NON-TUBERCULOUS MYCOBACTERIAL (NTM) INFECTIONS ISOLATED FROM BIRMINGHAM HEARTLANDS HOSPITAL: A CASE NOTES REVIEW.

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1 NON-TUBERCULOUS MYCOBACTERIAL (NTM) INFECTIONS ISOLATED FROM BIRMINGHAM HEARTLANDS HOSPITAL: A CASE NOTES REVIEW. K. Clay 1, K. Bhatt 1, D. Burns 1, J. Evans 2, S. Gardiner 2, EG. Smith 2, P. Hawkey 2, E. Moran 1, M. Dedicoat 1 Department of Infection and Tropical Medicine 1 Birmingham Heartlands Hospital Public Health England, Public Health Laboratory Birmingham 2

2 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

3 Moore et al. BMC Public Health 2010, 10:612 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) Figure 1 Rates of non-tuberculous mycobacteria reports (selected species), England, Wales and Northern Ireland,

4 Aims To review the annual rate of NTM infections within the Heart of England Foundation Trust isolated at the PHE regional mycobacterial laboratory from To perform a case notes review of patients with an isolated NTM infection from

5 Method Mycobacterial reference laboratory at Birmingham Heartlands Hospital (BHH) Database of all NTM infections Data collected from 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

6 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

7 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

8 Results Patient No Year Patient N o Mycobac requests No Mycobacteria requests

9 NTM infections 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

10 Demographics Number of patients Male 29 (70%) 29 (59%) 25 (54%) Female 12 (30%) 20 (41%) 21 (46%) Ethnicity White Ethnicity Asian Ethnicity - Black Ethnicity not stated Age range (years) Deceased (data recorded in 2013) 6 (15%) 17 (35%) 8 (17%) Deceased age range (median) (63) (74) (75)

11 Underlying medical conditions (n = 136) Underlying lung disease (exc. CF) 57 Cystic fibrosis 34 22% 15% 21% 6% Immunosuppressed (excluding HIV) HIV Underlying lung disease (exc. Cystic Fibrosis) Immunosuppressed (exc. HIV) 33 Cystic fibrosis HIV 10 No significant past medical history 24 36% No significant past medical history

12 Clinical significance 47% Clinically significant Not clinically significant 53% Clinically significant Not clinically significant Unknown

13 Treatment Antibiotics - indefinite Antibiotics - finite No antibiotics Toxicity Patient on abx Use of antibiotics in NTM Antibiotics toxicity

14 Cystic Fibrosis HIV = 34 patients = 10 patients

15 Limitations Online notes only Regional cystic fibrosis unit changes our population at risk

16 Summary NTM rates increasing Gender differences M.TB versus NTM MAC most common infection M.abscessus 2 nd 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

17 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 Moore J, Kruijshaar M, Ormerod P et al. Increasing reports of non-tuberculous mycobacteria in England, Wales and Northern Ireland, BMC Public Health 2010, 10;612 Watterson S, Drobniewski F. Modern laboratory diagnosis of mycobacterial infections. J Clin Pathol :