Nichttuberkulöse Mykobakteriosen unterscheiden sich in Klinik und Therapie erheblich
von Infektionen durch Erreger aus dem Mycobacterium-tuberculosis-Komplex. Bei HIV-Infizierten
spielen fast ausschließlich Infektionen durch Keime aus der Spezies Mycobacterium
avium eine Rolle, die sich als pulmonale Erkrankungen mit besonderen Charakteristika
und disseminierten Verläufen manifestieren. Bei Nicht-HIV-Infizierten prädisponieren
sowohl eine Reihe lokaler, resistenzmindernder Faktoren als auch systemische Umstände
zu Infektionen mit oder ohne Krankheitswert, die wegen ihres Facettenreichtums sowohl
des klinischen Erscheinungsbildes als auch der speziesspezifischen Behandlung praktisch
für jeden einzelnen Patienten eine individuelle Beurteilung erfordern. Die medikamentöse
Behandlung kann sich - im Gegensatz zur Tuberkulose - nur eingeschränkt auf Resistenztests
in vitro stützen und richtet sich daher zumindest zu Beginn nach den bisherigen klinischen
Erfahrungen und nur wenigen kontrollierten Studien. Angesichts der - im Vergleich
zur Tuberkulose - hohen Rezidivrate nach der medikamentösen Therapie sollte die operative
Sanierung lokaler Risikofaktoren (Bronchiektasen, Bullae, postspezifische Veränderungen)
und damit der Infektion regelhaft in Erwägung gezogen werden.
Non-tuberculous mycobacterioses differ substantially from infections with M. tuberculosis
complex in regard to both clinical presentation and treatment. In persons infected
with HIV the pathogenic organism is almost always M. avium complex, which leads to
various pulmonary diseases with specific characteristics and disseminated courses.
In patients not infected with HIV, a number of factors that reduce local resistance
and certain systemic conditions increase the risk of the infection's reaching a degree
of severity requiring treatment. Since these factors are associated with a wide variety
of clinical presentations and treatment is species-specific, assessment needs to be
individualised for almost all patients. In contrast to the treatment of tuberculosis,
in non-tuberculous mycobacterioses the extent to which the treatment can be based
on in vitro resistance tests is limited. Clinicians therefore have to draw on their
previous clinical experience and the few existing controlled studies, at least initially.
In view of the high rate of recurrence compared to tuberculosis, surgical removal
of local risk factors (bronchiectasis, bullae, post-specific changes) and thus the
mycobacterial infection itself should be considered in all cases.
Key words
nontuberculous mycobacterial disease - antimycobacterial chemotherapy - chronic lung
disease - HIV
Literatur
- 1
Dailloux M, Abalain ML, Laurain C. et al. .
Respiratory infections associated with nontuberculous mycobacteria in HIV-negative
patients.
Eur Respir J.
2006;
28
1211-1215
- 2
Doffinger R, Patel SY, Kumararatne DS..
Host genetic factors and mycobacterial infections: lessons from single gene disorders
affecting innate and adaptive immunity.
Microbes Infect.
2006;
8
1141-1450
- 3
Field SK, Cowie RL..
Lung disease due to the more common nontuberculous mycobacteria.
Chest.
2006;
129
1653-1672
- 4
Fowler SJ, French J, Screaton NJ. et al. .
Non-tuberculous mycobacteria in bronchiectasis: prevalence and patient characteristics.
Eur Respir J.
2006;
28
1204-1210
- 5 Gößwald A.. Klinik, Diagnostik, Therapie und Verlauf pulmonaler Infektionen durch
nichttuberkulöse Mykobakterien bei HIV-negativen Patienten in Berlin 1986-1998. Diss.
med., Freie Universität Berlin 2004
- 6
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
367-416
- 7
May T, Brel F, Beuscart C. et al. .
Comparison of combination therapy regimens for treatment of human immunodeficiency
virus-infected patients with disseminated bacteremia due to Mycobacterium avium. ANRS
Trial 033 Curavium Group. Agence Nationale de Recherche sur le Sida.
Clin Infect Dis.
1997;
25
621-629
- 8
Management of the opportunistic mycobacterial infections: Joint Tuberculosis Committee
guidelines 1999. Subcommittee of the Joint Tuberculosis Committee of the British Thoracic
Society.
Thorax.
2000;
55
210-218
- 9
Oliveira RS, Sircili MP, Oliveira EMD. et al. .
Identification of Mycobacterium avium genotypes with distinctive traits by combination
of IS1245-based restriction fragment length polymorphism and restriction analysis
of hsp65.
J Clin Microbiol.
2003;
41
44-49
- 10
Research Committee of the British Thoracic Society. .
disease caused by M avium intracellulare, M malmoense, and M xenopi in HIV negative
patients: rifampicin, ethambutol and isoniazid versus rifampicin and ethambutol.
Thorax.
2001;
56
167-172
- 11
Rodriguez JC Diaz, Lopez M, Ruiz M, Royo G..
In vitro activity of new fluoroquinolones and linezolid against non-tuberculous mycobacteria.
Int J Antimicrob Agents.
2003;
21
585-588
- 12
Roth A, Reischl U, Schönfeld N. et al. .
Mycobacterium heckeshornense sp. nov., a new pathogenic slowly growing Mycobacterium
sp. causing cavitary lung disease in an immunocompetent patient.
J Clin Microbiol.
2000;
38
4102-4107
- 13
Schönfeld N..
The mycobacterial mystery.
Eur Respir J.
2006;
28
1076-1078
- 14
Shafran SD, Singer J, Zarowny DP. et al. .
A comparison of two regimens for the treatment of Mycobacterium avium complex bacteremia
in AIDS: rifabutin, ethambutol, and clarithromycin versus rifampin, ethambutol, clofazimine,
and ciprofloxacin. Canadian HIV Trials Network Protocol 010 Study Group.
N Engl J Med.
1996;
335
377-383
- 15
Wallace Jr RJ, Brown BA, Griffith DE. et al. .
Initial clarithromycin monotherapy for Mycobacterium avium-intracellulare complex
lung disease.
Am J Respir Crit Care Med.
1994;
149
1335-1341
- 16
Woods GL..
Susceptibility testing for mycobacteria.
Clin Infect Dis.
2000;
31
1209-1215
1 Global initiative for chronic Obstructive Lung Disease
Korrespondenz
Dr. Nicolas Schönfeld
Lungenklinik Heckeshorn HELIOS Klinikum Emil von Behring
Walterhöferstraße 11
14165 Berlin
eMail: schoenfeld.berlin@t-online.de
