NON-TUBERCULOUS MYCOBACTERIAL

(NTM) INFECTIONS ISOLATED FROM

BIRMINGHAM HEARTLANDS HOSPITAL:

A CASE NOTES REVIEW.

K. Clay1, K. Bhatt1, D. Burns1, J. Evans2, S. Gardiner2,

EG. Smith2, P. Hawkey2, E. Moran1, M. Dedicoat1

Department of Infection and Tropical Medicine1

Birmingham Heartlands Hospital

Public Health England, Public Health Laboratory Birmingham2

Background

• 120 species (15 pathogenic)

• NTM mostly found in patients with underlying lung disease

or immune suppression

• Improving diagnostics (Watterson et al, 2000)

• Limited evidence

• Uncertain clinical significance

• NTM clinic

Moore et al. BMC Public Health 2010, 10:612

Figure 1 Rates of non-tuberculous mycobacteria reports (selected species), England, Wales and Northern Ireland, 1995-2006.

Rates of NTM increasing (England, Wales, N. Ireland)

0.9/100,000 in 1995 to 2.9/100,000 in 2006 (Moore et al, 2010)

Aims

• To review the annual rate of NTM infections within the

Heart of England Foundation Trust isolated at the PHE

regional mycobacterial laboratory from 2000 – 2010

• To perform a case notes review of patients with an

isolated NTM infection from 2008 - 2010

Method

• Mycobacterial reference laboratory at Birmingham

Heartlands Hospital (BHH)

• Database of all NTM infections

• Data collected from 2000 – 2010 for patients within the

Heartlands Trust

• Further review of online clinical records from 2008 to 2010

• Exclusion criteria

• Duplicate samples from the same patient within that year

• Patients from outside of the Heart of England NHS Foundation

Trust

Method

• Data collected

• Demographics

• NTM infection isolated

• Source of isolate

• Whether the infections was considered clinically relevant

• Criteria – as per American Thoracic Society (ATS) guidelines

• Treatment including planned duration

• Treatment toxicities

• Mortality

• Background medical conditions

• Lung disease/immunosuppression

• Smoking history

ATS guidelines 2007

• Significant results based on;

• Clinical significance

• Pulmonary symptoms

+ CXR – nodular/cavitatory changes

or HRCT – multifocal bronchiectasis + multinodular changes

• Microbiological significance

• > 1 sputum positive

• 1 bronchoalveolar lavage positive

• Lung biopsy + sputum or BAL positive

Results

5000

6000

7000

8000

9000

10000

11000

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

No Mycobacteriarequests

0

10

20

30

40

50

60

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Patient No Year Patient

No

Mycobac

requests

2000 18 6042

2001 14 6243

2002 20 6786

2003 16 6728

2004 10 6150

2005 30 6287

2006 44 8498

2007 43 9656

2008 41 9665

2009 49 10399

2010 46 10313

NTM infections 2000 - 2010 0 20 40 60 80 100 120 140

M. avium complex

M. abscessus

M. chelonae

M. gordonae

M. malmoense

M. kansasii

M. fortuitum

M. xenopi

M. chelatum

M. scrofulaceum

M. species

M. marinum

M. szulgi

M. mucogenicum

M. parascrofulaceum

M. peregrinum

M. simiae

M. smegmatis

M. terrae

2000 - 2010

2008 - 2010

Demographics

2008 2009 2010

Number of patients 41 49 46

Male 29 (70%) 29 (59%) 25 (54%)

Female 12 (30%) 20 (41%) 21 (46%)

Ethnicity – White 24 39 39

Ethnicity – Asian 10 9 4

Ethnicity - Black 5 1 1

Ethnicity – not stated 2 0 2

Age range (years) 17 - 93 4 - 91 20 - 83

Deceased (data recorded in 2013) 6 (15%) 17 (35%) 8 (17%)

Deceased age range (median) 58 – 83 (63) 24 – 90 (74) 24 – 95 (75)

Underlying medical conditions

2008 - 10 (n = 136)

Underlying lung disease (exc. CF) 57

Cystic fibrosis 34

Immunosuppressed (exc. HIV) 33

HIV 10

No significant past

medical history 24

2008 - 2010

21%

6%

36%

22%

15%

Immunosuppressed(excluding HIV)

HIV

Underlying lung disease(exc. Cystic Fibrosis)

Cystic fibrosis

No significant past medicalhistory

Clinical significance

2008 –

2010

Clinically significant 70

Not clinically significant 62

Unknown 4

53%

47%

Clinically significant

Not clinically significant

Treatment

54

12

67

Antibiotics - indefinite Antibiotics - finite No antibiotics

Use of antibiotics in NTM 2008 - 2010 Antibiotics toxicity 2008 - 2010

22

66

Toxicity Patient on abx

Cystic Fibrosis HIV

2008 – 2010 = 34 patients 2008 – 2010 = 10 patients

Limitations

• Online notes only

• Regional cystic fibrosis unit changes our population at risk

Summary

• NTM rates increasing

• Gender differences

• M.TB versus NTM

• MAC most common infection

• M.abscessus 2nd most common

• Low incidence of M.kansasii

• Strong association with immune suppression and lung

disease

• Minimal isolates in HIV positive patients

• Increased laboratory workload

• NTM clinic

References

Public Health England, Public Health Laboratory Birmingham - standard operating procedures

UK Standards for Microbiology Investigations. Investigations of Specimens for Mycobacterium species. PHE guidelines.

British Thoracic Society. Management of opportunist mycobacterial infections: Joint Tuberculosis Committee guidelines 1999

American Thoracic Society. An Official ATS/IDSA Statement: Diagnosis, Treatment, and Prevention of Nontuberculous Mycobacterial Diseases. 2007

Moore J, Kruijshaar M, Ormerod P et al. Increasing reports of non-tuberculous mycobacteria in England, Wales and Northern Ireland, 1995-2006. BMC Public Health 2010, 10;612

Watterson S, Drobniewski F. Modern laboratory diagnosis of mycobacterial infections. J Clin Pathol 2000 53: 727-732