論文No 1640
Microbiologic Outcome of Interventions Against Mycobacterium avium Complex Pulmonary Disease: A Systematic Review
Roland Diel, Albert Nienhaus, Felix C. Ringshausen, Elvira Richter, Tobias Welte, Klaus F. Rabe, Robert Loddenkemper
CHEST, Volume 153, Issue 4, Pages 888–921, 2018.
＜目的＞
Mycobacterium avium complex (MAC)で引き起こされる肺疾患(PD)は世界的に増加している。
現在のマクロライドベースの治療レジメンを評価するために細菌学的アウトカムを調べた文献をシステマティックレビューした。
＜方法＞
MEDLINE, Cochrane, and Embase databasesを使用して2017年4月までに発行された文献を検索した。
ランダム化試験におけるリスクのバイアスはコクランツールで評価した。
＜結果＞
333の論文を評価し、42本の2748名の患者を評価した。
18本の論文は後ろ向きチャートレビュー、18本は前向き、6本はランダム化試験だった。
喀痰培養陰性化がマクロライドを含む治療で起こり、治療後に細菌学的再発を差し引いた加重平均は52.3%(95% CI, 44.7%-59.9%)であった。
ATS推奨の３薬剤によるレジメン使用で治療成功率は 61.4% (95% CI, 49.7%-72.5%)であり、
マクロライド感受性で以前にマクロライドの治療を受けていない群で最低１年服用すると成功率は65.7% (95% CI, 53.3%-77.4%) まで上昇した。
６本のうち５本でリスクバイアスは低かった。
しかし、事後に当初の患者を除外(14.0%)、治療未完了 (17.6%)、アウトカムのパラメータ不一致（治療成功の定義は１７こもある）は
非ランダム化試験の比較を妨げた。
＜感想＞
ATS推奨の３剤１年以上をきちんと行いMACがマクロライドに感受性がある場合は、MACの治療成功率は65.7%だったようです。
Objective
Pulmonary disease (PD) caused by Mycobacterium avium complex (MAC) is increasing worldwide. We conducted a systematic review of studies that include microbiologic outcomes to evaluate current macrolide-based treatment regimens.
Methods
We searched literature published before April 2017 by using the MEDLINE, Cochrane, and Embase databases. Risk of bias in randomized trials was assessed using the Cochrane tool.
Results
We retrieved 333 citations and evaluated 42 studies including 2,748 patients: 18 studies were retrospective chart reviews, 18 were prospective, and six were randomized. The weighted average proportion of sputum culture conversions in macrolide-containing regimens after subtracting posttreatment microbiologic recurrences was 52.3% (95% CI, 44.7%-59.9%). Using the triple-drug regimens recommended by the American Thoracic Society (ATS) achieved treatment success in 61.4% (95% CI, 49.7%-72.5%), which further increased to 65.7% (95% CI, 53.3%-77.4%) when drugs were taken for at least 1 year by patients who were macrolide susceptible and had previously untreated MAC. The overall risk of bias was low in five of the six randomized trials. However, selective outcome reporting because of a posteriori exclusion of initially included patients (14.0%), uncompleted treatment (17.6%), and inconsistent use of outcome parameters (17 definitions of treatment success) hampered the comparison of nonrandomized trials.
Conclusions
To date, randomized studies on treatment outcome in patients with MAC PD are scarce. Long-term treatments with ATS-recommended regimens for patients who are macrolide susceptible are superior to other macrolide-based therapies. A standardized definition of treatment success and genotypic distinction between reinfection and relapse by means of pretreatment and posttreatment identification of MAC species in cases of microbiologic recurrences may help to optimize evaluation of treatment regimens in the future.