Treatment of osteomyelitis due to nontuberculous mycobacteria in adults
- Shannon Kasperbauer, MD
Shannon Kasperbauer, MD
- Assistant Professor of Medicine
- National Jewish Health
- Charles L Daley, MD
Charles L Daley, MD
- Professor of Medicine
- National Jewish Health
Nontuberculous mycobacteria (NTM) are a vast group of organisms that are widespread in the environment (table 1). They have been isolated from numerous environmental sources, including water and soil. NTM can cause a broad range of infections that vary depending on the NTM species and on the host’s immune status. In immunocompetent individuals, disease can present as chronic pneumonia, lymphadenitis, or skin, soft tissue, and/or bone infection. Immunocompromised individuals can also present with any of these findings, but disease in such patients may also manifest as disseminated infection. Unfortunately, NTM are seldom considered as a possible etiology in infections of the soft tissues and/or bones; therefore, delays in diagnosis and treatment are common.
The treatment of osteomyelitis due to NTM will be reviewed here. The epidemiology, clinical manifestations, and diagnosis of NTM osteomyelitis is discussed separately. (See "Epidemiology, clinical manifestations, and diagnosis of osteomyelitis due to nontuberculous mycobacteria".)
Other NTM infections and the management of osteomyelitis due to bacteria and Mycobacterium tuberculosis are reviewed elsewhere. (See "Epidemiology of nontuberculous mycobacterial infections" and "Microbiology of nontuberculous mycobacteria" and "Overview of nontuberculous mycobacteria (excluding MAC) in HIV-infected patients" and "Mycobacterium avium complex (MAC) infections in HIV-infected patients" and "Treatment of Mycobacterium avium complex lung infection in adults" and "Rapidly growing mycobacterial infections: Mycobacteria abscessus, chelonae, and fortuitum" and "Overview of osteomyelitis in adults" and "Hematogenous osteomyelitis in adults" and "Vertebral osteomyelitis and discitis in adults" and "Treatment and prevention of osteomyelitis following trauma in adults" and "Hematogenous osteomyelitis in children: Management" and "Skeletal tuberculosis".)
Osteomyelitis caused by nontuberculous mycobacteria (NTM) requires combination antimycobacterial therapy, often in conjunction with surgery. Concomitant immunosuppression should be minimized whenever possible. There are no randomized controlled trials or comparative observational studies that have evaluated the efficacy of treatment for NTM osteomyelitis. Thus, treatment recommendations are based upon case reports and small retrospective reviews, as well as on in vitro susceptibility patterns.
Unlike isolation of M. tuberculosis, isolation of an NTM species does not necessarily dictate initiation of therapy. Because NTM can be isolated as a result of contamination of a clinical specimen and because the pathogenicity of the various NTM species varies substantially, clinicians must determine the clinical significance of any isolate and whether treatment is indicated . In addition, the results of in vitro susceptibility testing for many NTM do not correlate with clinical response, and therefore the clinician should use these data with an appreciation for the limitations of such testing.
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- GENERAL APPROACH
- SUSCEPTIBILITY TESTING
- ANTIMYCOBACTERIAL THERAPY
- Rapidly growing mycobacteria
- - M. fortuitum complex
- - M. chelonae
- - M. abscessus
- - M. smegmatis
- Slowly growing mycobacteria
- - M. avium complex
- - M. kansasii
- - M. haemophilum
- - M. marinum
- - M. ulcerans
- - Other species
- Duration of therapy
- Monitoring during therapy
- Adverse effects
- Drug interactions
- MANAGING POOR TREATMENT RESPONSES
- SUMMARY AND RECOMMENDATIONS