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Immunomodulatory Effects of Macrolides Considering Evidence from Human and Veterinary Medicine. Microorganisms 2022; 10:microorganisms10122438. [PMID: 36557690 PMCID: PMC9784682 DOI: 10.3390/microorganisms10122438] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 11/17/2022] [Accepted: 12/05/2022] [Indexed: 12/13/2022] Open
Abstract
Macrolide antimicrobial agents have been in clinical use for more than 60 years in both human and veterinary medicine. The discovery of the non-antimicrobial properties of macrolides and the effect of immunomodulation of the inflammatory response has benefited patients with chronic airway diseases and impacted morbidity and mortality. This review examines the evidence of antimicrobial and non-antimicrobial properties of macrolides in human and veterinary medicine with a focus toward veterinary macrolides but including important and relevant evidence from the human literature. The complete story for these complex and important molecules is continuing to be written.
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OUP accepted manuscript. J Antimicrob Chemother 2022; 77:1218-1227. [DOI: 10.1093/jac/dkac025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Accepted: 01/05/2022] [Indexed: 11/14/2022] Open
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Ali AS, ASattar MA, Karim S, Kutbi D, Aljohani H, Bakhshwin D, Alsieni M, Alkreathy HM. Pharmacological basis for the potential role of Azithromycin and Doxycycline in management of COVID-19. ARAB J CHEM 2021; 14:102983. [PMID: 34909062 PMCID: PMC7797177 DOI: 10.1016/j.arabjc.2020.102983] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 12/27/2020] [Accepted: 12/28/2020] [Indexed: 01/25/2023] Open
Abstract
A novel corona virus SARS-CoV-2 has led to an outbreak of the highly infectious pandemic COVID-19 complicated viral pneumonia. Patients with risk factors frequently develop secondary infections where the role of appropriate antibiotics is mandatory. However, the efforts of drug repurposing lead to recognizing the role of certain antibiotics beyond the management of infection. The current review provided the detailed antiviral, immunomodulatory effect, unique pharmacokinetic profile of two antibiotics namely azithromycin (AZ) and doxycycline (DOX). It summarizes current clinical trials and concerns regarding safety issues of these drugs. Azithromycin (AZ) has amazing lung tissue access, wide range antibacterial efficacy, conceivable antiviral action against COVID-19. It also showed efficacy when combined with other antiviral drugs in limited clinical trials, but many clinicians raise concerns regarding cardiovascular risk in susceptible patients. DOX has a considerable role in the management of pneumonia, it has some advantages including cardiac safety, very good access to lung tissue, potential antiviral, and immunomodulation impact by several mechanisms. The pharmacological profiles of both drugs are heightening considering these medications for further studies in the management of COVID-19.
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Affiliation(s)
- Ahmed S Ali
- Department of Pharmacology Faculty of Medicine, King Abdulaziz University, Saudi Arabia
- Department of Pharmaceutics Faculty of Pharmacy, Assiut University, Egypt
| | - Mai A ASattar
- Department of Pharmacology Faculty of Medicine, King Abdulaziz University, Saudi Arabia
| | - Shahid Karim
- Department of Pharmacology Faculty of Medicine, King Abdulaziz University, Saudi Arabia
| | - Dina Kutbi
- Department of Pharmacology Faculty of Medicine, King Abdulaziz University, Saudi Arabia
| | - Hanin Aljohani
- Department of Pharmacology Faculty of Medicine, King Abdulaziz University, Saudi Arabia
| | - Duaa Bakhshwin
- Department of Pharmacology Faculty of Medicine, King Abdulaziz University, Saudi Arabia
| | - Mohammed Alsieni
- Department of Pharmacology Faculty of Medicine, King Abdulaziz University, Saudi Arabia
| | - Huda M Alkreathy
- Department of Pharmacology Faculty of Medicine, King Abdulaziz University, Saudi Arabia
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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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Maekawa T, Tamura H, Domon H, Hiyoshi T, Isono T, Yonezawa D, Hayashi N, Takahashi N, Tabeta K, Maeda T, Oda M, Ziogas A, Alexaki VI, Chavakis T, Terao Y, Hajishengallis G. Erythromycin inhibits neutrophilic inflammation and mucosal disease by upregulating DEL-1. JCI Insight 2020; 5:136706. [PMID: 32603314 DOI: 10.1172/jci.insight.136706] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 06/24/2020] [Indexed: 02/06/2023] Open
Abstract
Macrolide antibiotics exert antiinflammatory effects; however, little is known regarding their immunomodulatory mechanisms. In this study, using 2 distinct mouse models of mucosal inflammatory disease (LPS-induced acute lung injury and ligature-induced periodontitis), we demonstrated that the antiinflammatory action of erythromycin (ERM) is mediated through upregulation of the secreted homeostatic protein developmental endothelial locus-1 (DEL-1). Consistent with the anti-neutrophil recruitment action of endothelial cell-derived DEL-1, ERM inhibited neutrophil infiltration in the lungs and the periodontium in a DEL-1-dependent manner. Whereas ERM (but not other antibiotics, such as josamycin and penicillin) protected against lethal pulmonary inflammation and inflammatory periodontal bone loss, these protective effects of ERM were abolished in Del1-deficient mice. By interacting with the growth hormone secretagogue receptor and activating JAK2 in human lung microvascular endothelial cells, ERM induced DEL-1 transcription that was mediated by MAPK p38 and was CCAAT/enhancer binding protein-β dependent. Moreover, ERM reversed IL-17-induced inhibition of DEL-1 transcription, in a manner that was dependent not only on JAK2 but also on PI3K/AKT signaling. Because DEL-1 levels are severely reduced in inflammatory conditions and with aging, the ability of ERM to upregulate DEL-1 may lead to a novel approach for the treatment of inflammatory and aging-related diseases.
