Mycobacterium xenopi pulmonary infections: a multicentric retrospective study of 136 cases in north-east France

Abstract

Background: Owing to its low incidence, the management of Mycobacterium xenopi pulmonary infections is not clearly defined. A multicentre retrospective study was performed to describe the features of the disease and to evaluate its prognosis. Methods: All patients with M xenopi satisfying the 1997 ATS/IDSA criteria from 13 hospitals in north-east France (1983France ( -2003 were included in the study. Clinical, radiological and bacteriological characteristics and data on the management and outcome were collected. Results: 136 patients were included in the analysis, only 12 of whom presented with no co-morbidity. Three types of the disease were identified: (1) a classical cavitary form in patients with pre-existing pulmonary disease (n = 39, 31%); (2) a solitary nodular form in immunocompetent patients (n = 41, 33%) and (3) an acute infiltrate form in immunosuppressed patients (n = 45, 36%). 56 patients did not receive any treatment; the other 80 patients received first-line treatment containing rifamycin (87.5%), ethambutol (75%), isoniazid (66.2%), clarithromycin (30%) or fluoroquinolones (21%). After a follow-up of 36 months, 80 patients (69.1%) had died; the median survival was 16 months (range 10-22). Two independent prognostic factors were found: the acute infiltrate form was associated with a bad prognosis (hazard ratio 2.6, p = 0.001) and rifamycin-containing regimens provided protection (hazard ratio 0.325, p = 0.006). Clarithromycin-containing regimens did not improve the prognosis. Conclusions: In contrast to recent guidelines, this study showed three different types of the disease (cavitary, nodular or diffuse infiltrate forms) with a different prognosis. In order to improve survival, all patients with M xenopi infection should be treated with a rifamycincontaining regimen. The usefulness of clarithromycin remains to be evaluated.Mycobacterium xenopi is a non-tuberculous mycobacterium responsible for lung disease, 1 especially in north-east France, south-east UK and in Ontario, Canada. 2 3 According to the recent ATS/ IDSA statement, its usual feature is an apical cavitary process in patients with obstructive pulmonary disease. 4 However, other features have been described. 5 M xenopi infections are difficult to treat and there is no standard treatment. 2 3 5 Rifampin, ethambutol and sometimes isoniazid or fluoroquinolones are usually recommended in combination with clarithromycin. 4 Two randomised clinical trials have been conducted by Jenkins et al. 6 7 In the first study, 42 patients were treated with rifampin and ethambutol with or without isoniazid, without any difference in the clinical response. 6 The overall mortality rate at 5 years was 69%. In the second study, Jenkins et al compared clarithromycin with a ciprofloxacin-containing regimen in 371 patients infected with non-tuberculous mycobacteria and found no difference in the 34 patients infected with M xenopi. 7 As M xenopi infection could present with different clinical and radiological patterns depending on the patient's immuno...

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