David E. Griffith, MD, prepared useful practice aids pertaining to nontuberculous mycobacterial lung disease for this CME/MOC/CNE activity titled "Exploring the Path Forward in Nontuberculous Mycobacterial Lung Disease: A MasterClass on Risk Factors, Diagnosis, and Treatment." For the full presentation, monograph, complete CME/MOC/CNE information, and to apply for credit, please visit us at http://bit.ly/2WtMqXk. CME/MOC/CNE credit will be available until April 2, 2020.

1. A Guide to the Diagnosis and Management of Nontuberculous
Mycobacterial Lung Disease1-5
PRACTICE AID
This Practice Aid has been provided as a quick reference to help learners apply the information to their daily practice.
Clinical Symptoms
Clinical
Phenotypes
 Chronic cough
 Fever/chills
 Night sweats
 Weight loss
 Shortness of breath
 Hemoptysis
Diagnostic Criteria
Clinical
• Cough, fatigue, weight loss
Radiographic
• Nodular or cavitary opacities on chest radiograph or
• HRCT showing multifocal bronchiectasis with
multiple small nodules
Bacteriology
• Positive cultures from ≥2 separate expectorated sputum samples
• Positive cultures from ≥1 bronchial wash or lavage
• Transbronchial or other lung biopsy with mycobacterial
histopathologic features and positive culture for NTM or biopsy
showing mycobacterial histopathologic features and ≥1 sputum
or bronchial wash that is culture positive for NTM
Nodular
Bronchiectatic Cavitary Fibrocavitary
M. avium Complex
Treatment Algorithm Initial Treatment of MAC
Medical Treatment
Options in Refractory MAC
MAC
Cavities present
Yes
Yes
No
No
Clofazimine
Moxifloxacin
Ciprofloxacin
Linezolid/tedizolid
Bedaquilline
Daily
Rifampin
Ethambutol
Additional drug
Add amikacin
Consider surgery
Daily
Azithromycin
Rifampin
Ethambutol
3x/wk
Azithromycin
Rifampin
Ethambutol
Macrolide sensitive
Nodular
Bronchiectatic
Cavitary
Clarithromycin
1,000 mg 3x/wk or
azithromycin
500-600 mg 3x/wk
Macrolide
Clarithromycin
500-1,000 mg/day or
azithromycin
250-500 mg/day
25 mg/kg 3x/wkEthambutol 15 mg/kg day
Rifampin
600 mg 3x/wk
Rifamycin
Rifampin
450-600 mg/day
NoneAminoglycoside
Streptomycin
or amikacin
30% additional
culture
conversion
Change from
intermittent to
daily therapy
30% additional
culture
conversion
Use of clofazimine
30% additional
culture
conversion
Use of inhaled
liposomal amikacin
Duration: 12 mo culture negativity
Access the activity, “Exploring the Path Forward in Nontuberculous Mycobacterial Lung Disease: A MasterClass on Risk
Factors, Diagnosis, and Treatment,” at PeerView.com/PGE40.

2. erm(41): erythromycin ribosomal methylase (41); MAC: Mycobacterium aviumcomplex; NTM: nontuberculous mycobacteria.
1. Griffith DE et al. AmJRespirCritCareMed. 2007;175:367-416. 2. Koh WJ et al. AntimicrobAgentsChemother. 2015;59:4994-4996. 3. Jarand J et al. Chest. 2016;149:1285-1293. 4. Olivier KN et al. AmJRespirCritCareMed.2017;195:814-823. 5. Haworth CS et al. Thorax. 2017;72(Suppl 2):ii1-ii64.
A Guide to the Diagnosis and Management of Nontuberculous
Mycobacterial Lung Disease1-5
PRACTICE AID
Treatment of M. abscessus
Interpretation of Extended Clarithromycin Susceptibility Results for M. abscessus
M. abscessus
Subspecies
Any
M. massiliense
M. abscessusa
M. abscessus
M. bolletii
Clarithromycin
Susceptibility
Days 3-5
Susceptible
Resistant
Susceptible
Resistant
Resistant
Susceptible
Macrolide
Susceptibility
Phenotype
Inducible macrolide
resistance
High-level constitutive
macrolide resistance
Macrolide susceptible
Genetic Implication
23S ribosomal RNA
point mutation
Dysfunctional
erm(41) gene
Functional
erm(41) gene
Macrolide Effect
Immunomodulatory
Immunomodulatory
Antimycobacterial
Clarithromycin
Susceptibility
Day 14
Macrolide
≥1 other drug
IV amikacin
M. abscessus
Macrolide?
≥2 other drugs
IV amikacin
Macrolide
≥1 other drug
Inhaled amikacin
Macrolide?
≥2 other drugs
Inhaled amikacin
Imipenem (IV)
Cefoxitin (IV)
Tigecycline (IV)
Linezolid/tedizolid
Clofazimine
Moxifloxacin
Bedaquiline
Consider surgery for focal disease.
Duration: 12 mo culture negativity.
“Functional” erm(41) gene
Yes No
2+ mo 1-2+ mo
M. massiliense
M. abscessus
M. bolletti
a
15%-20% of M. abscessus will have a dysfunctional erm(41) gene (c28 sequevar).
Access the activity, “Exploring the Path Forward in Nontuberculous Mycobacterial Lung Disease: A MasterClass on Risk
Factors, Diagnosis, and Treatment,” at PeerView.com/PGE40.

