Protective effects of simvastatin on coronary artery function in swine with acute infection

BACKGROUND

The risk for coronary events may rise during acute infection. Perturbation in coronary endothelial function emerges as one important link. We investigated whether simvastatin could protect the coronary arterial function from the adverse effects of acute infection in swine.

METHODS

Coronary endothelium-dependent and -independent vasomotor responses were assessed by Doppler velocimetry in 12 Chlamydia pneumoniae-infected and 6 sham-infected swine 2 weeks after intratracheal inoculation. Half of animals from the infection group were pre-treated with simvastatin (80 mg daily), while the remaining animals received placebo. The treatment was started 2 weeks prior to inoculation and continued until the end of the study. ANOVA was used for statistical calculations. Data are mean+/-S.D.

RESULTS

All animals inoculated with C. pneumoniae developed IgM antibodies against this organism. As compared to noninfected animals, peak-to-baseline coronary flow velocity (CFV) ratio after bradykinin was significantly decreased in infected animals regardless of statin treatment (p=0.01). Intracoronary 10(-6) M acetylcholine caused slight dilatory responses in both noninfected and infected-treated animals (CFV ratio: 1.6+/-0.2 and 1.4+/-0.2, respectively; p>0.1), while a velocity drop (CFV ratio: 0.7+/-0.1; p<0.01 versus noninfected-infected and treated), indicating constriction, was observed in infected-nontreated animals; 10(-5) M acetylcholine caused vasoconstriction in all animals, with a significantly more prolonged response in the infected-nontreated group (p<0.01). Intracoronary adenosine and SNP induced similar dilatory responses in all groups (p>0.5). There were no differences in markers of systemic inflammation (fibrinogen, amyloid, and CRP) and lipid profile (HDL, LDL and total cholesterol) between the groups (p>0.2).

CONCLUSION

Acute infection is associated with impairment of the muscarinic and kinin-related reactivity of coronary circulation. These functional abnormalities are in part prevented by simvastatin through mechanisms unrelated to lipid lowering.

Feline ocular chlamydiosis: clinical and microbiological effects of topical and systemic therapy

Conjunctival swabs taken from a two-month-old kitten showing ocular discharge were found to be positive for Chlamydophila felis by PCR and isolation. The cat was treated with topical 1% tetracycline ophthalmic ointment twice a day for 60 days. At the end of the treatment, the cat showed no ocular signs and conjunctival swabs resulted PCR and isolation negative for C. felis. Forty days later, the ocular discharge recurred and C. felis was isolated from conjunctival swabs taken from both the cat's eyes. Twenty days of doxycycline systemic treatment at 10 mg/kg once daily was started. The treatment resulted in a complete clinical recovery after a few days. C. felis was not isolated or amplified on the 10th day after beginning the treatment. The cat's conjunctival swabs were also PCR and isolation negative on the 10th, 30th, 60th, 90th, 120th and 240th days after the end of therapy.

The Relationship between chlamydia trachomatis and chlamydia pneumoniae as the cause of neonatal conjunctivitis (ophthalmia neonatorum)

The authors examined 130 newborns and nursery children from September 1999 till May 2003 from the Prague district for the surmise of chlamydial conjunctivitis. Chlamydia infections were detected in conjunctival smears. Chlamydia trachomatis was confirmed in 20 (15.3%) using ligase chain reaction and C. pneumoniae in 16 (12.3%) children using an indirect immunofluorescent method. Direct captures of chlamydial infections of newborns were included in the study. The authors had also examined 671 newborns in a maternity hospital from January 2002 till May 2003. Conjunctival scraping had been done in 29 (4.3%) cases mainly for mucopurulent conjunctivitis. Chlamydial conjunctivitis was identified only in 4 (0.6%) cases, i.e. C. trachomatis and C. pneumoniae in 2 cases each. Initial clinical symptoms of both types of chlamydial conjunctivitis were similar (mucous discharge with various degrees of eyelid effusion and chemosis mainly on the tarsal conjunctiva). Clinical symptoms of the C. pneumoniae infection were later accompanied by pseudofollicular changes on the tarsal conjunctiva. The complication of this infection was lacrimal obstruction among half of newborns. Clarithromycin in syrup at a dose of 15 mg/kg/per day for 14 days ensured effective treatment of both chlamydial infections. Control scrapings were always negative and simultaneously the pathological conjunctival finding disappeared.

Azithromycin reduces Chlamydia pneumoniae-induced attenuation of eNOS and cGMP production by endothelial cells

BACKGROUND

Intracellular infections with cytomegalovirus (CMV) or Chlamydia pneumoniae (Cp) may play a role in the aetiology of atherosclerosis. Nitric oxide (NO) is a key regulator of endothelial function. Under pathological conditions uncoupling of endothelial nitric oxide synthase (eNOS) leads to vessel damage as a result of production of oxygen radicals instead of NO. We hypothesized that infection-induced atherosclerosis is initiated by changes in NO metabolism and may be reversed by azithromycin treatment.

METHODS

Confluent human umbilical vein endothelial cells (HUVECs) were infected with Cp or CMV. After 48 h of infection, production of eNOS, cyclic guanosine monophosphate (cGMP) and reactive oxygen species (ROS) was measured. Detection of cGMP was used as a reporter assay for the bioavailability of NO. Subsequently, Cp- and CMV-infected HUVECs were coincubated with 0.016 mg L(-1) and 1 mg L(-1) azithromycin.

RESULTS

Infection with Cp (MOI 1 and MOI 0.1) and CMV (MOI 1) caused a dose- and time-dependent reduction of eNOS production in the HUVECs: Cp MOI 1: 1141 +/- 74 pg mL(-1) (P < 0.01); Cp MOI 0.1: 3189 +/- 30 pg mL(-1) (P < 0.01); CMV: 3213 +/- 11 pg mL(-1) (P < 0.01) vs. 3868 +/- 83 pg mL(-1) for uninfected HUVECs. Chlamydia pneumoniae- but not CMV-infection also reduced cGMP-production (Cp: 0.195 +/- 0.030 pmol mL(-1) (P < 0.01); CMV: 0.371 +/- 27 pmol mL(-1) (P > 0.05) vs. 0.378 +/- 0.019 pmol mL(-1) for uninfected HUVECs). CMV-infection did not affect ROS production either, but Cp-infection reduced ROS-production by 21% (P > 0.05; Cp MOI 0.1) to 68% (P < 0.01; Cp MOI 1). Azithromycin treatment restored Cp-induced eNOS, cGMP and ROS production in a dose-dependent manner.