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Affiliation(s)
- Tomoki Maekawa
- Center for Advanced Oral Science.,Division of Microbiology and Infectious Diseases.,Division of Periodontology, and
| | - Hikaru Tamura
- Center for Advanced Oral Science.,Division of Microbiology and Infectious Diseases.,Division of Periodontology, and
| | - Hisanori Domon
- Center for Advanced Oral Science.,Division of Microbiology and Infectious Diseases
| | - Takumi Hiyoshi
- Center for Advanced Oral Science.,Division of Microbiology and Infectious Diseases
| | | | - Daisuke Yonezawa
- Center for Advanced Oral Science.,Division of Oral Science for Health Promotion, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Naoki Hayashi
- Department of Microbiology and Infection Control Sciences, Kyoto Pharmaceutical University, Yamashina, Japan
| | | | | | - Takeyasu Maeda
- Center for Advanced Oral Science.,Faculty of Dental Medicine, Universitas Airlangga, Surabaya, Indonesia
| | - Masataka Oda
- Department of Microbiology and Infection Control Sciences, Kyoto Pharmaceutical University, Yamashina, Japan
| | - Athanasios Ziogas
- Institute of Clinical Chemistry and Laboratory Medicine, Faculty of Medicine and University Clinic Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Vasileia Ismini Alexaki
- Institute of Clinical Chemistry and Laboratory Medicine, Faculty of Medicine and University Clinic Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Triantafyllos Chavakis
- Institute of Clinical Chemistry and Laboratory Medicine, Faculty of Medicine and University Clinic Carl Gustav Carus, TU Dresden, Dresden, Germany.,Centre for Cardiovascular Science, Queen's Medical Research Institute, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, United Kingdom
| | - Yutaka Terao
- Center for Advanced Oral Science.,Division of Microbiology and Infectious Diseases
| | - George Hajishengallis
- Laboratory of Innate Immunity and Inflammation, Department of Basic and Translational Sciences, Penn Dental Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Davidson RJ. In vitro activity and pharmacodynamic/pharmacokinetic parameters of clarithromycin and azithromycin: why they matter in the treatment of respiratory tract infections. Infect Drug Resist 2019; 12:585-596. [PMID: 30881064 PMCID: PMC6413744 DOI: 10.2147/idr.s187226] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Clarithromycin and azithromycin are second-generation macrolides established and widely used for treating a range of upper and lower respiratory tract infections. Extensive clinical trials data indicate that these drugs are highly effective in these applications and broadly comparable in their clinical and microbiological effectiveness. However, consideration of pharmacokinetic, metabolic, and tissue-penetration data, including the significant antibacterial activity of the metabolite 14-hydroxy-clarithromycin, plus the findings of pharmacodynamic modeling, provide evidence that the long half-life and lower potency of azithromycin predispose this agent to select for resistant isolates. Comparison of the "mutant-prevention concentrations" of clarithromycin and azithromycin, and examination of large-scale epidemiological data from Canada, also support the view that these drugs differ materially in their propensity to promote resistance among bacterial strains implicated in common respiratory infections, and that clarithromycin may offer important advantages over azithromycin that should be considered when choosing a macrolide to treat these conditions.
