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Madanhire T, McHugh G, Simms V, Ngwira L, Gonzalez-Martinez C, Semphere R, Moyo B, Calderwood C, Nicol M, Bandason T, Odland JO, Rehman AM, Ferrand RA. Longitudinal lung function trajectories in response to azithromycin therapy for chronic lung disease in children with HIV infection: a secondary analysis of the BREATHE trial. BMC Pulm Med 2024; 24:339. [PMID: 38997676 PMCID: PMC11245797 DOI: 10.1186/s12890-024-03155-x] [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: 05/03/2024] [Accepted: 07/08/2024] [Indexed: 07/14/2024] Open
Abstract
BACKGROUND Chronic lung disease (CLD) is common among children with HIV (CWH) including in those taking antiretroviral therapy (ART). Azithromycin has both antimicrobial and anti-inflammatory effects and has been effective in improving lung function in a variety of lung diseases. We investigated lung function trajectories among CWH with CLD on ART enrolled in a randomized controlled trial of adjuvant azithromycin. We also investigated factors that modified the effect of azithromycin on lung function. METHODS The study used data from a double-blinded placebo-controlled trial conducted in Malawi and Zimbabwe of 48 weeks on azithromycin (BREATHE: ClinicalTrials.gov NCT02426112) among CWH aged 6 to 19 years taking ART for at least six months who had a forced expiratory volume in one second (FEV1) z-score <-1.0. Participants had a further follow-up period of 24 weeks after intervention cessation. FEV1, forced vital capacity (FVC) and FEV1/FVC were measured at baseline, 24, 48 and 72-weeks and z-scores values calculated. Generalized estimating equations (GEE) models were used to determine the mean effect of azithromycin on lung-function z-scores at each follow-up time point. RESULTS Overall, 347 adolescents (51% male, median age 15 years) were randomized to azithromycin or placebo. The median duration on ART was 6.2 (interquartile range: 3.8-8.6) years and 56.2% had an HIV viral load < 1000copies/ml at baseline. At baseline, the mean FEV1 z-score was - 2.0 (0.7) with 44.7% (n = 155) having an FEV1 z-score <-2, and 10.1% had microbiological evidence of azithromycin resistance. In both trial arms, FEV1 and FVC z-scores improved by 24 weeks but appeared to decline thereafter. The adjusted overall mean difference in FEV1 z-score between the azithromycin and placebo arms was 0.004 [-0.08, 0.09] suggesting no azithromycin effect and this was similar for other lung function parameters. There was no evidence of interaction between azithromycin effect and baseline age, lung function, azithromycin resistance or HIV viral load. CONCLUSION There was no observed azithromycin effect on lung function z-scores at any time point suggesting no therapeutic effect on lung function. TRIAL REGISTRATION ClinicalTrials.gov NCT02426112. First registered on 24/04/2015.
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Affiliation(s)
- Tafadzwa Madanhire
- The Health Research Unit Zimbabwe, Biomedical Research & Training Institute, 10 Seagrave Road, Harare, Zimbabwe.
- MRC International Statistics and Epidemiology Group, London School of Hygiene & Tropical Medicine, London, UK.
| | - Grace McHugh
- The Health Research Unit Zimbabwe, Biomedical Research & Training Institute, 10 Seagrave Road, Harare, Zimbabwe
| | - Victoria Simms
- The Health Research Unit Zimbabwe, Biomedical Research & Training Institute, 10 Seagrave Road, Harare, Zimbabwe
- MRC International Statistics and Epidemiology Group, London School of Hygiene & Tropical Medicine, London, UK
| | - Lucky Ngwira
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Carmen Gonzalez-Martinez
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Department of Paediatrics and Child Health, University of Malawi College of Medicine, Blantyre, Malawi
| | - Robina Semphere
- Department of Paediatrics and Child Health, University of Malawi College of Medicine, Blantyre, Malawi
| | - Brewster Moyo
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Claire Calderwood
- The Health Research Unit Zimbabwe, Biomedical Research & Training Institute, 10 Seagrave Road, Harare, Zimbabwe
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK
| | - Mark Nicol
- Division of Medical Microbiology, Department of Pathology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Division of Infection and Immunity, School of Biomedical Sciences, University of Western Australia, Perth, Australia
