A Brief Overview of Mycobacterial Diseases in Children Table 3: Treatment Options for Mycobacterial Disease in Children
Mycobacterium Mycobacterium
tuberculosis*
Preventive therapy: latent INH monotherapy TB infection
INH and RMP
Curative therapy: 2 months 3 or 4 drugs combination: intensive phase with 4 drugs and 4 months continuation phase with 2 drugs**
INH
RMP PZA
EMB Treatment Option
Duration of Treatment 6–9 months
3–4 months Comment
Poor adherence with prolonged unsupervised therapy
Improved adherence. Demonstrated equivalent efficacy in clinical trials. Disadvantages: higher drug cost, higher risk of drug interaction in HIV disease
6 months
6 months 2 months
2 months
Potent early bactericidal activity: rapid killing of rapidly metabolising extracellular growing mycobacteria
Killing of slower growing intracellular mycobacteria
Killing activity against extracellular mycobacteria that persist within acidic centres of caseating granulomas
Killing activity against actively growing mycobacteria. Added in cases with multi-bacillary disease to reduce the risk of drug resistance
Non-tuberculous Disease Manifestation Mycobacteria
Peripheral lymphadenitis (MAC, M. scrofulaceum,. M. malmoense,
M. hemophilum, etc.)
Antimicrobial-based therapy: combination of a macrolide
(clarithromycin or azithromycin) and an anti-TB drug (rifabutin of EMB)
Pulmonary disease (MAC, Minimum of 3 drugs: M. kansasii, M. abscessus,
M.fortuitum, M. szulgai, M.
combination of a macrolide (clarithromycin or azithromycin)
2–4 months Treatment Option Surgical excision
Duration of Treatment
Not applicable Comment
The only intention-to-treat RCT in children showed surgical excision (96 % cure rate) to be superior to drug treatment (66 % cure rate). However, 28 % of children who underwent surgical excision had a complication Antimicrobial-based therapy should be reserved for children with recurrent disease or for whom surgical excision is impractical
Variable duration, For cavitary disease: if necessary addition generally until of parenteral amikacin or streptomycin sputum culture For severe or previously treated disease:
malmoense, M. simiae, etc.)* and 2 anti-TB drugs (RMP and EMB) up to 12 months parenteral aminoglycoside for the first 2–3 months Disseminated disease (MAI, Minimum of 3 drugs: M. chelonae, M. abscessus, combination of a macrolide M. xenopi, M. gordonae, M. (clarithromycin or azithromycin) kansasii, M. hemophilum, M. and 2 anti-TB drugs marinum, M. scrofulaceum, (RMP and EMB) M. malmoense, etc.) Soft tissue and skeletal infections (M. abscessus, M. chelonae, M. marinum, M. ulcerans)
negative Minimum of 3 drugs:
Combination of a Macrolide (Clarithromycin or Azithromycin) and 2 anti TB drugs (RMP and EMB)
Minimum of 4 months
For severe disease: addition of parenteral amikacin or Streptomycin for initial induction therapy may be considered Note that the use of rifabutin in children with HIV may lead to drug interactions with protease inhibitors and efavirenz Usually involves a combination of surgical excision and antimicrobial treatment. For soft tissue disease, duration of treatment is a minimum of 4 months
For bone disease, a minimum of 6 months is recommended. For M. marinum disease, 2 drugs (a macrolide plus RMP or EMB) are recommended until 1–2 months after resolution of the skin lesion
Mycobacterium Disease type leprae***
Paucibacillary Multibacillary MDT
2 drug regimen: Dapsone (1x daily) + RMP (1x monthly) 3 drug regimen:
Dapsone (1x daily) + Clofazimine normal dose (3x week)
+ RMP (1x monthly) + Clofazimine high dose (1x monthly)
*Based on new WHO recommendations.70
**Treatment recommendation for new smear positive pulmonary TB, new smear negative pulmonary TB with extensive parenchymal involvement, severe forms of extrapulmonary TB other than TB meningitis and severe concomitant HIV disease. For the treatment of TB meningitis, Streptomycin replaces EMB in the treatment. Children with paucibacillary and drug-sensitive disease can be effectively managed with only three drugs during the intensive phase treatment (with INH, RMP and PZA). ***Based on WHO and ATS/IDSA recommendations.74,75
ATS = American thoracic society; EMB = ethambutol; IDSA = Infectious Diseases Society of America; INH = izoniazid; M. = Mycobacterium; MAC = mycobacterium avium complex; MAI = Mycobacterium intracellulare; MDT = multidrug therapy; PZA = pyrazinamide; RMP = rifampicine; TB = tuberculosis; WHO = World Health Organization.
EUROPEAN INFECTIOUS DISEASE 105 6 months 12 months
The WHO recommends the following doses for children ≥10 years of age: RMP 450 mg one monthly, clofazimine 150 mg once monthly and 50 mg once every other day
and dapsone 50 mg daily. Children under the the age of 10 years should receive appropriately reduced doses of the above drugs
Comment
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