Non-tuberculous mycobacteria pulmonary disease: an integrated approach beyond antibiotics

Non-tuberculous mycobacteria pulmonary disease (NTM-PD) is an emerging condition with heterogeneous manifestations from both the microbiological and the clinical point of view. Diagnostic and therapeutic guidelines are available but unmet patients' and physicians' needs, including therapy-related adverse events, symptom control, management of comorbidities, risk of re-exposure to the pathogen and unfavourable outcomes are still relevant issues. In the present review, we provide currently available evidence for an integrated approach to NTM-PD beyond antibiotic therapy. This includes: 1) Avoidance of exposure to environments where mycobacteria are present and careful evaluation of lifestyle and habits; 2) Implementation of a personalised pulmonary rehabilitation plan and airway clearance techniques to improve symptoms, exercise capacity, health related quality of life (HRQoL) and functional capacity in daily living activities; 3) A nutritional evaluation and intervention to improve HRQoL and to control gastrointestinal side effects during antimicrobial therapy, particularly in those with low body mass index and history of weight loss; and 4) Management of comorbidities that impact disease outcomes, including structural lung diseases, immune status evaluation and psychological support when appropriate.