非典型分枝桿菌感染(atypical mycobacterium infection)

非典型分枝桿菌感染是指非結核菌(包括五種TB complex, 即M. tuberculosis, M. bovis, M. bovis BCG, M. africanum, M. microti，另外Mycobacterium canetti,也可引起tuberculosis )、麻風病的分枝桿菌感染，目前已知至少有120種，有以下不同之特性

 (BJD 2005 152, 727–734)

無內臟侵犯時

局限性病灶

I M. ulcerans infection (Buruli ulcer)

IIa Sporotrichoid lesions, aquagenic source (M. marinum, RGM, M. kansasii)

IIb Sporotrichoid lesions, nonaquagenic source (RGM, M. kansasii, M. avium complex)

IIIa Nonlymphocutaneous, aquagenic source (M. marinum, RGM, M. kansasii)

IIIb Nonlymphocutaneous, nonaquagenic, postsurgical, catheter-related (RGM)

Disseminated cutaneous

IV Folliculitis and ⁄or furunculosis after depilation or water-related (RGM)

V Lesions on lower and ⁄or upper limbs and immunosuppressive drugs (RGM)

有內臟侵犯時

Localized

VI Solitary lesions in immunosuppressed patients (M. kansasii, M. avium complex, RGM, M. simiae)

Disseminated cutaneous

VII Cutaneous and mucous membrane lesions and disseminated infection in patients with congenital (type-1 cytokine defect) or acquired immunosuppression (M. kansasii, M. avium complex, M. haemophilum, RGM, M. simiae, M. gordonae, M. marinum, M. scrofulaceum, M. szulgai, M. malmoense, M. terrae, M. xenopi, M. smegmatis and M. flavescens)

皮膚的分典型分枝桿菌的治療大規模研究很少, rapid grower一般依培養抗藥性用藥, 但其他類的分典型分枝桿菌則藥物感受性參考價值不高, 根據不同懷疑菌種，治療方式如下，一般至少要治療3月, 但以肺部分典型分枝桿菌的治療經驗, 多合併至少兩種藥物, 且待培養陰性後再治療6~12月

菌種	Disseminated infections	Lung	淋巴腺	Skin and soft tissue	Recommended Therapy
Photochromogene:I M. kansasii	60% with AIDS or  other immune deficiency	Typical resembling tuberculosis	Rare	Abscess, cellulitis,  Sporotirchoid	Isoniazid+EMB+rifampin, clarithromycin, sulfonamides, minocycline, amikacin
Photochromogene:I M. marinum (Fish-tank granuloma)	Rare			Typical Sporotirchoid, nodule, ulcer 2-3 wks after contact	Clarithromycin (100%), EMB (92.9)+RIF; Ciprofloxacin (53.5%), minocycline, Baktar, thermotherapy, 光動力療法
Scotochromogene:II M. scrofulaceum	Rare	Rare	Typical cervical	ulcer	See M. avium, surgery
Scotochromogene:II M. gordonae	台大一例		cervical	ulcer	Ciprofloxacin, EMB (anti-TB)
Nonphotochromogene M.avium/intracellulare	AIDS with CD4+ <50; rare in other immunodeficiciency or normal host	See M. intraced	In children (rare)	Ulcer, granuloma, nodule, panniculitis. May be localized, sporotrichoid or disseminated. Usually not linked to trauma	Clarithromycin; ethambutol, rifabutin, doxycycline, minocycline, surgery,, cycloserine, capreomycin, roxithromycin, ciprofloxacin
Nonphotochromogene M. haemophium	Typical in AIDS and other immunodeficiencies			Typical in AIDS, Ulcer, granuloma, nodule, sporotrichoid (one case only)	See m. avium rifamycins (56%), macrolides, quinolones, clofazimine, amikacin
Nonphotochromogene M. ulcerans				Buruli ulcer, granuloma, nodule	Anti-TB, surgery, minocycline, clarithromycin, Baktar
Nonphotochromogene M. malmoense				Ulcer, granuloma, nodule	Anti-TB, amikacin
M. szulgal	-	Rare	-	Typical	Rifampin, isoniazid, ethambutol
M. xenopi	Rare	Rare	-	-	See M. avium
Rapid grower: IV M. abscessus/ chelonae	Rare			Typical linked to surgery, single/multiple (4:6), abscess, granuloma,sporotrichoid (rare, M chelonae)	Debndement; clarithromycin (100%), clofazimine, amikacin (63.8%), linezolid (50%), tobramycin (78.8%)
Rapid grower: IV M. fortuihum	Rare	Rare		Typical linked to surgery (ulcer, abscess, nodule, cellulitis)  localized (90%)	Amikacin (100%), ciprofloxacin (85.7%)+ clarithromycin (67%); sulfonamides (66.7%), clofazimine, , Doxy (41%), imipenem (70%), linezolid (83%), surgery, minocycline

以下是肺部感染時建議用藥

菌種	建議處方	替代治療
M. kansasii	INH (300mg qd) +EMB (15mg/kg/d)+rifampin (600mg/d)	Clarithromycin (500mg/bid), sulfamethoxazole (1g bid), TMP (160 mg)/SMX (800 mg bid), streptomycin (0.5~1 g qd) IM, amikacin
M. gordonae	INH (300mg qd) +EMB (15mg/kg/d)+rifampin (600mg/d)
M. avium/intracellulare	Clarithromycin (500mg bid); Clarithromycin (500mg bid)/azithromycin (250mg qd) + EMB (15mg/kg qd) +/- Rifabutin (150-300mg qd)/RIF (600mg qd)	Amikacin (7.5-10mg/kg tiw) IM/IV; ciprofloxacin (750mg bid); streptomycin (0.5~1.0 g tiw) IM
M. haemophilum	RIF (600mg/d) +clarithromycin (500 mg/bid); Sulf (1g bid); TMP (160mg)/SMP(800mg bid); ciprofloxacin (750 mg bid); ofloxacin (400 mg bid); RFB (150-300 mg qd)
M. malmoense	INH (300mg qd) +EMB (15mg/kg/d)+rifampin (600mg/d)+ streptomycin (0.5~1 g /d)IM
M. genavense	Clarithromycin, EMB, AMK, RFB
M. xenopi	INH (300mg qd) +EMB (15mg/kg/d)+rifampin (600mg/d)+clarithromycin (500 mg bid)	Streptomycin (0.5~ 1 g tiw) IM
M. abscessus/ chelonae/ fortuihum (rapid) (依藥物測試結果)	Doxycycline (100mg bid); minocycline (100mg bid) or sulfamethoxazole (1g bid) or ciprofloxacin (750mg bid) or floxacin (400mg bid) or clzarithromycin (500mg bid)	Amikacin (7.5-10mg/kg/d, 2~4 wk) IM/IV, imipenem-cilastin (0.5g qid) IV, cefoxitin (3g q6h) IV, tobramycin (3-5 mg/kg qd) IM/IV

Fish tank granuloma

M arupense

M avium in AIDS