Guidelines Needed for Listing CF Patients with Nontuberculous Mycobacteria Infections for Lung Transplants, Survey Finds

Clinical centers around the world differ in the standards they use when considering cystic fibrosis (CF) patients with nontuberculous mycobacteria (NTM) infections for lung transplants, and few have a clear written policy, a U.K. study shows.

These findings reflect the need for standardized guidelines for listing cystic fibrosis patients with NTM infections for transplants.

In particular, despite anecdotal evidence to the contrary, researchers found that most centers surveyed do not consider NTM infections in cystic fibrosis an absolute contraindication for transplants. A contraindication is a condition or factor that serves as a reason to not recommend a particular treatment or procedure because of the harm it would cause the patient.

The study, “NonTuberculous Mycobacteria infection and lung transplantation in cystic fibrosis: a worldwide survey of clinical practice,” was published in the journal BMC Pulmonary Medicine.

Pulmonary infection with NTM in cystic fibrosis is particularly relevant when assessing patients’ suitability for a lung transplant. Although the prevalence varies in different countries and even within U.S. states, the overall incidence of NTM in cystic fibrosis patients has increased over the past decades.

The most common NTM species in cystic fibrosis are Mycobacterium abscessus complex and M. avium complex. Lung infection with M. abcessus complex has been associated with reduced lung function and is of particular clinical concern. Treatment of pulmonary disease with NTM typically requires multiple antibiotic regimens for prolonged periods, which may lead to relevant adverse effects.

NTM infection in cystic fibrosis patients has been regarded by some clinicians as an absolute contraindication for lung transplant due to poor post-transplant outcomes. In particular, the presence of M. abscessus complex before a transplant has been linked with severe complications and poor outcomes after the procedure.

However, some single-center case series have indicated that patients with an NTM infection who undergo a lung transplant have similar outcomes to those without an NTM infection.

Current guidelines from the International Society for Heart and Lung Transplantation recommend that patients with NTM should have controlled chronic infection before surgery, and a reasonable expectation for adequate control after the procedure, to be safely listed for a transplant.

In turn, recent U.S. and EU recommendations emphasize the need to evaluate cystic fibrosis patients for NTM and to start treatment before a transplant. However, final decisions are made by the clinicians involved and the clinical center.

Because different approaches can be taken, researchers in this study investigated current worldwide practices concerning the listing of cystic fibrosis patients with NTM for lung transplants.

To study this, they designed a survey with 16 questions addressing local practices on screening for NTM infection, contraindications to transplant, and patient management. They also included questions about practices involving the segregation of patients to avoid NTM transmission before and after transplant.

The survey was sent to 37 adult and pediatric lung transplant centers in North America, Europe, and Australia, of which 21 centers completed the questionnaire.

Results showed that only 29% of centers have a clear written policy regarding NTM. In addition, 16 centers, or 76%, require molecular identification of specific NTM species.

Only four centers considered infection with M. abscessus complex a contraindication for listing, but 76% regard it as a relative contraindication, which means additional caution should be used if other conditions or contraindications are present.

Results also revealed that 86% of centers require treatment before the transplant.

Only 61% of the clinical centers surveyed reported having policies in place regarding the segregation of patients depending on NTM status before a transplant, and just 48% reported having such a policy for patients after the procedure.

“The issue of Nontuberculous Mycobacteria infection in people with cystic fibrosis requiring lung transplantation is well-recognized however current international recommendations are not detailed and there is variation in practice between centres,” the researchers concluded.