Therapeutic Management Strategies Among Immunocompetent Infants with Nontuberculous Mycobacterial Pulmonary Infection

The prevalence of pulmonary nontuberculous mycobacteria (NTM) infection and disease is increasing globally. Pediatric studies on treatment of pulmonary NTM disease in immunocompetent infants are limited, and adult guidelines lack details regarding age-specific management strategies. This systematic review analyzes pharmaceutical, procedural, and supportive management strategies for pulmonary NTM infections in immunocompetent infants based on published case reports and series.

A systematic review of PubMed for case reports on pulmonary NTM infections in immunocompetent infants (≤24 months) until December 2023 was conducted. Demographic information, therapeutic interventions, procedural details, and patient outcomes were extracted to Covidence. Data on therapeutic strategies were summarized descriptively.

Twenty-six case reports describing 33 infants with pulmonary NTM were identified. Study demographics included: 55% female, median age at diagnosis was 12 months, and Mycobacterium avium complex (58%) was the most common NTM strain. Most patients (94%) received antibiotic therapy, with a median treatment duration of 30 weeks. Common regimens included combined ethambutol with rifampin (n=9) or clarithromycin (n=6), and clarithromycin with amikacin (n=6). Most patients started on therapy for tuberculosis before switching treatment courses after NTM diagnosis. Common antibiotic classes after NTM diagnosis were macrolides, antituberculous, and aminoglycosides. Non-pharmaceutical therapies included 79% undergoing diagnostic bronchoscopy, 39% receiving tissue debulking, 33% undergoing surgical biopsy for diagnostic confirmation, and 12% requiring lung resection. Two patients underwent surgical interventions without antibiotics. Supportive therapies included non-invasive supplemental oxygen (12%) and mechanical ventilation (6%), with three patients admitted to intensive care units. Overall survival rate was 94%.

This study reports diverse therapeutic approaches to management of immunocompetent infants with diagnosed pulmonary NTM disease, which utilized varying antibiotics and procedural interventions. Although few patient deaths were reported, these results suggest a need for additional prospective studies to compare efficacy of treatment regimens and establish tailored pediatric guidelines for disease management.