Hello everyone. Welcome to the European Respiratory Society Conference. Milan 2023. My name is Christoph Lager. I'm the medical Director of the Research Center Boel and it is my great pleasure to welcome you to practical advances in frontline strategies for optimizing clinical outcome in mycobacterium, avium complex lung disease. It's a focus on prompt intervention, individualized treatment goals, regimen adherence and guideline based assessments and antimicrobial therapy. Let me start with a few housekeeping uh rules. This webcast is being simulcasted with today's life satellite symposium at the er S 2023 here in Milan. It is AC me certified symposium and is jointly provided by the University of Massachusetts Medical School and CME Educational resources LLC and it has uh commercial support by an educational grant from the company in Smith. Continue learning with us. The entire program and additional pulmonary and respiratory CME offerings will be available as a clinical excellent webcast on multiple clinical websites including www clinical webcasts dot com. Also powerpoint slides from today's program will be available for download and clinical questions about mag lung disease management may be submitted to IQ and A dot com. Let's start with the program, all anti M patients are not created equal. But when is infection a disease, there's a growing interest in anti and pulmonary disease which we can see as Pup Met listings between 1990 the year 2022. From less than 50 to now, more than 300 every year. If we look for the incident or the prevalence of NTM Pulmonary disease, it seems that there is a slight increase in different settings. On the left side, you see as examples. Um the isolates of non tuberculous mycobacteria. Um more than 50% isolated in Denmark between 2011 and 2021. And on the bottom left isolates of non tuberculous mycobacteria in Scotland and again, here, more than 50% and even more than compared to Denmark, 81% isolates being pulmonary isolates um in Scotland from the year 2011 to 2019. On the left side, you see the trans in cystic fibrosis where it is has been stable between 2016 and 2020 in Germany with on all NTM cultures performed and there is a slight increase for mycobacterium abscessus perhaps and but in general, it is um slightly increasing after all but more or less stable. Whereas in the United States, there is an increase in the isolates from cystic fibrosis patients between 2010 and 2019. In almost all regions. Apart from the Midwest, there are many species of non tuberculous mycobacteria. And here you see a, a figure from a publication from the group of Enrico Toto in Italy of the mycobacterial family tree. The tree is so long that it wouldn't fit on the slides. Therefore, it is shown as a circle. And on the lower end at six o'clock to the right is the beginning and at six o'clock to the left is the end we see, for example, at around uh 10 o'clock, mycobacterium tuberculosis, we also see down to the left at six o'clock at the end of the spectrum, the bacteria of the mycobacterium avium complex and about at nine o'clock, mycobacterium can I which is closely related to mycobacterium tuberculosis at 11 o'clock. Um there is mycobacterium and almost at five o'clock, mycobacterium obsesses with the subspecies abscessus Poletti and Mai, the novel A TS er S and I DS A guidelines from 2020 for the first time, present evidence based for the management of four of these organisms. Mycobacterium avium complex, mycobacterium Kia, mycobacterium CPI and mycobacterium abscessus. And these 4 may also be clinically the most important ones. As many of the less common non tuberculous mycobacteria that also cause pulmonary diseases could not be covered in the 2020 international guidelines. The group of experts that were writing these guidelines were conducting systematic reviews and a consensus for management recommendations for this less common non tubercular, non tuberculous mycobacteria diseases caused by rapid growers, mycobacterium kilo and mycobacterium forum and by mycobacteria, God Malmo and soul. And thus covering all of the relevant non tuberculous mycobacteria that cause pulmonary diseases in clinical practice. Here, you see the different species again on the family tree of the non tuberculous mycobacteria. When is infection or disease, we have two major clinical entities in non tuberculous mycobacteria pulmonary disease. The one here shown on the left side is the nodular bronchiectatic form that has a more favorable course and it is more slowly in progression. And on the right side, the more aggressive form of the disease, which is called fibro cavitary, which is has the hallmark of cavitation within the lung tissue. This is progressing more rapidly and also has a worse prognosis compared to the nodular bronchiectatic form of the disease. And both forms can be present in the same patient apart from the A T SI DS A er S and AC M diagnostic criteria to initiate antimicrobial therapy because they are disease defining. There have been criteria proposed by Emmanuel Wolinsky already in the 19 eighties of the past, in the past century that are very plausible and guide physicians for the decision to initiate antimicrobial therapy. The first criterium is growth if acid fasts, bacill are seen on spear microscopy and a rapid end tuberculosis PC R result is negative. The plausible cause is the presence of a nontuberculous mycobacterial pulmonary infection. And that because of the large number of bacteria that result in visibility of them on uh microscopical examinations is then related to disease. Also, if there's a repeated isolation of the same species, this favors disease versus simple infection or colonization. Also isolation of a bacteria from a sterile source. For example, a plural infusion or a cerebral spinal fluid would rather favor disease than colonization. And very importantly, the pathogen ethnicity of the organism, mycobacteria is almost always associated with disease and should almost always prompt to initiate antimicrobial treatment. Whereas Mycobacterium God is almost never related to disease and should always never be treated with antibiotics. Although mycobacterium God, Donna is the third most common a mycoba nontuberculous mycobacterial species usually isolated in a specialized laboratory. And the fifth one, it's also important is the presence of immuno deficiency in for example, treat patients who are treated with tunics factor alpha antagonists um who are medically immunocompromised. Um It is much more likely that the finding of a non tuberculous microbacteria is a real finding causing disease. Um and a patient who is affected by HIV infection and a patient who has um other causes of um either inherited or acquired immuno deficiencies. The finding of non tuberculous mycobacteria from pulmonary or bronchial specimen is much more related to disease than to simple colonization. It's now my great pleasure to introduce my two esteemed colleagues who participate in today's program. The first presentation will be given by Professor David Griffith who is professor of Medicine at the National Jewish Health Institute in Denver, Colorado David is, has been the first author of the international A T SI DS A guidelines from 2007 and is one of the person who has mostly influenced the field of the management of non tuberculous mycobacterial pulmonary disease. In the past decades, he will present on translating the A T SI DS A, er S and SM guided directed management pathways and clinical trial results in an T MP D to the front lines of patient care. You focus on high risk patients and clinical findings, predictive of respiratory mac and pulmonary disease. Following David, my dear colleague, Professor Stefano Aliberti, who is the professor of at the Humanitas University and the Chief of the Respiratory Unit at the Human Humanitas Research Hospital in Milan Italy will follow Stefano is also an international renown expert in the field of non tuberculous mycobacterial disease and bronchialis. He will describe the critical role of longitudinal microbiological monitoring and me lung disease especially about guiding antibiotic selection, routine and intensity based on systematic microbiological testing, radiological findings and severity score indexes, especially the potential pitfalls of a watch and wait approach in high risk patients. And my name is Christof Langer. I'm the medical Director of the Research Center, boil a Leni Lung Center in Germany. I'm a Professor of Respiratory Medicine and International Health at the University of Lubeck in Germany. And my part will be the presentation of completing the journey from diagnosis to cure in patients affected by m lung disease. And this will include practical approaches to ensure that trial based results will translate to real world patient care.
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