Comparing clinical outcomes of antibiotics for treating mycobacterium avium complex infection in adults with HIV: a systematic review and network meta-analysis

This study aims to identify the comparative effects of different drug regimens in treating MAC. PubMed, EMBASE, CENTRAL, and EBSCO Open Dissertations were searched in September 2023. We included randomized controlled trials in people with HIV and MAC infection that compared any regimens and reported culture- conversion results. Antibiotic regimens were classified as azithromycin plus ethambutol (AZI+E); clarithromycin plus clofazimine (CLA+CLO); clarithromycin plus ethambutol (CLA+E); clarithromycin plus ethambutol and clofazimine (CLA+E+CLO); clarithromycin plus ethambutol and rifampicin/rifabutin (CLA+E+R); clarithromycin plus rifampicin/rifabutin (CLA+R); clofazimine plus ethambutol (CLO+E); and clofazimine plus ethambutol and rifampicin/rifabutin (CLO+E+R). Risk ratios (RRs) with 95% confidence interval (CI) were estimated using a random-effects model. The effects of treatment regimens were ranked using the surface under the cumulative ranking (SUCRA). Of 3,611 articles identified, 12 met (n = 2,987) the eligibility criteria. The following regimens showed higher culture-conversion outcomes (RR [95%CI]) compared to CLA+E: CLA+CLO (1.15 [0.73,1.81]), CLA+E+R (1.09 [0.80,1.47]), CLA+E+CLO (1.01 [0.69,1.46]), CLA+R [0.97 (0.56,1.70]), AZI+E (0.82 [0.60,1.13]), CLO+E+R (0.44 [0.25,0.77]), CLO+E (0.37 [0.19,0.72]). The SUCRA of CLA+CLO (80.9%) aligns with its highest comparative efficacy. The RR of culture conversion to negative was higher in ARV-treated patients. Adverse events were similar across regimens, except for a higher risk with CLO+E+R compared to CLA+CLO (7.21 [1.22-42.64]). Clarithromycin-based regimens remain the treatment of choice for MAC in people with HIV. Although clarithromycin plus clofazimine appears to be the most effective regimen, other clofazimine-based regimens should not be considered as the initial treatment choice. The effective ARV improving culture-conversion outcomes.