CONCLUSIONS

Infection with Cp in endothelial cells in vitro attenuates eNOS, cGMP and ROS production in HUVECs and azithromycin reverses Cp-induced effects on eNOS, cGMP and ROS-production. The results from our in vitro research support the role of antibiotic therapy for infection-induced atherosclerosis by indicating that azithromycin does actually improve endothelial function.

Chlamydia pneumoniae uses the mannose 6-phosphate/insulin-like growth factor 2 receptor for infection of endothelial cells

Several mechanisms for attachment and entry of Chlamydia have been proposed. We previously determined that the major outer membrane protein of Chlamydia trachomatis is glycosylated with a high-mannose oligosaccharide, and a similar structure inhibited the attachment and infectivity of C. trachomatis in epithelial cells. Because insulin-like growth factor 2 (IGF2) was shown to enhance the infectivity of Chlamydia pneumoniae but not C. trachomatis in endothelial cells, a hapten inhibition assay was used to analyze whether the mannose 6-phosphate (M6P)/IGF2 receptor that also binds M6P could be involved in infection of endothelial cells (HMEC-1) by Chlamydia. M6P and mannose 6-phosphate-poly[N-(2-hydroxyethyl)-acrylamide] (M6P-PAA) inhibited the infectivity of C. pneumoniae AR-39, but not C. trachomatis serovar UW5 or L2, while mannan inhibited the growth of C. trachomatis, but not C. pneumoniae. Using metabolically labeled organisms incubated with cells at 4 degrees C (organisms attach but do not enter) or at 37 degrees C (organisms attach and are internalized), M6P-PAA was shown to inhibit attachment and internalization of C. pneumoniae in endothelial cells but did not inhibit attachment or internalization of C. trachomatis serovar E or L2. These findings indicate that C. pneumoniae can utilize the M6P/IGF2 receptor and that the use of this receptor for attachment and entry differs between C. pneumoniae and C. trachomatis.

Chlamydophila pneumoniae respiratory tract infection aggravates therapy refractory bronchitis or pneumonia in childhood

BACKGROUND

Chlamydophila pneumoniae was frequently found in bronchial secretions of children with therapy-refractory bronchitis or pneumonia. It was studied, how the agent modifies the course of disease and what findings are associated with the infection.

PATIENTS AND METHODS

Bronchial secretions obtained at bronchoscopy of 428 children were studied for C. pneumoniae infection using polymerase chain reaction with enzyme immunoassay detection. Children tested negative and positive were compared for their clinical findings.

RESULTS

C. pneumoniae was found in 143 children (33 %). A C. pneumoniae infection has been found to be associated with a purulent bronchial inflammation (90/143 vs. 144/285, p = 0.02), a Streptococcus pneumoniae co-infection (13/143 vs. 6/285, p = 0.002) and a restrictive disturbance (11/51 vs. 8/93, p = 0.04). Purulent inflammation (Odds ratio 7.9; 95 % confidence interval [CI] 1.6-39.3), 2 co-infections (Odds ratio 14.3; 95 % CI 1.4-144.4) and co-infection with M. pneumoniae (4/4 versus 9/26, p = 0.03; Mantel Haentzel 3.0; 95 % CI 1.1-8.0) were identified as factors more often associated with a restrictive disturbance in children with bronchial C. pneumoniae infection. An adequate antibiotic therapy improved pulmonary function. No association was found for wheezing, eosinophil inflammation of the nasal mucosa, alpha-1 antitrypsin or immunoglobulin deficiency in serum, level of secretory IgA in bronchial mucus, pathological lung scintigram, gastro-esophageal reflux disease, sweat test and other co-infections.

CONCLUSIONS

In children with therapy-refractory bronchitis or pneumonia bronchial C. pneumoniae infection was associated with a more severe disease in case of several, mostly bacterial co-infections. Adequate antibiotic therapy for C. pneumoniae infection has been demonstrated to improve pulmonary function.

Chlamydia conjunctivitis and central retinal vein occlusion

PURPOSE

To report a case of coexistent Chlamydia conjunctivitis and central retinal vein occlusion (CRVO) in which both problems improved significantly after oral doxycyline.

DESIGN

Interventional case report.

METHODS

A healthy 39-year-old man presented with follicular and papillary conjunctivitis, unresponsive to topical antibiotic therapy, and a CRVO. The patient had serum IgG titers of 1:256 to both Chlamydia pneumonia and Chlamydia trachomatous.

RESULTS

Treatment with oral doxycyline (100 mg orally twice daily for 2 weeks) resulted in complete resolution of the conjunctivitis and rapid improvement of the CRVO.

CONCLUSIONS

Because of its ability to cause chronic vascular endothelial infection and localized inflammation, Chlamydia has been implicated in the development of arterial vascular disease. The positive Chlamydia serology, conjunctivitis, CRVO, and excellent response to doxycycline in this patient suggest that Chlamydia may have contributed to his vascular occlusion. Further studies investigating a possible association between Chlamydia and CRVO may be indicated.

Use of quantitative real-time PCR to monitor the response of Chlamydophila felis infection to doxycycline treatment

Fifteen cats infected with Chlamydophila felis were monitored for the presence of C. felis DNA on ocular swabs by using real-time PCR and for clinical signs of disease. The cats were assigned to three groups: oral doxycycline at 10 mg/kg of body weight/day for 7 days (six cats), oral doxycycline at 10 mg/kg/day for 14 days (five cats), and an untreated control group (four cats). The untreated cats remained positive for C. felis throughout the trial; clinical signs were most severe on days 14 to 21 postinfection, and then they declined. Treatment with 7 and 14 days of doxycycline decreased C. felis relative copy numbers and clinical signs rapidly. C. felis became undetectable in some of the cats during or after treatment. However, after the cessation of treatment, a recurrence of high relative copy numbers of C. felis and severe clinical signs in all cats was seen. Rescue treatment with 21 days of doxycycline was successful at eliminating infection in eight of the cats; a further 28 days of doxycycline was required to eliminate infection in the remaining three cats. It was concluded that 7, 14, and, in some cases, 21 days of treatment with oral doxycycline will not eliminate C. felis infection. At least 28 days of treatment with doxycycline is required to ensure elimination of the organism. Real-time PCR is a sensitive technique for monitoring C. felis infection and the response to antibiotic treatment.

