Box VII.

Recommendations for treating and preventing disseminated Mycobacterium avium complex (MAC) disease

Treating Disseminated MAC Disease

Preferred therapy

At least 2 drugs as initial therapy to prevent or delay emergence of resistance

Clarithromycin 500 mg PO twice daily (AI) plus ethambutol 15 mg/kg PO daily or

Azithromycin 500-600 mg (AII) plus ethambutol 15 mg/kg PO daily when drug interactions or intolerance precludes the use of clarithromycin

Note: Testing of susceptibility to clarithromycin or azithromycin is recommended.

Alternative therapy

Some experts would recommend addition of a third or a 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

The third or fourth drug options may include:

Rifabutin 300 mg PO daily (dose adjustment may be necessary based on drug-drug interactions)

or

A fluoroquinolone (e.g., levofloxacin 500 mg PO daily or moxifloxacin 400 mg PO daily), or

An injectable aminoglycoside (e.g., amikacin 10-15 mg/kg iv daily or streptomycin 1 gm iv or im daily)

Chronic maintenance therapy (secondary prophylaxis): Same as treatment regimens

Criteria for discontinuing chronic maintenance therapy

Completed at least 12 month therapy

No signs and symptoms of MAC disease

Have sustained (>6 months) CD4 count >100 cells/μl in response to ART

Indication for restarting secondary prophylaxis

CD4 <100 cells/µl

Other considerations

NSAIDs may be used for people with HIV who experience moderate to severe symptoms attributed to IRIS

If IRIS symptoms persist, a short-term course (four weeks-eight weeks) of systemic corticosteroid (equivalent to prednisone 20-40 mg) can be used

Preventing first episode of disseminated MAC disease (primary prophylaxis)

Primary prophylaxis is not recommended for adults and adolescents who immediately initiate ART. Indications for initiating primary prophylaxis

Not on fully suppressive ART, and

CD4 count

Preferred therapy

Azithromycin 1200 mg PO once weekly or Clarithromycin 500 mg PO BID or azithromycin 600 mg PO twice weekly

Alternative therapy

Rifabutin 300 mg PO daily (BI) (dose adjustment may be necessary based on drug-drug interactions)

Note: Active TB should be ruled out before starting rifabutin. Indication for discontinuing primary prophylaxis

Initiation of effective ART indication for restarting primary prophylaxis

CD4 count <50 cells/µl (only if not fully suppressive ART) ARTIII

ART: antiretroviral therapy, ARV, antiretroviral; BID, twice daily; CD4:CD4 T lymphocyte; cfu, colony-forming units; im, intramuscular; IRIS, immune reconstitution inflammatory syndrome; iv, intravenous; NSAIDs, non-steroidal anti-inflammatory drugs; PO, orally. Source: Ref. 19