(Vol.77 No.2 February 2002) <7>Kekkaku Vol.77 No.2:95-98,2002 The 76th Annual Meeting Symposium THE ESTIMATION OF THERAPEUTIC GUIDELINES AGAINST NON-TUBERCULOUS MYCOBACTERIOSIS Chairpersons:1Mitsunori SAKATANI and 2Fujiya KISHI Abstract Mizutani estimated three therapeutic guidlines in US, UK and Japan.(1) MAC infection: In USA, CAM and AZM are the essential drugs and combination therapy with EB, RFP/RBT and SM were recommended by ATS in 1997. In UK, the administration of CAM and AZM are restricted to the cases of treatment failure or the relapsed cases. In Japan, though the efficacy of CAM and AZM have been well understood, these drugs are officially not recommended as key drugs yet, because recommended dosage of such medications by ATS are not civered by medical health insurance. In Japan and USA, one year is estimated enough to finish the treatment with the regimens include CAM or AZM. In UK, two years are recommended for treatment peirod. The New-Quinolons and TH are listed as the other drugs for medications, but all guidlines stated that these drugs are not so useful. (2) M. kansasii infection:The all guidlines sated that RFP has an excellent activity against M. kansasii. The usefulness of INH is disputable, therefore ATS recommended the regimen with HRE(INH, EB and RFP). It comes to the same recommendation in Japan, but BTS recommend the prescription with RFP and EB. (3) The rapid growers: The anti-tuberculous drugs are recommended for these species in UK, but the ATS guidline stated that anti-tuberculous drugs have no effect for such species. Harada evaluated the usefulness of the Japanese guideline of treatment for non- tuberculous mycobacteriosis (NTM), studying the outcome of treatment and the prognosis of pulmonary MAC disease for 50 cases of long term follow-up and 33 dead cases in his hospital. The results were as follows:(1) The dead cases were older and severer on chest X-ray features at starting of initial tratment, comparing survived cases which were observed for more than 5 years. In clinical patterns, a tuberculosis-like pattern of primary infection type and secondary infection type were more frequent in deat cases than in survived cases. (2) Among dead cases, the cases of tuberculosis-like pattern died earlier than the cases of diffuse bronchiectatic pattern, inclining to be in persistent bacilli-positive condition. (3) In the long survivors more than 5 years, the rate of persistent bacilli-positive cases was 40%, but the rate of worsended cases on chest X-ray was 54%. (4) In long surviviors, becteriological prognoses are not correlative with the courses of chest X-ray features. (5) The bacteriological prognoses in 1-2 years of primarily treated cases following the Japanese guidline were better than the prognoses of other treated cases. These results showed that the prognoses of MAC patients were strongly affected by clinical features before treatment, and the Japanese guidline is useful for the treatment of pulmonary MAC disease. Kobashi analysed the many cases of pulmonary MAC disease for their treatment courses and prognoses. He studied 159 cases at the several hospitals of Chugoku-Shikoku Research Committee for Mycobacteriosis, in the peiod from 1995 to 2001. The number of cases treated with antituberculous drugs only were 33, and CAM was prescribed with anti-tuberculous drugs for 102 cases. The other cases were 24. By utilizing regimen with CAM, sputum conversion rate was 45%, but 39% were relapses. The 29% of cases clinically improved, for instance, chest X-ray features showed some improvements. While, by the treatment with anti-tuberculous drugs only, sputum conversion rate was 30%, the relapse rate was 70%, and clinicl improvement was obtained only in 17%. Among 102 patients treated with the regimen containing CAM, 41 cases were administered RFP, EB, SM and CAM, corresponding to the guidline. The sputum conversion rate and relapse rate for them were 59% and 38% respectively. The clinical improvement was obtained in 37% of cases. In the 61 patients treated with regimens containing other anti-tuberculous drugs and CAM, the conversion rate, relapse rate and improvement rate were 36%, 41% and 25% respectively. These results indicated that combined chemotherapy with RFP, EB, SM and CAM, which is recommended in Japanese guidline, was one of the most effective treatment for the pulmonary MAC disease. Kuba evaluated 85 NTM patients in his hospital on their therapeutic outcome from 1990 to 2000. The causative organism was M. avium complex in 38 patients, M. kansasii in 25, rapid growers in 14, and others in 8. In 38 patients with M. avium complex lung disease, 25 (66%) patinets were treated with conventional regimens that include RFP, INH, EB and/or SM, and 13(34%) patients were treated with CAM containing regimen with anti- tuberculous drugs. The sputum conversion rate was slightly higher in patients with CAM containing regimen (60%) compared with regimen contained anti-tuberculous drugs only (58%). The relapse rate were 0% and 47% respectively in these two groups. From these observations, the regimen which contained CAM seemed to be superior to the regimen with anti-tuberculous drugs only. Besides, regimen with higher dose of CAM (over 12 mg/kg) seems to be more effective than that with lower dose of CAM (under 12 mg/kg). Because, the sputum conversion rate and the rate of relapseless on former regimen were slightly higher than the rates on later regimen. The 85% of regimens applied for treatment of 25 cases with M. kansasii disease were with HRE, showing the 96% of sputum conversion