatment for rifampicin over empiric therapy (conditional recommendation, very low certainty in estimates of effect). ➤ In patients with M. xenopi pulmonary disease, the panel members felt there is insufficient evidence to make a recommendation for or against susceptibility-based treatment. ➤ In patients with M. abscessus pulmonary disease we suggest susceptibility-based treatment for macrolides and amikacin over empiric therapy (conditional recommendation, very low certainty in estimates of effect). For macrolides, a 14-day incubation and/or sequencing of the erm(41) gene is required in order to evaluate for potential inducible macrolide resistance.

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