Disseminated Mycobacterium avium Complex Disease
Last Updated: February 15, 2019; Last Reviewed: February 15, 2019
Recommendations for Preventing and Treating Disseminated Mycobacterium avium Complex (MAC) Disease
|Preventing First Episode of Disseminated MAC Disease (Primary Prophylaxis)
Indications for Initiating Primary Prophylaxis:
- Primary prophylaxis is not recommended for adults and adolescents who immediately initiate ART (AII).
- Not on fully suppressive ART, and
- CD4 count <50 cells/mm3 after ruling out disseminated MAC disease based on clinical assessment (which may include mycobacterial blood culture for some people with HIV) (AI)
- Azithromycin 1200 mg PO once weekly (AI), or
- Clarithromycin 500 mg PO BID (AI), or
- Azithromycin 600 mg PO twice weekly (BIII)
Indication for Discontinuing Primary Prophylaxis:
- Rifabutin 300 mg PO daily (BI) (dose adjustment may be necessary based on drug-drug interactions, please refer to Table 5 for dosing recommendation when used with ARV drugs).
- Note: Active TB should be ruled out before starting rifabutin.
Indication for Restarting Primary Prophylaxis:
- Initiation of effective ART (AI)
- CD4 count <50 cells/mm3 (only if not on fully suppressive ART) (AIII)
|Treating Disseminated MAC Disease
- At least 2 drugs as initial therapy to prevent or delay emergence of resistance (AI)
- Clarithromycin 500 mg PO twice daily (AI) plus ethambutol 15 mg/kg PO daily (AI), or
- Azithromycin 500–600 mg (AII) plus ethambutol 15 mg/kg PO daily (AI) when drug interactions or intolerance precludes the use of clarithromycin
- Note: Testing of susceptibility to clarithromycin or azithromycin is recommended.
- Some experts would recommend addition of a third or fourth drug for people with HIV with high mycobacterial loads (i.e., >2 log CFU/mL of blood), or in the absence of effective ART (CIII).
The Third or Fourth Drug Options May Include:
Chronic Maintenance Therapy (Secondary Prophylaxis):
- Rifabutin 300 mg PO daily (CI) (dose adjustment may be necessary based on drug-drug interactions), or
- A fluoroquinolone (CIII) (e.g., levofloxacin 500 mg PO daily or moxifloxacin 400 mg PO daily), or
- An injectable aminoglycoside (CIII) (e.g., amikacin 10–15 mg/kg IV daily or streptomycin 1 gm IV or IM daily)
Criteria for Discontinuing Chronic Maintenance Therapy (AII):
- Same as treatment regimens
Indication for Restarting Secondary Prophylaxis:
- Completed at least 12 months therapy, and
- No signs and symptoms of MAC disease, and
- Have sustained (>6 months) CD4 count >100 cells/mm3 in response to ART
- CD4 <100 cells/mm3 (AIII)
- NSAIDs may be used for people with HIV who experience moderate to severe symptoms attributed to IRIS (CIII).
- If IRIS symptoms persist, a short-term course (4 weeks–8 weeks) of systemic corticosteroid (equivalent to prednisone 20–40 mg) can be used (CII).