DESAFIOS NO TRATAMENTO DO MYCOBACTERIUM ABSCESSUS

abordagem da resistência macrolídea intrínseca e opções de resgate terapêutico

Abstract

The Mycobacterium abscessus complex is the most pathogenic group among rapidly growing nontuberculous mycobacteria, being responsible for pulmonary and extrapulmonary infections associated with significant therapeutic challenges. Pulmonary disease is the most common manifestation, occurring predominantly in individuals with structural lung diseases such as bronchiectasis and cystic fibrosis, and is characterized by a chronic and progressive course.

One of the main determinants of therapeutic outcomes is macrolide susceptibility, strongly influenced by the presence of the erm(41) gene, which confers inducible resistance in the abscessus and bolletii subspecies, while massiliense generally remains susceptible. In addition, acquired resistance due to mutations in the rrl gene further complicates clinical management.

Current recommendations emphasize the use of susceptibility testing to guide treatment, although the correlation between in vitro results and clinical response is well established mainly for macrolides and amikacin. In the presence of macrolide resistance, treatment becomes even more challenging, with no standardized or consistently effective regimen available.

Alternative agents such as linezolid, clofazimine, bedaquiline, rifabutin, tetracycline derivatives, and β-lactams show variable activity, generally supported by limited clinical evidence. New compounds and therapeutic strategies are under development but remain largely in experimental stages.