| | - Tsitsi Bandason
- The Health Research Unit Zimbabwe, Biomedical Research & Training Institute, 10 Seagrave Road, Harare, Zimbabwe
| | - Jon O Odland
- Faculty of Health Sciences, UiT, The Arctic University of Norway, Tromsø, Norway
- School of Health Systems and Public Health, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - Andrea M Rehman
- MRC International Statistics and Epidemiology Group, London School of Hygiene & Tropical Medicine, London, UK
| | - Rashida A Ferrand
- The Health Research Unit Zimbabwe, Biomedical Research & Training Institute, 10 Seagrave Road, Harare, Zimbabwe
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK
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Paukner S, Kimber S, Cumper C, Rea-Davies T, Sueiro Ballesteros L, Kirkham C, Hargreaves A, Gelone SP, Richards C, Wicha WW. In Vivo Immune-Modulatory Activity of Lefamulin in an Influenza Virus A (H1N1) Infection Model in Mice. Int J Mol Sci 2024; 25:5401. [PMID: 38791439 PMCID: PMC11121702 DOI: 10.3390/ijms25105401] [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: 04/08/2024] [Revised: 05/07/2024] [Accepted: 05/13/2024] [Indexed: 05/26/2024] Open
Abstract
Lefamulin is a first-in-class systemic pleuromutilin antimicrobial and potent inhibitor of bacterial translation, and the most recent novel antimicrobial approved for the treatment of community-acquired pneumonia (CAP). It exhibits potent antibacterial activity against the most prevalent bacterial pathogens that cause typical and atypical pneumonia and other infectious diseases. Early studies indicate additional anti-inflammatory activity. In this study, we further investigated the immune-modulatory activity of lefamulin in the influenza A/H1N1 acute respiratory distress syndrome (ARDS) model in BALB/c mice. Comparators included azithromycin, an anti-inflammatory antimicrobial, and the antiviral oseltamivir. Lefamulin significantly decreased the total immune cell infiltration, specifically the neutrophils, inflammatory monocytes, CD4+ and CD8+ T-cells, NK cells, and B-cells into the lung by Day 6 at both doses tested compared to the untreated vehicle control group (placebo), whereas azithromycin and oseltamivir did not significantly affect the total immune cell counts at the tested dosing regimens. Bronchioalveolar lavage fluid concentrations of pro-inflammatory cytokines and chemokines including TNF-α, IL-6, IL-12p70, IL-17A, IFN-γ, and GM-CSF were significantly reduced, and MCP-1 concentrations were lowered (not significantly) by lefamulin at the clinically relevant 'low' dose on Day 3 when the viral load peaked. Similar effects were also observed for oseltamivir and azithromycin. Lefamulin also decreased the viral load (TCID50) by half a log10 by Day 6 and showed positive effects on the gross lung pathology and survival. Oseltamivir and lefamulin were efficacious in the suppression of the development of influenza-induced bronchi-interstitial pneumonia, whereas azithromycin did not show reduced pathology at the tested treatment regimen. The observed anti-inflammatory and immune-modulatory activity of lefamulin at the tested treatment regimens highlights a promising secondary pharmacological property of lefamulin. While these results require confirmation in a clinical trial, they indicate that lefamulin may provide an immune-modulatory activity beyond its proven potent antibacterial activity. This additional activity may benefit CAP patients and potentially prevent acute lung injury (ALI) and ARDS.
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Affiliation(s)
- Susanne Paukner
- Nabriva Therapeutics GmbH, Leberstrasse 20, 1110 Vienna, Austria;
| | - Sandra Kimber
- Charles River Discovery, Portishead BS20 7AW, UK; (S.K.); (C.C.); (T.R.-D.); (L.S.B.); (C.K.); (C.R.)
| | - Charlotte Cumper
- Charles River Discovery, Portishead BS20 7AW, UK; (S.K.); (C.C.); (T.R.-D.); (L.S.B.); (C.K.); (C.R.)
| | - Tina Rea-Davies
- Charles River Discovery, Portishead BS20 7AW, UK; (S.K.); (C.C.); (T.R.-D.); (L.S.B.); (C.K.); (C.R.)
| | - Lorena Sueiro Ballesteros
- Charles River Discovery, Portishead BS20 7AW, UK; (S.K.); (C.C.); (T.R.-D.); (L.S.B.); (C.K.); (C.R.)
| | - Christopher Kirkham
- Charles River Discovery, Portishead BS20 7AW, UK; (S.K.); (C.C.); (T.R.-D.); (L.S.B.); (C.K.); (C.R.)
| | | | | | - Claire Richards
- Charles River Discovery, Portishead BS20 7AW, UK; (S.K.); (C.C.); (T.R.-D.); (L.S.B.); (C.K.); (C.R.)
