Macrolides decreased infectious exacerbations in non-cystic fibrosis bronchiectasis

The use of azithromycin or erythromycin resulted in a decrease in infectious pulmonary exacerbations among patients with non-cystic fibrosis bronchiectasis, data from two studies suggest.

In the first study, 83 patients enrolled in the Bronchiectasis and Long-term Azithromycin Treatment (BAT) study were randomly assigned to 250 mg daily azithromycin or placebo for 12 months. The study took place from April 2008 to September 2010 in 14 hospitals in the Netherlands.

The median number of exacerbations in the azithromycin group was zero vs. two in the placebo group. Among all of the patients, 32 of those who received placebo and 20 of those who received azithromycin had at least one exacerbation. In an analysis of the forced expiratory volume in the first second of expiration over time, there was an increase of 1.03% per 3 months in the azithromycin groups and a decrease of 0.1% in the placebo group.

“Azithromycin maintenance therapy is very effective in reducing infections and has a positive effect on quality of life and lung function,” Josje Altenburg, MD, of the department of pulmonary diseases at Medical Centre Alkmaar in the Netherlands, told Infectious Disease News. “Patients with non-cystic fibrosis bronchiectasis who have three or more exacerbations yearlight might now be considered for long-term, low-dose macrolide therapy. However, additional antibiotic resistance in the treatment group warrants too widespread use of this treatment regimen. It should be confined to those with three or more infectious exacerbations yearly.”

Josje Altenburg

In the second study, 117 patients were randomly assigned to 400 mg twice-daily erythromycin or placebo for 12 months. The study took place from October 2008 to December 2011 at one hospital in Australia. All of the adult patients had experienced at least two or more infective exacerbations in the preceding year.

The number of pulmonary exacerbations was reduced significantly overall, with a mean of 1.29 per patient per year compared with 1.97 per patient per year in the placebo group. There also was a lower incidence of exacerbation in a subgroup of patients with Pseudomonas aeruginosa airway infection at baseline. Erythromycin also reduced the 24-hour sputum production and the attenuated lung function decline.

“Low-dose erythromycin significantly improved clinical outcomes in bronchiectasis, however, this is at the expense of significant increases in macrolide resistance in commensal oropharyngeal bacterial flora,” David Serisier, MBBS, DM, FRACP, of Mater Health Services and the University of Queensland in South Brisbane, Australia, told Infectious Disease News. “Clinicians should therefore think carefully before prescribing macrolides, which should be restricted to subsets of patients to protect against increases in macrolide-resistant bacteria.”

David Serisier

In an accompanying editorial, J. Stuart Elborn, MD, and Michael M. Tunney, PhD, of Queen’s University Belfast in the United Kingdom, wrote that it is important for physicians to determine which patients with bronchiectasis should be prescribed a macrolide and which macrolide to use.

“Erythromycin and azithromycin are both effective for reducing exacerbations and have similar effects on antimicrobial resistance,” they wrote. “The effect of long-term macrolide use on antibiotic resistance in these patients is not clear, but we should dissuade clinicians from prescribing macrolides for patients whose clinical characteristics differ from those for whom a positive effect was seen in these studies.”

For more information:

Altenburg J. JAMA. 2013;309:1251-1259.

Elborn J. JAMA. 2013;309:1295-1296.

Serisier D. JAMA. 2013;309:1260-1267.

Disclosure: The researchers and Elborn and Tunney report no relevant disclosures.