Management of Mycobacterium Avium Complex in HIV-Infected Patients

Introduction to MAC Treatment

The Centers for Disease Control and Prevention recommends that MAC treatment in HIV-infected patients should be continued for at least 12 months and can be discontinued only when patients meet all three criteria: completion of ≥12 months of therapy, sustained CD4+ count >100 cells/µL for ≥6 months on HAART, and complete resolution of MAC symptoms 1, 2, 3

The American Thoracic Society suggests that treatment of MAC in AIDS patients should be considered lifelong unless immune restoration is achieved by antiretroviral therapy 1, 2, 4, 5
The Centers for Disease Control and Prevention notes that this recommendation reflects the high risk of relapse in persistently immunosuppressed patients 6, 3

The Infectious Diseases Society of America recommends that MAC treatment can be discontinued after a minimum of 12 months of completed MAC treatment, with a sustained CD4+ T-lymphocyte count >100 cells/µL for at least 6 months after initiating HAART, and complete resolution of MAC symptoms 1, 6, 2, 3
The American College of Physicians suggests that patients must remain completely asymptomatic with respect to MAC signs and symptoms, with no fever, night sweats, weight loss, or other manifestations of active disease 1, 6, 2, 3

The National Institutes of Health recommends a preferred regimen of clarithromycin 500 mg twice daily, ethambutol 15 mg/kg daily, and rifabutin 300 mg daily (optional third agent, with dose adjustments for antiretroviral interactions) 2, 4, 5
The Centers for Disease Control and Prevention notes that azithromycin is preferred over clarithromycin during pregnancy due to birth defect concerns with clarithromycin in animal studies 3

The Infectious Diseases Society of America recommends that secondary prophylaxis must be reintroduced if the CD4+ count decreases to <100 cells/µL or if any signs or symptoms of MAC recurrence develop 1, 6, 2, 3

The American Thoracic Society suggests that for treatment failure or resistance, a salvage regimen should include at least two new drugs not previously used, and consider adding amikacin or streptomycin as an injectable agent 3
The Centers for Disease Control and Prevention notes that clofazimine should not be used as it is associated with increased mortality 6, 3

The National Institutes of Health recommends that rifabutin is a cytochrome P-450 inducer and requires dose modifications with protease inhibitors and NNRTIs, and clarithromycin levels are increased by protease inhibitors, but no dose adjustment is currently recommended 1, 2, 4, 6
The Infectious Diseases Society of America notes that azithromycin has no CYP450 interactions and can be used safely with all antiretrovirals 6

The American College of Physicians recommends that treatment should not be stopped prematurely, even if patients feel better after a few months, the full 12-month minimum is essential 1, 3
The Centers for Disease Control and Prevention suggests that CD4+ count alone should not be relied upon, all three criteria (duration, immune recovery, symptom resolution) must be met simultaneously 1, 2, 3
The National Institutes of Health notes that clarithromycin should not be used at doses >500 mg twice daily, as higher doses are associated with increased mortality 6, 2, 5
The Infectious Diseases Society of America recommends that clofazimine should not be added to treatment regimens, as it is associated with adverse clinical outcomes and higher mortality 6, 3