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Pei G, Guo L, Liang S, Chen F, Ma N, Bai J, Deng J, Li M, Qin C, Feng T, He Z. Long-Term Erythromycin Treatment Alters the Airway and Gut Microbiota: Data from Chronic Obstructive Pulmonary Disease Patients and Mice with Emphysema. Respiration 2024; 103:461-479. [PMID: 38663359 DOI: 10.1159/000538911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 04/10/2024] [Indexed: 06/20/2024] Open
Abstract
INTRODUCTION Although long-term macrolide antibiotics could reduce the recurrent exacerbation of chronic obstructive pulmonary disease (COPD), the side effect of bacterial resistance and the impact on the microbiota remain concerning. We investigated the influence of long-term erythromycin treatment on the airway and gut microbiota in mice with emphysema and patients with COPD. METHODS We conducted 16S rRNA gene sequencing to explore the effect of erythromycin treatment on the lung and gut microbiota in mice with emphysema. Liquid chromatography-mass spectrometry was used for lung metabolomics. A randomized controlled trial was performed to investigate the effect of 48-week erythromycin treatment on the airway and gut microbiota in COPD patients. RESULTS The mouse lung and gut microbiota were disrupted after cigarette smoke exposure. Erythromycin treatment depleted harmful bacteria and altered lung metabolism. Erythromycin treatment did not alter airway or gut microbial diversity in COPD patients. It reduced the abundance of pathogens, such as Burkholderia, in the airway of COPD patients and increased levels of symbiotic bacteria, such as Prevotella and Veillonella. The proportions of Blautia, Ruminococcus, and Lachnospiraceae in the gut were increased in COPD patients after erythromycin treatment. The time to the first exacerbation following treatment was significantly longer in the erythromycin treatment group than in the COPD group. CONCLUSION Long-term erythromycin treatment reduces airway and gut microbe abundance in COPD patients but does not affect microbial diversity and restores microbiota balance in COPD patients by reducing the abundance of pathogenic bacteria.
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Affiliation(s)
- Guangsheng Pei
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital and College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China
| | - Liyan Guo
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Siqiao Liang
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Fugang Chen
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Nan Ma
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Jing Bai
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Jingmin Deng
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Meihua Li
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Chunhai Qin
- Department of Pulmonary and Critical Care Medicine, Guiping People's Hospital, Guiping, China
| | - Tao Feng
- Department of Pulmonary and Critical Care Medicine, Wuming Hospital of Guangxi Medical University, Nanning, China
| | - Zhiyi He
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
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Moja L, Zanichelli V, Mertz D, Gandra S, Cappello B, Cooke GS, Chuki P, Harbarth S, Pulcini C, Mendelson M, Tacconelli E, Ombajo LA, Chitatanga R, Zeng M, Imi M, Elias C, Ashorn P, Marata A, Paulin S, Muller A, Aidara-Kane A, Wi TE, Were WM, Tayler E, Figueras A, Da Silva CP, Van Weezenbeek C, Magrini N, Sharland M, Huttner B, Loeb M. WHO's essential medicines and AWaRe: recommendations on first- and second-choice antibiotics for empiric treatment of clinical infections. Clin Microbiol Infect 2024; 30 Suppl 2:S1-S51. [PMID: 38342438 DOI: 10.1016/j.cmi.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 01/26/2024] [Accepted: 02/04/2024] [Indexed: 02/13/2024]
Abstract
The WHO Model List of Essential Medicines (EML) prioritizes medicines that have significant global public health value. The EML can also deliver important messages on appropriate medicine use. Since 2017, in response to the growing challenge of antimicrobial resistance, antibiotics on the EML have been reviewed and categorized into three groups: Access, Watch, and Reserve, leading to a new categorization called AWaRe. These categories were developed taking into account the impact of different antibiotics and classes on antimicrobial resistance and the implications for their appropriate use. The 2023 AWaRe classification provides empirical guidance on 41 essential antibiotics for over 30 clinical infections targeting both the primary health care and hospital facility setting. A further 257 antibiotics not included on the EML have been allocated an AWaRe group for stewardship and monitoring purposes. This article describes the development of AWaRe, focussing on the clinical evidence base that guided the selection of Access, Watch, or Reserve antibiotics as first and second choices for each infection. The overarching objective was to offer a tool for optimizing the quality of global antibiotic prescribing and reduce inappropriate use by encouraging the use of Access antibiotics (or no antibiotics) where appropriate. This clinical evidence evaluation and subsequent EML recommendations are the basis for the AWaRe antibiotic book and related smartphone applications. By providing guidance on antibiotic prioritization, AWaRe aims to facilitate the revision of national lists of essential medicines, update national prescribing guidelines, and supervise antibiotic use. Adherence to AWaRe would extend the effectiveness of current antibiotics while helping countries expand access to these life-saving medicines for the benefit of current and future patients, health professionals, and the environment.
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Affiliation(s)
- Lorenzo Moja
- Health Products Policy and Standards, World Health Organization, Geneva, Switzerland.
| | - Veronica Zanichelli
- Health Products Policy and Standards, World Health Organization, Geneva, Switzerland
| | - Dominik Mertz
- Department of Medicine, McMaster University, Hamilton, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada; World Health Organization Collaborating Centre for Infectious Diseases, Research Methods and Recommendations, McMaster University, Hamilton, Canada
| | - Sumanth Gandra
- Division of Infectious Diseases, Department of Internal Medicine, Washington University School of Medicine in St. Louis, Missouri, United States
| | - Bernadette Cappello
- Health Products Policy and Standards, World Health Organization, Geneva, Switzerland
| | - Graham S Cooke
- Department of Infectious Diseases, Imperial College London, London, UK
| | - Pem Chuki
- Antimicrobial Stewardship Unit, Jigme Dorji Wangchuck National Referral Hospital, Thimphu, Bhutan
| | - Stephan Harbarth
- Infection Control Programme, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland; World Health Organization Collaborating Centre on Infection Prevention and Control and Antimicrobial Resistance, Geneva, Switzerland
| | - Celine Pulcini
- APEMAC, and Centre régional en antibiothérapie du Grand Est AntibioEst, Université de Lorraine, CHRU-Nancy, Nancy, France
| | - Marc Mendelson
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Evelina Tacconelli
- Infectious Diseases Unit, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Loice Achieng Ombajo
- Department of Clinical Medicine and Therapeutics, University of Nairobi, Nairobi, Kenya; Center for Epidemiological Modelling and Analysis, University of Nairobi, Nairobi, Kenya
| | - Ronald Chitatanga
- Antimicrobial Resistance National Coordinating Centre, Public Health Institute of Malawi, Blantyre, Malawi
| | - Mei Zeng
- Department of Infectious Diseases, Children's Hospital of Fudan University, Shanghai, China
| | | | - Christelle Elias
- Service Hygiène et Epidémiologie, Hospices Civils de Lyon, Lyon, France; Centre International de Recherche en Infectiologie, Institut National de la Santé et de la Recherche Médicale U1111, Centre National de la Recherche Scientifique Unité Mixte de Recherche 5308, École Nationale Supérieure de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Per Ashorn
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University and Tampere University Hospital, Tampere, Finland
| | | | - Sarah Paulin
- Antimicrobial Resistance Division, World Health Organization, Geneva, Switzerland
| | - Arno Muller
- Antimicrobial Resistance Division, World Health Organization, Geneva, Switzerland
| | | | - Teodora Elvira Wi
- Department of Global HIV, Hepatitis and STIs Programme, World Health Organization, Geneva, Switzerland
| | - Wilson Milton Were
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Elizabeth Tayler
- WHO Regional Office for the Eastern Mediterranean (EMRO), World Health Organisation, Cairo, Egypt
| | | | - Carmem Pessoa Da Silva
- Antimicrobial Resistance Division, World Health Organization, Geneva, Switzerland; Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - Nicola Magrini
- NHS Clinical Governance, Romagna Health Authority, Ravenna, Italy; World Health Organization Collaborating Centre for Evidence Synthesis and Guideline Development, Bologna, Italy
| | - Mike Sharland
- Centre for Neonatal and Paediatric Infections, Institute for Infection and Immunity, St George's University of London, London, UK
| | - Benedikt Huttner
- Health Products Policy and Standards, World Health Organization, Geneva, Switzerland
| | - Mark Loeb
- Department of Medicine, McMaster University, Hamilton, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada; World Health Organization Collaborating Centre for Infectious Diseases, Research Methods and Recommendations, McMaster University, Hamilton, Canada
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Weeks JR, Staples KJ, Spalluto CM, Watson A, Wilkinson TMA. The Role of Non-Typeable Haemophilus influenzae Biofilms in Chronic Obstructive Pulmonary Disease. Front Cell Infect Microbiol 2021; 11:720742. [PMID: 34422683 PMCID: PMC8373199 DOI: 10.3389/fcimb.2021.720742] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 07/15/2021] [Indexed: 11/13/2022] Open
Abstract
Non-typeable Haemophilus influenzae (NTHi) is an ubiquitous commensal-turned-pathogen that colonises the respiratory mucosa in airways diseases including Chronic Obstructive Pulmonary Disease (COPD). COPD is a progressive inflammatory syndrome of the lungs, encompassing chronic bronchitis that is characterised by mucus hypersecretion and impaired mucociliary clearance and creates a static, protective, humid, and nutrient-rich environment, with dysregulated mucosal immunity; a favourable environment for NTHi colonisation. Several recent large COPD cohort studies have reported NTHi as a significant and recurrent aetiological pathogen in acute exacerbations of COPD. NTHi proliferation has been associated with increased hospitalisation, disease severity, morbidity and significant lung microbiome shifts. However, some cohorts with patients at different severities of COPD do not report that NTHi is a significant aetiological pathogen in their COPD patients, indicating other obligate pathogens including Moraxella catarrhalis, Streptococcus pneumoniae and Pseudomonas aeruginosa as the cause. NTHi is an ubiquitous organism across healthy non-smokers, healthy smokers and COPD patients from childhood to adulthood, but it currently remains unclear why NTHi becomes pathogenic in only some cohorts of COPD patients, and what behaviours, interactions and adaptations are driving this susceptibility. There is emerging evidence that biofilm-phase NTHi may play a significant role in COPD. NTHi displays many hallmarks of the biofilm lifestyle and expresses key biofilm formation-promoting genes. These include the autoinducer-mediated quorum sensing system, epithelial- and mucus-binding adhesins and expression of a protective, self-produced polymeric substance matrix. These NTHi biofilms exhibit extreme tolerance to antimicrobial treatments and the immune system as well as expressing synergistic interspecific interactions with other lung pathogens including S. pneumoniae and M. catarrhalis. Whilst the majority of our understanding surrounding NTHi as a biofilm arises from otitis media or in-vitro bacterial monoculture models, the role of NTHi biofilms in the COPD lung is now being studied. This review explores the evidence for the existence of NTHi biofilms and their impact in the COPD lung. Understanding the nature of chronic and recurrent NTHi infections in acute exacerbations of COPD could have important implications for clinical treatment and identification of novel bactericidal targets.
