Abscesos mamarios múltiples por Mycobacterium abscessus en mastopexia secundaria con implantes mamarios / Multiple breast abscesses due to Mycobacterium abscessus in secondary mastopexy with breast implant

Las infecciones periprotésicas son una complicación poco frecuente en cirugía de implantes mamarios, pero de difícil resolución si son causadas por gérmenes como las micobacterias. Mycobacterium abscessus es una micobacteria no tuberculosa de rápido crecimiento, que se presenta de manera atípica, generando abscesos y fístulas cutáneas. En este reporte presentamos el caso de una paciente que fue intervenida por recambio de implantes mamarios y mastopexia secundaria. La paciente presentó un seroma temprano como manifestación inicial y posteriormente desarrolló múltiples abscesos en todo el parénquima mamario. El tratamiento instaurado en la paciente fue la extracción del implante mamario,curaciones diarias de la herida, antibioticoterapia prolongada y punciones periódicas guiadas por ecografía, con cultivo del material obtenido. El objetivo de nuestro reporte fue presentar esta complicación generada por un germen poco frecuente, su forma de presentación, diagnóstico y el tratamiento establecido

Although periprosthetic infections are a rare complication in breast implant surgery, they are difficult to resolve if they entail germs like mycobacteria. Mycobacterium abscessus is a rapidly growing, nontuberculous mycobacterium that occurs atypically and generates abscesses and cutaneous fistulas. In this report, we present the case of a patient that underwent surgery for a breast implant replacement and a secondary mastopexy. The initial manifestation the patient evinced was an early seroma. Later, she developed multiple abscesses in all the breast parenchyma. The treatment established for the patient involved extracting the breast implant, daily cleaning and dressing of the wound, prolonged antibiotic therapy, and periodical punctures guided by ultrasound, accompanied by culture sampling. The aim of this report is to present this infrequent germ-generated complication, its form of manifestation, its diagnosis, and the established treatment.

Queratitis por Mycobaterium abscessus: comunicación del primer caso en Paraguay / Keratitis due to Mycobaterium abscessus: first case report in Paraguay

Resumen Se presenta un caso clínico de queratitis por Mycobacterium abscessus en una mujer de 76 años, residente en la ciudad de Asunción, sin traumatismo ni cirugía ocular previa y con antecedente de una queratouveitis herpética. Por tratarse de una queratitis causada por un agente etiológico poco frecuente y por la importancia de un diagnóstico correcto y oportuno para la instauración del tratamiento adecuado, se comunica el primer caso de queratitis por micobacterias en Paraguay.

Abstract We present a clinical case of keratitis caused by M. abscessus in a 76-year-old female patient, resident in the city of Asunción, without trauma or previous ocular surgery and with a history of herpetic keratouveitis. Because it is a keratitis caused by a rare etiological agent and because of the importance of a correct and timely diagnosis for the establishment of appropriate treatment, the present case is reported, the first of Mycobacteria keratitis in Paraguay.

Cord factor producer Mycobacterium abscessus subsp. bolletii in asymptomatic immunocompetent host sputa samples

Abstract We report a case of Mycobacterium abscessus subsp. bolletii colonization in upper respiratory tract of an immunocompetent patient, who was misdiagnosed as tuberculosis by Acid Fast Bacilli (AFB) and cord factor formation observed directly from the sputa culture in liquid medium. This fact reflected a significant impact on the individual case's life and showed the importance to identify the mycobacteria isolated from clinical sample at species level, and to determine the true implication of nontuberculous mycobacteria (NTM) detected in clinical samples.

Coinfección por Mycobacterium abscessus y Mycobacterium tuberculosis en un paciente con síndrome de Cushing exógeno y otras comorbilidades / Mycobacterium abscessus and Mycobacterium tuberculosis coinfection in a patient with exogenous Cushing syndrome and other comorbilities

RESUMEN Mycobacterium abscessus es una micobacteria no tuberculosa de crecimiento rápido, que produce infección pulmonar, cutánea, diseminada y otras, sobre todo en pacientes con comorbilidades. El diagnóstico se basa en la identificación de la micobacteria por medios de cultivo o por pruebas moleculares. El tratamiento con macrólidos y amikacina continúa siendo el ideal, aunque depende de la localización y de la gravedad de la infección, sin embargo, se han identificado genes de resistencia en algunas subespecies que limitan la eficacia antibiótica. Presentamos el caso de un paciente con coinfección cutánea por Mycobacterium abscessus y Mycobacterium tuberculosis, quien presenta un síndrome de Cushing exógeno, factor predisponente para estas infecciones. Además, se identificaron hidatidosis y aspergilosis pulmonares. El tratamiento antituberculoso del paciente se ajustó para manejar ambas micobacterias, y su evolución fue favorable.