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Beigelman A, Goss CW, Wang J, Srinivasan M, Boomer J, Zhou Y, Bram S, Casper TJ, Coverstone AM, Kanchongkittiphon W, Kuklinski C, Storch GA, Schechtman KB, Castro M, Bacharier LB. Azithromycin therapy in infants hospitalized for respiratory syncytial virus bronchiolitis: Airway matrix metalloproteinase-9 levels and subsequent recurrent wheeze. Ann Allergy Asthma Immunol 2024; 132:623-629. [PMID: 38237675 DOI: 10.1016/j.anai.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Revised: 12/30/2023] [Accepted: 01/02/2024] [Indexed: 02/12/2024]
Abstract
BACKGROUND Early life respiratory syncytial virus (RSV) bronchiolitis is a significant risk factor for childhood asthma. In vitro and in vivo studies suggested that decreasing levels of airway matrix metalloproteinase (MMP)-9 during RSV bronchiolitis may be associated with clinical benefits. OBJECTIVE To investigate whether azithromycin therapy during severe RSV bronchiolitis reduces upper airway MMP-9 levels, whether upper airway MMP-9 levels correlate with upper airway interleukin IL-8 levels, and whether MMP-9 level reduction is associated with reduced post-RSV recurrent wheeze (RW). METHODS A total of 200 otherwise healthy 1- to 18-month-old infants hospitalized with RSV bronchiolitis were randomized into a double-blind, placebo-controlled trial of oral azithromycin (10 mg/kg daily for 7 days followed by 5 mg/kg daily for 7 days) or placebo. Infants were followed for 2 to 4 years for the outcome of RW (3 or more wheezing episodes). Nasal lavage samples for MMP-9 levels were obtained at baseline, day 14 (end of the study treatment), and after 6 months. RESULTS Upper airway MMP-9 levels were highly correlated with IL-8 levels at all 3 time points: randomization, day 14, and 6 months (r = 0.80; P < .0001 for all time points). MMP-9 levels were similar between treatment groups at randomization, were lower on day 14 among children treated with azithromycin (P = .0085), but no longer different after 6 months. MMP-9 levels at baseline and change from baseline to day 14 were not associated with the development of RW (P = .49, .39, respectively). CONCLUSION Azithromycin therapy in children hospitalized with RSV bronchiolitis had a short-term anti-inflammatory effect in reducing upper airway MMP-9 levels. However, the reduction in MMP-9 levels did not relate to subsequent RW post-RSV. TRIAL REGISTRATION This study is a secondary analysis of the Azithromycin to Prevent Wheezing following severe RSV bronchiolitis-II clinical trial registered at Clinicaltrials.gov (NCT02911935).
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Affiliation(s)
- Avraham Beigelman
- The Kipper Institute of Allergy and Immunology, Schneider Children's Medical Center of Israel and the Tel Aviv University, Petach Tikvah, Israel.
| | - Charles W Goss
- Division of Biostatistics, Washington University School of Medicine, St. Louis, Missouri
| | - Jinli Wang
- Division of Biostatistics, Washington University School of Medicine, St. Louis, Missouri
| | - Mythili Srinivasan
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Jonathan Boomer
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Kansas Medical Center, Kansas City, Kansas
| | - Yanjiao Zhou
- Department of Medicine, University of Connecticut School of Medicine, Farmington, Connecticut
| | - Sarah Bram
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Timothy J Casper
- Department of Pediatrics, Mercy Children's Hospital, St. Louis, Missouri
| | - Andrea M Coverstone
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | | | - Cadence Kuklinski
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Gregory A Storch
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Kenneth B Schechtman
- Division of Biostatistics, Washington University School of Medicine, St. Louis, Missouri
| | - Mario Castro
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Kansas Medical Center, Kansas City, Kansas
| | - Leonard B Bacharier
- Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt University Medical Center, Nashville, Tennessee
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4
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Du S, Shang L, Zou X, Deng X, Sun A, Mu S, Zhao J, Wang Y, Feng X, Li B, Wang C, Liu S, Lu B, Liu Y, Zhang R, Tong Y, Cao B. Azithromycin Exposure Induces Transient Microbial Composition Shifts and Decreases the Airway Microbiota Resilience from Outdoor PM 2.5 Stress in Healthy Adults: a Randomized, Double-Blind, Placebo-Controlled Trial. Microbiol Spectr 2023; 11:e0206622. [PMID: 37093053 PMCID: PMC10269807 DOI: 10.1128/spectrum.02066-22] [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: 06/03/2022] [Accepted: 03/28/2023] [Indexed: 04/25/2023] Open
Abstract
Inappropriate antibiotic prescriptions are common for patients with upper respiratory tract infections (URTIs). Few data exist regarding the effects of antibiotic administration on airway microbiota among healthy adults. We conducted a randomized, double-blind, placebo-controlled trial to characterize the airway microbiota longitudinally in healthy adults using 16S rRNA gene sequencing and quantification. Both the induced sputum and oral wash samples were collected over a 60-day period following a 3-day intervention with 500 mg azithromycin or placebo. Environmental information, including air quality data (particulate matter [PM2.5] and PM10, air quality index [AQI] values), were also collected during the study. A total of 48 healthy volunteers were enrolled and randomly assigned into two groups. Azithromycin did not alter bacterial load but significantly reduced species richness and Shannon index. Azithromycin exposure resulted in a decrease in the detection rate and relative abundance of different genera belonging to Veillonellaceae, Leptotrichia, Fusobacterium, Neisseria, and Haemophilus. In contrast, the relative abundance of taxa belonging to Streptococcus increased immediately after azithromycin intervention. The shifts in the diversity of the microbiology composition took between 14 and 60 days to recover, depending on the measure used: either UniFrac phylogenetic distance or α-diversity. Outdoor environmental perturbations, especially the high concentration of PM2.5, contributed to novel variability in microbial community composition of the azithromycin group at D30 (30 days after baseline). The network analysis found that azithromycin altered the microbial interactions within airway microbiota. The influence was still obvious at D14 when the relative abundance of most taxa had returned to the baseline level. Compared to the sputum microbiota, oral cavity microbiota had a different pattern of change over time. The induced sputum microbial data can represent the airway microbiota composition in healthy adults. Azithromycin may have transient effects in the airway microbiota of healthy adults and decrease the airway microbiota resilience against outdoor environmental stress. The influence of azithromycin on microbial interactions is noteworthy, although the airway microbiota has returned to a near-baseline level. IMPORTANCE The influence of antibiotic administration on the airway microbiota of healthy adults remains unknown. This study is a randomized, double-blind, placebo-controlled trial aiming to investigate the microbial shifts in airways after exposure to azithromycin among heathy adults. We find that azithromycin changes the airway microbial community composition of healthy adults and decreases the airway microbiota resilience against outdoor environmental stress. This study depicts the longitudinal recovery trajectory of airway microbiota after the antibiotic perturbation and may provide reference for appropriate antibiotic prescription.