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Affiliation(s)
- Ross J Davidson
- Department of Pathology and Laboratory Medicine, Division of Microbiology, Queen Elizabeth II Health Sciences Center, Halifax, NS, Canada,
- Department of Medicine,
- Department of Pathology,
- Department of Microbiology & Immunology, Dalhousie University, Halifax, NS, Canada,
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Hansen MP, Scott AM, McCullough A, Thorning S, Aronson JK, Beller EM, Glasziou PP, Hoffmann TC, Clark J, Del Mar CB. Adverse events in people taking macrolide antibiotics versus placebo for any indication. Cochrane Database Syst Rev 2019; 1:CD011825. [PMID: 30656650 PMCID: PMC6353052 DOI: 10.1002/14651858.cd011825.pub2] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Macrolide antibiotics (macrolides) are among the most commonly prescribed antibiotics worldwide and are used for a wide range of infections. However, macrolides also expose people to the risk of adverse events. The current understanding of adverse events is mostly derived from observational studies, which are subject to bias because it is hard to distinguish events caused by antibiotics from events caused by the diseases being treated. Because adverse events are treatment-specific, rather than disease-specific, it is possible to increase the number of adverse events available for analysis by combining randomised controlled trials (RCTs) of the same treatment across different diseases. OBJECTIVES To quantify the incidences of reported adverse events in people taking macrolide antibiotics compared to placebo for any indication. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), which includes the Cochrane Acute Respiratory Infections Group Specialised Register (2018, Issue 4); MEDLINE (Ovid, from 1946 to 8 May 2018); Embase (from 2010 to 8 May 2018); CINAHL (from 1981 to 8 May 2018); LILACS (from 1982 to 8 May 2018); and Web of Science (from 1955 to 8 May 2018). We searched clinical trial registries for current and completed trials (9 May 2018) and checked the reference lists of included studies and of previous Cochrane Reviews on macrolides. SELECTION CRITERIA We included RCTs that compared a macrolide antibiotic to placebo for any indication. We included trials using any of the four most commonly used macrolide antibiotics: azithromycin, clarithromycin, erythromycin, or roxithromycin. Macrolides could be administered by any route. Concomitant medications were permitted provided they were equally available to both treatment and comparison groups. DATA COLLECTION AND ANALYSIS Two review authors independently extracted and collected data. We assessed the risk of bias of all included studies and the quality of evidence for each outcome of interest. We analysed specific adverse events, deaths, and subsequent carriage of macrolide-resistant bacteria separately. The study participant was the unit of analysis for each adverse event. Any specific adverse events that occurred in 5% or more of any group were reported. We undertook a meta-analysis when three or more included studies reported a specific adverse event. MAIN RESULTS We included 183 studies with a total of 252,886 participants (range 40 to 190,238). The indications for macrolide antibiotics varied greatly, with most studies using macrolides for the treatment or prevention of either acute respiratory tract infections, cardiovascular diseases, chronic respiratory diseases, gastrointestinal conditions, or urogynaecological problems. Most trials were conducted in secondary care settings. Azithromycin and erythromycin were more commonly studied than clarithromycin and roxithromycin.Most studies (89%) reported some adverse events or at least stated that no adverse events were observed.Gastrointestinal adverse events were the most commonly reported type of adverse event. Compared to placebo, macrolides caused more diarrhoea (odds ratio (OR) 1.70, 95% confidence interval (CI) 1.34 to 2.16; low-quality evidence); more abdominal pain (OR 1.66, 95% CI 1.22 to 2.26; low-quality evidence); and more nausea (OR 1.61, 95% CI 1.37 to 1.90; moderate-quality evidence). Vomiting (OR 1.27, 95% CI 1.04 to 1.56; moderate-quality evidence) and gastrointestinal disorders not otherwise specified (NOS) (OR 2.16, 95% CI 1.56 to 3.00; moderate-quality evidence) were also reported more often in participants taking macrolides compared to placebo.The number of additional people (absolute difference in risk) who experienced adverse events from macrolides was: gastrointestinal disorders NOS 85/1000; diarrhoea 72/1000; abdominal pain 62/1000; nausea 47/1000; and vomiting 23/1000.The number needed to treat for an additional harmful outcome (NNTH) ranged from 12 (95% CI 8 to 23) for gastrointestinal disorders NOS to 17 (9 to 47) for abdominal pain; 19 (12 to 33) for diarrhoea; 19 (13 to 30) for nausea; and 45 (22 to 295) for vomiting.There was no clear consistent difference in gastrointestinal adverse events between different types of macrolides or route of administration.Taste disturbances were reported more often by participants taking macrolide antibiotics, although there were wide confidence intervals and moderate heterogeneity (OR 4.95, 95% CI 1.64 to 14.93; I² = 46%; low-quality evidence).Compared with participants taking placebo, those taking macrolides experienced hearing loss more often, however only four studies reported this outcome (OR 1.30, 95% CI 1.00 to 1.70; I² = 0%; low-quality evidence).We did not find any evidence that macrolides caused more cardiac disorders (OR 0.87, 95% CI 0.54 to 1.40; very low-quality evidence); hepatobiliary disorders (OR 1.04, 95% CI 0.27 to 4.09; very low-quality evidence); or changes in liver enzymes (OR 1.56, 95% CI 0.73 to 3.37; very low-quality evidence) compared to placebo.We did not find any evidence that appetite loss, dizziness, headache, respiratory symptoms, blood infections, skin and soft tissue infections, itching, or rashes were reported more often by participants treated with macrolides compared to placebo.Macrolides caused less cough (OR 0.57, 95% CI 0.40 to 0.80; moderate-quality evidence) and fewer respiratory tract infections (OR 0.70, 95% CI 0.62 to 0.80; moderate-quality evidence) compared to placebo, probably because these are not adverse events, but rather characteristics of the indications for the antibiotics. Less fever (OR 0.73, 95% 0.54 to 1.00; moderate-quality evidence) was also reported by participants taking macrolides compared to placebo, although these findings were non-significant.There was no increase in mortality in participants taking macrolides compared with placebo (OR 0.96, 95% 0.87 to 1.06; I² = 11%; low-quality evidence).Only 24 studies (13%) provided useful data on macrolide-resistant bacteria. Macrolide-resistant bacteria were more commonly identified among participants immediately after exposure to the antibiotic. However, differences in resistance thereafter were inconsistent.Pharmaceutical companies supplied the trial medication or funding, or both, for 91 trials. AUTHORS' CONCLUSIONS The macrolides as a group clearly increased rates of gastrointestinal adverse events. Most trials made at least some statement about adverse events, such as "none were observed". However, few trials clearly listed adverse events as outcomes, reported on the methods used for eliciting adverse events, or even detailed the numbers of people who experienced adverse events in both the intervention and placebo group. This was especially true for the adverse event of bacterial resistance.
