EIN members recently discussed how to treat a highly resistant non-tuberculosis mycobacterial infection, including how to deal with a shortage of a key antibacterial drug.

A member from Florida described a 73-year-old retired physician with refractory acute myeloid leukemia and prolonged neutropenia with fevers, who developed M. abscessus bacteremia, followed 10 days later by skin nodules that were biopsy-proven to be caused by the same organism on culture. The organism was susceptible only to amikacin, kanamycin, clofazimine, cefoxitin, imipenem, azithromycin, clarithromycin, and tigecycline.

The patient also had a severe allergy to cephalosporins and penicillin, the member wrote, along with a history of intolerance with tetracyclines taken by mouth, including very bad nausea and vomiting.

“The patient is hemodynamically stable and wants to be treated at home,” the member continued, and the patient had been on azithromycin and linezolid until testing revealed resistance to the latter. “Considering that he has been bacteremic, what would you recommend?” The member also inquired about how to acquire amikacin, given a current U.S. shortage of the drug, and whether to desensitize the patient to cefoxitin.

A respondent in Maryland shared information from the drug shortages webpage maintained by the Food and Drug Administration (FDA), which provides details about current shortages, how to report new ones, and how limited supplies of these drugs can be obtained. (See related article in this issue.) EIN is also conducting a survey of members about shortages and how they are affecting practices. A March 2011 white paper (PDF) provides additional background about the problem.

A member in Florida cited a March 2011 article in Infectious Diseases in Clinical Practice describing “a case almost exactly like your own, including the retired physician part. The patient had disseminated M. abscessus in which antibiotics alone (eight weeks of meropenem, amikacin, azithromycin, and levofloxacin and four weeks of tigecycline with other antibiotics prior to the former) were unsuccessful and only after adding interferon gamma was he cured and is still alive today, two years later.”

Another member in Florida suggested using tigecycline, in addition to ondansetron to help with nausea. The member was treating a patient with a deep tissue infection secondary to M. abscessus using this approach. “My patient has systemic mastocytosis and significant allergy history,” the member wrote, and so far, the patient was tolerating the treatment.

“We successfully treated a similar case with a combination of amikacin, tigecycline, clarithromycin, and cefoxitin,” a New York EIN member reported. “The cefoxitin was probably superfluous, but I would use at least three meds.”

Given the patient’s beta-lactam allergy, a respondent in Oregon agreed with the original poster’s suggested therapy, and advised a regimen of tigecycline 50 mg daily, amikacin 10 mg/kg TIW, and azithromycin 250 mg daily. “Eventually you will need to drop his parenteral therapy and mop up for several months with an oral regimen of two to three drugs,” the member continued. “Imipenem is another good option, and he might not cross-react. I would leave this to try for later if needed.”

A Colorado respondent suggested using imipenem/cilastatin, amikacin, and azithromycin. “I would apply for clofazimine through the FDA as well,” the member added, referencing a drug that is not FDA approved but which may be obtained under FDA’s compassionate use process pending approval by the relevant institution’s Institutional Review Board (IRB).

The Florida member who posted in the initial question later reported that a supply of amikacin had been allocated, the patient remained on azithromycin, and the institution was “in process to get the clofazimine through the IRB and FDA.”

E-mail the Emerging Infections Network.

The Emerging Infections Network (EIN) is a provider-based sentinel network designed to help the public health community detect trends in emerging infectious diseases.

A joint project of IDSA and the Pediatric Infectious Diseases Society (PIDS) with funding from the Centers for Disease Control and Prevention (CDC), EIN tracks emerging infectious diseases and keeps the public health community up to date with new disease trends, difficult cases, and other issues affecting members’ clinical practices. The Network provides a great opportunity for members to share knowledge quickly across large geographical distances. Both IDSA and PIDS members are eligible to join. Click here for more information or to join EIN.

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