rate and 8% of relapse rate. It was suggested that CAM-containing regimen for MAC disease and HRE regimen for M. kansasii disease, those are recommended in Japanese guidline, are clinically useful. The 14 cases with rapid growers were treated with many kinds of regimen. The sputum conversion rate and relapseless rate were 86% and 57%. Effects of treatment were not correlative to the regimens with CAM or without CAM. Suzuki studied the clinical sourses of hospitalized cases with NTM other than MAC or M. kansasii. In sputa of 60 cases between 1996 and 2000, 19 strains of M. abscessus, 16 strains of M. fortuitum, 11 strains of M. goldonae, 5 strains of M. chelonae, 4 strains of M. suzulgai and 5 strains of other rare NTM were identified. The 17 cases with M. abscessus, 9 cases with M. fortuitum, 3 cases with M. szulgai, and 3 cases with other rare strains were satisfied with diagnostic criteria of nontuberculous mycobacterial lung disease proposed by ATS. These 32 cases consisted of 18 men and 14 women, and mean age of the patients were 66. The underlying disorders comprised healed tuberculosis in 9 cases, gastrectomy in 3 cases, pulmonary MAC disease in 2 cases, lung cancer in 2 cases and others in 7 cases, but any underlying disorders was not recongnised in 9 cases. The 18 of 30 patients showed sputum conversion by chemotherapy within 3.2 months on an average. All of 8 patients treated with regimens recommended by ATS or Japanese Society for Tuberculosis showed sputum conversion, while only 10 of 24 patients treated with other regimens got sufficient results. In the other regimens, prescriptions with RFP and EB plus CAM, or with HRE were representative. As mentioned above, many NTM cases were analyzed in their chemotherapeutic regimens and outcomes. The results showed that the regimens recommended by ATS or Japanese Society for Tuberculosis might be superior than the other regimens. However, even such regimens resulted not so sufficiently as in the treatment for pulmonary tuberculosis. The development of new anti-NTM drugs and also the new effective regimnes for the treatment of NTM other than M. kansasii is strongly expected. Key words:Nontuberculous mycobacteriosis. Mycobacterium avium complex, Mycobacterium kansasii, Guideline for tratment 1National Kinki-Chuo Hospital for Chest Diseases, 2Hokkaido Social Insurance Hospital Correspondence to:Mitsunori Sakatani, National Kinki-Chuo Hospital, 1180 Nagasone-cho, Sakai-shi, Osaka 591-8555, Japan. (E-mail:Sak-ri@kinchu.hosp.go.jp) <8>Kekkaku Vol.77 No.2:99-101,2002 The 76th Annual Meeting Mini Symposium NEW GUIDELINES FOR MYCIBACTERIUM TUBERCULOSIS EXPERIMENTAL METHODS AND OPPOSITION OF GENERAL HOSPITAL CLINICAL LABORATORY Chairpersons:1Kiyoharu YAMANAKA and 2Katsuko OKUZUMI Topics of symposium and Presenters: 1. Present status of acid-fast bacteria test and its problems from views of laboratory technicians:Mitsuaki NAGASAWA(Department of Clinical Laboratory, National Defense of Medical College) 2. A new guideline for tubercle bacillus (T.B.) test:Toyoko OGURI (Juntendo University Hospital) 3. Laboratory manager's views for acid-fast bacteria test:Kiyoharu YAMANAKA(Otemae Hospital) 4. Quality control of outside examination: Tosho TAKAHASHI(Shinko Hospital) Abstract In ordinary general hospitals lacking a ward to use exclusively for T.B., technicians in charge of acid-fast bacteria test are working without the aid of special doctors for T.B. However, the techinicians often discover a patient positive for smear test for the first, bacause such patient is apt to visit hospital with suspect of some disease other than T.B. Therefore, they are required to quickly produce reliable and accurate results of the smears test for acid-fast bacteria from a doctor in charge. Recently, the test procedures for acid-fast bacteria have been markedly progressed as seen in gene analysis, use of liquid culture medium and automatic culture system and knowledge necessary to perform the test are much increased. In facilities lacking a special and/or leader doctor for T.B., laboratory technicians are racking to prepare a routime manual for the test suitable for each facility. In last year, a new guideline for T.B. test has been introduced under such circumferences after 20 years from the last revision. Here, we described the present status and problems in acid-fast bacteria test in general hospitals lacking T.B. ward for exclusive use, aiming to inform the specialists in the academic field of T.B. and make clear what laboratory technicians should do. It seems necessary to clarify the practical procedures and range of our works according to the procedures defined by the guideline. Thus, it would be easy to realize the purpose of guideline in the routine test of our general hospitals. Furthermore, we proposed some problems to put it in practice as daily procedures, especially in hospital whit no special ward for T.B. We hope that the opinions of laboratory technicians in charge of the test are reflected to the revision of guideline in future. We thanks to, Drs. T. Abe and H. Saito for their valuable advice to hold this symposium. Key words:New guidelines for Mycobacterium tuberculosis test, Opposition of general hospital laboratory, The present state and problems for T.B. test, Quality Control 1Department of Clinical Laboratory, Otemae Hospital, 2Department of Clinical Labortory, University of Tokyo Hospital Correspondence to:Katsuko Okuzumi, Department of Clinical Laboratory, University of Tokyo Hospital, 7-3-1, Hongo, Bunkyo-ku, Tokyo 113-8655 Japan. (E-mail:okuzumi-lab@h.u-tokyo.ac.jp)