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Affiliation(s)
| | - Anna M Scott
- Bond UniversityCentre for Research in Evidence‐Based Practice (CREBP)14 University DriveGold CoastQueenslandAustralia4229
| | - Amanda McCullough
- Bond UniversityCentre for Research in Evidence‐Based Practice (CREBP)14 University DriveGold CoastQueenslandAustralia4229
| | - Sarah Thorning
- Gold Coast Hospital and Health ServiceGCUH LibraryLevel 1, Block E, GCUHSouthportQueenslandAustralia4215
| | - Jeffrey K Aronson
- Oxford UniversityNuffield Department of Primary Care Health SciencesOxfordOxonUKOX26GG
| | - Elaine M Beller
- Bond UniversityCentre for Research in Evidence‐Based Practice (CREBP)14 University DriveGold CoastQueenslandAustralia4229
| | - Paul P Glasziou
- Bond UniversityCentre for Research in Evidence‐Based Practice (CREBP)14 University DriveGold CoastQueenslandAustralia4229
| | - Tammy C Hoffmann
- Bond UniversityCentre for Research in Evidence‐Based Practice (CREBP)14 University DriveGold CoastQueenslandAustralia4229
| | - Justin Clark
- Bond UniversityCentre for Research in Evidence‐Based Practice (CREBP)14 University DriveGold CoastQueenslandAustralia4229
| | - Chris B Del Mar
- Bond UniversityCentre for Research in Evidence‐Based Practice (CREBP)14 University DriveGold CoastQueenslandAustralia4229
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8
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Herath SC, Normansell R, Maisey S, Poole P. Prophylactic antibiotic therapy for chronic obstructive pulmonary disease (COPD). Cochrane Database Syst Rev 2018; 10:CD009764. [PMID: 30376188 PMCID: PMC6517028 DOI: 10.1002/14651858.cd009764.pub3] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND There has been renewal of interest in the use of prophylactic antibiotics to reduce the frequency of exacerbations and improve quality of life in chronic obstructive pulmonary disease (COPD). OBJECTIVES To determine whether or not regular (continuous, intermittent or pulsed) treatment of COPD patients with prophylactic antibiotics reduces exacerbations or affects quality of life. SEARCH METHODS We searched the Cochrane Airways Group Trials Register and bibliographies of relevant studies. The latest literature search was performed on 27 July 2018. SELECTION CRITERIA Randomised controlled trials (RCTs) that compared prophylactic antibiotics with placebo in patients with COPD. DATA COLLECTION AND ANALYSIS We used the standard Cochrane methods. Two independent review authors selected studies for inclusion, extracted data, and assessed risk of bias. We resolved discrepancies by involving a third review author. MAIN RESULTS We included 14 studies involving 3932 participants in this review. We identified two further studies meeting inclusion criteria but both were terminated early without providing results. All studies were published between 2001 and 2015. Nine studies were of continuous macrolide antibiotics, two studies were of intermittent antibiotic prophylaxis (three times per week) and two were of pulsed antibiotic regimens (e.g. five days every eight weeks). The final study included one continuous, one intermittent and one pulsed arm. The antibiotics investigated were azithromycin, erythromycin, clarithromycin, doxycyline, roxithromycin and moxifloxacin. The study duration varied from three months to 36 months and all used intention-to-treat analysis. Most of the pooled results were of moderate quality. The risk of bias of the included studies was generally low.The studies recruited participants with a mean age between 65 and 72 years and mostly at least moderate-severity COPD. Five studies only included participants with frequent exacerbations and two studies recruited participants requiring systemic steroids or antibiotics or both, or who were at the end stage of their disease and required oxygen. One study recruited participants with pulmonary hypertension secondary to COPD and a further study was specifically designed to asses whether eradication of Chlamydia pneumoniae reduced exacerbation rates.The co-primary outcomes for this review were the number of exacerbations and quality of life.With use of prophylactic antibiotics, the number of participants experiencing one or more exacerbations was reduced (odds ratio (OR) 0.57, 95% CI 0.42 to 0.78; participants = 2716; studies = 8; moderate-quality evidence). This represented a reduction from 61% of participants in the control group compared to 47% in the treatment group (95% CI 39% to 55%). The number needed to treat for an additional beneficial outcome with prophylactic antibiotics given for three to 12 months to prevent one person from experiencing an exacerbation (NNTB) was 8 (95% CI 5 to 17). The test for subgroup difference suggested that continuous and intermittent antibiotics may be more effective than pulsed antibiotics (P = 0.02, I² = 73.3%).The frequency of exacerbations per patient per year was also reduced with prophylactic antibiotic treatment (rate ratio 0.67; 95% CI 0.54 to 0.83; participants = 1384; studies = 5; moderate-quality evidence). Although we were unable to pool the result, six of the seven studies reporting time to first exacerbation identified an increase (i.e. benefit) with antibiotics, which was reported as statistically significant in four studies.There was a statistically significant improvement in quality of life as measured by the St George's Respiratory Questionnaire (SGRQ) with prophylactic antibiotic treatment, but this was smaller than the four unit improvement that