Management of non-tuberculous mycobacterial pulmonary disease (NTM-PD): A European wide NTM-NET survey

Abstract

Introduction NTM-PD is rare and complex. Guidelines focus on diagnosis and initial pharmacological management. There is limited guidance on drug monitoring, second-line management and access to advisory platforms. This survey aimed to explore current clinical practice across EU/EEA & UK and identify knowledge gaps to inform future guidelines. Methods An online survey, including questions to determine diagnostic capability, medicines availability and treatment monitoring, was distributed via pan-European networks. Results 34 centres across 20 EU/EEA & UK countries responded. The majority (79%) were from specialist NTM referral centres. Use of formal advisory platforms varied, with 53%(n=18) presenting NTM-PD cases at regional or national level. Of these, 50%(n=9) reported this being less frequently than monthly. All centres perform CT thorax in suspected cases of NTM-PD and proceed to bronchoalveolar lavage if initial sputum culture is negative. Induced sputum facilities were available in 71%(n=24) centres. Drug-interaction monitoring relied on consultation with pharmacists (n=17,50%), national guidelines (n=16,47%) and online tools (n=9,26%). Use of injectable anti-microbials for the treatment of NTM-PD is rising. In the past two years, 82%(n=28) centres used injectables. The most frequently used were amikacin (100%), tigecycline (61%) and imipenem (50%). Second-line agents including nebulised amikacin, linezolid and clofazimine were used by 68%(n=23), 74%(n=25) and 76%(n=26) respondents, respectively. Five respondents reported that clofazimine was used in the initial treatment regimen for certain cases, such as in extensive disease or as first line for M. Abscessus. Ten (29%) centres prescribed Bedaquiline for NTM-PD. Treatment duration varied between 3-6 months (n=7,70%) and 6-12 months (n=3,30%). Indication cited was either refractory M. Abscessus or MACs. Two thirds of respondents had patients who underwent surgery for NTM-PD in the past 5 years. Common indications included cavities, solitary lesions, haemoptysis, and failed treatment response. Follow-up of stable patients varied, 24%(n=8) did monthly reviews, while 68%(n=23) followed up every 2-4 months. Conclusions There is significant variation in practice between countries within EU/EEA & UK. Use of injectable and second-line therapy is increasing with limited international/national guidance available. Ensuring access to evidence-based guidelines incorporating these anti-microbials and expert advisory groups is essential to ensure consistent, high-quality NTM-PD care.