ABSTRACT Mycobacterium abscessus is a fast-growing non-tuberculous mycobacterium that causes lung, skin, disseminated and other infections, mainly in patients with comorbidities. The diagnosis is based on the identification of the mycobacterium by culture media or molecular tests. Treatment with macrolides and amikacin remains the optimal choice, although it depends on the location and severity of the infection; however, resistance genes have been identified in some subspecies that limit antibiotic efficacy. We present the case of a patient with cutaneous coinfection by Mycobacterium abscessus and Mycobacterium tuberculosis, who presented exogenous Cushing syndrome, a predisposing factor for these infections. In addition, hydatidosis and pulmonary aspergillosis were identified. The patient's anti-tuberculosis treatment was adjusted to manage both mycobacteria, resulting in a favorable evolution.

Mycobacterium abscessus urinary tract infection: case report / Infecção urinária por Mycobacterium abscessus: relato de caso

Abstract Urinary tract infection is a serious public health issue that predominantly affects women. In men, it is more often associated with prostatic hyperplasia and bladder catheterization. Urogenital tuberculosis presents with nonspecific with nonspecific symptoms and the diagnosis can be made in the presence of sterile leukocyturia and recurrent infection with acid urine. Non-tuberculous mycobacteria or other non-tuberculosis mycobacteria are opportunistic pathogens that inhabit the soil, water or environment surfaces, and usually cause diseases in immunocompromised individuals. Mycobacterium abscessus is an agent that causes lung, skin and soft tissue hospital infections. Urinary tract infections by this pathogen are rare.

Resumo Infecção do trato urinário é um sério problema de saúde pública que acomete predominantemente as mulheres. Em homens, está mais relacionada com hiperplasia prostática e cateterismo vesical. A tuberculose urogenital cursa com sintomas inespecíficos e o diagnóstico pode ser aventado na presença de leucocitúria estéril, e infecção recorrente com urina ácida. Micobactérias não tuberculosas ou mycobacteria other than tuberculosis são patógenos oportunistas que habitam o solo, a água ou superfícies do meio ambiente, e geralmente causam doenças em imunodeprimidos. Mycobacterium abscessus é um agente que causa infecções nosocomiais, pulmonares, de pele e de tecidos moles. Infecção urinária decorrente desse patógeno é considerada rara.

Efficacy of Moxifloxacin against in Zebrafish Model / 生物医学与环境科学（英文）

Objective@#Moxifloxacin (MFX) shows good activity against and can be a possible antibiotic therapy to treat infection; however, other studies have shown a lower or no activity. We aimed to evaluate MFX activity against using zebrafish (ZF) model .@*Methods@#A formulation of labeled with CM-Dil was micro-injected into ZF. Survival curves were determined by recording dead ZF every day. ZF were lysed, and colony-forming units (CFUs) were enumerated. Bacteria dissemination and fluorescence intensity in ZF were analyzed. Inhibition rates of MFX and azithromycin (AZM, positive control) were determined and compared.@*Results@#Significantly increased survival rate was observed with different AZM concentrations. However, increasing MFX concentration did not result in a significant decrease in ZF survival curve. No significant differences in bacterial burdens by CFU loads were observed between AZM and MFX groups at various concentrations. Bacterial fluorescence intensity in ZF was significantly correlated with AZM concentration. However, with increasing MFX concentration, fluorescence intensity decreased slightly when observed under fluorescence microscope. Transferring rates at various concentrations were comparable between the MFX and AZM groups, with no significant difference.@*Conclusion@#MFX showed limited efficacy against using ZF model. Its activity needs to be confirmed.