Effects of antibiotic therapy on outcomes of patients with coronary artery disease: a meta-analysis of randomized controlled trials

CONTEXT

Although Chlamydia pneumoniae infection has been associated with the initiation and progression of atherosclerosis, results of clinical trials investigating antichlamydial antibiotics as adjuncts to standard therapy in patients with coronary artery disease (CAD) have been inconsistent.

OBJECTIVE

To conduct a meta-analysis of clinical trials of antichlamydial antibiotic therapy in patients with CAD.

DATA SOURCES

The MEDLINE and Cochrane Central Register of Controlled Trials databases were searched from 1966 to April 2005 for English-language trials of antibiotic therapy in patients with CAD. Bibliographies of retrieved articles were searched for further studies. Presentations at major scientific meetings (2003-2004) were also reviewed. Search terms included antibacterial agents, myocardial infarction, unstable angina, and coronary arteriosclerosis.

STUDY SELECTION

Eligible studies were prospective, randomized, placebo-controlled trials of antichlamydial antibiotic therapy in patients with CAD that reported all-cause mortality, myocardial infarction, or unstable angina. Of the 110 potentially relevant articles identified, 11 reports enrolling 19,217 patients were included.

DATA EXTRACTION

Included studies were reviewed to determine the number of patients randomized, mean duration of follow-up, and end points. End points of interest included all-cause mortality, myocardial infarction (MI), and a combined end point of MI and unstable angina.

DATA SYNTHESIS

Event rates were combined using a random-effects model. Antibiotic therapy had no impact on all-cause mortality among treated vs untreated patients (4.7% vs 4.6%; odds ratio [OR], 1.02; 95% confidence interval [CI], 0.89-1.16; P = .83), on the rates of MI (5.0% vs 5.4%; OR, 0.92; 95% CI, 0.81-1.04; P = .19), or on the combined end point of MI and unstable angina (9.2% vs 9.6%; OR, 0.91; 95% CI, 0.76-1.07; P = .25).

CONCLUSION

Evidence available to date does not demonstrate an overall benefit of antibiotic therapy in reducing mortality or cardiovascular events in patients with CAD.

Secondary prevention of atherosclerosis through chlamydia pneumoniae eradication (SPACE Trial): a randomised clinical trial in patients with peripheral arterial disease

BACKGROUND

Sero-epidemiological and experimental studies suggest that Chlamydia pneumoniae infections play an important role in the development of atherosclerosis. Clinical trials have shown contradictory results regarding the efficacy of antibiotics to prevent atherosclerosis-related complications in patients with coronary artery disease. Our aim was to study the effect of a short course of azithromycin on the incidence of cardiovascular events and peripheral vascular function in patients with stable peripheral arterial disease (PAD).

PATIENTS AND METHODS

Five hundred and nine PAD-patients were randomised to receive either a 3-day course of azithromycin (500 mg daily) or placebo, with 2 years of follow-up. C. pneumoniae serology was determined at baseline. Clinical endpoints were death, coronary events (myocardial infarction, unstable angina, and/or coronary revascularization procedures), cerebral events (stroke, TIA, and/or carotid endarterectomy) and peripheral arterial complications (increased PAD-symptoms with decreased ankle-brachial index (ABPI, 0.1-point decrease after 12 months), and/or peripheral revascularization procedures).

RESULTS

Five hundred and nine patients (160 women) with an atherosclerotic risk factor profile were randomised, 257 patients to azithromycin and 252 to placebo. Four hundred and forty nine patients (88%) had intermittent claudication and 60 (12%) had critical limb ischemia. By 24-month follow up, 182 patients (36%) developed 252 complications (45 deaths, 34 coronary events, 34 cerebral events and 139 peripheral arterial complications). C. pneumoniae IgA-titres were associated with the development of cardiovascular events. Nevertheless, the number of complications (131 in the azithromycin group vs. 121 in the placebo group) and the number of patients that developed complications (98 (38%) in the azithromycin vs. 84 (33%) in the placebo group) was comparable in both treatment groups. Life table analysis showed no effect of azithromycin on survival or ABPI.

CONCLUSION

A short-term course of azithromycin offers no benefits for survival or ankle pressure in PAD-patients.

Role of atypical bacteria and azithromycin therapy for children with recurrent respiratory tract infections

BACKGROUND

The aim of this study of 352 patients, 1-14 years of age, with acute respiratory infections and a history of recurrent respiratory tract infections (RRTIs), and 208 healthy subjects was to evaluate whether Mycoplasma pneumoniae and Chlamydia pneumoniae played a role in causing acute respiratory episodes among children with RRTIs and whether specific antibiotic treatment for these bacteria could improve the acute episodes and reduce recurrences.

METHODS

The patients were blindly randomized to receive azithromycin (10 mg/kg/d for 3 days weekly, for 3 weeks) together with symptom-specific agents or symptom-specific agents alone. Acute M. pneumoniae and/or C. pneumoniae infection was diagnosed if the child had a significant antibody response in paired sera and/or if the DNA of the bacteria was detected in nasopharyngeal aspirates.

RESULTS

Atypical bacterial infections were identified for 190 patients (54.0%) and 8 healthy control subjects (3.8%; P < 0.0001). Short term (1-month) clinical success was significantly more frequent among the patients who had received azithromycin together with symptom-specific agents than among those who had received symptom-specific agents alone, but the difference was significant only for the group of patients with atypical bacteria. In contrast, long term (6-month) clinical success was significantly more frequent among the patients who had received azithromycin in addition to symptom-specific agents, regardless of whether they experienced infections with atypical bacteria or other pathogens, although positive outcomes were significantly more frequent among those with atypical bacteria.

CONCLUSIONS

Atypical bacteria seem to play a role among children with RRTIs, and prolonged azithromycin therapy can significantly improve the acute episodes and reduce the risk of recurrences.