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Affiliation(s)
- Jake R Weeks
- Clinical and Experimental Sciences, University of Southampton Faculty of Medicine, Southampton, United Kingdom
| | - Karl J Staples
- Clinical and Experimental Sciences, University of Southampton Faculty of Medicine, Southampton, United Kingdom.,National Institute for Health Research (NIHR) Southampton Biomedical Research Centre, Southampton General Hospital, Southampton, United Kingdom
| | - C Mirella Spalluto
- Clinical and Experimental Sciences, University of Southampton Faculty of Medicine, Southampton, United Kingdom.,National Institute for Health Research (NIHR) Southampton Biomedical Research Centre, Southampton General Hospital, Southampton, United Kingdom
| | - Alastair Watson
- Clinical and Experimental Sciences, University of Southampton Faculty of Medicine, Southampton, United Kingdom.,National Institute for Health Research (NIHR) Southampton Biomedical Research Centre, Southampton General Hospital, Southampton, United Kingdom.,Birmingham Medical School, University of Birmingham, Birmingham, United Kingdom
| | - Tom M A Wilkinson
- Clinical and Experimental Sciences, University of Southampton Faculty of Medicine, Southampton, United Kingdom.,National Institute for Health Research (NIHR) Southampton Biomedical Research Centre, Southampton General Hospital, Southampton, United Kingdom
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Yan M, Saxena FE, Calzavara A, Brown KA, Garber G, Gershon AS, Johnstone J, Kumar M, Langford BJ, Lee S, Schwartz KL, Daneman N. Long-term macrolide therapy for chronic obstructive pulmonary disease: a population-based time series analysis. CMAJ Open 2021; 9:E576-E584. [PMID: 34021016 PMCID: PMC8177912 DOI: 10.9778/cmajo.20200157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Macrolides are recommended as an adjunctive treatment for patients with moderate to severe chronic obstructive pulmonary disease (COPD) who experience recurrent exacerbations. The objective of this study was to examine temporal trends in the provision of long-term macrolide therapy, specifically before and after publication of the landmark MACRO trial in August 2011 showing efficacy of macrolides for this indication. METHODS We performed an interrupted time series analysis using population-level health administrative data. The study cohort consisted of all Ontario residents who had COPD, were using at least 1 long-acting inhaler, and were aged 65 years and older between Apr. 1, 2004, and Mar. 31, 2018. We compared the baseline characteristics of eligible patients before and after publication of the MACRO trial. Our primary outcome was overall prevalence of long-term macrolide therapy; secondary outcomes were incidence of COPD-related hospitalizations, emergency department visits and outpatient exacerbations requiring high-dose steroids in each quarter. We performed an interrupted time series analysis to assess for changes in the incidence of macrolide prophylaxis by quarter-year over the study period. RESULTS The rate of long-term macrolide use increased from 0.8 per 1000 people in 2004 to 13.8 per 1000 people in 2018 (in the severe COPD group, the rate increased from 1.3 to 32.3 per 1000 people). The interrupted time series analysis showed that, before 2011, the prevalence of macrolide prophylaxis increased at a rate of 0.44 (95% confidence interval [CI] 0.39-0.50) per 1000 people per year; after 2011, the rate of increase grew by 1.18 (95% CI 1.07-1.29) per 1000 people to 1.63 (95% CI 1.56-1.69) per 1000 people per year. The seasonal pattern of COPD-related health care visits remained stable over the study period, and there was no detectable reduction in hospitalizations or emergency department visits at the population level. INTERPRETATION In the past decade, there has been a significant rise in the use of long-term macrolide therapy for patients with COPD. As this practice becomes increasingly common, it will be important to monitor its potential benefits on COPD exacerbations but also its potential effects on adverse events and antimicrobial resistance patterns.
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Affiliation(s)
- Marie Yan
- Department of Medicine (Yan, Garber, Gershon), University of Toronto, Toronto, Ont.; Department of Medicine (Yan), University of British Columbia, Vancouver, BC; ICES (Saxena, Calzavara, Brown, Gershon, Kumar, Lee, Schwartz, Daneman), Toronto, Ont.; Dalla Lana School of Public Health (Brown, Johnstone), University of Toronto, Toronto, Ont.; Public Health Ontario (Brown, Garber, Johnstone, Langford, Schwartz, Daneman), Toronto, Ont.; Ottawa Hospital Research Institute (Garber), Ottawa, Ont.; Sunnybrook Health Sciences Centre (Gershon, Daneman); Sinai Health System (Johnstone); Unity Health Toronto (Schwartz), Toronto, Ont
| | - Farah E Saxena
- Department of Medicine (Yan, Garber, Gershon), University of Toronto, Toronto, Ont.; Department of Medicine (Yan), University of British Columbia, Vancouver, BC; ICES (Saxena, Calzavara, Brown, Gershon, Kumar, Lee, Schwartz, Daneman), Toronto, Ont.; Dalla Lana School of Public Health (Brown, Johnstone), University of Toronto, Toronto, Ont.; Public Health Ontario (Brown, Garber, Johnstone, Langford, Schwartz, Daneman), Toronto, Ont.; Ottawa Hospital Research Institute (Garber), Ottawa, Ont.; Sunnybrook Health Sciences Centre (Gershon, Daneman); Sinai Health System (Johnstone); Unity Health Toronto (Schwartz), Toronto, Ont
| | - Andrew Calzavara
- Department of Medicine (Yan, Garber, Gershon), University of Toronto, Toronto, Ont.; Department of Medicine (Yan), University of British Columbia, Vancouver, BC; ICES (Saxena, Calzavara, Brown, Gershon, Kumar, Lee, Schwartz, Daneman), Toronto, Ont.; Dalla Lana School of Public Health (Brown, Johnstone), University of Toronto, Toronto, Ont.; Public Health Ontario (Brown, Garber, Johnstone, Langford, Schwartz, Daneman), Toronto, Ont.; Ottawa Hospital Research Institute (Garber), Ottawa, Ont.; Sunnybrook Health Sciences Centre (Gershon, Daneman); Sinai Health System (Johnstone); Unity Health Toronto (Schwartz), Toronto, Ont
| | - Kevin A Brown
- Department of Medicine (Yan, Garber, Gershon), University of Toronto, Toronto, Ont.; Department of Medicine (Yan), University of British Columbia, Vancouver, BC; ICES (Saxena, Calzavara, Brown, Gershon, Kumar, Lee, Schwartz, Daneman), Toronto, Ont.; Dalla Lana School of Public Health (Brown, Johnstone), University of Toronto, Toronto, Ont.; Public Health Ontario (Brown, Garber, Johnstone, Langford, Schwartz, Daneman), Toronto, Ont.; Ottawa Hospital Research Institute (Garber), Ottawa, Ont.; Sunnybrook Health Sciences Centre (Gershon, Daneman); Sinai Health System (Johnstone); Unity Health Toronto (Schwartz), Toronto, Ont
| | - Gary Garber
- Department of Medicine (Yan, Garber, Gershon), University of Toronto, Toronto, Ont.; Department of Medicine (Yan), University of British Columbia, Vancouver, BC; ICES (Saxena, Calzavara, Brown, Gershon, Kumar, Lee, Schwartz, Daneman), Toronto, Ont.; Dalla Lana School of Public Health (Brown, Johnstone), University of Toronto, Toronto, Ont.; Public Health Ontario (Brown, Garber, Johnstone, Langford, Schwartz, Daneman), Toronto, Ont.; Ottawa Hospital Research Institute (Garber), Ottawa, Ont.; Sunnybrook Health Sciences Centre (Gershon, Daneman); Sinai Health System (Johnstone); Unity Health Toronto (Schwartz), Toronto, Ont
| | - Andrea S Gershon
- Department of Medicine (Yan, Garber, Gershon), University of Toronto, Toronto, Ont.; Department of Medicine (Yan), University of British Columbia, Vancouver, BC; ICES (Saxena, Calzavara, Brown, Gershon, Kumar, Lee, Schwartz, Daneman), Toronto, Ont.; Dalla Lana School of Public Health (Brown, Johnstone), University of Toronto, Toronto, Ont.; Public Health Ontario (Brown, Garber, Johnstone, Langford, Schwartz, Daneman), Toronto, Ont.; Ottawa Hospital Research Institute (Garber), Ottawa, Ont.; Sunnybrook Health Sciences Centre (Gershon, Daneman); Sinai Health System (Johnstone); Unity Health Toronto (Schwartz), Toronto, Ont
| | - Jennie Johnstone
- Department of Medicine (Yan, Garber, Gershon), University of Toronto, Toronto, Ont.; Department of Medicine (Yan), University of British Columbia, Vancouver, BC; ICES (Saxena, Calzavara, Brown, Gershon, Kumar, Lee, Schwartz, Daneman), Toronto, Ont.; Dalla Lana School of Public Health (Brown, Johnstone), University of Toronto, Toronto, Ont.; Public Health Ontario (Brown, Garber, Johnstone, Langford, Schwartz, Daneman), Toronto, Ont.; Ottawa Hospital Research Institute (Garber), Ottawa, Ont.; Sunnybrook Health Sciences Centre (Gershon, Daneman); Sinai Health System (Johnstone); Unity Health Toronto (Schwartz), Toronto, Ont
| | - Matthew Kumar
- Department of Medicine (Yan, Garber, Gershon), University of Toronto, Toronto, Ont.; Department of Medicine (Yan), University of British Columbia, Vancouver, BC; ICES (Saxena, Calzavara, Brown, Gershon, Kumar, Lee, Schwartz, Daneman), Toronto, Ont.; Dalla Lana School of Public Health (Brown, Johnstone), University of Toronto, Toronto, Ont.; Public Health Ontario (Brown, Garber, Johnstone, Langford, Schwartz, Daneman), Toronto, Ont.; Ottawa Hospital Research Institute (Garber), Ottawa, Ont.; Sunnybrook Health Sciences Centre (Gershon, Daneman); Sinai Health System (Johnstone); Unity Health Toronto (Schwartz), Toronto, Ont
| | - Bradley J Langford