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Affiliation(s)
- Sisi Du
- China-Japan Friendship Hospital, National Clinical Research Center for Respiratory Diseases, National Center for Respiratory Medicine, Clinical Center for Pulmonary Infections, Capital Medical University, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
- Department of Pulmonary and Critical Care Medicine, Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
| | - Lianhan Shang
- China-Japan Friendship Hospital, National Clinical Research Center for Respiratory Diseases, National Center for Respiratory Medicine, Clinical Center for Pulmonary Infections, Capital Medical University, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
- Department of Pulmonary and Critical Care Medicine, Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
| | - Xiaohui Zou
- China-Japan Friendship Hospital, National Clinical Research Center for Respiratory Diseases, National Center for Respiratory Medicine, Clinical Center for Pulmonary Infections, Capital Medical University, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
- Department of Pulmonary and Critical Care Medicine, Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
| | - Xiaoyan Deng
- China-Japan Friendship Hospital, National Clinical Research Center for Respiratory Diseases, National Center for Respiratory Medicine, Clinical Center for Pulmonary Infections, Capital Medical University, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
- Department of Pulmonary and Critical Care Medicine, Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
- Tsinghua University-Peking University Joint Center for Life Sciences, Beijing, China
| | - Aihua Sun
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
- Department of Pulmonary and Critical Care Medicine, Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
| | - Shengrui Mu
- China-Japan Friendship Hospital, National Clinical Research Center for Respiratory Diseases, National Center for Respiratory Medicine, Clinical Center for Pulmonary Infections, Capital Medical University, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
- Department of Pulmonary and Critical Care Medicine, Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
| | - Jiankang Zhao
- China-Japan Friendship Hospital, National Clinical Research Center for Respiratory Diseases, National Center for Respiratory Medicine, Clinical Center for Pulmonary Infections, Capital Medical University, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
- Department of Pulmonary and Critical Care Medicine, Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
| | - Yimin Wang
- China-Japan Friendship Hospital, National Clinical Research Center for Respiratory Diseases, National Center for Respiratory Medicine, Clinical Center for Pulmonary Infections, Capital Medical University, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
- Department of Pulmonary and Critical Care Medicine, Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
- Department of Pulmonary and Critical Care Medicine, Jin Yin-tan Hospital, Wuhan, Hubei, China
| | - Xiaoxuan Feng
- China-Japan Friendship Hospital, National Clinical Research Center for Respiratory Diseases, National Center for Respiratory Medicine, Clinical Center for Pulmonary Infections, Capital Medical University, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
- Department of Pulmonary and Critical Care Medicine, Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
| | - Binbin Li
- China-Japan Friendship Hospital, National Clinical Research Center for Respiratory Diseases, National Center for Respiratory Medicine, Clinical Center for Pulmonary Infections, Capital Medical University, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
- Department of Pulmonary and Critical Care Medicine, Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
| | - Chunlei Wang
- China-Japan Friendship Hospital, National Clinical Research Center for Respiratory Diseases, National Center for Respiratory Medicine, Clinical Center for Pulmonary Infections, Capital Medical University, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
- Department of Pulmonary and Critical Care Medicine, Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
| | - Shuai Liu
- China-Japan Friendship Hospital, National Clinical Research Center for Respiratory Diseases, National Center for Respiratory Medicine, Clinical Center for Pulmonary Infections, Capital Medical University, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
- Department of Pulmonary and Critical Care Medicine, Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
| | - Binghuai Lu
- China-Japan Friendship Hospital, National Clinical Research Center for Respiratory Diseases, National Center for Respiratory Medicine, Clinical Center for Pulmonary Infections, Capital Medical University, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
- Department of Pulmonary and Critical Care Medicine, Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
| | - Yingmei Liu
- China-Japan Friendship Hospital, National Clinical Research Center for Respiratory Diseases, National Center for Respiratory Medicine, Clinical Center for Pulmonary Infections, Capital Medical University, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
- Department of Pulmonary and Critical Care Medicine, Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
| | - Rongrong Zhang
- State Key Laboratory of Pathogen and Biosecurity, Beijing Institute of Microbiology and Epidemiology, Beijing, China
- College of Information Science and Technology, Beijing University of Chemical Technology, Beijing, China
| | - Yigang Tong
- State Key Laboratory of Pathogen and Biosecurity, Beijing Institute of Microbiology and Epidemiology, Beijing, China
- College of Information Science and Technology, Beijing University of Chemical Technology, Beijing, China
| | - Bin Cao
- China-Japan Friendship Hospital, National Clinical Research Center for Respiratory Diseases, National Center for Respiratory Medicine, Clinical Center for Pulmonary Infections, Capital Medical University, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
- Department of Pulmonary and Critical Care Medicine, Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
- Tsinghua University-Peking University Joint Center for Life Sciences, Beijing, China
- Changping Laboratory, Beijing, China
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Rolfe RJ, Shaikh H, Tillekeratne LG. Mass drug administration of antibacterials: weighing the evidence regarding benefits and risks. Infect Dis Poverty 2022; 11:77. [PMID: 35773722 PMCID: PMC9243730 DOI: 10.1186/s40249-022-00998-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 06/09/2022] [Indexed: 11/10/2022] Open
Abstract
Background Mass drug administration (MDA) is a strategy to improve health at the population level through widespread delivery of medicine in a community. We surveyed the literature to summarize the benefits and potential risks associated with MDA of antibacterials, focusing predominantly on azithromycin as it has the greatest evidence base.