Toll-like receptors 2 and 4 do not contribute to clearance of Chlamydophila pneumoniae in mice, but are necessary for the release of monokines

Activation of immune cells by Chlamydophila pneumoniae in vitro has been shown to be toll-like receptor (TLR2)-dependent, but TLR4 is also involved to a minor extent. To investigate the role of TLR2 and TLR4 in vivo, a murine model of C. pneumoniae infection was established. Mice were infected intranasally with a low inoculum of 106 C. pneumoniae elementary bodies (EB) and spreading of bacteria was monitored by real-time PCR. The bronchoalveolar lavage (BAL) showed maximal bacterial load on the day of infection and the lung 2 days later. By day 95, C. pneumoniae were eradicated completely. In serum, anti-C. pneumoniae IgG became detectable on day 18 by microimmunofluorescence test. The course of infection was mild with no apparent symptoms, lack of acute phase response and no induction of tumor necrosis factor-alpha and interleukin-6 in BAL, lung supernatants or blood. Infection of TLR2-/- and C3H/HeJ mice revealed no differences in clearance of bacteria and serological responses compared to wild-type controls, even if a dose of 10(7) EB was used. Intracellular replication of C. pneumoniae in the lungs was proven by the efficacy of antibiotic treatment. These findings indicate that in vivo TLR2 and TLR4 are not important for the development of antibodies and elimination of C. pneumoniae.

Antibiotic treatment of Chlamydia pneumoniae after acute coronary syndrome

BACKGROUND

Chlamydia pneumoniae has been found within atherosclerotic plaques, and elevated titers of antibody to this organism have been linked to a higher risk of coronary events. Pilot studies have suggested that antibiotic treatment may reduce the risk of cardiovascular events.

METHODS

We enrolled 4162 patients who had been hospitalized for an acute coronary syndrome within the preceding 10 days and evaluated the efficacy of long-term treatment with gatifloxacin, a bactericidal antibiotic known to be effective against C. pneumoniae, in a double-blind, randomized, placebo-controlled trial. Subjects received 400 mg of gatifloxacin daily during an initial 2-week course of therapy that began 2 weeks after randomization, followed by a 10-day course every month for the duration of the trial (mean duration, 2 years), or placebo. The primary end point was a composite of death from all causes, myocardial infarction, documented unstable angina requiring rehospitalization, revascularization (performed at least 30 days after randomization), and stroke.

RESULTS

A Kaplan-Meier analysis revealed that the rates of primary-end-point events at two years were 23.7 percent in the gatifloxacin group and 25.1 percent in the placebo group (hazard ratio, 0.95; 95 percent confidence interval, 0.84 to 1.08; P=0.41). No benefit was seen in any of the prespecified secondary end points or in any of the prespecified subgroups, including patients with elevated titers to C. pneumoniae or C-reactive protein.

CONCLUSIONS

Despite long-term treatment with a bactericidal antibiotic effective against C. pneumoniae, no reduction in the rate of cardiovascular events was observed.

Azithromycin for the secondary prevention of coronary events

BACKGROUND

Epidemiologic, laboratory, animal, and clinical studies suggest that there is an association between Chlamydia pneumoniae infection and atherogenesis. We evaluated the efficacy of one year of azithromycin treatment for the secondary prevention of coronary events.

METHODS

In this randomized, prospective trial, we assigned 4012 patients with documented stable coronary artery disease to receive either 600 mg of azithromycin or placebo weekly for one year. The participants were followed for a mean of 3.9 years at 28 clinical centers throughout the United States.

RESULTS

The primary end point, a composite of death due to coronary heart disease, nonfatal myocardial infarction, coronary revascularization, or hospitalization for unstable angina, occurred in 446 of the participants who had been randomly assigned to receive azithromycin and 449 of those who had been randomly assigned to receive placebo. There was no significant risk reduction in the azithromycin group as compared with the placebo group with regard to the primary end point (risk reduction, 1 percent [95 percent confidence interval, -13 to 13 percent]). There were also no significant risk reductions with regard to any of the components of the primary end point, death from any cause, or stroke. The results did not differ when the participants were stratified according to sex, age, smoking status, presence or absence of diabetes mellitus, or C. pneumoniae serologic status at baseline.

CONCLUSIONS

A one-year course of weekly azithromycin did not alter the risk of cardiac events among patients with stable coronary artery disease.

Antibiotics for the secondary prevention of ischemic heart disease: a meta-analysis of randomized controlled trials

BACKGROUND

Infections have been suspected in the pathogenesis of ischemic heart disease (IHD) for more than 100 years. Chlamydia pneumoniae has been identified in atherosclerotic specimens, and in some studies antibody titers to C pneumoniae have been related to the risk of myocardial infarction. The numerous clinical trials that have studied the use of antibiotics in the secondary prevention of IHD have had conflicting results.

METHODS

This study is a meta-analysis of the published randomized controlled trials on the secondary prevention of IHD with antibiotics. Studies included in the analysis were limited to those studies that used antibiotics effective against C pneumoniae, enrolled patients with known IHD, and examined clinical outcomes related to IHD. Inclusion in the analysis was limited to well-designed randomized controlled trials that met inclusion criteria established by an expert panel.

RESULTS

Nine published studies, with a total of 11 015 participants, were identified that met the criteria for this meta-analysis. Four of the studies reported a benefit from antibiotics, whereas 5 found no effect. A funnel plot of the published studies did not suggest the existence of other unpublished data. The combined effect found no benefit from antibiotics in the prevention of cardiovascular events in subjects with known IHD (relative risk, 0.94 [95% confidence interval, 0.86-1.03]) or mortality (relative risk, 0.94 [95% confidence interval, 0.79-1.12]).

CONCLUSION

In patients with known IHD, macrolide antibiotics for C pneumoniae did not result in a statistically significant reduction in recurrent cardiac events or mortality over 3 months to 3 years.

Atypical pathogens and respiratory tract infections

The atypical respiratory pathogens Chlamydia pneumoniae, Mycoplasma pneumoniae and Legionella pneumophila are now recognised as a significant cause of acute respiratory-tract infections, implicated in community-acquired pneumonia, acute exacerbations of chronic bronchitis, asthma, and less frequently, upper respiratory-tract infections. Chronic infection with C. pneumoniae is common among patients with chronic obstructive pulmonary disease and may also play a role in the natural history of asthma, including exacerbations. The lack of a gold standard for diagnosis of these pathogens still handicaps the current understanding of their true prevalence and role in the pathogenesis of acute and chronic respiratory infections. While molecular diagnostic techniques, such as polymerase chain reaction, offer improvements in sensitivity, specificity and rapidity over culture and serology, the need remains for a consistent and reproducible diagnostic technique, available to all microbiology laboratories. Current treatment guidelines for community-acquired pneumonia recognise the importance of atypical respiratory pathogens in its aetiology, for which macrolides are considered suitable first-line agents. The value of atypical coverage in antibiotic therapy for acute exacerbations of chronic bronchitis and exacerbations of asthma is less clear, while there is no evidence to suggest that atypical pathogens should be covered in antibiotic treatment of upper respiratory-tract infections.