- Department of Medicine (Yan, Garber, Gershon), University of Toronto, Toronto, Ont.; Department of Medicine (Yan), University of British Columbia, Vancouver, BC; ICES (Saxena, Calzavara, Brown, Gershon, Kumar, Lee, Schwartz, Daneman), Toronto, Ont.; Dalla Lana School of Public Health (Brown, Johnstone), University of Toronto, Toronto, Ont.; Public Health Ontario (Brown, Garber, Johnstone, Langford, Schwartz, Daneman), Toronto, Ont.; Ottawa Hospital Research Institute (Garber), Ottawa, Ont.; Sunnybrook Health Sciences Centre (Gershon, Daneman); Sinai Health System (Johnstone); Unity Health Toronto (Schwartz), Toronto, Ont
| | - Samantha Lee
- Department of Medicine (Yan, Garber, Gershon), University of Toronto, Toronto, Ont.; Department of Medicine (Yan), University of British Columbia, Vancouver, BC; ICES (Saxena, Calzavara, Brown, Gershon, Kumar, Lee, Schwartz, Daneman), Toronto, Ont.; Dalla Lana School of Public Health (Brown, Johnstone), University of Toronto, Toronto, Ont.; Public Health Ontario (Brown, Garber, Johnstone, Langford, Schwartz, Daneman), Toronto, Ont.; Ottawa Hospital Research Institute (Garber), Ottawa, Ont.; Sunnybrook Health Sciences Centre (Gershon, Daneman); Sinai Health System (Johnstone); Unity Health Toronto (Schwartz), Toronto, Ont
| | - Kevin L Schwartz
- Department of Medicine (Yan, Garber, Gershon), University of Toronto, Toronto, Ont.; Department of Medicine (Yan), University of British Columbia, Vancouver, BC; ICES (Saxena, Calzavara, Brown, Gershon, Kumar, Lee, Schwartz, Daneman), Toronto, Ont.; Dalla Lana School of Public Health (Brown, Johnstone), University of Toronto, Toronto, Ont.; Public Health Ontario (Brown, Garber, Johnstone, Langford, Schwartz, Daneman), Toronto, Ont.; Ottawa Hospital Research Institute (Garber), Ottawa, Ont.; Sunnybrook Health Sciences Centre (Gershon, Daneman); Sinai Health System (Johnstone); Unity Health Toronto (Schwartz), Toronto, Ont
| | - Nick Daneman
- Department of Medicine (Yan, Garber, Gershon), University of Toronto, Toronto, Ont.; Department of Medicine (Yan), University of British Columbia, Vancouver, BC; ICES (Saxena, Calzavara, Brown, Gershon, Kumar, Lee, Schwartz, Daneman), Toronto, Ont.; Dalla Lana School of Public Health (Brown, Johnstone), University of Toronto, Toronto, Ont.; Public Health Ontario (Brown, Garber, Johnstone, Langford, Schwartz, Daneman), Toronto, Ont.; Ottawa Hospital Research Institute (Garber), Ottawa, Ont.; Sunnybrook Health Sciences Centre (Gershon, Daneman); Sinai Health System (Johnstone); Unity Health Toronto (Schwartz), Toronto, Ont.
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Janjua S, Mathioudakis AG, Fortescue R, Walker RA, Sharif S, Threapleton CJ, Dias S. Prophylactic antibiotics for adults with chronic obstructive pulmonary disease: a network meta-analysis. Cochrane Database Syst Rev 2021; 1:CD013198. [PMID: 33448349 PMCID: PMC8092479 DOI: 10.1002/14651858.cd013198.pub2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) is a chronic respiratory condition characterised by persistent respiratory symptoms and airflow limitation. Acute exacerbations punctuate the natural history of COPD and are associated with increased morbidity and mortality and disease progression. Chronic airflow limitation is caused by a combination of small airways (bronchitis) and parenchymal destruction (emphysema), which can impact day-to-day activities and overall quality of life. In carefully selected patients with COPD, long-term, prophylactic use of antibiotics may reduce bacterial load, inflammation of the airways, and the frequency of exacerbations. OBJECTIVES To assess effects of different prophylactic antibiotics on exacerbations, quality of life, and serious adverse events in people with COPD in three separate network meta-analyses (NMAs), and to provide rankings of identified antibiotics. SEARCH METHODS To identify eligible randomised controlled trials (RCTs), we searched the Cochrane Airways Group Specialised Register of trials and clinical trials registries. We conducted the most recent search on 22 January 2020. SELECTION CRITERIA We included RCTs with a parallel design of at least 12 weeks' duration evaluating long-term administration of antibiotics prophylactically compared with other antibiotics, or placebo, for patients with COPD. DATA COLLECTION AND ANALYSIS This Cochrane Review collected and updated pair-wise data from two previous Cochrane Reviews. Searches were updated and additional studies included. We conducted three separate network meta-analyses (NMAs) within a Bayesian framework to assess three outcomes: exacerbations, quality of life, and serious adverse events. For quality of life, we collected data from St George's Respiratory Questionnaire (SGRQ). Using previously validated methods, we selected the simplest model that could adequately fit the data for every analysis. We used threshold analysis to indicate which results were robust to potential biases, taking into account each study's contributions to the overall results and network structure. Probability ranking was performed for each antibiotic class for exacerbations, quality of life, and serious adverse events. MAIN RESULTS Characteristics of studies and participants Eight trials were conducted at multiple sites that included hospital clinics or academic health centres. Seven were single-centre trials conducted in hospital clinics. Two trials did not report settings. Trials durations ranged from 12 to 52 weeks. Most participants had moderate to severe disease. Mean age ranged from 64 years to 73 years, and more males were recruited (51% to 100%). Forced expiratory volume in one second (FEV₁) ranged from 0.935 to 1.36 L. Most participants had previous exacerbations. Data from 12 studies were included in the NMAs (3405 participants; 16 treatment arms including placebo). Prophylactic antibiotics evaluated were macrolides (azithromycin and erythromycin), tetracyclines (doxycyclines), quinolones (moxifloxacin) and macrolides plus tetracyclines (roxithromycin plus doxycycline). Risk of bias and threshold analysis Most studies were at low risk across domains, except detection bias, for which only seven studies were judged at low risk. In the threshold analysis for exacerbations, all comparisons in which one antibiotic was compared with another were robust to sampling variation, especially macrolide comparisons. Comparisons of classes with placebo were sensitive to potential bias, especially macrolide versus placebo, therefore, any bias in the comparison was likely to favour the active class, so any adjustment would bring the estimated relative effect closer to the null value, thus quinolone may become the best class to prevent exacerbations. Exacerbations Nine studies were included (2732 participants) in this NMA (exacerbations analysed as time to first exacerbation or people with one or more exacerbations). Macrolides and quinolones reduced exacerbations. Macrolides had a greater effect in reducing exacerbations compared with placebo (macrolides: hazard ratio (HR) 0.67, 95% credible interval (CrI) 0.60 to 0.75; quinolones: HR 0.89, 95% CrI 0.75 to 1.04), resulting in 127 fewer people per 1000 experiencing exacerbations on macrolides. The difference in exacerbations between tetracyclines and placebo was uncertain (HR 1.29, 95% CrI 0.66 to 2.41). Macrolides ranked first (95% CrI first to second), with quinolones ranked second (95% CrI second to third). Tetracyclines ranked fourth, which was lower than placebo (ranked third). Contributing studies were considered as low risk of bias in a threshold analysis. Quality of life (SGRQ) Seven studies were included (2237 participants) in this NMA. SGRQ scores improved with macrolide treatment compared with placebo (fixed effect-fixed class effect: mean difference (MD) -2.30, 95% CrI -3.61 to -0.99), but the mean difference did not reach the minimally clinical important difference (MCID) of 4 points. Tetracyclines and quinolones did not improve quality of life any more than placebo, and we did not detect a difference between antibiotic classes. Serious adverse events Nine studies were included (3180 participants) in the NMA. Macrolides reduced the odds of a serious adverse event compared with placebo (fixed effect-fixed class effect: odds ratio (OR) 0.76, 95% CrI 0.62 to 0.93). There was probably little to no difference in the effect of quinolone compared with placebo or tetracycline plus macrolide compared with placebo. There was probably little to no difference in serious adverse events between quinolones or tetracycline plus macrolide. With macrolide treatment 49 fewer people per 1000 experienced a serious adverse event compared with those given placebo. Macrolides ranked first, followed by quinolones. Tetracycline did not rank better than placebo. Drug resistance Ten studies reported drug resistance. Results were not combined due to variation in outcome measures. All studies concluded that prophylactic antibiotic administration was associated with the development of antimicrobial resistance. AUTHORS' CONCLUSIONS This NMA evaluated the safety and efficacy of different antibiotics used prophylactically for COPD patients. Compared to placebo, prolonged administration of macrolides (ranked first) appeared beneficial in prolonging the time to next exacerbation, improving quality of life, and reducing serious adverse events. No clear benefits were associated with use of quinolones or tetracyclines. In addition, antibiotic resistance was a concern and could not be thoroughly assessed in this review. Given the trade-off between effectiveness, safety, and risk of antibiotic resistance, prophylactic administration of antibiotics may be best reserved for selected patients, such as those experiencing frequent exacerbations. However, none of the eligible studies excluded patients with previously isolated non-tuberculous mycobacteria, which would contraindicate prophylactic administration of antibiotics, due to the risk of developing resistant non-tuberculous mycobacteria.
