It’s in the water, embedded in the soil, and lingers in the air we breathe. Every day, we are exposed to microscopic bacteria which often go unnoticed. But then, symptoms appear: chronic cough, fatigue, fever, night sweats, and unexplained weight loss.
The culprit? Nontuberculous mycobacteria (NTM)—a bacteria found in the environment that causes a condition often mistaken for other lung diseases impacting individuals with pre-existing lung conditions or weakened immune systems.
As NTM cases rise, the UAB Nontuberculous Mycobacterial (NTM) Program, led by Bryan Garcia, M.D., in partnership with German Henostroza, M.D., has formed a multidisciplinary team to provide individualized care, improve diagnosis, and enhance treatment outcomes for patients with NTM.
With many unanswered questions about why some people are more vulnerable, UAB’s NTM Program is working hard to uncover the disease’s underlying factors and advance care for those affected.
The Journey to a Diagnosis
In 95% of cases, NTM disease affects the lungs, leading to bronchiectasis—permanent airway damage that makes bacterial clearance difficult. Because NTM symptoms mimic other lung diseases, diagnosis is often delayed.
Unlike typical respiratory infections, NTM is linked to unexpected risk factors, including frequent gardening, prolonged soil exposure, and even long, hot showers.
“Risk factors for NTM are things that we traditionally don’t believe are tremendously risky,” said Henostroza. “It’s important to look at the risk factors that the patient has to develop NTM infections and what other comorbidities they have because mycobacteria are environmental.”
Demographics also play a role. About 85% of cases occur in postmenopausal Caucasian women in their 60s and 70s with slender body types and no smoking history. The remaining 15% are primarily men, many of whom are heavy smokers. Additionally, a significant number of NTM patients have underlying immunosuppression, further increasing their risk.
Geography matters, too. Coastal regions see higher infection rates, with an estimated 100,000 to 150,000 Americans affected. Most individuals receiving treatment live in the southeastern region of the United States, spanning from South Carolina to the Texas coast.
The Road to a Diagnosis
Because symptoms of NTM often mimic other lung diseases, the diagnosis process can be challenging.
The primary diagnostic method remains sputum examination—a process that analyzes lung mucus using an acid-fast bacilli smear and culture test. While effective, this approach has remained unchanged for decades.
For patients who cannot produce sputum, a bronchoscopy—an invasive procedure where a thin, flexible tube is inserted into the lungs—may be necessary to allow specialists to collect airway samples directly, improving the accuracy of the diagnosis.
Other technologies such as MALDI-TOF mass spectrometry, laser-based identification methods, and molecular testing, improve bacterial detection once cultures are established. However, these methods are not widely available.
Chest imaging can also be beneficial. While not a definitive test, it can reveal characteristic lung changes that raise suspicion of NTM, prompting further investigation and leading to earlier diagnoses.
The Burden of Treatment
For some patients, receiving an accurate NTM diagnosis can take years. But even after the disease is identified, the journey is far from over.
“The first thing we do is establish a rapport with the patients,” said Henostroza. “They need to understand that the treatment process is long.”
Standard treatment for NTM can last up to 18 months, placing a significant burden on patients. Some patients are required to take up to five antibiotics daily, totaling nearly 2,000 pills over the course of therapy.
Managing this intensive regimen and its side effects is a priority for Drs. Garcia and Henostroza. They’ve formed a multidisciplinary team including a microbiologist, pharmacist, and patient care coordinator that meets weekly to develop individualized treatment plans. They carefully adjust medications to minimize side effects such as nausea, appetite loss, and gastrointestinal distress, ensuring each patient receives a tolerable and effective regimen.
“We work together and collaborate with our patients to ensure treatment doesn’t become worse than the illness itself,” said Garcia.
One major advancement in the UAB NTM program is the introduction of in-house drug sensitivity testing, led by Filipe Cerqueira, Ph.D., associate director of the Clinical Microbiology Program. This innovation has reduced the typical trial-and-error process patients go through when trying new medications by identifying patient-specific drug sensitivities, an analysis that once took up to four months.
“We are now able to make informed decisions in two weeks, leading to better, faster care,” explained Cerqueira.
Addressing Cost and Expanding Access to Treatment
With the extensive use of antibiotics required to treat NTM, UAB experts prioritize patients access to care. Some essential medications, such as inhaled antibiotics, can cost up to $100,000 annually. While many insurance plans cover antimicrobial treatments, some patients rely on assistance programs.
UAB also participates in the Compassionate Use Program, which provides access to medications that may not be widely available.
“Because of this program, we have access to drugs these bacteria may have never been exposed to, we can offer more treatment options, especially for patients with resistant infections or medication intolerances,” Garcia said.
Beyond antibiotics, lifestyle modifications play a critical role in managing NTM.
“Weight-bearing exercise and proper nutrition are just as important as medication,” Garcia explained.
In fact, about 30% of UAB’s NTM patients only require observation rather than immediate treatment. Those who engage in regular exercise make up the majority of this group.
The Need for Continued Research
NTM cases are rising, yet much remains unknown about susceptibility factors. Furthermore, despite extensive treatment plans, infections often return.
“Most people get it again. It’s something about these individuals that we don’t yet understand that puts them at risk,” Garcia said. “Patients will likely live with this disease.”
Garcia emphasized the need for new drug development approaches. “We need pathways forward that don’t rely solely on cures but focus on improving other outcomes. This has been a major barrier to research.”
Understanding why certain demographics are more susceptible is crucial for developing targeted therapies.
“We have suspicions about why some people are vulnerable, but no definitive answers,” Garcia said. “We need ongoing research to understand the underlying mechanisms.”
Researchers are also exploring noninvasive diagnostic methods, including blood-based tests, to accelerate diagnosis, particularly for NTM infections outside the lungs.
The UAB Nontuberculous Mycobacterial (NTM) Program is located at The Kirklin Clinic Pulmonary Clinic, where a dedicated team of specialists provides comprehensive, patient-centered care. Through multidisciplinary collaboration, expedited diagnostics, and ongoing clinical research, the team remains committed to improving outcomes for patients with NTM as the prevalence of the disease rises.
For more information about the UAB NTM Clinic and nontuberculous mycobacteria, check out UAB MedCast featuring Drs. Bryan Garcia and German Henostroza.