Bedaquiline as Treatment for Disseminated Nontuberculous Mycobacteria Infection in 2 Patients Co-Infected With HIV

Eliza Gil; Nicola Sweeney; Veronica Barrett; Stephen Morris-Jones; Robert F. Miller; Victoria J. Johnston; Michael Brown

Disclosures

Emerging Infectious Diseases. 2021;27(3):944-948. 

In This Article

Conclusions

Treating disseminated NTM infections is challenging and often complicated by antimicrobial resistance and adverse effects of combination drug therapy. In multidrug-resistant M. tuberculosis, bedaquiline has been shown to decrease the time to sputum culture negativity and improve outcomes,[8] leading to interest in its use for NTM infections.

In vitro sensitivity of NTM to bedaquiline has been demonstrated,[9,10] although several species, including M. novocastrense, M. shimodei, and M. xenopi, are intrinsically resistant.[11] In addition, although bedaquiline is bactericidal against many mycobacterial species, it might only be bacteriostatic against M. avium.[12] Despite this feature, bedaquiline has been used in salvage treatment for pulmonary infections with NTM,[13] but little experience regarding its use for disseminated NTM infections has been published.

These 2 case-patients were given bedaquiline on compassionate grounds, given the lack of alternative options because of drug resistance and toxicity. For both patients, bedaquiline enabled construction of an antimicrobial drug regimen that included >2 drugs to which the organism was susceptible in vitro and probably contributed to their positive outcomes. Both patients tolerated the drug and made good clinical progress after its initiation. Given the need for combination therapy, it is impossible to attribute the positive outcome of these cases to a single drug. Both patients received bedaquiline and clofazimine because there is evidence that this combination is synergistic against NTMs in vitro.[14] Case-patient 2 only achieved sustained mycobacterial culture negativity after treatment with bedaquiline and tedizolid.

Use of bedaquiline as salvage therapy for pulmonary NTM infection is often complicated by the emergence of drug resistance and disease relapse.[15] These case-patients received bedaquiline for ≥1 year, and neither showed evidence of the acquisition of drug resistance or disease relapse over that time or since. These case-patients provide support for use of bedaquiline for treatment of disseminated NTM infection, particularly when standard regimens cannot be used because of drug resistance or adverse drug effects.

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