MAC Therapy Guidelines

Disseminated MAC Disease (HIV/AIDS Patients)

The American Academy of Family Physicians recommends clarithromycin 500 mg twice daily or azithromycin 500 mg daily, combined with ethambutol 15 mg/kg daily, with optional rifabutin 300 mg daily, for the treatment of disseminated MAC in HIV/AIDS patients, continued lifelong unless immune reconstitution occurs 1, 2
The American Thoracic Society suggests that clarithromycin 500 mg twice daily is the preferred macrolide, as it clears bacteremia more rapidly than azithromycin, in patients with disseminated MAC disease 3
The Centers for Disease Control and Prevention recommend that ethambutol 15 mg/kg daily must be added as the second drug in all regimens for the treatment of disseminated MAC in HIV/AIDS patients 1, 3
The National Institutes of Health suggest that rifabutin 300 mg daily may be used as an optional third drug in the treatment of disseminated MAC in HIV/AIDS patients, adjusted for antiretroviral interactions 1, 2
The American Academy of Family Physicians warns that clarithromycin 1000 mg twice daily should never be used due to increased mortality compared to 500 mg twice daily 1, 2

The American Thoracic Society recommends azithromycin 500 mg three times weekly or 250 mg daily, combined with rifampin and ethambutol 15 mg/kg, for the treatment of MAC pulmonary disease in non-HIV patients 4, 5
The Infectious Diseases Society of America suggests that treatment should be continued until 12 consecutive months of negative sputum cultures while on therapy, with monthly sputum cultures to monitor response 4, 5

The European Respiratory Society recommends azithromycin 250-500 mg three times weekly for patients with chronic obstructive pulmonary disease (COPD) and ≥3 exacerbations requiring steroids and ≥1 hospitalization per year, with a minimum trial period of 6-12 months to assess efficacy 6, 7
The British Thoracic Society suggests that azithromycin 500 mg three times weekly, 250 mg daily, or erythromycin ethylsuccinate 400 mg twice daily may be used for patients with bronchiectasis and ≥3 exacerbations per year 7

The American Heart Association recommends that an ECG should be performed to assess QTc interval before initiating macrolide therapy, and contraindicated if QTc >450 ms (men) or >470 ms (women) 6, 7
The National Institutes of Health suggest that baseline liver function tests should be performed before initiating macrolide therapy, and repeated at 1 month and every 6 months thereafter 6, 7

The American Academy of Family Physicians warns that rifabutin reduces clarithromycin serum levels and cannot be used with certain protease inhibitors, and may cause arthralgias, uveitis, neutropenia, and liver abnormalities 1, 2, 3