is regarded as being clinically significant (mean difference (MD) -1.94, 95% CI -3.13 to -0.75; participants = 2237; studies = 7, high-quality evidence).Prophylactic antibiotics showed no significant effect on the secondary outcomes of frequency of hospital admissions, change in forced expiratory volume in one second (FEV1), serious adverse events or all-cause mortality (moderate-quality evidence). There was some evidence of benefit in exercise tolerance, but this was driven by a single study of lower methodological quality.The adverse events that were recorded varied among the studies depending on the antibiotics used. Azithromycin was associated with significant hearing loss in the treatment group, which was in many cases reversible or partially reversible. The moxifloxacin pulsed study reported a significantly higher number of adverse events in the treatment arm due to the marked increase in gastrointestinal adverse events (P < 0.001). Some adverse events that led to drug discontinuation, such as development of long QTc or tinnitus, were not significantly more frequent in the treatment group than the placebo group but pose important considerations in clinical practice.The development of antibiotic resistance in the community is of major concern. Six studies reported on this, but we were unable to combine results. One study found newly colonised participants to have higher rates of antibiotic resistance. Participants colonised with moxifloxacin-sensitive pseudomonas at initiation of therapy rapidly became resistant with the quinolone treatment. A further study with three active treatment arms found an increase in the degree of antibiotic resistance of isolates in all three arms after 13 weeks treatment. AUTHORS' CONCLUSIONS Use of continuous and intermittent prophylactic antibiotics results in a clinically significant benefit in reducing exacerbations in COPD patients. All studies of continuous and intermittent antibiotics used macrolides, hence the noted benefit applies only to the use of macrolide antibiotics prescribed at least three times per week. The impact of pulsed antibiotics remains uncertain and requires further research.The studies in this review included mostly participants who were frequent exacerbators with at least moderate-severity COPD. There were also older individuals with a mean age over 65 years. The results of these studies apply only to the group of participants who were studied in these studies and may not be generalisable to other groups.Because of concerns about antibiotic resistance and specific adverse effects, consideration of prophylactic antibiotic use should be mindful of the balance between benefits to individual patients and the potential harms to society created by antibiotic overuse. Monitoring of significant side effects including hearing loss, tinnitus, and long QTc in the community in this elderly patient group may require extra health resources.
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Affiliation(s)
- Samantha C Herath
- Westmead Public HospitalDepartment of Respiratory and Sleep MedicineSydneyNew South WalesAustralia
| | - Rebecca Normansell
- St George's, University of LondonCochrane Airways, Population Health Research InstituteLondonUKSW17 0RE
| | - Samantha Maisey
- St George's University of LondonPopulation Health Research InstituteLondonUK
| | - Phillippa Poole
- University of AucklandDepartment of MedicinePrivate Bag 92019AucklandNew Zealand
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9
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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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10
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Effects of Low-Dose and Long-Term Treatment with Erythromycin on Interleukin-17 and Interleukin-23 in Peripheral Blood and Induced Sputum in Patients with Stable Chronic Obstructive Pulmonary Disease. Mediators Inflamm 2016; 2016:4173962. [PMID: 27127346 PMCID: PMC4834156 DOI: 10.1155/2016/4173962] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2016] [Accepted: 03/10/2016] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To study the effects of low-dose and long-term treatment with erythromycin on IL-17 and IL-23, in peripheral blood and induced sputum, in patients with stable chronic obstructive pulmonary disease (COPD). METHODS Patients were randomly divided into placebo-treated group, group A (12 months of additive treatment with erythromycin, N = 18), and group B (6 months of additive treatment with erythromycin followed by 6 months of follow-up, N = 18). Inflammatory cells in induced sputum, pulmonary function, and the 6-minute walk distance (6MWD) were analyzed. Concentrations of IL-17 and IL-23 in peripheral blood and sputum were measured using enzyme-linked immunosorbent assays. RESULTS After treatment, sputum and peripheral blood concentrations of IL-17 and IL-23 significantly decreased in groups A and B compared with placebo-treated group. There were no significant differences after erythromycin withdrawal at months 9 and 12 in group B compared with placebo-treated group. An increase in 6MWD was observed after treatment. CONCLUSIONS Erythromycin was beneficial and reduced airway inflammation in COPD patients. Underlying mechanisms may involve inhibition of IL-17 and IL-23 mediated airway inflammation. COPD patients treated with erythromycin for 6 months experienced improved exercise capacity. Finally, treatment for 12 months may be more effective than treatment for 6 months.