Main body High-quality evidence from randomized controlled trials (RCTs) indicate that MDA-azithromycin is effective in reducing the prevalence of infection due to yaws and trachoma. In addition, RCTs suggest that MDA-azithromycin reduces under-five mortality in certain low-resource settings that have high childhood mortality rates at baseline. This reduction in mortality appears to be sustained over time with twice-yearly MDA-azithromycin, with the greatest effect observed in children < 1 year of age. In addition, observational data suggest that infections such as skin and soft tissue infections, rheumatic heart disease, acute respiratory illness, diarrheal illness, and malaria may all be treated by azithromycin and thus incidentally impacted by MDA-azithromycin. However, the mechanism by which MDA-azithromycin reduces childhood mortality remains unclear. Verbal autopsies performed in MDA-azithromycin childhood mortality studies have produced conflicting data and are underpowered to answer this question. In addition to benefits, there are several important risks associated with MDA-azithromycin. Direct adverse effects potentially resulting from MDA-azithromycin include gastrointestinal side effects, idiopathic hypertrophic pyloric stenosis, cardiovascular side effects, and increase in chronic diseases such as asthma and obesity. Antibacterial resistance is also a risk associated with MDA-azithromycin and has been reported for both gram-positive and enteric organisms. Further, there is the risk for cross-resistance with other antibacterial agents, especially clindamycin. Conclusions Evidence shows that MDA-azithromycin programs may be beneficial for reducing trachoma, yaws, and mortality in children < 5 years of age in certain under-resourced settings. However, there are significant potential risks that need to be considered when deciding how, when, and where to implement these programs. Robust systems to monitor benefits as well as adverse effects and antibacterial resistance are warranted in communities where MDA-azithromycin programs are implemented. Graphical Abstract ![]()
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Affiliation(s)
- Robert J Rolfe
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, NC, USA.,Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Hassaan Shaikh
- Department of Medicine, University of Pittsburgh Medical Center, McKeesport, PA, USA
| | - L Gayani Tillekeratne
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, NC, USA. .,Duke Global Health Institute, Duke University, Durham, NC, USA. .,Department of Medicine, Faculty of Medicine, University of Ruhuna, Galle, Sri Lanka.
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Prathapan P. A determination of pan-pathogen antimicrobials? MEDICINE IN DRUG DISCOVERY 2022; 14:100120. [PMID: 35098103 PMCID: PMC8785259 DOI: 10.1016/j.medidd.2022.100120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Revised: 01/01/2022] [Accepted: 01/17/2022] [Indexed: 11/29/2022] Open
Abstract
While antimicrobial drug development has historically mitigated infectious diseases that are known, COVID-19 revealed a dearth of 'in-advance' therapeutics suitable for infections by pathogens that have not yet emerged. Such drugs must exhibit a property that is antithetical to the classical paradigm of antimicrobial development: the ability to treat infections by any pathogen. Characterisation of such 'pan-pathogen' antimicrobials requires consolidation of drug repositioning studies, a new and growing field of drug discovery. In this review, a previously-established system for evaluating repositioning studies is used to highlight 4 therapeutics which exhibit pan-pathogen properties, namely azithromycin, ivermectin, niclosamide, and nitazoxanide. Recognition of the pan-pathogen nature of these antimicrobials is the cornerstone of a novel paradigm of antimicrobial development that is not only anticipatory of pandemics and bioterrorist attacks, but cognisant of conserved anti-infective mechanisms within the host-pathogen interactome which are only now beginning to emerge. Ultimately, the discovery of pan-pathogen antimicrobials is concomitantly the discovery of a new class of antivirals, and begets significant implications for pandemic preparedness research in a world after COVID-19.