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Affiliation(s)
- Sadia Janjua
- Cochrane Airways, Population Health Research Institute, St George's, University of London, London, UK
| | - Alexander G Mathioudakis
- Division of Infection, Immunity and Respiratory Medicine, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
- North West Lung Centre, Wythenshawe Hospital, Manchester University Foundation Trust, Manchester, UK
| | - Rebecca Fortescue
- Cochrane Airways, Population Health Research Institute, St George's, University of London, London, UK
| | - Ruth Ae Walker
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Sahar Sharif
- Centre for Reviews and Dissemination, University of York, York, UK
| | | | - Sofia Dias
- Centre for Reviews and Dissemination, University of York, York, UK
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6
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Dhar R, Talwar D, Singh V, Dumra H, Rajan S, Jindal SK. Expert recommendations on the role of macrolides in chronic respiratory diseases. Lung India 2021; 38:174-182. [PMID: 33687013 PMCID: PMC8098884 DOI: 10.4103/lungindia.lungindia_498_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background: India contributes to 32% of the total global disability-adjusted life years, due to chronic respiratory diseases. This has led to a high rate of health loss from these diseases. Antibiotics are commonly used in the management of respiratory disorders. With excellent tissue penetration, prolonged tissue persistence, and favorable side effect profile, macrolides are one of the best treatment options being recommended for respiratory, urogenital, dermal, and other bacterial infections. Still, there is a lack of clinical trial data on the use of macrolides in the management of respiratory chronic disease, and hence, there is a need for clinical guidance on their use in Indian setting. Methods: A systematic review of the literature was conducted on PubMed, Cochrane database, and Google Scholar. Existing guidelines, meta-analyses, systematic reviews, randomized controlled trials (RCTs), non-RCTs, landmark studies, and key-cited articles were selected. Recommendations were based on available evidence and expert panel's logical empiricism and consensus. Results and Discussion: This article discusses evidence-based and clinical practice based management of chronic respiratory conditions including chronic obstructive pulmonary disease, asthma, bronchiectasis, diffusive panbronchiolitis, and organizing pneumonia. The authors reviewed different respiratory conditions, role of macrolides in their management, adverse events and antimicrobial resistance associated with macrolides, evidence review of various clinical trials, guideline recommendations, and clinical recommendations.
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Affiliation(s)
- Raja Dhar
- Department of Pulmonology, Fortis Hospital, Kolkata, West Bengal, India
| | - Deepak Talwar
- Respiratory Center, Pulmonology and Sleep Medicine, Metro Group of Hospitals, Noida, Uttar Pradesh, India
| | | | - Harjit Dumra
- "Sparsh" Chest Diseases Center, Ahmedabad, Gujarat, India
| | - Sujeet Rajan
- Respiratory Medicine, Bombay Hospital Institute of Medical Sciences, Mumbai, Maharashtra, India
| | - S K Jindal
- Pulmonary Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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7
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Smith D, Du Rand I, Addy CL, Collyns T, Hart SP, Mitchelmore PJ, Rahman NM, Saggu R. British Thoracic Society guideline for the use of long-term macrolides in adults with respiratory disease. Thorax 2020; 75:370-404. [PMID: 32303621 DOI: 10.1136/thoraxjnl-2019-213929] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- David Smith
- North Bristol Lung Centre, Southmead Hospital, Bristol, UK
| | | | - Charlotte Louise Addy
- Centre for Medical Education, Queens University Belfast, Regional Respiratory Centre, Belfast City Hospital, Belfast, UK
| | - Timothy Collyns
- Medical Microbiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Simon Paul Hart
- Cardiovascular and Respiratory Studies, Hull York Medical School/University of Hull, Hull, UK
| | - Philip J Mitchelmore
- Institute of Biomedical and Clinical Science, College of Medicine & Health, University of Exeter, Exeter, UK.,Department of Respiratory Medicine, Royal Devon and Exeter Hospital, Exeter, UK
| | - Najib M Rahman
- Oxford Respiratory Trials Unit and Oxford NIHR Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Ravijyot Saggu
- Pharmacy, University College London Hospitals NHS Foundation Trust, London, UK
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8
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Albertson TE, Chenoweth JA, Pearson SJ, Murin S. The pharmacological management of asthma-chronic obstructive pulmonary disease overlap syndrome (ACOS). Expert Opin Pharmacother 2020; 21:213-231. [PMID: 31955671 DOI: 10.1080/14656566.2019.1701656] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Introduction: Asthma-chronic obstructive pulmonary disease overlap syndrome (ACOS) is a disease phenotype that shares T helper lymphocyte cell Th1/neutrophilic/non-Type-2 Inflammation pathways thought to be key in COPD and Th2/eosinophilic/Type-2 inflammatory pathways of asthma. The pharmacology of treating ACOS is challenging in severe circumstances.Areas covered: This review evaluates the stepwise treatment of ACOS using pharmacological treatments used in both COPD and asthma. The most common medications involve the same inhalers used to treat COPD and asthma patients. Advanced stepwise therapies for ACOS patients are based on patient characteristics and biomarkers. Very few clinical trials exist that focus specifically on ACOS patients.Expert opinion: After inhalers, advanced therapies including phosphodiesterase inhibitors, macrolides, N-acetylcysteine and statin therapy for those ACOS patients with a COPD appearance and exacerbations are available. In atopic ACOS patients with exacerbations, advanced asthma therapies (leukotriene receptor antagonists and synthesis blocking agents.) are used. ACOS patients with elevated blood eosinophil/IgE levels are considered for immunotherapy or therapeutic monoclonal antibodies blocking specific Th2/Type-2 interleukins or IgE. Symptom control, stabilization/improvement in pulmonary function and reduced exacerbations are the metrics of success. More pharmacological trials of ACOS patients are needed to better understand which patients benefit from specific treatments.Abbreviations: 5-LOi: 5-lipoxygenase inhibitor; ACOS: asthma - COPD overlap syndrome; B2AR: Beta2 adrenergic receptors; cAMP: cyclic adenosine monophosphate; cGMP: cyclic guanosine monophosphate; CI: confidence interval; COPD: chronic obstructive pulmonary disease; CRS : chronic rhinosinusitis; cys-LT: cysteinyl leukotrienes; DPI: dry powder inhaler; EMA: European Medicines Agency; FDA: US Food and Drug Administration; FDC: fixed-dose combination; FeNO: exhaled nitric oxide; FEV1: forced expiratory volume in one second; FVC: forced vital capacity; GM-CSF: granulocyte-macrophage colony-stimulating factor; ICS : inhaled corticosteroids; IL: interleukin; ILC2: Type 2 innate lymphoid cells; IP3: Inositol triphosphate; IRR: incidence rate ratio; KOLD: Korean Obstructive Lung Disease; LABA: long-acting B2 adrenergic receptor agonist; LAMA: long-acting muscarinic receptor antagonist; LRA: leukotriene receptor antagonist; LT: leukotrienes; MDI: metered-dose inhalers; MN: M-subtype muscarinic receptors; MRA: muscarinic receptor antagonist; NAC: N-acetylcysteine; NEB: nebulization; OR: odds ratio; PDE: phosphodiesterase; PEFR: peak expiratory flow rate; PGD2: prostaglandin D2; PRN: as needed; RR: risk ratio; SABA: short-acting B2 adrenergic receptor agonist; SAMA: short-acting muscarinic receptor antagonist; SDMI: spring-driven mist inhaler; Th1: T helper cell 1 lymphocyte; Th2: T helper cell 2 lymphocytes; TNF-α: tumor necrosis factor alpha; US : United States.
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Affiliation(s)
- Timothy E Albertson
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of California, Davis, Sacramento, CA, USA.,Department of Emergency Medicine, University of California, Davis, Sacramento, CA, USA.,Veterans Administration Northern California Health Care System, Department of Medicine, Mather, CA, USA
| | - James A Chenoweth
- Department of Emergency Medicine, University of California, Davis, Sacramento, CA, USA.,Veterans Administration Northern California Health Care System, Department of Medicine, Mather, CA, USA
| | - Skyler J Pearson
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of California, Davis, Sacramento, CA, USA.,Veterans Administration Northern California Health Care System, Department of Medicine, Mather, CA, USA
| | - Susan Murin
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of California, Davis, Sacramento, CA, USA.,Veterans Administration Northern California Health Care System, Department of Medicine, Mather, CA, USA
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9
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Visser SK, Bye P, Morgan L. Management of bronchiectasis in adults. Med J Aust 2019; 209:177-183. [PMID: 30107772 DOI: 10.5694/mja17.01195] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 06/18/2018] [Indexed: 12/19/2022]
Abstract
Once neglected in research and underappreciated in practice, there is renewed interest in bronchiectasis unrelated to cystic fibrosis. Bronchiectasis is a chronic lung disease characterised by chronic cough, sputum production and recurrent pulmonary exacerbations. It is diagnosed radiologically on high resolution computed tomography chest scan by bronchial dilatation (wider than the accompanying artery). The causes of bronchiectasis are diverse and include previous respiratory tract infections, chronic obstructive pulmonary disease, asthma, immunodeficiency and connective tissue diseases. A large proportion of cases are idiopathic, reflecting our incomplete understanding of disease pathogenesis. Progress in the evidence base is reflected in the 2017 European management guidelines and the 2015 update to the Australian guidelines. Effective airway clearance remains the cornerstone of bronchiectasis management. This should be personalised and reviewed regularly by a respiratory physiotherapist. There is now robust evidence for the long term use of oral macrolide antibiotics in selected patients to reduce exacerbation frequency. The routine use of long term inhaled corticosteroids and/or long-acting bronchodilators should be avoided, unless concomitant chronic obstructive pulmonary disease or asthma exists. The evidence for nebulised agents including hypertonic saline, mannitol and antibiotics is evolving; however, access is challenging outside tertiary clinics, and nebulising equipment is required. Smokers should be supported to quit. All patients should receive influenza and pneumococcal vaccination. Patients with impaired exercise capacity should attend pulmonary rehabilitation. There is an important minority of patients for whom aetiology-specific treatment exists. The prevalence of bronchiectasis is increasing worldwide; however, the burden of disease within Australia is not well defined. To this end, the Australian Bronchiectasis Registry began recruitment in 2016 and is interoperable with the European and United States bronchiectasis registries to enable collaborative research. The recent addition of a bronchiectasis diagnosis-related group to the Australian Refined Diagnostic Related Group classification system will allow definition of the disease burden within the Australian hospital system.