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11
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Liapikou A, Torres A. The clinical management of lower respiratory tract infections. Expert Rev Respir Med 2016; 10:441-452. [PMID: 26894943 DOI: 10.1586/17476348.2016.1156537] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The 2010 Global Burden of Disease Study reported that lower respiratory tract infections, including pneumonia, are the fourth most common cause of death globally. The etiology of acute bronchitis and asthma exacerbations is mostly viral and the therapy is symptomatic. Management decisions in community acquired pneumonia regarding site of care, extent of assessment, and level of treatment are based primarily on disease severity (outpatient, inpatient, ICU admission). Antibiotics are the main choice of treatment for patients with pneumonia, acute exacerbations (AE) of COPD (including increased sputum purulence and worsening shortness of breath) and AE of non-CF bronchiectasis. Inhaled antibiotics may represent a more optimal approach for the treatment and prevention of AE of non-CF bronchiectasis. Approved strategies for the prevention of exacerbations include smoking cessation and rehabilitation programs, drug therapy and vaccination.
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Affiliation(s)
| | - Antoni Torres
- b Department of Pneumology, Institut Clinic del Tórax, Institut d'investigacions Biomèdiques August Pi i Sunyer - IDIBAPS , University of Barcelona - UB - Ciber de Enfermedades Respiratorias - CIBERES, Hospital Clinic , Barcelona , Spain
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12
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Shafuddin E, Mills GD, Holmes MD, Poole PJ, Mullins PR, Black PN. A double-blind, randomised, placebo-controlled study of roxithromycin and doxycycline combination, roxithromycin alone, or matching placebo for 12 weeks in adults with frequent exacerbations of chronic obstructive pulmonary disease. J Negat Results Biomed 2015; 14:15. [PMID: 26346300 PMCID: PMC4562194 DOI: 10.1186/s12952-015-0034-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2014] [Accepted: 09/02/2015] [Indexed: 11/17/2022] Open
Abstract
Background Azithromycin prophylaxis has been shown to reduce COPD exacerbations but there is poor evidence for other antibiotics. We compared exacerbation rates in COPD patients with a history of frequent exacerbations (at least three moderate or severe COPD exacerbations in the past two years) during a 12-week treatment course and over a subsequent 48-week follow up period. Results 292 patients were randomised to one of three treatments for 12 weeks: roxithromycin 300 mg daily and doxycycline 100 mg daily (n = 101); roxithromycin 300 mg daily (n = 97); or matching placebos (n = 94). There were no differences in the annualised moderate and severe exacerbation rates after treatment with roxithromycin/doxycycline (2.83 (95 % CI 2.37-3.40)) or roxithromycin only (2.69 (2.26-3.21)) compared to placebo (2.5 (2.08-3.03)) (p = 0.352 and p = 0.5832 respectively). Furthermore, there were no differences in the annualised exacerbation rates during 12-week treatment with roxithromycin/doxycycline (1.64 (95 % CI 1.17-2.30)), roxithromycin only (1.75 (1.24-2.41)) or placebo (2.23 (1.68-3.03)) (p = 0.1709 and p = 0.2545 respectively). There were also no significant differences between groups for spirometry or quality of life scores over either the 12-week treatment or 48-week post-treatment periods. Both active treatments were associated with nausea but otherwise adverse events were comparable among treatment groups. Conclusions Twelve-weeks of prophylaxis with roxithromycin/doxycycline combination or roxithromycin alone did not reduce COPD exacerbations in patients with history of frequent exacerbations. These findings do not support the use of these antibiotics to prevent exacerbations in COPD patients. Electronic supplementary material The online version of this article (doi:10.1186/s12952-015-0034-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Eskandarain Shafuddin
- Respiratory Research Unit, Department of Respiratory Medicine, Waikato Hospital, Hamilton, New Zealand.
| | - Graham D Mills
- Respiratory Research Unit, Department of Respiratory Medicine, Waikato Hospital, Hamilton, New Zealand.
| | - Mark D Holmes
- Respiratory Clinical Trials Unit, Royal Adelaide Hospital, Adelaide, SA, Australia.
| | - Phillippa J Poole
- Faculty of Medical and Health Sciences, The University of Auckland and Auckland Hospital, Auckland, New Zealand.
| | - Peter R Mullins
- Department of Statistics, The University of Auckland, Auckland, New Zealand.
