Omadacycline in first-line combination therapy for pulmonary Mycobacterium abscessus infection: a case series

Mycobacterium abscessus complex (MABSC) represents the second most common cause of nontuberculous mycobacterial pulmonary disease, associated with up to 17% of cases. Treatment of MABSC disease is complex, lengthy, and involves multidrug regimens due to high rates of intrinsic antimicrobial resistance; cure rates remain poor. There are currently no approved treatments for MABSC, and only limited data are available to guide treatment decisions for individual patients. Omadacycline, a tetracycline class-derived aminomethylcycline that is not approved for treatment of nontuberculous mycobacterial pulmonary infections, has been granted orphan drug designation by the US Food and Drug Administration. Here, we describe three cases using omadacycline as part of a first-line treatment regimen for patients with MABSC pulmonary infections, based on multiple factors, including resistance profile, toxicity, minimizing use of intravenous therapy, and expert recommendation. The clinical improvements of these patients, together with promising in vitro and early clinical development data, indicate that omadacycline warrants further investigation as a potential first-line option for incorporating into MABSC pulmonary disease treatment regimens.