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Affiliation(s)
- Praveen Prathapan
- New Biochemistry, University of Oxford, South Parks Road, Oxford OX1 3QU, United Kingdom
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7
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Beigelman A, Srinivasan M, Goss CW, Wang J, Zhou Y, True K, Ahrens E, Burgdorf D, Haslam MD, Boomer J, Bram S, Burnham CAD, Casper TJ, Coverstone AM, Kanchongkittiphon W, Kuklinski C, Storch GA, Wallace MA, Yin-DeClue H, Castro M, Schechtman KB, Bacharier LB. Azithromycin to Prevent Recurrent Wheeze Following Severe Respiratory Syncytial Virus Bronchiolitis. NEJM EVIDENCE 2022; 1:10.1056/evidoa2100069. [PMID: 37621674 PMCID: PMC10448891 DOI: 10.1056/evidoa2100069] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Abstract
BACKGROUND Early-life severe respiratory syncytial virus (RSV) bronchiolitis is a risk factor for childhood asthma. Because azithromycin may attenuate airway inflammation during RSV bronchiolitis, we evaluated whether it would reduce the occurrence of post-RSV recurrent wheeze. METHODS We prospectively enrolled 200 otherwise healthy 1- to 18-month-old children hospitalized with RSV bronchiolitis in this single-center, double-blind, placebo-controlled study and randomly assigned them to receive oral azithromycin (10 mg/kg daily for 7 days, followed by 5 mg/kg daily for 7 days) or placebo. Randomization was stratified by recent open-label antibiotic use. The primary outcome was the occurrence of recurrent wheeze, defined as a third episode of post-RSV wheeze over the following 2 to 4 years. RESULTS As an indication of the biologic activity of azithromycin, nasal wash interleukin-8 levels, at day 14 after randomization, were lower among azithromycin-treated participants (P<0.01). Despite evidence of biologic activity, azithromycin did not reduce the risk of post-RSV recurrent wheeze (47% in the azithromycin group vs. 36% in the placebo group; adjusted hazard ratio, 1.45; 95% confidence interval [CI], 0.92 to 2.29; P=0.11). Azithromycin also did not modify the risk of recurrent wheeze among participants already receiving other antibiotic treatment at the time of enrollment (hazard ratio, 0.94; 95% CI, 0.43 to 2.07). There was a potential signal among antibiotic-naïve participants who received azithromycin to have an increased risk of recurrent wheeze (hazard ratio, 1.79; 95% CI, 1.03 to 3.1). CONCLUSIONS Azithromycin therapy for 14 days during acute severe RSV bronchiolitis did not reduce recurrent wheeze occurrence over the following 2 to 4 years. Our data suggest no benefit of azithromycin administration with the goal of preventing recurrent wheeze in later life. (Funded by the National Heart, Lung, and Blood Institute; ClinicalTrials.gov number, NCT02911935.).
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Affiliation(s)
- Avraham Beigelman
- Division of Allergy and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis
- Kipper Institute of Allergy and Immunology, Schneider Children's Medical Center of Israel and the Tel Aviv University, Petach Tikvah, Israel
| | - Mythili Srinivasan
- Division of Hospitalist Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis
| | - Charles W Goss
- Division of Biostatistics, Washington University School of Medicine, St. Louis
| | - Jinli Wang
- Division of Biostatistics, Washington University School of Medicine, St. Louis
| | - Yanjiao Zhou
- Department of Medicine, University of Connecticut School of Medicine, Farmington, CT
| | - Kelly True
- Division of Allergy and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis
| | - Elizabeth Ahrens
- Division of Allergy and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis
| | - Dana Burgdorf
- Division of Allergy and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis
| | | | - Jonathan Boomer
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Kansas Medical Center, Kansas City, KS
| | - Sarah Bram
- Division of Hospitalist Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis
| | - Carey-Ann D Burnham
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis
| | | | - Andrea M Coverstone
- Division of Allergy and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis
| | | | - Cadence Kuklinski
- Division of Allergy and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis
| | - Gregory A Storch
- Division of Pediatric Infectious Disease, Department of Pediatrics, Washington University School of Medicine, St. Louis
| | - Meghan A Wallace
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis
| | - Huiqing Yin-DeClue
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Kansas Medical Center, Kansas City, KS
| | - Mario Castro
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Kansas Medical Center, Kansas City, KS
| | | | - Leonard B Bacharier
- Department of Pediatrics, Monroe Carell Jr Children's Hospital at Vanderbilt University Medical Center, Nashville
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8
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Sauer A, Peukert K, Putensen C, Bode C. Antibiotics as immunomodulators: a potential pharmacologic approach for ARDS treatment. Eur Respir Rev 2021; 30:210093. [PMID: 34615700 PMCID: PMC9489085 DOI: 10.1183/16000617.0093-2021] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 07/02/2021] [Indexed: 11/05/2022] Open
Abstract
First described in the mid-1960s, acute respiratory distress syndrome (ARDS) is a life-threatening form of respiratory failure with an overall mortality rate of approximately 40%. Despite significant advances in the understanding and treatment of ARDS, no substantive pharmacologic therapy has proven to be beneficial, and current management continues to be primarily supportive. Beyond their antibacterial activity, several antibiotics such as macrolides and tetracyclines exert pleiotropic immunomodulatory effects that might be able to rectify the dysregulated inflammatory response present in patients with ARDS. This review aims to provide an overview of preclinical and clinical studies that describe the immunomodulatory effects of antibiotics in ARDS. Moreover, the underlying mechanisms of their immunomodulatory properties will be discussed. Further studies are necessary to investigate their full therapeutic potential and to identify ARDS phenotypes which are most likely to benefit from their immunomodulatory effects.