| | - Peter N Black
- Faculty of Medical and Health Sciences, The University of Auckland and Auckland Hospital, Auckland, New Zealand
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13
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Gualdoni GA, Lingscheid T, Schmetterer KG, Hennig A, Steinberger P, Zlabinger GJ. Azithromycin inhibits IL-1 secretion and non-canonical inflammasome activation. Sci Rep 2015; 5:12016. [PMID: 26152605 PMCID: PMC4495566 DOI: 10.1038/srep12016] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Accepted: 05/29/2015] [Indexed: 12/28/2022] Open
Abstract
Deregulation of inflammasome activation was recently identified to be involved in the pathogenesis of various inflammatory diseases. Although macrolide antibiotics display well described immunomodulatory properties, presumably involved in their clinical effects, their impact on inflammasome activation has not been investigated. We compared the influence of macrolides on cytokine induction in human monocytes. The role of intracellular azithromycin-accumulation was examined by interference with Ca++-dependent uptake. We have also analysed the signalling cascades involved in inflammasome activation, and substantiated the findings in a murine sepsis model. Azithromycin, but not clarithromycin or roxithromycin, specifically inhibited IL-1α and IL-1β secretion upon LPS stimulation. Interference with Ca++-dependent uptake abolished the cytokine-modulatory effect, suggesting a role of intracellular azithromycin accumulation in the modulatory role of this macrolide. Azithromycin’s inhibiting effects were observed upon LPS, but not upon flagellin, stimulation. Consistent with this observation, we found impaired induction of the LPS-sensing caspase-4 whereas NF-κB signalling was unaffected. Furthermore, azithromycin specifically affected IL-1β levels in a murine endotoxin sepsis model. We provide the first evidence of a differential impact of macrolides on the inflammasome/IL-1β axis, which may be of relevance in inflammasome-driven diseases such as chronic obstructive pulmonary disease or asthma.
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Affiliation(s)
- Guido A Gualdoni
- Institute of Immunology, Center for Pathophysiology, Infectiology and Immunology, Medical University of Vienna, Vienna, Austria
| | - Tilman Lingscheid
- Department of Infectious Diseases and Pulmonary Medicine, Charité - Universitätsmedizin Berlin, Germany
| | - Klaus G Schmetterer
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Annika Hennig
- Institute of Immunology, Center for Pathophysiology, Infectiology and Immunology, Medical University of Vienna, Vienna, Austria
| | - Peter Steinberger
- Institute of Immunology, Center for Pathophysiology, Infectiology and Immunology, Medical University of Vienna, Vienna, Austria
| | - Gerhard J Zlabinger
- Institute of Immunology, Center for Pathophysiology, Infectiology and Immunology, Medical University of Vienna, Vienna, Austria
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14
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Bafadhel M, Haldar K, Barker B, Patel H, Mistry V, Barer MR, Pavord ID, Brightling CE. Airway bacteria measured by quantitative polymerase chain reaction and culture in patients with stable COPD: relationship with neutrophilic airway inflammation, exacerbation frequency, and lung function. Int J Chron Obstruct Pulmon Dis 2015; 10:1075-83. [PMID: 26089657 PMCID: PMC4468933 DOI: 10.2147/copd.s80091] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Potentially pathogenic microorganisms can be detected by quantitative real-time polymerase chain reaction (qPCR) in sputum from patients with COPD, although how this technique relates to culture and clinical measures of disease is unclear. We used cross-sectional and longitudinal data to test the hypotheses that qPCR is a more sensitive measure of bacterial presence and is associated with neutrophilic airway inflammation and adverse clinical outcomes. METHODS Sputum was collected from 174 stable COPD subjects longitudinally over 12 months. Microbial sampling using culture and qPCR was performed. Spirometry and sputum measures of airway inflammation were assessed. FINDINGS Sputum was qPCR-positive (>10(6) copies/mL) in 77/152 samples (Haemophilus influenzae [n=52], Moraxella catarrhalis [n=24], Streptococcus pneumoniae [n=19], and Staphylococcus aureus [n=7]). Sputum was culture-positive in 50/174 samples, with 49 out of 50 culture-positive samples having pathogen-specific qPCR bacterial loads >10(6) copies/mL. Samples that had qPCR copy numbers >10(6)/mL, whether culture-positive or not, had increased sputum neutrophil counts. H. influenzae qPCR copy numbers correlated with sputum neutrophil counts (r=0.37, P<0.001), were repeatable within subjects, and were >10(6)/mL three or more times in 19 patients, eight of whom were repeatedly sputum culture-positive. Persistence, whether defined by culture, qPCR, or both, was associated with a higher sputum neutrophil count, lower forced expiratory volume in 1 second (FEV1), and worsened quality of life. INTERPRETATION qPCR identifies a significant number of patients with potentially bacteria-associated neutrophilic airway inflammation and disease that are not identified by traditional culture-based methods.