Utilização do sistema MGIT 960 TB eXIST como teste de suscetibilidade a fármacos para Mycobacterium abscessus e análise de possível interferentes genéticos no perfil de resistência / Use of the MGIT 960 TB eXIST system as a drug susceptibility test for Mycobacterium abscessus and analysis of possible genetic interferences in the resistance profile

As espécies do grupo Mycobacterium abscessus (MAG) podem causar infecções em diferentes órgãos e tecidos, sendo M. abscessus a terceira micobactéria não tuberculosa mais isolada, e são responsáveis por 80% das infecções pulmonares causadas pelas micobactérias de crescimento rápido (MCR). Suas infecções são de difícil resolução devido a sua resistência intríseca e adquirida à maioria das classes de antibióticos usualmente utilizados, tornando este grupo de grande preocupação para a saúde pública. O teste de suscetibilidade aos antimicrobianos (TSA) é recomendado para auxiliar na escolha terapêutica e a única metodologia validada é a concentração inibitória mínima, recomendada pelo Clinical & Laboratory Standards Institute. Este projeto teve como objetivo avaliar o TSA pelo sistema automatizado BACTEC MGIT 960/TB eXiST para isolados do MAG. Além disso, foi avaliada a presença de plasmídeos. A cepa M. abscessus ATCC 19977 foi utilizada para desenvolver o protocolo e, subsequentemente, o TSA foi realizado para 31 isolados de MAG frente a quatro antibióticos tanto pelo sistema BACTEC MGIT 960/TB eXiST quanto pelo método padrão REMA. A comparação entre os dois métodos mostrou que não houve erros críticos. No geral, o sistema BACTEC MGIT 960/TB eXiST forneceu corretamente as informações clinicamente relevantes, com a única exceção sendo uma discrepância menor. Todos os isolados testados foram sensíveis (4 µg/mL) a amicacina, com a exceção de um isolado resistente. Para imipenem, todos os isolados foram resistentes (32 µg/mL), enquanto para cefoxitina apenas dois isolados foram sensíveis (16 µg/mL). Em relação a claritromicina, 14 isolados foram sensíveis (2 µg/mL) enquanto os restantes foram resistentes (8 µg/mL). A ánalise genômica evidenciou que apenas dois isolados apresentaram plasmídeos. O isolado 381 apresentou dois contigs, sendo um deles idêntico ao fago Adler, enquanto o isolado 1189 apresentou um único contig com diversos mecanismos de defesa celular, incluindo uma metalo beta-lactamase. Este estudo descreve um 7 protocolo de TSA para MCR pelo sistema MGIT 960/TB eXiST e que a aplicação do método a um conjunto de isolados clínicos demonstrou que o sistema é confiável e altamente reprodutível.

Use of MALDI-TOF MS in diagnostic microbiology for identification of species that conventional methods usually fail to identify

(MALDI-TOF MS) has been used in clinical diagnostic laboratories for the identification of microorganisms. It has a relevant advantage compared to other methods in terms of speed to provide results, being an alternative for addressing restrictions in clinical diagnosis as it may replace or complement existing identification techniques. This is especially important because some rare microorganisms would be identified only by higher cost techniques which are not widely available, such as genetic sequencing. Thus, the present paper reports two cases in which uncommon microorganisms were identified effectively and quickly. (AU)

Hyptis brevipes and Paullinia pinnata extracts and their fractions presenting activity against Mycobacterium abscessos SubSP. massiliense

Medicinal plants are of great interest for the discovery of new biomolecules with diversified effects. Over the last decade different outbreaks caused by Mycobacterium abscessos subsp. Massiliense have been reported, evidencing it as an important emerging pathogen in underdeveloped countries. This study investigated the antimycobacterial activity of six Brazilian medicinal plant extracts and their fractions. Hyptis brevipes, Tocoyena formosa, Randia armata, Paullinia pinnata, La foensia pacari And Anadenanthera colubrina were evaluated against M. a. massiliense. Total extracts from the medicinal plants H. brevipes, T. formosa, P. pinnata and L. pacari presented a minimal bactericidal concentration of 1 mg/mL. After fractioning, the ethanolic fractions from H. brevipes and P. pinnata presented bactericidal activity, and the ethyl acetate fraction from H. brevipes and T. formosa presented antimycobacterial action. The best bactericidal function of all plant fractions was the ethanolic, which contained rutin and rosmarinic acid that were shown to have microbicidal activity.