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Affiliation(s)
| | - Peter Bye
- Royal Prince Alfred Hospital, Sydney, NSW
| | - Lucy Morgan
- Concord Repatriation General Hospital, Sydney, NSW
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10
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Threapleton CJD, Janjua S, Fortescue R, Baker EH. Head-to-head oral prophylactic antibiotic therapy for chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2019; 5:CD013024. [PMID: 31125127 PMCID: PMC6534184 DOI: 10.1002/14651858.cd013024.pub2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD; including chronic bronchitis and emphysema) is a chronic respiratory condition characterised by shortness of breath, cough and recurrent exacerbations. Long-term antibiotic use may reduce both bacterial load and inflammation in the airways. Studies have shown a reduction of exacerbations with antibiotics in comparison to placebo in people with COPD, but there are concerns about antibiotic resistance and safety. OBJECTIVES To compare the safety and efficacy of different classes of antibiotics (continuous, intermittent or pulsed) for prophylaxis of exacerbations in patients with COPD. SEARCH METHODS We searched the Cochrane Airways Group Trials Register and bibliographies of relevant studies. The latest literature search was conducted on 6 February 2019. SELECTION CRITERIA Randomised controlled trials (RCTs) were selected that compared one prophylactic antibiotic with another in patients with COPD. DATA COLLECTION AND ANALYSIS We used the standard Cochrane methods. Two independent review authors selected trials for inclusion, extracted data and assessed risk of bias. Discrepancies were resolved by involving a third review author. MAIN RESULTS We included two RCTs, both published in 2015 involving a total of 391 participants with treatment duration of 12 to 13 weeks. One RCT compared a quinolone (moxifloxacin pulsed, for 5 days every 4 weeks), with a tetracycline (doxycycline continuous) or a macrolide (azithromycin intermittent).The second RCT compared a tetracycline (doxycycline continuous) plus a macrolide (roxithromycin continuous), with roxithromycin (continuous) alone.The trials recruited participants with a mean age of 68 years, with moderate-severity COPD. Both trials included participants who had between two and five exacerbations in the previous one to two years. In one trial, 17% of patients had previously been using inhaled corticosteroids. In the other study, all patients were positive for Chlamydophila pneumoniae (C pneumoniae).Overall, we judged the evidence presented to be of very low-certainty, mainly due to imprecision, but we also had concerns about indirectness and methodological quality of the included studies. The primary outcome measures for this review included exacerbations, quality of life, drug resistance and serious adverse events.Macrolide + tetracycline versus macrolide There was no clear difference between treatments in improvement in quality of life as assessed by the Chronic Respiratory Questionnaire (CRQ). The CRQ scale ranges from 0 to 10 and higher scores on the scale indicate better quality of life. CRQ sub-scales for dyspnoea (mean difference (MD) 0.58, 95% confidence interval (CI) -0.84 to 2.00; 187 participants; very low-certainty evidence), fatigue (MD 0.02, 95% CI -1.08 to 1.12; 187 participants; very low-certainty evidence), emotional function (MD -0.37, 95% CI -1.74 to 1.00; 187 participants; very low-certainty evidence), or mastery (MD -0.79, 95% CI -1.86 to 0.28; 187 participants; very low-certainty evidence) at 12 weeks. For serious adverse events, it was uncertain if there was a difference between combined roxithromycin and doxycycline versus roxithromycin alone at 48 weeks follow-up after active treatment of 12 weeks (odds ratio (OR) 1.00, 95% CI 0.52 to 1.93; 198 participants; very low-certainty evidence). There were five deaths reported in the combined treatment arm, versus three in the single treatment arm at 48 weeks follow-up after active treatment of 12 weeks (OR 1.63, 95% CI 0.38 to 7.02; 198 participants; very low-certainty evidence).Quinolone versus tetracycline There was no clear difference between moxifloxacin and doxycycline for the number of participants experiencing one or more exacerbations (OR 0.44, 95% CI 0.14 to 1.38; 50 participants, very low-certainty evidence) at 13 weeks. There were no serious adverse events or deaths reported in either treatment groups. We did not identify any evidence for our other primary outcomes.Quinolone versus macrolide There was no clear difference between moxifloxacin and azithromycin for the number of participants experiencing one or more exacerbations (OR 1.00, 95% CI 0.32 to 3.10; 50 participants; very low-certainty evidence) at 13 weeks. There were no serious adverse events or deaths reported in either treatment groups. We did not identify any evidence for our other primary outcomes.Marcolide versus tetracycline There was no clear difference between azithromycin and doxycycline for the number of participants experiencing one or more exacerbations (OR 0.44, 95% CI 0.14 to 1.38; 50 participants; very low-certainty evidence) at 13 weeks. There were no serious adverse events or deaths reported in either treatment groups. We did not identify any evidence for our other primary outcomes.We did not find head-to-head evidence for impact of antibiotics on drug resistance. AUTHORS' CONCLUSIONS It is not clear from the evidence included in this review whether there is a difference in efficacy or safety between different classes or regimens of prophylactic antibiotic, given for 12 to 13 weeks to people with COPD. Whilst no head-to-head comparisons of antibiotic resistance were identified, concerns about this continue. The sample size in this review is small and both included studies are of short duration. Thus, there is considerable uncertainty in effects observed and the effects of different prophylactic antibiotics requires further research.
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Affiliation(s)
| | - Sadia Janjua
- St George's, University of LondonCochrane Airways, Population Health Research InstituteLondonUKSW17 0RE
| | - Rebecca Fortescue
- St George's, University of LondonCochrane Airways, Population Health Research InstituteLondonUKSW17 0RE
| | - Emma H Baker
- St George's, University of LondonClinical PharmacologyLondonUK
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11
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Wang D, Fu W, Dai J. Meta-analysis of macrolide maintenance therapy for prevention of disease exacerbations in patients with noncystic fibrosis bronchiectasis. Medicine (Baltimore) 2019; 98:e15285. [PMID: 31027086 PMCID: PMC6831383 DOI: 10.1097/md.0000000000015285] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Macrolide maintenance treatment remains controversial for patients with noncystic fibrosis (non-CF) bronchiectasis, we performed a meta-analysis to estimate the benefits and safety of macrolides therapy in adults and children with non-CF bronchiectasis. METHODS PubMed, Embase, the Cochrane Library, and Web of Science databases were searched for all the randomized controlled trials of macrolides for treating non-CF bronchiectasis. The primary outcome was improvement of bronchiectasis exacerbations. Secondary outcomes included adverse events and macrolide resistance. RESULTS A total of 10 studies involving 602 patients were included in the analysis. Pooled results showed that macrolide therapy significantly reduced the number of patients who suffered from exacerbations (RR = 1.56, 95% CI = 1.14-2.14, P = .006, I = 72%), number of patients who experienced at least 3 exacerbations (RR = 0.55, 95% CI = 0.39-0.77, P = .0005, I = 40%), average exacerbations per patient during the observation time (SMD = -0.69, 95% CI = -1.06 to -0.32, P = .0002, I = 60%), and bronchiectasis exacerbation-related admissions (RR = 0.46, 95% CI = 0.23-0.96, P = .04, I = 0%). Specified subgroup analyses of the number of patients free from exacerbations were further performed; macrolide therapy showed a significant benefit in both children (RR 5.03, 95% CI 2.02-12.50, P = .0005, I = 45%) and adults (RR = 1.66, 95% CI = 1.37-2.02, P < .00001, I = 79%); azithromycin showed a significant reduction on the number of patients who suffered from exacerbations (RR = 2.25, 95% CI = 1.67-3.02, P < .00001, I = 0%), was different from erythromycin (RR = 1.33, 95% CI = 0.92-1.94, P = .13, I = 0%) and roxithromycin (RR = 1.14, 95% CI = 0.97-1.35, P = .11, I = 0%). The pooled results also showed no higher risk of adverse events (RR = 0.98, 95% CI = 0.85-1.13, P = .80, I = 8%), even a lower risk of severe adverse events (RR = 0.53, 95% CI = 0.33-0.85, P = .009, I = 0%). However, a higher risk of macrolide resistance (RR = 3.59, 95% CI 2.6-4.96, P < .00001, I = 0%) was observed. CONCLUSION For both children and adults with non-CF bronchiectasis, macrolide maintenance therapy can effectively reduce bronchiectasis exacerbations, especially for patients with more frequent exacerbations and needing hospital treatment. Azithromycin was more effective than other macrolides. Macrolide maintenance therapy did not increase the risk of adverse events, but may increase the risk of macrolide resistance.
