Hello, my name is Christoph Langer. I'm the Medical Director of the Research Center Borel in Germany. And I welcome everyone who is participating in this webinar which is lively recorded at the European Respiratory Society annual conference from Vienna in Austria. We're presenting the latest news on mac mycobacterium avium Complex Pulmonary Disease. And together with me today here in Vienna are Professor Stefano Aliberti from Milan and Professor David Griffith from Denver in Colorado. We will start with an introduction on the mandate for individualized care in patients with nontuberculous mycobacterial lung disease and limited options. A look at pub met shows that there is an increased interest in non tuberculous mycobacteria pulmonary disease. Over the past decade, the number of publications that are listed in pub med have increased from around 100 in the year 2010 to more than 300 in the year 2022 23 and 24. We also see that the incidence of non tuberculous mycobacteria disease in different parts of the world is probably increasing as non tuberculous mycobacteria are usually not to be reported to public health authorities. In contrast to tuberculosis, the data on disease are not as accurate as in tuberculosis countries like Denmark, which have a national registry report an increase in total number and in pulmonary diseases caused by non tuberculous mycobacteria between 2011 and 2021. Also in Scotland between 2011 and 2019. He has shown on the left, lower part of uh the image have an increase in all isolates of non tuberculous mycobacteria over the past decade. And in specific um conditions like in cystic fibrosis in Germany between 2016 and 2020. Here on the upper right corner, there's an uh increase in any non tuberculous mycobacteria findings. And also in cystic fibrosis in the United States, there's a slight increase over the past decade in um the isolation of organisms that belong to non tuberculous mycobacteria in these cystic fibrosis patients. If we look at the family tree of mycobacteria, this is becoming denser over the years with now almost 200 different species identified. And is that since the family tree doesn't fit on the picture anymore, it is now curled up as a family wheel. And you see in at six o'clock, this um wheel is divided and what is uh at six o'clock towards the left side is the beginning of the tree. And what is at six o'clock to the right side is the end of the tree. So those two species that are divided at six o'clock here are those that are most distant genetically from each other. We cannot discuss all of the non tuberculous mycobacteria today. And our focus is really on the species of the Mycobacterium Avium complex. Just for information, mycobacterium tuberculosis is here at about 10 o'clock on this wheel. And the organisms of interest of the mycobacterium avium complex are down here a little bit towards the left side of six o'clock. Other organisms that are important is mycobacterium Kasi almost at nine o'clock and mycobacterium copy almost at 11 o'clock on this wheel. The other really important organisms that are also covered in the A TS IDSA S and ACM International guidelines are the organisms of the mycobacterium abscessus complex, which are emerging pathogens over the past few years and are the most difficult to treat among these four different non tuberculous mycobacteria species that I mentioned. The A TSE RSS made an I DS A. So the uh four big international professional societies in infectious diseases and respiratory diseases in the United States of America and in Europe, um joined forces in 2022 published jointly in the European Respiratory Societies journal, the European Respiratory Journal and the I DS A journal, the Clinical Infectious Diseases Journal, a joint statement for the treatment of non tuberculous mycobacteria pulmonary disease. However, due to the methodological issues that were are now involved in drafting such evidence-based guidelines, it's uh these guidelines could cover only four different groups of species. Those of the mycobacterium avium complex microbacterium, Kansas microbacterium copy and mycobacterium abscessus to cover additional organisms. The same group of authors came together to perform additional systematic reviews of the literature to arrive at consensus statements for the management of patients affected by less commonly occurring non tuberculous mycobacteria causing pulmonary disease. Those are mycobacterium kone microbacterium for tuum as rapid growers and mycobacterium gen Avenza microbacteria goone microbacterium Malmo enza microbacterium Z uh and my suga if we now look at these organisms in blue, that are covered by the first guideline from 2020 the organisms in brown covered by the second guideline published in 2022. We have almost all of the relevant non tuberculous mycobacteria species. Now for the first time in history, evidence-based international management guidelines. When is infection a disease? This is really a complicated issue in non tuberculous mycobacteria disease because you find organisms like mycobacterium goone that are very frequently isolated among the non tuberculous mycobacteria but they rarely ever cause disease. We have two different radiological phenotypes. The one is the nodular bronchiectatic phenotype here shown on the left with bronchiectasis and multiple nodules within the lung pereny. And here is seen on the right, the fibro cavity form that forms cavitation with thick, a relatively thick um fibrous walls around the cavities, which is the phenotype that has a less um pre less um beneficial prognosis for affected patients. Emmanuel Wolinsky, which is the nestor of non tuberculous mycobacteria already in 1981 in a milestone editorial addressed that question. When is infection a disease. And he found five very plausible principles that should be taken into account when to consider the indication for therapy. The first is growth if acid-fast bacila are visible on sputum smear microscopy, it means that there are abundant bacteria and that that should favor a decision to initiate treatment and the isolation. The source. First of all, the isolation, there's repeated isolates of the same species that favors that, that species is pathogenic and that should be in favor of initiating treatment. The source of isolation from a sterile a compartment is more indicative of initiating treatment than for example, from Sputum, which may be contaminated from the pharynx. The species plays an important role. There are species that are almost always pathogenic like mycobacterium Kasia or species like the ones already mentioned mycobacterium goone, which almost never cause disease in humans. And then last but not least, very importantly, the situation of the host is there this a person that has a known risk factor like immunodeficiency, for example, acquired immunodeficiency due to chemotherapy or due to the human immunodeficiency virus HIV, that would favor the initiation of therapy versus those um in immunocompetence hosts. It is my great pleasure to introduce my two distinguished expert faculty members today. Professor Stefano Aliberti from Milan Italy where he is a professor of respiratory medicine at the Humanitas University. He is there the chief of, of the Respiratory Division and he is also the chair of the Italian Registry of non tuberculous mycobacteria called Irene. He will present on antimicrobial decision making and mac lung disease. Welcome Stefano, the second distinguished expert that is on our faculty today is Professor David Griffith. He is a professor of Medicine at the National Jewish Health Hospital in Denver, Colorado. He has been the leading author of the a previous edition of the A TS IDS, a international treatment recommendation and is um S Professor Aliberti, one of the international leading experts for the management of patients with nontuberculous mycobacterial disease. He will present on translating results of new mac lung focused trials evaluating quality of life improvements, TTP and micro bacterial conversion metrics to optimize antimicrobial drug selection. Welcome David and it's now my pleasure um to uh hand over to uh Professor Aliberti. My name is Christoph Langer. I'm the medical director of the research Center Borstel, which is the Leibniz Lung Center in Borstel, Germany. I'm a professor of Respiratory Medicine and International Health at the University of Lubeck in Germany. And I will also lead the discussion after the two expert presentations with case based uh discussions around anti M disease.
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