Suggested antimycobacterial regimens for NTM pulmonary infections in children^[1-3]

Mycobacteria species and patient characteristics	Suggested regimen	Comments
Mycobacterium tuberculosis not yet excluded
	Isoniazid, plus Rifampin (rifampicin), plus Ethambutol, plus Azithromycin (preferred) or clarithromycin, plus* Pyrazinamide^¶	Provides empiric coverage for M. tuberculosis and two NTM species commonly isolated from children with NTM pulmonary disease (MAC and Mycobacterium kansasii) Modify regimen when NTM species is identified and speciation M. tuberculosis is confirmed or excluded
MAC infection
HIV-negative, with nodular or noncavitating disease	A rifamycin (rifampin [rifampicin] or rifabutin), plus Ethambutol, plus Azithromycin (preferred*) or clarithromycin	Administer regimen 3 times per week Continue until sputum cultures negative for ≥1 year
HIV-negative, with fibrocavitary disease or extensive bronchiectasis	A rifamycin (rifampin [rifampicin] or rifabutin), plus Ethambutol, plus Azithromycin (preferred) or clarithromycin, plus* An aminoglycoside (amikacin or streptomycin)	Administer rifamycin, ethambutol, and macrolide daily Aminoglycoside: For children: Administer daily For adolescents: Amikacin may be administered 3 times per week Discontinue aminoglycoside after 8 weeks Continue other agents until sputum cultures negative for ≥1 year
HIV-positive	Treat as for children with disseminated NTM infection	Refer to UpToDate content on disseminated NTM infection
Mycobacterium abscessus infection
	Azithromycin (preferred) or clarithromycin, plus* Amikacin, plus Cefoxitin or a carbapenem (eg, imipenem, meropenem) For M. abscessus subspecies abscessus or M. abscessus subspecies bolletii, add another drug (eg, linezolid, tigecycline)^Δ	Select drugs based on susceptibility testing Use at least 3 active drugs initially; may narrow to 2 drugs after 4 to 8 weeks Continue until there is symptomatic and radiographic improvement
Mycobacterium kansasii infection
Rifampin-susceptible	Rifampin (rifampicin), plus Ethambutol, plus Either a macrolide (azithromycin [preferred*] or clarithromycin) or isoniazid^◊	Continue until sputum cultures negative for ≥1 year
Rifampin-resistant or intolerance to a first-line medication	Treat with 3 drugs based upon in vitro susceptibilities Options include macrolides, fluoroquinolones, aminoglycosides, and trimethoprim-sulfamethoxazole	Continue until sputum cultures negative for 12 to 18 months

This table is meant for use with UpToDate content on NTM pulmonary infections in children. Refer to UpToDate content for additional details.

NTM: nontuberculous mycobacteria; MAC: Mycobacterium avium complex (M. avium and Mycobacterium intracellulare).

* Azithromycin is generally preferred to clarithromycin because of once daily dosing and fewer drug interactions.

¶ It is reasonable to exclude pyrazinamide if the 5-drug regimen is too difficult.

Δ Although the macrolide may be continued for its immunomodulatory effects, it should not count as 1 of the active drugs.

◊ Daily therapy is necessary for cavitary M. kansasii pulmonary disease or if isoniazid is included in the initial regimen. If a macrolide is included in the initial regimen for noncavitary M. kansasii pulmonary disease, therapy can be given 3 times per week.

References:

Griffith DE, Aksamit T, Brown-Elliott BA, et al. An official ATS/IDSA statement: Diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases. Am J Respir Crit Care Med 2007; 175:367.
American Academy of Pediatrics. Nontuberculous mycobacteria (environmental mycobacteria, mycobacteria other than Mycobacterium tuberculosis). In: Red Book: 2021-2024 Report of the Committee on Infectious Diseases, 32^nd ed, Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH (Eds), American Academy of Pediatrics, Itasca, IL 2021. p.814.
Daley CL, Iaccarino JM, Lange C, et al. Treatment of nontuberculous mycobacterial pulmonary disease: An official ATS/ERS/ESCMID/IDSA clinical practice guideline. Clin Infect Dis 2020; 71:905.

Graphic 131834 Version 4.0

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Suggested antimycobacterial regimens for NTM pulmonary infections in children[1-3]

Suggested antimycobacterial regimens for NTM pulmonary infections in children^[1-3]