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Affiliation(s)
- Donghai Wang
- Center of Respiratory Disorders, Children's Hospital of Chongqing Medical University
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
| | - Wenlong Fu
- Center of Respiratory Disorders, Children's Hospital of Chongqing Medical University
| | - Jihong Dai
- Center of Respiratory Disorders, Children's Hospital of Chongqing Medical University
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
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12
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Cui Y, Luo L, Li C, Chen P, Chen Y. Long-term macrolide treatment for the prevention of acute exacerbations in COPD: a systematic review and meta-analysis. Int J Chron Obstruct Pulmon Dis 2018; 13:3813-3829. [PMID: 30538443 PMCID: PMC6254503 DOI: 10.2147/copd.s181246] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Acute exacerbation of COPD (AECOPD) is associated with an increased hospitalization and mortality. Azithromycin and erythromycin are the recommended drugs to reduce the risk of exacerbations. However, the most suitable duration of therapy and drug-related adverse events are still a matter of debate. The aim of this meta-analysis was to assess the current evidence regarding the efficacy and safety of long-term macrolide treatment for COPD. Materials and methods We comprehensively searched PubMed, Embase, the Cochrane Library, and the Web of Science and performed a systematic review and cumulative meta-analysis of all randomized controlled trials (RCTs) and retrospective studies. Results Eleven RCTs and one retrospective study including a total of 2,151 cases were carried out. Long-term macrolide treatment significantly reduced the total number of cases with one or more exacerbations (OR=0.40; 95% CI=0.24–0.65; P<0.01) and the rate of exacerbations per patient per year (risk ratio [RR]=0.60; 95% CI=0.45–0.78; P<0.01). Subgroup analyses showed that the minimum duration for drug efficacy for both azithromycin and erythromycin therapy was 6 months. In addition, macrolide therapy could improve the St George Respiratory Questionnaire (SGRQ) total score (P<0.01) but did not achieve the level of clinical significance. The frequency of hospitalizations was not significantly different between the treatment and control groups (P=0.50). Moreover, chronic azithromycin treatment was more likely to increase adverse events (P<0.01). Conclusion Prophylactic azithromycin or erythromycin treatment has a significant effect in reducing the frequency of AECOPD in a time-dependent manner. However, long-term macrolide treatment could increase the occurrence of adverse events and macrolide resistance. Future large-scale, well-designed RCTs with extensive follow-up are required to identify patients in whom the benefits outweigh risks.
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Affiliation(s)
- Yanan Cui
- Department of Respiratory Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China,
| | - Lijuan Luo
- Department of Respiratory Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China,
| | - Chenbei Li
- Biomedical Clinical Medicine, The Queen Marry University of London of Nanchang University, Jiangxi, China
| | - Ping Chen
- Department of Respiratory Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China,
| | - Yan Chen
- Department of Respiratory Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China,
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13
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Petitpierre N, Cottin V, Marchand-Adam S, Hirschi S, Rigaud D, Court-Fortune I, Jouneau S, Israël-Biet D, Molard A, Cordier JF, Lazor R. A 12-week combination of clarithromycin and prednisone compared to a 24-week prednisone alone treatment in cryptogenic and radiation-induced organizing pneumonia. SARCOIDOSIS VASCULITIS AND DIFFUSE LUNG DISEASES 2018; 35:230-238. [PMID: 32476907 DOI: 10.36141/svdld.v35i3.6547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 07/02/2017] [Accepted: 02/06/2018] [Indexed: 11/02/2022]
Abstract
Background: Some data suggest that anti-inflammatory macrolides may be effective to treat organizing pneumonia (OP) and prevent relapses, but no formal comparison with prednisone alone is available. To explore this issue, we retrospectively compared the efficacy of a 12-week combined regimen of clarithromycin and prednisone with a 24-week prednisone alone regimen in OP. Methods: A standard 12-week regimen of combined clarithromycin and prednisone was designed for the treatment of cryptogenic or radiation-induced OP, aiming at reducing the cumulated prednisone dose and the relapse rate. Its use was left to the discretion of the treating physicians, members of the Groupe d'Etudes et de Recherche sur les Maladies Orphelines Pulmonaires. Data were compared to a historical control group treated with a standard 24-week prednisone alone regimen. Results: 16 patients were treated with combined therapy and 21 with prednisone alone. Complete radiological remission was achieved in 63% of the combined therapy group and 81% of the prednisone alone group (p=0.38). Symptomatic relapses occurred in 81% of the combined therapy group, and 52% of the prednisone alone group (p=0.14). No side effect of clarithromycin was reported. Conclusions: In patients with cryptogenic or radiation-induced OP, a 12-week regimen of clarithromycin and prednisone showed no benefit on remission rate and relapse rate as compared to a 24-week prednisone only regimen. (Sarcoidosis Vasc Diffuse Lung Dis 2018; 35: 230-238).
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Affiliation(s)
- Nicolas Petitpierre
- Interstitial and rare lung diseases Unit, Department of Respiratory Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | - Vincent Cottin
- Department of Respiratory Medicine and Reference Center for rare lung diseases, Lyon University Hospital, Lyon, France
| | | | - Sandrine Hirschi
- Department of Respiratory Medicine, Strasbourg University Hospital, Strasbourg, France
| | | | | | - Stéphane Jouneau
- Department of Respiratory Medicine, Competences center for rare pulmonary diseases, IRSET UMR 1085, Rennes 1 University, Rennes University Hospital, Rennes, France
| | - Dominique Israël-Biet
- Department of Respiratory Medicine, Georges-Pompidou European Hospital, Paris, France
| | - Anita Molard
- Department of Respiratory Medicine, Strasbourg University Hospital, Strasbourg, France
| | - Jean-François Cordier
- Department of Respiratory Medicine and Reference Center for rare lung diseases, Lyon University Hospital, Lyon, France
| | - Romain Lazor
- Interstitial and rare lung diseases Unit, Department of Respiratory Medicine, Lausanne University Hospital, Lausanne, Switzerland.,Department of Respiratory Medicine and Reference Center for rare lung diseases, Lyon University Hospital, Lyon, France
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14
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Zimmermann P, Ziesenitz VC, Curtis N, Ritz N. The Immunomodulatory Effects of Macrolides-A Systematic Review of the Underlying Mechanisms. Front Immunol 2018; 9:302. [PMID: 29593707 PMCID: PMC5859047 DOI: 10.3389/fimmu.2018.00302] [Citation(s) in RCA: 165] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Accepted: 02/02/2018] [Indexed: 12/11/2022] Open
Abstract
Background The mechanisms underlying the non-antimicrobial immunomodulatory properties of macrolides are not well understood. Objectives To systematically review the evidence for the immunomodulatory properties of macrolides in humans and to describe the underlying mechanism and extent of their influence on the innate and adaptive immune system. Methods A systematic literature search was done in MEDLINE using the OVID interface from 1946 to December 2016 according to the preferred reporting items for systematic reviews and meta-analysis (PRISMA). Original articles investigating the influence of four macrolides (azithromycin, clarithromycin, erythromycin, and roxithromycin) on immunological markers in humans were included. Results We identified 22 randomized, controlled trials, 16 prospective cohort studies, and 8 case–control studies investigating 47 different immunological markers (186 measurements) in 1,834 participants. The most frequently reported outcomes were a decrease in the number of neutrophils, and the concentrations of neutrophil elastase, interleukin (IL)-8, IL-6, IL-1beta, tumor necrosis factor (TNF)-alpha, eosinophilic cationic protein, and matrix metalloproteinase 9. Inhibition of neutrophil function was reported more frequently than eosinophil function. A decrease in T helper (Th) 2 cells cytokines (IL-4, IL-5, IL-6) was reported more frequently than a decrease in Th1 cytokines (IL-2, INF-gamma). Conclusion Macrolides influence a broad range of immunological mechanisms resulting in immunomodulatory effects. To optimize the treatment of chronic inflammatory diseases by macrolides, further studies are necessary, particularly comparing different macrolides and dose effect relationships.
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Affiliation(s)
- Petra Zimmermann
- Department of Paediatrics, The University of Melbourne, Parkville, VIC, Australia.,Infectious Diseases & Microbiology Research Group, Murdoch Children's Research Institute, Parkville, VIC, Australia.,Infectious Diseases Unit, The Royal Children's Hospital Melbourne, Parkville, VIC, Australia.,Infectious Diseases Unit, University of Basel Children's Hospital, Basel, Switzerland
| | - Victoria C Ziesenitz
- Paediatric Pharmacology, University of Basel Children's Hospital, Basel, Switzerland
| | - Nigel Curtis
- Department of Paediatrics, The University of Melbourne, Parkville, VIC, Australia.,Infectious Diseases & Microbiology Research Group, Murdoch Children's Research Institute, Parkville, VIC, Australia.,Infectious Diseases Unit, The Royal Children's Hospital Melbourne, Parkville, VIC, Australia
| | - Nicole Ritz
- Infectious Diseases & Microbiology Research Group, Murdoch Children's Research Institute, Parkville, VIC, Australia.,Infectious Diseases Unit, University of Basel Children's Hospital, Basel, Switzerland.,Paediatric Pharmacology, University of Basel Children's Hospital, Basel, Switzerland
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15
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Shen Y, Huang S, Kang J, Lin J, Lai K, Sun Y, Xiao W, Yang L, Yao W, Cai S, Huang K, Wen F. Management of airway mucus hypersecretion in chronic airway inflammatory disease: Chinese expert consensus (English edition). Int J Chron Obstruct Pulmon Dis 2018; 13:399-407. [PMID: 29430174 PMCID: PMC5796802 DOI: 10.2147/copd.s144312] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Airway mucus hypersecretion is one of the most important characteristics of chronic airway inflammatory diseases. Evaluating and managing airway mucus hypersecretion is of great importance for patients with chronic airway inflammatory diseases. This consensus statement describes the pathogenesis, clinical features, and the management of airway mucus hypersecretion in patients with chronic airway inflammatory diseases in the People's Republic of China. The statement has been written particularly for respiratory researchers, pulmonary physicians, and patients.
