Disseminated Mycobacterium avium Complex Disease
Last Updated: May 7, 2013; Last Reviewed: June 14, 2017
Recommendations for Preventing and Treating Disseminated Mycobacterium avium Complex (MAC) Disease
|Preventing 1st Episode of Disseminated MAC Disease (Primary Prophylaxis)
Indications for Initiating Primary Prophylaxis:
- CD4 count <50 cells/mm3 after ruling out disseminated MAC disease based on clinical assessment (which may include mycobacterial blood culture for some patients) (AI)
- Azithromycin 1200 mg PO once weekly (AI), or
- Clarithromycin 500 mg PO BID (AI), or
- Azithromycin 600 mg PO twice weekly (BIII)
Note: Active TB should be ruled out before starting rifabutin.
- Rifabutin 300 mg PO daily (BI) (dosage adjusted may be necessary based on drug-drug interactions, please refer to Table 5 for dosing recommendation when used with ARV drugs).
Indication for Discontinuing Primary Prophylaxis:
Indication for Restarting Primary Prophylaxis:
- CD4 count >100 cells/mm3 for ≥3 months in response to ART (AI)
- CD4 count <50 cells/mm3 (AIII)
|Treating Disseminated MAC Disease
At least 2 drugs as initial therapy to prevent or delay emergence of resistance (AI)
Note: Testing of susceptibility to clarithromycin or azithromycin is recommended.
- Clarithromycin 500 mg PO twice daily (AI) + ethambutol 15 mg/kg PO daily (AI), or
- Azithromycin 500–600 mg (AII) + ethambutol 15 mg/kg PO daily (AI) when drug interactions or intolerance precludes the use of clarithromycin
Addition of a third or fourth drug should be considered for patients with advanced immunosuppression (CD4 count <50 cells/mm3), high mycobacterial loads (>2 log CFU/mL of blood), or in the absence of effective ART (CIII).
The 3rd or 4th drug options may include:
Chronic Maintenance Therapy (Secondary Prophylaxis)
- Rifabutin 300 mg PO daily (CI) (dosage adjusted may be necessary based on drug-drug interactions), or
- An aminoglycoside (CIII) such as amikacin 10–15 mg/kg IV daily or streptomycin 1 gm IV or IM daily, or
- A fluoroquinolone (CIII) such as levofloxacin 500 mg PO daily or moxifloxacin 400 mg PO 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 patients who experience moderate to severe symptoms attributed to IRIS (CIII).
- If IRIS symptoms persist, a short term (4–8 weeks) of systemic corticosteroid (equivalent to 20–40 mg of prednisone) can be used (CII).