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Resumen
La incidencia de enfermedad infecciosa pulmonar (EIP) por micobacterias no tuberculosas (MNT) está aumentando de manera significativa en los últimos años. Las MNT son patógenos oportunistas ambientales y su creciente asociación con EIP se debe a factores como mayor exposición a estos microorganismos, aumento de sensibilidad de las técnicas diagnósticas e incremento de pacientes con factores predisponentes. En ocasiones resulta difícil diferenciar si un aislamiento de muestra respiratoria corresponde a una contaminación o está implicado en la patogenia de la enfermedad. Las guías de la American Thoracic Society/Infectious Diseases Society of America combinan criterios clínicos y microbiológicos para un correcto diagnóstico de EIP por MNT. Aunque no validados para todas, sí resaltan la importancia del diagnóstico de especie. La identificación mediante métodos convencionales es la pauta habitual en los laboratorios de microbiología clínica, si bien no siempre permite la diferenciación de especie, debiendo utilizarse en la actualidad nuevos métodos moleculares de hibridación con sondas, amplificación genómica y técnicas de secuenciación. La comunicación clínico-microbiólogo es conveniente para establecer la pauta diagnóstica más adecuada y poder decidir cuándo remitir el aislado al laboratorio de referencia. Aunque el CLSI ha publicado una actualización en las pautas de estudio de sensibilidad in vitro, persiste el debate acerca de su utilidad en el manejo de la EIP por MNT. El objetivo de esta revisión es describir las MNT más relevantes en patología pulmonar, los factores predisponentes a esta infección, su diagnóstico mediante nuevas alternativas y la correlación in vitro con la respuesta del paciente al tratamiento.
Palabras clave:
Micobacterias atípicas no tuberculosas
Enfermedad infecciosa pulmonar
Diagnóstico microbiológico
Estudios de sensibilidad
Abstract
Nontuberculous mycobacteria (NTM) are increasingly associated with infectious pulmonary disease. NTM are ubiquitous environmental pathogens with high isolation rates worldwide. The greater frequency of NTM associated with pulmonary diseases is probably due to a combination of increased exposure, improved diagnostic methods and an increase in the prevalence of risk factors predisposing individuals to infection. Difficulty may arise in determining whether an isolate from a respiratory sample is in fact a contaminant or a pathogenic organism. The ATS/IDSA guidelines highlight the importance of following microbiological and clinical criteria in making a diagnosis of NTM lung infection. These criteria may not be useful for all NTM and species-level identification is strongly recommended. Mycobacteria identification by conventional methods has been the standard in most clinical microbiology laboratories. However, conventional testing alone does not allow identification of many NTM. Newer, rapid molecular methods such as commercially available nucleic acid probes, genomic amplification and DNA sequence analysis should be used. Communication between the clinician and the laboratorian is essential to decide whether an isolate could be sent to a reference laboratory to determine the best method for species identification. Although the CLSI has recently published an approved standard for NTM susceptibility testing, there is ongoing debate about the role of in vitro susceptibility for managing patients with NTM disease. The goal of this review is to describe the mycobacteria involved in lung disease, the factors that predispose to this infection, its diagnosis with alternative procedures and the correlation between in vitro and in vivo treatment response.
Keywords:
Nontuberculous mycobacteria
Pulmonary infectious diseases
Microbiological diagnosis
Susceptibility testing
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