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Affiliation(s)
- Yongchun Shen
- Department of Respiratory and Critical Care Medicine, West China Hospital of Sichuan University and Division of Pulmonary Diseases, State Key Laboratory of Biotherapy of China, Chengdu
| | - Shaoguang Huang
- Department of Pulmonary Disease, Ruijin Hospital, Shanghai Jiao Tong University, Shanghai
| | - Jian Kang
- Department of Respiratory Medicine, Institute of Respiratory Diseases, The First Affiliated Hospital of China Medical University, Shenyang
| | - Jiangtao Lin
- Department of Respiratory Diseases, China-Japan Friendship Hospital, Beijing
| | - Kefang Lai
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Diseases, First Affiliated Hospital of Guangzhou Medical University, Guangzhou
| | - Yongchang Sun
- Department of Respiratory and Critical Care Medicine, Peking University Third Hospital, Beijing
| | - Wei Xiao
- Department of Respiratory Medicine, Qilu Hospital of Shandong University, Jinan
| | - Lan Yang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an
| | - Wanzhen Yao
- Department of Respiratory and Critical Care Medicine, Peking University Third Hospital, Beijing
| | - Shaoxi Cai
- Department of Respiratory and Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou
| | - Kewu Huang
- Division of Pulmonary and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Fuqiang Wen
- Department of Respiratory and Critical Care Medicine, West China Hospital of Sichuan University and Division of Pulmonary Diseases, State Key Laboratory of Biotherapy of China, Chengdu
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Qiu S, Zhong X. Macrolides: a promising pharmacologic therapy for chronic obstructive pulmonary disease. Ther Adv Respir Dis 2016; 11:147-155. [PMID: 28030992 PMCID: PMC5933650 DOI: 10.1177/1753465816682677] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Chronic inflammation plays a central role in the pathogenesis of chronic
obstructive pulmonary disease (COPD). However, there are no effective
anti-inflammatory pharmacologic therapies available for COPD so far. Recent
evidence suggests that an immunologic mechanism has a role in the pathogenesis
of COPD. Macrolides possess anti-inflammatory and immune-modulating effects may
be helpful in the treatment of COPD. Several clinical studies have shown that
long-term use of macrolides reduces the frequency of COPD exacerbations.
However, the subgroups that most effectively respond to long-term treatment of
macrolides still need to be determined. The potential adverse events to
individuals and the microbial resistance in community populations raises great
concern on the long-term use of macrolides. Thus, novel macrolides have
anti-inflammatory and immuno-modulating effects, but without antibiotic effects,
and are promising as an anti-inflammatory agent for the treatment of COPD. In
addition, the combination of macrolides and other anti-inflammatory
pharmacologic agents may be a new strategy for the treatment of COPD.
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Affiliation(s)
- Shilin Qiu
- Department of Respiratory Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Xiaoning Zhong
- Department of Respiratory Medicine, The First Affiliated Hospital of Guangxi Medical University, Shuangyong road, Nanning, Guangxi 530021, China
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17
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Arenas A, Rada G. Are prophylactic antibiotics useful in chronic obstructive pulmonary disease? Medwave 2015; 15 Suppl 3:e6309. [PMID: 26571418 DOI: 10.5867/medwave.2015.6309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Bacterial infections are one of the main causes of chronic obstructive pulmonary disease exacerbation, so the use of prophylactic antibiotics, especially macrolides, has been proposed in these patients. However, it is unclear whether antibiotics use is worth the risk and cost. Searching in Epistemonikos database, which is maintained by screening 30 databases, we identified five systematic reviews including eight randomized trials. We combined the evidence using meta-analysis and generated a summary of findings table following the GRADE approach. We concluded prophylactic antibiotics probably decrease exacerbations in chronic obstructive pulmonary disease, but have no effect on hospitalizations or mortality.
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Affiliation(s)
- Alex Arenas
- Departamento de Medicina Interna, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile; Proyecto Epistemonikos, Santiago, Chile. Address: Facultad de Medicina, Pontificia Universidad Católica de Chile, Lira 63, Santiago Centro, Chile.
| | - Gabriel Rada
- Departamento de Medicina Interna, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile; Proyecto Epistemonikos, Santiago, Chile; Programa de Salud Basada en Evidencia, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile; GRADE working group; The Cochrane Collaboration
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18
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Ni W, Shao X, Cai X, Wei C, Cui J, Wang R, Liu Y. Prophylactic use of macrolide antibiotics for the prevention of chronic obstructive pulmonary disease exacerbation: a meta-analysis. PLoS One 2015; 10:e0121257. [PMID: 25812085 PMCID: PMC4374882 DOI: 10.1371/journal.pone.0121257] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Accepted: 01/29/2015] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Acute exacerbations of chronic obstructive pulmonary disease (AECOPDs) can lead to high frequencies and rates of hospitalization and mortality. Macrolides are a class of antibiotics that possess both antimicrobial and anti-inflammatory properties. Since the occurrence of AECOPDs is associated with aggravation of airway inflammation and bacterial infections, prophylactic macrolide treatment may be an effective approach towards the prevention of AECOPDs. METHODS We systemically searched the PubMed, Embase and Cochrane Library databases to identify randomized controlled trials (RCTs) that evaluated the effect of prophylactic macrolide therapy on the prevention of AECOPDs. The primary outcomes were the total number of patients with one or more exacerbations as well as the rate of exacerbations per patient per year. RESULTS Nine RCTs comprising 1666 patients met the inclusion criteria. Pooled evidence showed macrolides could reduce the frequency of exacerbations in patients with COPD by both unweighted (RR = 0.70; 95% CI: 0.56-0.87; P < 0.01) and weighted approaches (RR = 0.58, 95% CI: 0.43-0.78, P < 0.01). Subgroup analysis showed only 6-12 months of erythromycin or azithromycin therapy could be effective. Moreover, among studies with 6-12 months of azithromycin therapy, both the daily dosing regimen and the intermittent regimen significantly reduced exacerbation rates. The overall number of hospitalizations and the all-cause rate of death were not significantly different between the treatment and control groups. A tendency for more adverse events was found in the treatment groups (OR = 1.55, 95%CI: 1.003-2.39, P = 0.049). CONCLUSIONS Our results suggest 6-12 months erythromycin or azithromycin therapy could effectively reduce the frequency of exacerbations in patients with COPD. However, Long-term treatment may bring increased adverse events and the emergence of macrolide-resistance. A recommendation for the prophylactic use of macrolide therapy should weigh both the advantages and disadvantages.
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Affiliation(s)
- Wentao Ni
- Department of Respiratory Diseases, Chinese People’s Liberation Army General Hospital, Beijing, China
| | - Xiaodi Shao
- Department of Respiratory Diseases, Chinese People’s Liberation Army General Hospital, Beijing, China
| | - Xuejiu Cai
- Department of Respiratory Diseases, Chinese People’s Liberation Army General Hospital, Beijing, China
| | - Chuanqi Wei
- Department of Respiratory Diseases, Chinese People’s Liberation Army General Hospital, Beijing, China
| | - Junchang Cui
- Department of Respiratory Diseases, Chinese People’s Liberation Army General Hospital, Beijing, China
| | - Rui Wang
- Department of Clinical Pharmacology, Chinese People’s Liberation Army General Hospital, Beijing, China
| | - Youning Liu
- Department of Respiratory Diseases, Chinese People’s Liberation Army General Hospital, Beijing, China
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19
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Siekmeier R, Hofmann T, Scheuch G. Inhalation of macrolides: a novel approach to treatment of pulmonary infections. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2015; 839:13-24. [PMID: 25252902 DOI: 10.1007/5584_2014_50] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
Systemic antibiotic treatment is established for many pulmonary diseases, e.g., cystic fibrosis (CF), bronchiectasis and chronic obstructive pulmonary disease (COPD) where recurrent bacterial infections cause a progressive decline in lung function. In the last decades inhalative administration of antibiotics was introduced into clinical routine, especially tobramycin, colistin, and aztreonam for treatment of CF and bronchiectasis. Even though they are important in systemic treatment of these diseases due to their antimicrobial spectrum and anti-inflammatory and immunomodulatory properties, macrolides (e.g., azithromycin, clarithromycin, erythromycin, and telithromycin) up to now are not administered by inhalation. The number of in vitro aerosol studies and in vivo inhalation studies is also sparse. We analyzed publications on preparation and administration of macrolide aerosols available in PUBMED focusing on recent publications. Studies with solutions and dry powder aerosols were published. Publications investigating physicochemical properties of aerosols demonstrated that macrolide aerosols may serve for inhalation and will achieve sufficient lung deposition and that the bitter taste can be masked. In vivo studies in rats demonstrated high concentrations and areas under the curve sufficient for antimicrobial treatment in alveolar macrophages and epithelial lining fluid without lung toxicity. The obtained data demonstrate the feasibility of macrolide inhalation which should be further investigated.
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Affiliation(s)
- R Siekmeier
- Drug Regulatory Affairs, Pharmaceutical Institute, University Bonn, Bonn, Germany,
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20
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Montes de Oca M, López Varela MV, Acuña A, Schiavi E, Rey MA, Jardim J, Casas A, Tokumoto A, Torres Duque CA, Ramírez-Venegas A, García G, Stirbulov R, Camelier A, Bergna M, Cohen M, Guzmán S, Sánchez E. ALAT-2014 Chronic Obstructive Pulmonary Disease (COPD) Clinical Practice Guidelines: questions and answers. Arch Bronconeumol 2015; 51:403-16. [PMID: 25596991 DOI: 10.1016/j.arbres.2014.11.017] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Revised: 11/10/2014] [Accepted: 11/17/2014] [Indexed: 11/17/2022]
Abstract
ALAT-2014 COPD Clinical Practice Guidelines used clinical questions in PICO format to compile evidence related to risk factors, COPD screening, disease prognosis, treatment and exacerbations. Evidence reveals the existence of risk factors for COPD other than tobacco, as well as gender differences in disease presentation. It shows the benefit of screening in an at-risk population, and the predictive value use of multidimensional prognostic indexes. In stable COPD, similar benefits in dyspnea, pulmonary function and quality of life are achieved with LAMA or LABA long-acting bronchodilators, whereas LAMA is more effective in preventing exacerbations. Dual bronchodilator therapy has more benefits than monotherapy. LAMA and combination LABA/IC are similarly effective, but there is an increased risk of pneumonia with LABA/IC. Data on the efficacy and safety of triple therapy are scarce. Evidence supports influenza vaccination in all patients and anti-pneumococcal vaccination in patients <65years of age and/or with severe airflow limitation. Antibiotic prophylaxis may decrease exacerbation frequency in patients at risk. The use of systemic corticosteroids and antibiotics are justified in exacerbations requiring hospitalization and in some patients managed in an outpatient setting.