Clinical aspects in patients with pulmonary infection caused by mycobacteria of the Mycobacterium abscessus complex, in the Brazilian Amazon / Aspectos clínicos em pacientes com infecção pulmonar por micobactérias do complexo Mycobacterium abscessus na Amazônia brasileira

ABSTRACT Objective: To describe the clinical manifestations of patients with pulmonary infection caused by mycobacteria of the Mycobacterium abscessus complex (MABSC), and to compare these manifestations with those of patients infected with other nontuberculous mycobacteria (NTM). Methods: This was a retrospective cohort study involving 43 patients divided into two groups: the MABSC group, consisting of patients with pulmonary infection caused by MABSC (n = 17); and the NTM group, consisting of patients with pulmonary infection caused by NTM other than MABSC (n = 26). Patients were previously treated with a regimen of rifampin, isoniazid, pyrazinamide, and ethambutol before the diagnosis of NTM was confirmed by two culture-positive sputum samples. The nucleotide sequences of the hsp65, 16S rRNA, and/or rpoB genes were analyzed to identify the mycobacteria. Data were collected on demographic, clinical, and radiological characteristics, as well as on treatment responses and outcomes. Results: Loss of appetite was the only clinical manifestation that was significantly more common in the MABSC group than in the NTM group (p = 0.0306). The chance of having to use a second treatment regimen was almost 12 times higher in the MABSC group than in the NTM group. Treatment success was significantly higher in the NTM group than in the MABSC group (83.2% vs. 17.6%; p < 0.0001). The chance of recurrence was approximately 37 times higher in the MABSC group than in the NTM group. Conclusions: In the study sample, treatment response of pulmonary disease caused by MABSC was less favorable than that of pulmonary disease caused by other NTM.

RESUMO Objetivo: Descrever as manifestações clínicas de pacientes com infecção pulmonar por micobactérias do complexo Mycobacterium abscessus (CMA) e compará-las com as daqueles infectados com outras micobactérias não tuberculosas (MNT). Métodos: Estudo de coorte retrospectivo envolvendo 43 pacientes divididos em dois grupos: grupo CMA, com pacientes com infecção pulmonar por CMA (n = 17); e grupo MNT, com pacientes com infecção pulmonar por MNT que não CMA (n = 26). Os pacientes foram previamente tratados com o esquema rifampicina, isoniazida, pirazinamida e etambutol antes de o diagnóstico de MNT ser confirmado com culturas positivas em duas amostras de escarro diferentes. As sequências nucleotídicas dos genes hsp65, RNAr 16S e/ou rpoB foram analisadas para a identificação das micobactérias. Foram coletadas características demográficas, clínicas e radiológicas, assim como respostas terapêuticas e desfechos. Resultados: A única manifestação clínica significativamente mais frequente no grupo CMA que no grupo MNT foi hiporexia (p = 0,0306). A chance de haver a necessidade de utilização de um segundo esquema terapêutico foi quase 12 vezes maior no grupo CMA que no grupo MNT. O sucesso terapêutico foi significativamente maior no grupo MNT que no grupo CMA (83,2% vs. 17,6%; p < 0,0001). A chance de recidiva no grupo CMA foi aproximadamente 37 vezes maior que no grupo MNT. Conclusões: Na amostra estudada, a resposta terapêutica da doença pulmonar causada por CMA evoluiu de forma menos favorável do que naquela causada pelas demais MNT.

Comparación y evaluación de métodos cuantitativos para determinar la susceptibilidad antimicrobiana de cepas del complejo Mycobacterium abscessus / Comparison and Evaluation of Quantitative Methods for Determining Antimicrobial Susceptibility of Complex Mycobacterium Abscessus Strains / Comparação e avaliação de métodos quantitativos para determinar a susceptibilidade antimicrobiana de cepas do complexo Mycobacterium abscessos