3. PRACTICE AID
This Practice Aid has been provided as a quick resource for healthcare professionals to provide to their patients.
Key Facts About NTM
Nontuberculous
mycobacterium are
organisms naturally found
in soil and water
In some susceptible people,
an NTM organism infects the airways
and lung tissue leading to disease
NTM infections can become
chronic and require
ongoing treatment
Success of your NTM treatment relies on YOU,
your healthcare providers, and your medications
You can play an ACTIVE ROLE in the progress of your treatment:
Engage actively with your healthcare providers; ask questions and
keep your doctor informed of any change in your condition
Make any necessary lifestyle changes (eg, exercise and hydration)
Seek the support of family and friends
Implement and adhere to the treatment plan and medications you and
your doctor have agreed on, and follow through with full commitment
M
E
D
I
C
A
T
I
O
N
S
You will likely need to take multiple medications for a long period
of time. Adhere to your prescribed dosing schedule, and do not stop
when you begin to feel better. The doctor will tell you when the bacteria
have been controlled long enough to stop taking your medications.
Your medications may have some side effects. Call your doctor to discuss
any side effects and determine whether any medication or dosage changes
are required. If you are having a severe reaction, call your doctor or
pharmacist immediately. However, unless your reaction is life-threatening,
do not stop taking any of your medications (doing so can lead to your
infection becoming drug resistant).
Certain combinations of antibiotics work better together because
they attack the bacteria in more than one way. Drug combinations are
often prescribed to effectively treat a specific strain of NTM. It is important
that your sputum samples be sent to a qualified lab for precise species
identification and sensitivity testing. Depending on the strain of NTM,
medications may be added or changed.
Oral (pills, liquids)
Make sure you understand how often/what time of day to take
the medications and whether they should be taken before, after,
or with meals
Medications infused by IV via a port or “PICC” line (either hospital or home)
Ensure you know how often IV medications need to be administered
(duration of treatment may vary from weeks to more than a year)
It is important to learn how to care for your central catheter
(port or PICC line) to avoid introducing any other infections
Inhaled medications (eg, antibiotics, anti-inammatories such as steroids or
bronchodilators, which may potentially minimize side effects or complications)
Learn how to care for the nebulizer to maintain sterile conditions and
avoid introducing other bacteria/infections into your lungs; run the unit to
clear and dry the tubing, and sterilize the nebulizer mouthpiece regularly
Access the activity, “Exploring the Path Forward in Nontuberculous Mycobacterial Lung Disease: A MasterClass on Risk
Factors, Diagnosis, and Treatment,” at PeerView.com/PGE40.
Nontuberculous Mycobacterial (NTM) Lung Disease:
A Patient’s Guide1,2

4. EKGs: electrocardiograms; IV: intravenous; PICC: peripherally inserted central catheter.
1. https://www.ntminfo.org/wp-content/uploads/2018/04/englishpamphlet_ntminfo.pdf. Accessed January 30, 2019. 2. https://www.lung.org/lung-health-and-diseases/lung-disease-lookup/nontuberculosis-mycobacteria/. Accessed January 30, 2019.
PRACTICE AID
Access the activity, “Exploring the Path Forward in Nontuberculous Mycobacterial Lung Disease: A MasterClass on Risk
Factors, Diagnosis, and Treatment,” at PeerView.com/PGE40.
Other Important Treatment Elements and Considerations
NTM lung disease is a serious infection that can have a significant impact on your life: Join a support group or online support community!
NTM Info & Research: https://www.ntminfo.org/forums/
American Lung Association: 1-800-LUNGUSA
Hearing, Vision, and Other Testing
• Some antibiotics can affect your hearing or vision; ask your doctor about getting baseline tests before beginning treatment
• Regular hearing and vision checkups are recommended to ensure any problem is detected before it progresses
• Patients with certain heart conditions may be at risk of developing a dangerous irregular heart rhythm when taking some types of antibiotics
• Speak with your doctor about getting evaluated for these heart conditions and having regular EKGs, if taking one of these medications
Clear Your Lungs and Sinuses (Airway Clearance)
• You and your doctor or respiratory therapist may have selected one or more ways to clear the mucus from your lungs:
Chest physical therapy with postural drainage
Use of an airway clearance device
Inhaled saline solution
• REMEMBER, every time you cough out infected mucus, there is that much less in your lungs to do damage and that much less for the
antibiotics to overcome
Stay Well Hydrated
• Patients with NTM disease need adequate fluids
• Fluid is essential for thinning mucus secretions, which in turn helps you clear mucus from your airways
• It also helps the kidneys and liver process medications
• Try to minimize drinks such as alcohol, coffee, and tea, which act as diuretics (promote urination) and can result in dehydration
Exercise
• Exercise is important to help maintain and improve overall endurance
• Some patients report that the hard breathing associated with exercise helps them clear their lungs
• Weight training can also help your muscles become more efficient at extracting oxygen from the blood
• Exercise is a recommended part of most treatment plans, but you must discuss the extent and type with your doctor before starting an exercise regimen
Nontuberculous Mycobacterial (NTM) Lung Disease:
A Patient’s Guide1,2