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Affiliation(s)
- María Montes de Oca
- Hospital Universitario de Caracas, Universidad Central de Venezuela, Caracas, Venezuela.
| | | | - Agustín Acuña
- Hospital Universitario de Caracas, Universidad Central de Venezuela, y Centro Médico Docente La Trinidad, Caracas, Venezuela
| | - Eduardo Schiavi
- Hospital de Rehabilitación Respiratoria «María Ferrer», Buenos Aires, Argentina
| | | | - José Jardim
- Universidade Federal de São Paulo, São Paulo, Brasil
| | | | | | | | | | | | - Roberto Stirbulov
- Facultad de Ciencias Médicas, Santa Casa de San Pablo, São Paulo, Brasil
| | - Aquiles Camelier
- Universidade Federal da Bahia e Escola Bahiana de Medicina, Salvador, Brasil
| | - Miguel Bergna
- Hospital Dr. Antonio Cetrángolo, Vicente López, Buenos Aires, Argentina
| | - Mark Cohen
- Hospital Centro Médico, Guatemala, Guatemala
| | | | - Efraín Sánchez
- Hospital Universitario de Caracas, Universidad Central de Venezuela, y Centro Médico Docente La Trinidad, Caracas, Venezuela
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21
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Qiu SL, Zhong XN. Current status and inspiration on macrolides in the treatment of chronic obstructive pulmonary disease. J Transl Int Med 2015; 3:85-88. [PMID: 27847894 PMCID: PMC4936464 DOI: 10.1515/jtim-2015-0015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
| | - Xiao-ning Zhong
- Address for Correspondence: Xiao-ning Zhong, Department of Respiratory Medicine, First Affiliated Hospital of Guangxi Medical University, Nanning 530021, Guangxi Zhuang Autonomous Region, China. E-mail:
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22
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Simpson JL, Powell H, Baines KJ, Milne D, Coxson HO, Hansbro PM, Gibson PG. The effect of azithromycin in adults with stable neutrophilic COPD: a double blind randomised, placebo controlled trial. PLoS One 2014; 9:e105609. [PMID: 25148049 PMCID: PMC4141795 DOI: 10.1371/journal.pone.0105609] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Accepted: 07/21/2014] [Indexed: 11/19/2022] Open
Abstract
Background Chronic Obstructive Pulmonary Disease (COPD) is a progressive airway disease characterised by neutrophilic airway inflammation or bronchitis. Neutrophilic bronchitis is associated with both bacterial colonisation and lung function decline and is common in exacerbations of COPD. Despite current available therapies to control inflammation, neutrophilic bronchitis remains common. This study tested the hypothesis that azithromycin treatment, as an add-on to standard medication, would significantly reduce airway neutrophil and neutrophils chemokine (CXCL8) levels, as well as bacterial load. We conducted a randomised, double-blind, placebo-controlled study in COPD participants with stable neutrophilic bronchitis. Methods Eligible participants (n = 30) were randomised to azithromycin 250 mg daily or placebo for 12 weeks in addition to their standard respiratory medications. Sputum was induced at screening, randomisation and monthly for a 12 week treatment period and processed for differential cell counts, CXCL8 and neutrophil elastase assessment. Quantitative bacteriology was assessed in sputum samples at randomisation and the end of treatment visit. Severe exacerbations where symptoms increased requiring unscheduled treatment were recorded during the 12 week treatment period and for 14 weeks following treatment. A sub-group of participants underwent chest computed tomography scans (n = 15). Results Nine participants with neutrophilic bronchitis had a potentially pathogenic bacteria isolated and the median total bacterial load of all participants was 5.22×107 cfu/mL. Azithromycin treatment resulted in a non-significant reduction in sputum neutrophil proportion, CXCL8 levels and bacterial load. The mean severe exacerbation rate was 0.33 per person per 26 weeks in the azithromycin group compared to 0.93 exacerbations per person in the placebo group (incidence rate ratio (95%CI): 0.37 (0.11,1.21), p = 0.062). For participants who underwent chest CT scans, no alterations were observed. Conclusions In stable COPD with neutrophilic bronchitis, add-on azithromycin therapy showed a trend to reduced severe exacerbations sputum neutrophils, CXCL8 levels and bacterial load. Future studies with a larger sample size are warranted. Trial Registration Australian New Zealand Clinical Trials Registry ACTRN12609000259246
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Affiliation(s)
- Jodie L. Simpson
- Centre for Asthma and Respiratory Diseases and Hunter Medical Research Institute, Faculty of Health and Medicine, The University of Newcastle, Callaghan, New South Wales, Australia
- * E-mail:
| | - Heather Powell
- Department of Respiratory and Sleep Medicine, Hunter New England Area Health Service, Newcastle, New South Wales, Australia
| | - Katherine J. Baines
- Centre for Asthma and Respiratory Diseases and Hunter Medical Research Institute, Faculty of Health and Medicine, The University of Newcastle, Callaghan, New South Wales, Australia
| | - David Milne
- Auckland District Health Board, Auckland, New Zealand
| | - Harvey O. Coxson
- Department of Radiology and James Hogg Research Centre, University of British Columbia, Vancouver, Canada
| | - Philip M. Hansbro
- Centre for Asthma and Respiratory Diseases and Hunter Medical Research Institute, Faculty of Health and Medicine, The University of Newcastle, Callaghan, New South Wales, Australia
| | - Peter G. Gibson
- Centre for Asthma and Respiratory Diseases and Hunter Medical Research Institute, Faculty of Health and Medicine, The University of Newcastle, Callaghan, New South Wales, Australia
- Department of Respiratory and Sleep Medicine, Hunter New England Area Health Service, Newcastle, New South Wales, Australia
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Meijer M, Rijkers GT, van Overveld FJ. Neutrophils and emerging targets for treatment in chronic obstructive pulmonary disease. Expert Rev Clin Immunol 2014; 9:1055-68. [PMID: 24168412 DOI: 10.1586/1744666x.2013.851347] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Chronic obstructive pulmonary disease (COPD) is characterized by a decreased airflow due to airway narrowing that, once it occurs, is not fully reversible. The disease usually is progressive and associated with an enhanced inflammatory response in the lungs after exposure to noxious particles or gases. After removal of the noxious particles, the inflammation can continue in a self-sustaining manner. It has been established that improper activation of neutrophils lies at the core of the pathology. This paper provides an overview of the mechanisms by which neutrophils can induce the pulmonary damage of COPD. As the pathogenesis of COPD is slowly being unraveled, new points of intervention are discovered, some of which with promising results.
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Affiliation(s)
- Mariska Meijer
- Department of Science, University College Roosevelt, Lange Noordstraat 1, 4113 CB Middelburg, The Netherlands
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Macrolide treatment in patients with bronchiectasis: More attention should be paid to the number of exacerbations. Pulm Pharmacol Ther 2014; 27:213-4. [DOI: 10.1016/j.pupt.2013.12.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2013] [Revised: 12/23/2013] [Accepted: 12/25/2013] [Indexed: 11/23/2022]
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Macrolide therapy in adults and children with non-cystic fibrosis bronchiectasis: a systematic review and meta-analysis. PLoS One 2014; 9:e90047. [PMID: 24603554 PMCID: PMC3946068 DOI: 10.1371/journal.pone.0090047] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Accepted: 01/27/2014] [Indexed: 01/17/2023] Open
Abstract
Background A systematic review and meta-analysis was conducted to evaluate the efficacy and safety of macrolide therapy in adults and children with bronchiectasis. Methods We searched the PUBMED, EMBASE, CENTRAL databases to identify relevant studies. Two reviewers evaluated the studies and extracted data independently. The primary outcome was the number of bronchiectasis exacerbations. Secondary outcomes included exacerbation-related admissions, quality of life (QoL), spirometry, 6-minute walk test (6MWT) and adverse events. Results Nine eligible trials with 559 participants were included. Six were conducted on adults, and the remaining on children. Macrolide therapy significantly reduced the number of patients experiencing one or more exacerbation in adults [risk ratio (RR) = 0.59; 95% CI, 0.40 to 0.86; P = 0.006; I2 = 65%] and children [RR = 0.86; 95% CI, 0.75–0.99; P = 0.04; I2 = 0%], but not the number of patients with admissions for exacerbation. Macrolide therapy was also associated with reduced frequency of exacerbations in adults (RR = 0.42; 95% CI, 0.29 to 0.61; P<0.001; I2 = 64%) and children (RR = 0.50; 95% CI, 0.35 to 0.71; P<0.001). Pooled analyses suggested that spirometry, including FEV1 and FVC, were significantly improved in adults but not in children. Macrolide therapy improved the QoL (WMD, −6.56; 95% CI, −11.99 to −1.12; P = 0.02; I2 = 86%) but no significant difference in 6MWT (WMD, 4.15; 95% CI, −11.83 to 20.13; P = 0.61; I2 = 31%) and the overall adverse events (RR, 0.96; 95% CI, 0.82 to 1.13; P = 0.66; I2 = 0%) in adults. However, reports of diarrhea and abdominal discomforts were higher with macrolide therapy. Conclusions Macrolide maintenance therapy, both in adults and children, was effective and safe in reducing bronchiectasis exacerbations, but not the admissions for exacerbations. In addition, macrolide administration in adults was associated with improvement in QoL and spirometry, but not 6WMT. Future studies are warranted to verify the optimal populations and clarify its potential effects on antimicrobial resistance.
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