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Affiliation(s)
- Andrea Sauer
- Dept of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Konrad Peukert
- Dept of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Christian Putensen
- Dept of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Christian Bode
- Dept of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
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9
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Aranda-Abreu GE, Aranda-Martínez JD, Araújo R, Hernández-Aguilar ME, Herrera-Covarrubias D, Rojas-Durán F. Observational study of people infected with SARS-Cov-2, treated with amantadine. Pharmacol Rep 2020; 72:1538-1541. [PMID: 33040252 PMCID: PMC7547815 DOI: 10.1007/s43440-020-00168-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 09/16/2020] [Accepted: 10/01/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND We conducted an observational study of 15 patients from a Southeastern area of Mexico with symptoms compatible with SARS-Cov-2, which were treated with the antiviral amantadine. METHODOLOGY In this study, data were collected from 15 individuals with clinical symptoms of COVID-19 infection, which were treated on an ambulatory basis with 100 mg of amantadine for a period of 14 days. RESULTS This drug demonstrated its effectiveness, as patients recovered successfully with this treatment without the necessity of attending a hospital to use mechanical ventilation. All patients developed IgG antibodies to SARS-Cov-2. CONCLUSION Amantadine can be used as a viable and cost-effective alternative for treating people with severe acute respiratory syndrome (SARS-Cov-2) on an ambulatory basis, while the vaccine is not available.
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Affiliation(s)
| | | | | | | | | | - Fausto Rojas-Durán
- Universidad Veracruzana/Centro de Investigaciones Cerebrales, Xalapa, Veracruz Mexico
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10
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Saglani S, Wisnivesky JP, Charokopos A, Pascoe CD, Halayko AJ, Custovic A. Update in Asthma 2019. Am J Respir Crit Care Med 2020; 202:184-192. [PMID: 32338992 DOI: 10.1164/rccm.202003-0596up] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Sejal Saglani
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Juan P Wisnivesky
- Division of General Internal Medicine and.,Division of Pulmonary and Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Antonios Charokopos
- Division of Pulmonary and Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Christopher D Pascoe
- Department of Physiology and Pathophysiology, University of Manitoba, Winnipeg, Manitoba, Canada; and.,Biology of Breathing Group, Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada
| | - Andrew J Halayko
- Department of Physiology and Pathophysiology, University of Manitoba, Winnipeg, Manitoba, Canada; and.,Biology of Breathing Group, Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada
| | - Adnan Custovic
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
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11
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Mac Aogáin M, Lau KJX, Cai Z, Kumar Narayana J, Purbojati RW, Drautz-Moses DI, Gaultier NE, Jaggi TK, Tiew PY, Ong TH, Siyue Koh M, Lim Yick Hou A, Abisheganaden JA, Tsaneva-Atanasova K, Schuster SC, Chotirmall SH. Metagenomics Reveals a Core Macrolide Resistome Related to Microbiota in Chronic Respiratory Disease. Am J Respir Crit Care Med 2020; 202:433-447. [PMID: 32320621 PMCID: PMC7397787 DOI: 10.1164/rccm.201911-2202oc] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 04/22/2020] [Indexed: 12/16/2022] Open
Abstract
Rationale: Long-term antibiotic use for managing chronic respiratory disease is increasing; however, the role of the airway resistome and its relationship to host microbiomes remains unknown.Objectives: To evaluate airway resistomes and relate them to host and environmental microbiomes using ultradeep metagenomic shotgun sequencing.Methods: Airway specimens from 85 individuals with and without chronic respiratory disease (severe asthma, chronic obstructive pulmonary disease, and bronchiectasis) were subjected to metagenomic sequencing to an average depth exceeding 20 million reads. Respiratory and device-associated microbiomes were evaluated on the basis of taxonomical classification and functional annotation including the Comprehensive Antibiotic Resistance Database to determine airway resistomes. Co-occurrence networks of gene-microbe association were constructed to determine potential microbial sources of the airway resistome. Paired patient-inhaler metagenomes were compared (n = 31) to assess for the presence of airway-environment overlap in microbiomes and/or resistomes.Measurements and Main Results: Airway metagenomes exhibit taxonomic and metabolic diversity and distinct antimicrobial resistance patterns. A "core" airway resistome dominated by macrolide but with high prevalence of β-lactam, fluoroquinolone, and tetracycline resistance genes exists and is independent of disease status or antibiotic exposure. Streptococcus and Actinomyces are key potential microbial reservoirs of macrolide resistance including the ermX, ermF, and msrD genes. Significant patient-inhaler overlap in airway microbiomes and their resistomes is identified where the latter may be a proxy for airway microbiome assessment in chronic respiratory disease.Conclusions: Metagenomic analysis of the airway reveals a core macrolide resistome harbored by the host microbiome.