Chlamydia pneumoniae infections in mouse models: relevance for atherosclerosis research

Mouse models have been frequently used in the study of Chlamydia pneumoniae (also known as Chlamydophila pneumoniae) infections. This gram-negative obligate intracellular bacterium causes respiratory infections, followed by dissemination of the bacterium to various organs throughout the body, including cardiovascular tissues, supporting the current hypothesis of a relationship between C. pneumoniae and atherosclerosis. Recently, clinical trials evaluated the effect of antichlamydial antibiotics on secondary cardiovascular events. Although small studies showed some effect, the large WIZARD study did not confirm these results, and the role of antichlamydial antibiotics in prevention of secondary events was questioned. To address these issues, data obtained from mouse models were systematically reviewed here. C. pneumoniae infections showed atherogenic properties in mice that were reproducible and confirmed by different research groups. However, antibiotic therapy was of limited value in these mouse models. Antibiotic therapy effectively cleared the acute infection, but did not influence the atherogenic properties of C. pneumoniae unless the therapy was started early during the acute infection. The results summarized here may help to better understand the results of the clinical antibiotic trials.

Progression of peripheral arterial occlusive disease is associated with Chlamydia pneumoniae seropositivity and can be inhibited by antibiotic treatment

A possible influence of Chlamydia pneumoniae seropositivity on the clinical course of peripheral arterial occlusive disease (PAOD) has not been investigated previously. Though roxithromycin therapy was found to inhibit progression of PAOD, the nature of this effect (antibiotic or anti-inflammatory) has remained elusive. The course of PAOD was prospectively assessed in elderly men during 4 years, comparing 51 C. pneumoniae seropositive (IgG>/=1:128) with 46 seronegative patients (IgG<1:64 and IgA<1:32). Twenty of the seropositive patients were treated with roxithromycin (400 mg daily) for 4 weeks. Limitation of the walking distance to 200 m or less was observed in 55% of the seropositive untreated patients as compared to 30% of both, seronegative and macrolide-treated patients. The number of invasive revascularizations per patient was 1.7 in the seropositive untreated group as compared to 0.5 in the seronegative and the macrolide-treated group. Considering possible confounding variables, such as classical vascular risk factors, ordinal regression analyses showed a significant association of C. pneumoniae seropositivity with limitation of the walking distance (p=0.027) and need for invasive revascularization (p=0.037). The effect of macrolide treatment on these outcome measures was marked (p<0.001 and p=0.040, respectively) during 2.7 years but decreased in the second part of the observation period. This study provides good evidence that C. pneumoniae are involved in the progression of PAOD and that antibiotic treatment directed against C. pneumoniae is effective in inhibiting this process.

Antimicrobial selection for community-acquired lower respiratory tract infections in the 21st century: a review of gemifloxacin

Community-acquired lower respiratory tract infections (LRTIs) are more prevalent in the elderly than in children and younger adults and form a significant proportion of all consultations and hospital admissions in this older age group. Furthermore, in a world of increasing life expectancy the trend seems unlikely to be reversed. Antimicrobial treatment of community-acquired pneumonia (CAP) must cover Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis, and in many circumstances should also cover the intracellular (atypical) pathogens. In contrast, acute exacerbations of chronic bronchitis (AECB) are mainly associated with H. influenzae and S. pneumoniae and not with atypical bacteria: in severe cases, other Gram-negative bacteria may be involved. Frequently in LRTIs, the aetiology of the infection cannot be identified from the laboratory specimens and treatment has to be empirical. In such situations it is important to not only to use an antibiotic that covers all likely organisms, but also one that has good activity against these organisms given the local resistance patterns. Gemifloxacin is a new quinolone antibiotic that targets pneumococcal DNA gyrase and topoisomerase IV and is highly active against S. pneumoniae including penicillin-, macrolide- and many ciprofloxacin-resistant strains, as well as H. influenzae and the atypical pathogens. In clinical trials in CAP and AECB, gemifloxacin has been shown to be as effective a range of comparators and demonstrated an adverse event profile that was in line with the comparator agents. In one long-term study in AECB significantly more patients receiving gemifloxacin than clarithromycin remained free of recurrence after 26 weeks. The improved potency, broad spectrum of activity and proven clinical and bacteriological efficacy and safety profile should make it a useful agent in the 21st century battle against community-acquired LRTIs.

Antimicrobial therapy in community-acquired pneumonia among emergency patients in a university hospital in Japan

As antimicrobial therapy for pneumonia has not been well established in Japan, this study was designed to obtain a more definitive standard for antimicrobial treatment of this condition. Two hundred and thirty-one emergency patients admitted to Kyorin University Hospital between January 1998 and December 2000 were retrospectively analyzed in respect to their age, underlying disease, causative organism, and primary treatment with antimicrobial agent. Furthermore, the severity and prognosis were analyzed for those patients who had not responded to initial treatment with antimicrobial agents. The majority of the patients were elderly (over 65 years old; mean overall age 66.7 +/- 15.2 years) and had severe pneumonia; underlying diseases were recognized at a high rate in patients with severe pneumonia (P < 0.05) and in those classified as elderly (P < 0.0001). The most common underlying conditions in elderly patients were respiratory, cardiovascular (P < 0.01), and cerebrovascular (P < 0.05) diseases. The most common causative organisms were Haemophilus influenzae, Staphylococcus aureus, Streptococcus pneumoniae, and Mycoplasma pneumoniae. In patients with severe pneumonia, S. aureus, Klebsiella pneumoniae, and Pseudomonas aeruginosa were identified as the most common causative organisms. Complications associated with antimicrobial treatment were observed in those patients with K. pneumoniae isolates who also had severe pneumonia and were frequently treated with penicillin. Furthermore, increased mortality rates were observed in patients not responding well to the initial treatment with antimicrobial agents. Thus, the selection of appropriate initial antimicrobial agents is an important factor affecting the prognosis of patients with community-acquired pneumonia.

Glucocorticoids increase in vitro and in vivo activities of antibiotics against Chlamydophila pneumoniae

The in vitro and in vivo antichlamydial activities of dexamethasone and beclomethasone alone and in combination with an antibiotic were tested. In vitro, dexamethasone and beclomethasone decreased the number of inclusion-forming units versus the control number (P < 0.001). The combination of glucocorticoids with azithromycin, telithromycin, or levofloxacin was more active than antibiotics used alone (P < 0.001). The combination, tested in a murine Chlamydophila pneumoniae infection model, produced similar results.