Resumen Introducción: el complejo Mycobacterium abscessus incluye especies patógenas emergentes multirresistentes, lo cual limita las opciones terapéuticas para tratar las infecciones causadas por dichos microorganismos. En este estudio se compararon las concentraciones inhibitorias mínimas (CIM) obtenidas mediante dos métodos cuantitativos, se establecieron los puntos de corte empleados en el micrométodo colorimétrico (MMC) y se evaluó la susceptibilidad antimicrobiana. Materiales y métodos: la CIM de nueve antibióticos fue determinada mediante el MMC y la microdilución en caldo (MDC) para 19 cepas del complejo M. abscessus. El test F de Snedecor se utilizó para establecer la diferencia significativa de las CIM entre los dos métodos y se determinaron los puntos de corte mediante la técnica de distribución de la probabilidad para el MMC. Resultados: se encontró una correlación de los resultados de la CIM del 50% entre MMC y MDC para los antibióticos ensayados. Probablemente esta discrepancia en los resultados se deba a diferencias en algunos parámetros técnicos de cada procedimiento. Todas las cepas fueron sensibles a la amikacina y resistentes a meropenem y ampicilina-sulbactam. Independientemente de la especie del complejo M. abscessus, las fluoroquinolonas mostraron una baja actividad inhibitoria (0-25%) sobre los aislados clínicos, resultados que son similares a los reportados por otros autores. Conclusión: Los patrones de multirresistencia observados en las cepas analizadas sugieren la necesidad de utilizar las pruebas de susceptibilidad como herramientas que permitan orientar y optimizar las conductas terapéuticas en infecciones producidas por M. abscessus.

Abstract Introduction: The Mycobacterium abscessus complex includes multidrug resistant emerging pathogens, which limit therapeutic options for treating infections caused by these microorganisms. In this study, the minimum inhibitory concentrations (MICS) obtained by 2 quantitative methods were compared, the cut-off points used in the colorimetric micromethod (CMM) were established and the antimicrobial susceptibility was evaluated. Materials and Methods: The MIC for nine antibiotics was determined by CMM and broth microdilution (BMD) for 19 strains of M. abscessus complex. The Snedecor F test was used to establish the significant difference in the CIM between the methods, cutoff points were determined by the probability distribution method for the CMM. Discussion: A correlation of 50% between CMM and BMD for antibiotics tested was found. Probably, this discrepancy in the results is due to differences in some technical parameters of each procedure. All strains were susceptible to amikacin and were resistant to meropenem and ampicillin-sulbactam. Independently of the species of M. abscessus complex, fluoroquinolones showed a low inhibitory activity (0-25%) on clinical isolates, results that are similar to those reported by other authors. Conclussion: The Multidrug resistance patterns observed in the strains tested suggest the need for susceptibility testing as tools to guide and optimize the therapeutic behavior in infections caused by M. abscessus.

Resumo Introdução: o complexo Mycobacterium abscessus inclui espécies patógenas emergentes multirresistentes, o qual limita as opções terapêuticas para tratar as infeções causadas por estes microrganismos. Neste estudo compararam-se as concentrações inibitórias mínimas (CIMS) obtidas mediante 2 métodos quantitativos, se estabeleceram os pontos de corte empregados no micrométodo colorimétrico (MMC) e se avaliou a susceptibilidade antimicrobiana. Materiais e métodos: a CIM de 9 antibióticos foi determinada mediante o MMC e microdiluição em caldo (MDC) para 19 cepas do complexo M. abscessus. O teste F de Snedecor utilizou-se para estabelecer a diferença significativa das CIMS entre os dois métodos e determinaram-se os pontos de corte mediante a técnica de distribuição da probabilidade para o MMC. Resultados: se encontrou uma correlação dos resultados da CIM do 50% entre MMC e MDC para os antibióticos testados. Provavelmente, esta discrepância nos resultados se deve a diferenças em alguns parâmetros técnicos de cada procedimento. Todas as cepas foram sensíveis à amikacina e resistentes a meropenem e ampicilina-sulbactam. Independentemente da espécie do complexo M. abscessos, as fluoroquinolonas mostraram uma baixa atividade inibitória (0-25%) sobre os isolados clínicos, resultados que são similares aos reportados por outros autores. Conclussão: Os patrões de multirresistência observados nas cepas analisadas, sugerem a necessidade de utilizar as provas de susceptibilidade como ferramentas que permitam orientar e otimizar as condutas terapêuticas em infeções produzidas por M. abscessus.

