Beyond the guidelines: flexible and comprehensive care for nontuberculous mycobacterial pulmonary disease

<title>Extract</title> Nontuberculous mycobacterial pulmonary disease (NTM-PD) continues to be a challenging condition to diagnose and treat. As widespread environmental organisms, nontuberculous mycobacteria (NTM) are frequent colonisers/contaminants, and positive cultures alone are not sufficient to make the diagnosis of pulmonary disease. Establishing a diagnosis involves fulfilling a set of clinical, radiological and microbiological criteria [1]. Standard antibiotic regimens are complex and vary by species, typically comprising a minimum of three drugs with treatment durations often exceeding 18 months [1, 2]. NTM organisms have innate resistance to most conventional antibiotics, so the arsenal of effective drugs is limited [3]. Parenteral formulations (intravenous and/or inhaled) are often required for resistant strains, severe/cavitary disease, and/or intolerance to other agents. Despite the length and complexity of treatment, microbiological cure rates remain suboptimal (∼60% and 45% for <italic>Mycobacterium avium</italic> complex (MAC) and <italic>M. abscessus</italic>, respectively) and recurrence is common [4–7]. Therefore, the decision to pursue antimicrobial therapy must be patient-centred, carefully weighing the potential benefits and risks. Depending on the severity and stability of disease, antibiotics are not always necessary [1, 8].