Abstract Introduction Mycobacterium abscessus is a rapidly growing nontuberculous mycobacterium (NTM) known to cause severe infections involving the skin, soft tissue, and respiratory tract. Its isolation alone does not confirm disease; clinical correlation is essential, particularly in patients with chronic airway disease or implanted medical devices. Case Description A 46-year-old female with a history of obesity hypoventilation syndrome (OHS), tracheomalacia, vocal cord dysfunction, and tracheostomy dependence presented with tracheostomy site bleeding and cellulitis (Figure 1). The patient had recently completed a 2-month course of intravenous meropenem, oral linezolid, and oral azithromycin after wound cultures identified M. abscessus. Upon readmission, purulent drainage persisted. Repeat wound cultures isolated M. abscessus, this time with inducible macrolide resistance. Antibiotic regimen was escalated to intravenous amikacin, intravenous cefoxitin, oral linezolid, and inhaled tobramycin. Oral azithromycin was later reintroduced. During therapy, the patient developed acute kidney injury and myelosuppression. After five months, culture conversion was achieved, and she was discharged with a plan to complete an additional three months of oral and inhaled antimicrobials. Discussion This case highlights the diagnostic and therapeutic complexity of M. abscessus infection in the setting of chronic tracheostomy dependence. M. abscessus is a known colonizer of the airway, and distinguishing true infection from colonization requires clinical correlation, especially in patients with risk factors such as airway instrumentation, tracheomalacia, and impaired mucociliary clearance. This organism is among the most drug-resistant NTM species, largely due to intrinsic resistance mechanisms and the presence of the erm(41) gene, which confers inducible resistance to macrolides, typically the cornerstone of NTM therapy. Treatment is complicated by limited antibiotic options, significant toxicity, and the need for prolonged multidrug regimens. Optimal therapy often includes parenteral agents like amikacin and cefoxitin or imipenem, in combination with oral agents such as linezolid and macrolides (used for immunomodulatory effects when resistance is present). This patient’s nephrotoxicity and myelosuppression reflect the well-documented adverse effects associated with long-term multidrug regimens. A multidisciplinary approach, including pulmonology, infectious diseases, otolaryngology, and pharmacy is critical to manage and provide comprehensive care. Despite inducible macrolide resistance, azithromycin was retained for its immunomodulatory benefits, which have shown utility in chronic airway inflammation and NTM management. Conclusions M. abscessus infection at a tracheostomy site, although rare, should be suspected in cases of persistent inflammation and drainage. Aggressive, individualized treatment guided by susceptibility patterns and careful monitoring of adverse effects is essential for successful outcomes. This abstract is funded by: None
Archila et al. (Fri,) studied this question.