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