ATS GUIDELINES Bundle

2 Introduction ➤ Nontuberculous mycobacteria (NTM) represent over 190 species and subspecies, some of which can produce disease in humans of all ages and can affect both pulmonary and extrapulmonary sites. ➤ This guideline focuses on pulmonary disease in adults (without cystic fibrosis or human immunodeficiency virus infection) caused by the most common NTM pathogens such as Mycobacterium avium complex, Mycobacterium kansasii, and Mycobacterium xenopi among the slowly growing NTM and Mycobacterium abscessus among the rapidly growing NTM. ➤ The Panel recommends that clinical, radiographic, and microbiologic data be collected to monitor response to therapy, expectations be set for the patient's progress and patient cooperation be enlisted in identifying adverse drug reactions. (See full text guideline for further details) Diagnosis Table 1. Clinical, Radiographic and Microbiologic Criteria for Diagnosis NTM Pulmonary Disease a Clinical Pulmonary or Systemic Symptoms Both clinical and radiologic criteria required Radiologic Nodular or cavitary opacities on chest radiograph, or a high-resolution computed tomography scan that shows bronchiectasis with multiple small nodules and Appropriate exclusion of other diagnoses Microbiologic b 1. Positive culture results from at least two separate expectorated sputum samples. If the results are nondiagnostic, consider repeat sputum AFB smears and cultures or 2. Positive culture results from at least one bronchial wash or lavage or 3. Transbronchial or other lung biopsy with mycobacterial histologic features (granulomatous inflammation or AFB) and positive culture for NTM or biopsy showing mycobacterial histologic features (granulomatous inflammation or AFB) and one or more sputum or bronchial washings that are culture positive for NTM a Expert consultation should be obtained when NTM are recovered that are either infrequently encountered or that usually represent environmental contamination. Patients who are suspected of having NTM pulmonary disease but do not meet the diagnostic criteria should be followed until the diagnosis is firmly established or excluded. Making the diagnosis of NTM pulmonary disease does not per se, necessitate the institution of therapy, which is a decision based on the potential risks and benefits of therapy for individual patients. b When 2 positive cultures are obtained, the isolates should be the same NTM species (or subspecies in the case of M. abscessus) in order to meet disease criteria.

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