Treatment with clarithromycin prior to coronary artery bypass graft surgery does not prevent subsequent cardiac events

BACKGROUND

Recently, it has been suggested that Chlamydia pneumoniae possibly plays a possible role in the pathogenesis of atherosclerosis. We investigated whether treatment with clarithromycin prior to coronary artery bypass graft (CABG) surgery would prevent subsequent cardiovascular events and mortality.

METHODS

Patients who were scheduled for CABG surgery were randomly assigned to receive either clarithromycin or placebo until the day of surgery in a double-blind trial. During the 2 years of follow-up, mortality and cardiovascular events were assessed.

RESULTS

Follow-up at 2 years was achieved for 473 patients. The mean duration of treatment was 16 days. Patient characteristics at baseline were well balanced between the 2 treatment groups. Mortality was equal in the 2 groups: 10 (4.2%) of 238 patients in the clarithromycin group and 9 (3.8%) of 235 patients in the placebo group (relative risk, 1.10; 95% CI, 0.42-2.89; P=1.0). Also, there were no significant differences in the proportion of patients who experienced cardiovascular events during the follow-up period: 20 (8.4%) of 238 patients in the clarithromycin group and 19 (8.1%) of 235 patients in the placebo group (relative risk, 1.04; 95% CI, 0.55-1.98; P=1.0). The overall rate of such events was 58 (12.3%) of 473 patients.

CONCLUSIONS

Treatment with clarithromycin in patients scheduled for CABG surgery did not reduce the subsequent occurrence of cardiovascular events or mortality during a 2-year follow-up period.

[Effect of therapy with antibiotics on lipid metabolism and antioxidant reserve of patients with ischemic heart disease during Chlamydia pneumoniae infection]

Effect of therapy with azithromycin and doxycycline on lipid metabolism, processes of lipid peroxidation and state of antioxidant defense was studied in patients with ischemic heart disease with elevated titer of antibodies to Chlamydia Pneumonia. Therapy with azithromycin (500 mg/day for 2 months) was associated with lowering of antibody titer, moderate improvement of lipid spectrum, marked decrease of activity of lipid peroxidation and augmentation of blood plasma antioxidant reserve. There were no such changes in a group of doxycycline treated patients. This difference can be attributed to more pronounced antimicrobial activity of azithromycin against Chlamydophila Pneumonia and its intrinsic antioxidant properties.

Advances in the management of Chlamydia pneumoniae infections

One of the major characteristics of Chlamydia spp. is its ability to cause prolonged, often subclinical infections. Chronic, persistent infection with Chlamydia pneumoniae has been implicated in the pathogenesis of several chronic diseases initially not thought to be infectious, including asthma, arthritis and atherosclerosis. C. pneumoniae is susceptible in vitro to a wide range of antimicrobial agents that target either protein or DNA synthesis, including macrolides, ketolides, tetracyclines, quinolones and rifamycins. Practically all treatment studies evaluating presented or published to date have used serology alone for diagnosis of C. pneumoniae infection, which only provides a clinical end point. The results of several treatment studies that did perform culture found that erythromycin, azithromycin (Zithromax, clarithromycin (Biaxin, levofloxacin (Levaquin and moxifloxacin (Avelox had a 70 to 90% efficacy in eradicating C. pneumoniae from the respiratory tract of children and adults with pneumonia. Persistence of the organism does not appear to be due to the development of antibiotic resistance. However, one cannot extrapolate from this experience to the treatment of chronic C. pneumoniae infection, especially cardiovascular disease. As there are no reliable serologic markers for chronic or persistent C. pneumoniae infection, it cannot be determined who is infected and who is not, which means that it cannot be assumed that any effect seen is due to successful treatment or eradication of C. pneumoniae.

Antibody levels against Chlamydia pneumoniae and outcome of roxithromycin therapy in patients with acute myocardial infarction. Results from a sub-study of the randomised Antibiotic Therapy in Acute Myocardial Infarction (ANTIBIO) trial

BACKGROUND

Results of studies concerning prevention of cardiovascular disease by treatment with macrolide antibiotics targeting C. pneumoniae infection are still controversial. This study describes the results of different tests for infection with C. pneumoniae as well as the effect of treatment with roxithromycin in patients with acute myocardial infarction (AMI) in relation to their serostatus against C. pneumoniae.

METHODS

We analysed blood of 160 patients who came from the ANTIBIOtic therapy after an AMI ( ANTIBIO-) study, a prospective, randomised, placebo-controlled, double-blind study to investigate the effect of roxithromycin 300 mg/OD for 6 weeks in patients with an AMI. Anti- Chlamydia IgG-, IgA-, and IgM-antibodies of these patients were analysed by means of different test systems.

RESULTS

There was a good correlation between the two IgG and IgA methods (r = 0.900, p < 0.001 and r = 0.878, p < 0.001, respectively), but marked differences in the prevalence of positive tests. This resulted in only moderate concordance values, as expressed by the Kappa coefficients, for IgG kappa = 0.611 (95% CI = 0.498-0.724, p < 0.001) and for IgA kappa = 0.431 (95% CI: 0.322-0.540, p < 0.001). No significant association between positive C. pneumonia titers and the combined clinical endpoint during the 12 month follow-up could be found. In all test systems used, patients with positive anti- C. pneumoniae titers did not benefit from roxithromycin therapy (p = ns).

CONCLUSION

Depending on the test system used, there are large differences in the prevalence of anti- C. pneumoniae seropositive patients. Clinical events during the 12 month follow-up after AMI did not depend on serostatus against C. pneumoniae and treatment with roxithromycin did not influence these events, independently of the serostatus against C. pneumoniae. However, the power of this subgroup analysis was low to detect small but significant differences.

Severe Chlamydia pneumoniae infection in a patient with mild neutropenia during treatment of Hodgkin?s disease

Chlamydia pneumoniae is known to cause acute respiratory tract infections in the non-immunocompromised population. So far, no data about the incidence of chlamydial infections in neutropenic patients are available. Macrolide antibiotics are not considered to be first-line treatment options in neutropenic patients. We report the case of a patient with Hodgkin's disease who developed C. pneumoniae pneumonia during mild neutropenia. C. pneumoniae should be considered as a causative agent of pneumonia in neutropenic patients.

