In the present study, we showed that a lower BACES severity in MAC-PD patients is associated with a higher culture conversion rate and shorter latency to conversion after treatment. In addition, intermittent antibiotic treatment did not affect the culture conversion rate in the mild disease group. Our findings suggest that daily and intermittent antibiotic therapy may have equivalent efficacy in mildly affected MAC-PD patients and that an intermittent treatment strategy may be useful to reduce pill burden in mild MAC-PD disease. Thus, our data implies that treatment response can be predicted based on disease severity and that therapeutic strategies can also be individualized according to the severity of MAC-PD.
Notably, treatment outcomes, defined as negative sputum culture conversion rate, differed significantly among the MAC-PD patient groups stratified by BACES severity. Originally, the BACES severity scoring system was based on five-year survival rates. Notably, based on our current findings, microbiological response can also be predicted using the BACES score. Several clinical or microbiological characteristics were previously identified as factors associated with culture conversion or treatment success 12,17−21. In particular, previous studies found that a poor microbiological response was associated with fibrocavitary disease, positive AFB smear, and previously treated NTM 12,18,19. However, there were some differences in the factors in each study, and no study showed analysis that could be applicable to real-world practice by composing individual factors comprehensively. An important cause of this limitation is the lack of indicators to assess the severity of MAC-PD. The heterogeneity in outcomes reported in previous meta-analysis is also presumed to be due to these above mentioned limitations 7,8,22. In these contexts, BACES or other severity scoring systems may help in predicting treatment outcomes or strategies for MAC-PD patients.
Another important finding of our study was that intermittent antibiotic treatment did not have a negative effect on culture conversion at the end of treatment in the mild BACES MAC-PD group. These findings may enable the more specific selection of target populations that would benefit from intermittent therapy with low pill burdens, instead of daily treatment. For treating MAC-PD, previous cohort studies found that intermittent therapy was effective for treating MAC-PD patients with the noncavitary NB form of disease 12,14,23,24. However, in real-world practice, there are some cases in which distinguishing between “advanced” and mild disease can be difficult. Some patients have severe bronchiectasis or destruction of the lung parenchyma without cavities, whereas others have only small cavitary nodules with mild bronchiectais. Notably, in our study, most (91%) of the mild BACES group did not have a cavity. Thus, our data implies that mild MAC-PD can be categorized by integrating several indicators such as BMI, age, and ESR, in addition to cavities.
Interestingly, in the severe group, the culture conversion rate did not significantly increase even when the treatment period was extended to more than 12 months, whereas in the mild group, some additional patients achieved culture conversion after 12 months of treatment. These findings suggest that, in severe MAC-PD patients, when the treatment response is poor, the antibiotic regimen may need to be changed at an early stage or other interventions may be required. Conversely, in the mild group, some MAC-PD patients who did not achieve culture conversion even after one year of treatment could potentially achieve culture conversion if treatment were extended. These data may suggest that the treatment of refractory disease or the timing of regimen change should be determined differently depending on the severity of MAC-PD. In addition, in our study, the time from treatment to culture conversion was shorter among patients with mild disease than among those with either moderate or severe disease, suggesting that eventually the overall treatment period may be shortened in mild cases of MAC-PD. However, no studies have yet adjusted the duration of treatment for MAC-PD according to disease severity. Nevertheless, it will be important to determine whether some patients might benefit from a shorter treatment period without negatively affecting prognosis.
There are some limitations to our study. First, because it was conducted at a single referral centre, our data may not be generalizable to other geographic areas. Second, this study might include unexpected biases that result from excluding patients who changed treatment method according to the patient's condition. Third, the BACES scoring system has not been validated in many cohorts of patients. Fourth, in the moderate and severe groups categorized by BACES, the treatment outcomes of intermittent versus daily treatment could not be properly compared. As shown in Supplementary Table 1, 28% (141/503) of the moderate group and 6% (10/158) of the severe group received intermittent treatment, instead of daily treatment; however, although their culture conversion rate did not differ significantly according to treatment modalities (p = 0.451 for the moderate group and p = 0.090 for the severe group), this result may not be valid due to the large differences in the ratios between intermittent versus daily treatment among the two groups. Lastly, in our study, treatment outcome was defined as negative conversion, not microbiological cure, because there is a possibility that the microbiological cure may be affected by the differences in the duration of antibiotic maintenance between the comparison groups.
In conclusion, we showed that a lower BACES severity score in MAC-PD patients is associated with a higher culture conversion rate and shorter latency to conversion after treatment. Also, intermittent antibiotic treatment in the mild disease group did not affect the culture conversion rate. These data suggest that treatment modalities with a lower antibiotic burden are worth considering, especially in mild cases of MAC-PD.