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Affiliation(s)
| | - Kenny J. X. Lau
- Singapore Centre for Environmental Life Sciences Engineering, Nanyang Technological University, Singapore, Singapore
| | - Zhao Cai
- Singapore Centre for Environmental Life Sciences Engineering, Nanyang Technological University, Singapore, Singapore
| | | | - Rikky W. Purbojati
- Singapore Centre for Environmental Life Sciences Engineering, Nanyang Technological University, Singapore, Singapore
| | - Daniela I. Drautz-Moses
- Singapore Centre for Environmental Life Sciences Engineering, Nanyang Technological University, Singapore, Singapore
| | - Nicolas E. Gaultier
- Singapore Centre for Environmental Life Sciences Engineering, Nanyang Technological University, Singapore, Singapore
| | | | - Pei Yee Tiew
- Lee Kong Chian School of Medicine and
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore, Singapore
| | - Thun How Ong
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore, Singapore
| | - Mariko Siyue Koh
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore, Singapore
| | - Albert Lim Yick Hou
- Department of Respiratory and Critical Care Medicine, Tan Tock Seng Hospital, Singapore, Singapore; and
| | - John A. Abisheganaden
- Department of Respiratory and Critical Care Medicine, Tan Tock Seng Hospital, Singapore, Singapore; and
| | - Krasimira Tsaneva-Atanasova
- Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, United Kingdom
| | - Stephan C. Schuster
- Singapore Centre for Environmental Life Sciences Engineering, Nanyang Technological University, Singapore, Singapore
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12
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Cheng GS, Bondeelle L, Gooley T, He Q, Jamani K, Krakow EF, Flowers MED, de Latour RP, Michonneau D, Socié G, Chien JW, Chevret S, Bergeron A. Azithromycin Use and Increased Cancer Risk among Patients with Bronchiolitis Obliterans after Hematopoietic Cell Transplantation. Biol Blood Marrow Transplant 2019; 26:392-400. [PMID: 31682980 DOI: 10.1016/j.bbmt.2019.10.025] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 10/08/2019] [Accepted: 10/25/2019] [Indexed: 01/13/2023]
Abstract
Azithromycin exposure during the early phase of allogeneic hematopoietic cell transplantation (HCT) has been associated with an increased incidence of hematologic relapse. We assessed the impact of azithromycin exposure on the occurrence of relapse or new subsequent neoplasm (SN) in patients with bronchiolitis obliterans syndrome (BOS) after HCT who are commonly treated with azithromycin alone or in combination with other agents. In a retrospective study of patients with BOS from 2 large allograft centers, the effect of azithromycin exposure on the risk of relapse or SN was estimated from a Cox model with a time-dependent variable for treatment initiation. The Cox model was adjusted on time-fixed covariates measured at cohort entry, selected for their potential prognostic value. Similar models were used to assess the exposure effect on the cause-specific hazard of relapse, SN, and death free of those events. Sensitivity analyses were performed using propensity score matching. Among 316 patients, 227 (71.8%) were exposed to azithromycin after BOS diagnosis. The corresponding adjusted hazard ratio (HR) in patients exposed to azithromycin versus unexposed was 1.51 (95% confidence interval [CI], 0.90 to 2.55) for relapse or SN, 0.82 (95% CI, 0.37 to 1.83) for relapse, and 2.00 (95% CI, 1.01 to 3.99) for SN. Patients exposed to azithromycin had a significantly lower cause-specific hazard of death free of neoplasm and relapse (adjusted HR, 0.54; 95% CI, 0.34 to 0.89). In conclusion, exposure to azithromycin after BOS after HCT was associated with an increased risk of SN but not relapse.
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Affiliation(s)
- Guang-Shing Cheng
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington
| | - Louise Bondeelle
- AP-HP, Université de Paris, Hôpital Saint-Louis, Service de Pneumologie, Paris, France
| | - Ted Gooley
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Qianchuan He
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Kareem Jamani
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Elizabeth F Krakow
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Medical Oncology, Department of Medicine, University of Washington, Seattle, Washington
| | - Mary E D Flowers
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Medical Oncology, Department of Medicine, University of Washington, Seattle, Washington
| | | | - David Michonneau
- AP-HP, Hématologie-Transplantation Hôpital St Louis, Université de Paris et INSERM UMR 1160, Paris, France
| | - Gérard Socié
- AP-HP, Hématologie-Transplantation Hôpital St Louis, Université de Paris et INSERM UMR 1160, Paris, France
| | - Jason W Chien
- Infectious Diseases Therapeutic Area, Janssen Biopharma, South San Francisco, California
| | - Sylvie Chevret
- AP-HP, Hôpital Saint-Louis, Service de Biostatistique et Information Médicale, Paris, France; Université de Paris, ECSTRRA, UMR 1153 CRESS, Biostatistics and Clinical Epidemiology Research Team, Paris, France
| | - Anne Bergeron
- AP-HP, Université de Paris, Hôpital Saint-Louis, Service de Pneumologie, Paris, France; Université de Paris, ECSTRRA, UMR 1153 CRESS, Biostatistics and Clinical Epidemiology Research Team, Paris, France.
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