Effects of a brief course of azithromycin on soluble cell adhesion molecules and markers of inflammation in survivors of an acute coronary syndrome: A double-blind, randomized, placebo-controlled study

BACKGROUND

The anti-chlamydial antibiotic, azithromycin, may improve outcome in patients who survive an acute coronary syndrome. The mechanisms are, however, poorly understood. The aims of this study were to define any relationship between Chlamydia pneumoniae seropositivity and levels of specific markers of endothelial activation (soluble cell adhesion molecules) and more general markers of inflammation (C-reactive protein [CRP] and interleukin-6 [IL-6]) and to assess whether azithromycin had any effect on such markers.

METHODS

Patients who survived an acute coronary syndrome were randomized to receive treatment with azithromycin (n = 72) or placebo (n = 69) for 5 days. Before therapy, C pneumoniae IgA and IgG titers were checked, with serum levels of soluble intercellular adhesion molecule-1 (sICAM-1), soluble vascular cell adhesion molecule-1, soluble E-selectin (sE-selectin), soluble P-selectin, high-sensitivity CRP, and IL-6. They were rechecked 3 months later.

RESULTS

There were no significant correlations between C pneumoniae titers and levels of CRP, IL-6, or soluble cell adhesion molecules. However, azithromycin treatment significantly reduced mean sICAM-1 levels (P =.006). This effect was more marked in patients with elevated titers of C pneumoniae IgA and IgG. Soluble E-selectin levels were also reduced in patients who were seropositive, but no effects were seen on other endothelial or inflammatory markers.

CONCLUSIONS

After an acute coronary syndrome, a 5-day course of azithromycin reduces levels of sICAM-1, a marker of endothelial cell activation. Although these data suggest a potentially beneficial role for azithromycin, they should be interpreted with caution.

Chlamydophila abortus infection in a pregnant woman associated with indirect contact with infected goats

Reported here is the case of a pregnant woman who developed a severe Chlamydophila abortus infection after indirect contact with infected goats resulting in preterm stillbirth. The woman fully recovered after treatment with doxycycline. In the goat herd with which her husband worked Chlamydophila abortus was actively circulating, as shown by positive serology. When pregnant women present with rapidly worsening influenza-like illness, special attention should be given to possible contact (direct or indirect) with animals when recording the anamnesis. Pregnant women, especially those who live in rural areas, should generally be made aware of the risks of zoonotic diseases and how to avoid them.

High prevalence of Chlamydia pneumoniae infection in cyclosporin A-induced post-transplant gingival overgrowth tissue and evidence for the possibility of persistent infection despite short-term treatment with azithromycin

BACKGROUND

Cyclosporin A (CsA) induces gingival overgrowth (GO) in up to a quarter of CsA-treated renal transplant recipients. A short-term therapy with azithromycin effectively reduces GO, indicating a possible involvement of microorganisms in the pathogenesis of CsA-induced GO. We aimed to determine if there could be any relationship between infection with Chlamydia pneumoniae and GO pathogenesis. In addition, we determined the long-term persistence rate of C. pneumoniae infection in residual GO tissue when azithromycin treatment failed to eliminate GO.

METHODS

Chlamydia pneumoniae IgG and IgM antibody titres were measured by microimmunofluorescence technique in sera of kidney recipients with (n = 11) and without (n = 89) GO. GOs were rated and gingivectomies were performed before treatment with 500 mg of azithromycin for 3 days and at months 6 and 12 post-treatment when C. pneumoniae titres were re-evaluated. Nested polymerase chain reaction was performed to identify C. pneumoniae-specific DNA in GO tissues. Results of C. pneumoniae antibody titres from patients with GO were compared with pair-matched controls without GO.

RESULTS

Chlamydia pneumoniae IgM titres were elevated in five of 11 patients with GO and in none without GO, whereas the difference of C. pneumoniae IgG titres between patients with GO and pair-matched controls did not reach significance (P<0.57). Chlamydia pneumoniae-specific DNA was found in 10 of 11 GO tissue samples pre-treatment. Azithromycin therapy effectively reduced GO and C. pneumoniae IgM titres. In residual GO, C. pneumoniae-specific DNA remained detectable after 1 year in all GO tissue samples despite azithromycin treatment. The C.pneumoniae IgM titres correlated with GO scores.

CONCLUSION

Chlamydia pneumoniae infection is highly prevalent in CsA-induced GO. The infection can persist over a long period in residual GO despite short-term azithromycin therapy. The results indicate that CsA immunosuppression enhances C. pneumoniae infection rates in non-cardiovascular tissue.

Infectious agents and atherosclerosis: current perspectives and unsolved issues

The large amount of data accumulated in recent years has reinforced the idea that infectious agents may play a significant role in the pathogenesis of atherosclerosis and in the clinical manifestations of vascular disease. Seroepidemiological and experimental data linking Herpesviridae and Chlamydia pneumoniae to atherosclerosis appear to be confirmed by a number of studies, while the available evidence regarding Helicobacter pylori is more conflicting, partly due to the fact that the interest in this agent is more recent. Infectious agents may influence atherogenesis through a number of mechanisms, ranging from cell lysis to the stimulation of adhesion molecule expression and cytokine production by infected cells. The development of atherosclerosis after an acute infection seems unlikely. Rather, it appears that a chronic, persistent form of infection, especially with Chlamydia pneumoniae, may favor those structural and proinflammatory changes in the vascular wall which are necessary for the formation of an atheroma. A persistent chlamydial infection is accompanied by an increased production of microbial heat shock protein 60, which may induce antigenic mimicry and a chronic inflammatory reaction in the vascular wall. Pharmacological trials have yielded conflicting indications regarding the hypothesis that treatment with macrolide antibiotics may limit the progression of vascular disease and the recurrence of cardiovascular events, although in a limited number of cases. However, antimicrobial drugs do not act specifically against a single infectious agent and more specific therapeutic agents would be needed in order to test a causative link between a single infectious agent and vascular disease.

Macrolide Therapy forChlamydia pneumoniaein the Secondary Prevention of Coronary Artery Disease: A Meta-Analysis of Randomized Controlled Trials

STUDY OBJECTIVE

As recent studies have shown that antibiotic therapy to eradicate Chlamydia pneumoniae may be beneficial in the secondary prevention of coronary artery disease, and studies to date may have lacked statistical power, we conducted a meta-analysis of randomized controlled trials to determine the role of antibiotic therapy in this patient population.