Enfermedad pulmonar causada por complejo Mycobacterium avium y M. abscessus / Pulmonary disease caused by Mycobacterium avium complex and M. abscessus

Resumen Introducción: después del complejo Mycobacterium tuberculosis, las principales especies de micobacterias causando enfermedad pulmonar son el complejo Mycobacterium avium (MAC) y Mycobacterium abscessus, el tratamiento es prolongado, presentan un amplio perfil de resistencia y algunas veces es necesaria la resección quirúrgica del tejido, dificultando la curación de algunos casos. Objetivo: realizar un análisis de los casos a los que se les aisló de muestras pulmonares MAC y M. abscessus en el periodo de 2012-2014 en el Laboratorio Nacional de Referencia de Colombia. Material y métodos: se realizó un estudio de serie de casos de 42 personas a las que se les aisló de muestras pulmonares MAC y M. abscessus, los cuales fueron identificados mediante pruebas fenotípicas y genotípicas. La fuente de información fue el Formato Único de Vigilancia de las Micobacterias que se recibe con cada uno de los aislados que llegan al INS. Se analizaron las variables edad, sexo, tipo de muestra y presencia de factores de riesgo. Resultados: en 32 de los casos se identificó MAC y en 10 M. abscessus como agente etiológico causante de enfermedad pulmonar, 26 (61.9%) de los casos tenían entre 51 y 86 años. Los principales factores de riesgo fueron: antecedente de tratamiento antituberculosis 16 (38.1%) y persona con VIH 7 (16.7%) y sin factor de riesgo 9 (21.2%) casos. Discusión: este trabajo reporta como agente etiológico MAC y M. abscessus en personas mayores de 50 años sin factores de riesgo, con antecedentes de tuberculosis, indicando que se debe fortalecer la realización de cultivo e identificación de especie en éstas para que tengan un adecuado diagnóstico y tratamiento.

Abstract Introduction: after the Mycobacterium tuberculosis complex, the main species of mycobacteria causing lung disease are Mycobacterium avium complex and Mycobacterium abscessus. The treatment is prolonged; they present a broad resistance profile and sometimes the surgical resection of the tissue is necessary, making healing difficult in some cases. Objective: to perform an analysis of the cases to which MAC and M. abscessus were isolated from pulmonary samples in the period from 2012 to 2014 in the National Reference Laboratory of Colombia. Materials and Methods: a case series study of 42 individuals to whom Mac and M. abcessus were isolated from pulmonary samples that were identified by phenotypic and genotypic tests, was carried out. The source of information was the unique format of surveillance of mycobacteria that is received with each of the isolates that come to the National Health Institute. The variables age, sex, type of sample and presence of risk factors were analyzed. Results: in 32 patients MAC was identified as etiological agent causing pulmonary disease and in 10 cases, M. abscessus was the agent. 26 (61.9%) of the patients were between 51 and 86 years of age. The main risk factors were: antecedent of anti-tuberculosis treatment in16 (38.1%),7 with HIV (16.7%) and without risk factor 9 cases (21.2%).

Infección de región parotídea por Mycobacterium abscessus / Mycobacterium abscessus infection of the parotid region

Mycobacterium abscessus es una de las micobacterias de crecimiento rápido asociadas a infecciones localizadas de heridas post traumáticas y quirúrgicas, infecciones crónicas pulmonares e infecciones cutáneas diseminadas en pacientes inmunosuprimidos. Raramente han sido descritos infecciones en región parotídea por micobacterias de crecimiento rápido. Aquí se reporta el caso de una infección en lóbulo superficial de la glándula parótida de pacientesin compromiso inmune, sin cirugías previas ni traumas aparentes, causado por Mycobacterium abscessus. Estas micobacterias deben ser consideradas en el momento de realizar el diagnóstico tanto clínico como laboratorial, ya que son bacterias emergentes y pueden presentarse de manera inusual, de modo a no demorar el diagnóstico del agente etiológico, debido a que requieren prolongada antibioticoterapia y son bastante resistentes a los antibióticos, especialmente el M. abscessus, que es una de las más resistentes

Mycobacterium abscessus is one of the fast-growing mycobacteria associated to localized infections of post-traumatic injuries, surgical wounds, pulmonary chronic infections and disseminated cutaneous infections in immunosupressed patients. Fast-growing mycobacteria infections of the parotid region have been rarely described. We report the case of a Mycobacterium abscessus infection of the superficial lobe of the parotid gland without immune compromise, previous surgeries or apparent trauma. Thesemycobacteria should be considered at the time of clinical and laboratory diagnosis, as they are emerging bacteria and could present in an unusual manner, in order not to delay the diagnosis of the etiological agent because they require long antibiotic therapy and are pretty resistant to antibiotics specially M. abscessus which is one of the most resistant