Adding inhaled amikacin from the start raised culture conversion in newly diagnosed MAC lung disease

The edition in brief

ENCORE, published in AJRCCM on 30 September, randomised 425 adults with newly diagnosed Mycobacterium avium complex lung disease to amikacin liposome inhalation suspension or placebo, each with azithromycin and ethambutol for 12 months. Symptom scores improved more with inhaled amikacin (difference 3.1 points at month 13), culture conversion by month 13 was 82.4% against 55.6%, and durable conversion at month 15 was 76.2% against 47.6%. The drug is currently licensed for refractory disease, so first-line use is beyond the licence and guidelines have not changed. A Danish nested case-control study in Chest found azithromycin was not associated with new NTM isolation in bronchiectasis (OR 1.31) or COPD (OR 1.29) under the prespecified exposure definition; broader associations clustered near testing dates, suggesting testing driven by indication. An international working group revised the definition of acute exacerbation across all fibrotic ILDs and proposed a wider 'acute respiratory worsening' framework. A US cohort of 6,637 patients found subspecialty ILD clinic care associated with more CT, more antifibrotic use and lower hospitalisation and death. The pearl covers checks before long-term azithromycin.