DESIGN

Systematic review and meta-analysis of randomized controlled trials.

PATIENTS

A total of 12,032 patients from nine studies.

MEASUREMENTS AND MAIN RESULTS

We searched MEDLINE, EMBASE, the Cochrane Controlled Trials Register, and abstracts of conference proceedings to identify pertinent studies. The random effects model was used to estimate a pooled relative risk. Heterogeneity was assessed using the bootstrap version of the Q statistic with 1000 replications. In total, we reviewed nine randomized controlled trials enrolling 12,032 patients; six enrolled patients with acute coronary syndrome, two enrolled patients with stable coronary artery disease, and one enrolled a mixed population. Compared with placebo, macrolide therapy was not associated with a significant reduction in any coronary event (relative risk [RR] 0.98, 95% confidence interval [CI] 0.88-1.08), myocardial infarction or angina (RR 0.89, 95% CI 0.68-1.16), or overall mortality (RR 0.95, 95% CI 0.81-1.12).

CONCLUSION

Our results do not support routine use of antichlamydial therapy for secondary prevention of coronary events.

Progression of early carotid atherosclerosis is only temporarily reduced after antibiotic treatment of Chlamydia pneumoniae seropositivity

BACKGROUND

Chlamydia pneumoniae (Cp) infection has been associated with atherosclerosis and cardiovascular events. There are controversial results regarding the beneficial effects of antibiotic therapy on future cardiovascular end points.

METHODS AND RESULTS

We determined the long-term effect of a 30-day roxithromycin therapy on intima-to-media thickness (IMT) progression of the common carotid artery in 272 consecutive Cp-positive and Cp-negative patients with ischemic stroke in a prospective, double-blind, randomized trial with a follow-up of 4 years. Cp IgG (> or =1:64) or IgA (> or =1:16) antibodies were initially found in 125 (46%) patients. During the 3 years before antibiotic therapy, Cp-positive patients showed an enhanced IMT progression even after adjustment for other cardiovascular risk factors (0.12 [0.11 to 0.14] versus 0.07 [0.05 to 0.09] mm/year; P<0.005). The 62 Cp-positive patients given roxithromycin showed a reduced IMT progression during the first 2 years compared with the Cp-positive patients without therapy (0.07 [0.045 to 0.095] versus 0.11 [0.088 to 0.132] mm/year; P<0.01). However, IMT progression increased again during the third and fourth year to similar values as before treatment. No significant difference in the occurrence of future cardiovascular events was found between both groups during follow-up.

CONCLUSIONS

The only limited positive impact of antibiotic therapy on early atherosclerosis progression in Cp-positive patients observed in our study may explain the negative results of most antibiotic trials on clinical end points.

Efficacy of azithromycin for the treatment of feline chlamydophilosis

The current recommended treatment for feline chlamydophilosis involves daily oral administration of antimicrobials to all cats within an affected group for a prolonged period of time (4-6 weeks). Not surprisingly, owner compliance can be poor resulting in apparent treatment failure. Recent anecdotal evidence, supported by its efficacy in the treatment of Chlamydia trachomatis infection in humans, has suggested that azithromycin may offer an alternative by allowing less frequent dosing for a shorter duration. A clinical trial was designed to evaluate the efficacy of azithromycin for the treatment of chlamydia (Chlamydophila felis) infection in cats. Whilst azithromycin, given at 10-15 mg/kg daily for 3 days and then twice weekly, provided a similar, rapid resolution of clinical signs and negative isolation scores as doxycycline, C felis was re-isolated in four out of the five cats treated. Furthermore, even daily administration of azithromycin to chronically infected cats was ineffective in clearing infection. The azithromycin protocols used here were therefore found to be unsuccessful in eliminating the carriage of this strain of C felis.

[Choice of antimicrobial drug for infections caused by Chlamydia trachomatis and Chlamydophila pneumoniae]

Chlamydia (C.) trachomatis is the most common bacterial cause of sexually transmitted disease in the world. A well documented feature of chlamydial infection is its high rate of recurrence among sexually active populations. However, it is difficult to distinguish whether the high rate of recurrent disease is due to reinfection or to persistent infection with the same organism. Of particular concern in this era of increasing antibiotic resistance is whether persistent infection is the consequence of increasing resistance to standard antimicrobial therapy. Azithromycin and doxycycline are considered by the Centers for Disease Control and Prevention (CDC) as first line drugs for the treatment of chlamydial infections; erythromycin, ofloxacin and levofloxacin are recommended as alternative-regimen. Although C. trachomatis has been historically sensitive to these antibiotics, in vitro resistance is being increasingly reported. However, although in vitro antimicrobial resistance has been described, the clinical significance of these findings is unknown. C. pneumoniae is associated with community-acquired pneumonias, acute exacerbations of chronic bronchitis, otitis media, sinusitis and reactive airway disease. Persistent nasopharyngeal infection with C. pneumoniae has been documented in adults following acute respiratory infection. Chronic infection with C. pneumoniae has also been implicated in the pathogenesis of atherosclerosis, although this is still very controversial. Azithromycin, clarithromycin and quinolones are frequently used for the treatment of C. pneumoniae respiratory infections. Microbiologic failure has been described in C. pneumoniae infections, even after prolonged courses of azithromycin, erythromycin and doxycycline.

[Significance of antibacterial therapy of Chlamydophila pneumoniae infection in patients with bronchial asthma]

AIM

To study effects of eradication of Chlamydophila pneumoniae CP) infection in bronchial asthma (BA) on BA course and changes in quality of life (QOL) in BA patients.

MATERIAL AND METHODS

194 BA patients in clinical remission participated in the trial. Microbiological diagnosis of asymptomatic CP infection was made serologically (ELISA, indirect enzyme immunoassay) using polymerase chain reaction. Clinical and biochemical tests, assessment of pulmonary ventilation function, QOL by AQLQ during 6-week antimicrobial therapy were made in 56 patients.

RESULTS

Patients with stable BA had high frequency of serological signs of clinically asymptomatic CP infection (52%) deteriorating BA symptoms and QOL. Antibacterial therapy of latent CP infection with azitromycin significantly improved BA course and QOL of BA patients.

CONCLUSION

When laboratory tests detect CP infection in patients with long-term course of BA, especially in smoking males with moderate and severe BA it is clinically valid to prescribe addition of azitromycin to basic antiinflammatory treatment of BA.