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Affiliation(s)
- Mona Bafadhel
- Respiratory Medicine Unit, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Koirobi Haldar
- Department of Infection, Immunity and Inflammation, University of Leicester, Leicester, UK
| | - Bethan Barker
- Department of Infection, Immunity and Inflammation, University of Leicester, Leicester, UK
- Institute for Lung Health, National Institute for Health Research Respiratory Biomedical Research Unit, Glenfield Hospital, University of Leicester, Leicester, UK
| | - Hemu Patel
- Department of Clinical Microbiology, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Vijay Mistry
- Department of Infection, Immunity and Inflammation, University of Leicester, Leicester, UK
- Institute for Lung Health, National Institute for Health Research Respiratory Biomedical Research Unit, Glenfield Hospital, University of Leicester, Leicester, UK
| | - Michael R Barer
- Department of Infection, Immunity and Inflammation, University of Leicester, Leicester, UK
- Institute for Lung Health, National Institute for Health Research Respiratory Biomedical Research Unit, Glenfield Hospital, University of Leicester, Leicester, UK
- Department of Clinical Microbiology, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Ian D Pavord
- Respiratory Medicine Unit, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Christopher E Brightling
- Department of Infection, Immunity and Inflammation, University of Leicester, Leicester, UK
- Institute for Lung Health, National Institute for Health Research Respiratory Biomedical Research Unit, Glenfield Hospital, University of Leicester, Leicester, UK
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15
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Macrolide antibiotics for treatment of asthma in adults: a meta-analysis of 18 randomized controlled clinical studies. Pulm Pharmacol Ther 2014; 31:99-108. [PMID: 25252142 DOI: 10.1016/j.pupt.2014.09.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Revised: 08/31/2014] [Accepted: 09/14/2014] [Indexed: 02/05/2023]
Abstract
Mounting studies have been showed that long-term macrolides used in patients with asthma could improve the lung function and symptoms. However, a large number of studies have reported inconclusive results. The aim of this meta-analysis was to investigate the effect of macrolide antibiotics in patients with asthma. We have performed a search in PubMed, Embase, China National Knowledge Internet (CNKI), and Wanfang databases. The weighed mean difference (WMD) or standardized mean difference (SMD) was used to evaluate the pooled effect. Statistical analysis was performed by STATA 11.0 software. Totally 1306 patients were included in the meta-analysis. The overall results indicated that statistically significance of long-term macrolides therapy in patients with asthma on forced expiratory volume in 1 s (FEV1) (WMD: 0.11, P < 0.01), peak expiratory flow (PEF) (SMD: 0.25, P = 0.001), airway hyper-responsiveness (AHR) (SMD: 0.90, P = 0.04), forced vital capacity (FVC) (WMD: 0.18, P = 0.05) and FEV1/FVC (WMD: 1.93, P < 0.001), but no statistically significance on FEV1/predict, FVC/predict, symptom scores, quality of life scores (QOL), reliever inhaler puffs per 24 h, and cell counts in sputum and blood. The subgroup analysis indicated macrolides could increase FEV1 and PEF in Caucasian and Asian, decrease AHR in Caucasian, while cells counts of sputum improvement among Asian. Therefore, the study suggested that long-term marolides therapy in asthma may improved the FEV1, PEF, AHR, FVC, FEV1/FVC and cells counts in sputum, but it can't improve other lung function (FEV1/predict and FVC/predict) and clinical outcomes (such as symptom, quality of life etc.).
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16
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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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Parameswaran GI, Sethi S. Long-term macrolide therapy in chronic obstructive pulmonary disease. CMAJ 2014; 186:1148-52. [PMID: 25096664 DOI: 10.1503/cmaj.121573] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Ganapathi Iyer Parameswaran
- Division of Infectious Diseases (Parameswaran) and Division of Pulmonary, Critical Care and Sleep Medicine (Sethi), Department of Medicine, University at Buffalo, The State University of New York, Buffalo, NY; Veterans Affairs Western New York Healthcare System (Parameswaran, Sethi), Buffalo, NY
| | - Sanjay Sethi
- Division of Infectious Diseases (Parameswaran) and Division of Pulmonary, Critical Care and Sleep Medicine (Sethi), Department of Medicine, University at Buffalo, The State University of New York, Buffalo, NY; Veterans Affairs Western New York Healthcare System (Parameswaran, Sethi), Buffalo, NY.
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18
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Fouka E, Lamprianidou E, Arvanitidis K, Filidou E, Kolios G, Miltiades P, Paraskakis E, Antoniadis A, Kotsianidis I, Bouros D. Low-Dose Clarithromycin Therapy Modulates Th17 Response In Non-Cystic Fibrosis Bronchiectasis Patients. Lung 2014; 192:849-55. [DOI: 10.1007/s00408-014-9619-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Accepted: 06/22/2014] [Indexed: 12/27/2022]
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Abstract
BACKGROUND There has been renewal of interest in the use of prophylactic antibiotics to reduce the frequency of exacerbations and improve quality of life in chronic obstructive pulmonary disease (COPD). OBJECTIVES To determine whether or not regular treatment of COPD patients with prophylactic antibiotics reduces exacerbations or affects quality of life. SEARCH METHODS We searched the Cochrane Airways Group Trials Register and bibliographies of relevant studies. The latest literature search was August 2013. SELECTION CRITERIA Randomised controlled trials (RCTs) that compared prophylactic antibiotics with placebo in patients with COPD. DATA COLLECTION AND ANALYSIS We used the standard methods of The Cochrane Collaboration. Data were extracted and analysed by two independent review authors. MAIN RESULTS Seven RCTs involving 3170 patients were included in this systematic review. All studies were published between 2001 and 2011. Five studies were of continuous antibiotics and two studies were of intermittent antibiotic prophylaxis (termed 'pulsed' for this review). The antibiotics investigated were azithromycin, erythromycin, clarithromycin and moxifloxacin. Azithromycin, erythromycin and clarithromycin are macrolides while moxifloxacin is a fourth-generation synthetic fluoroquinolone antibacterial agent. The study duration varied from three months to 36 months and all used intention-to-treat analysis. Most of the results were of moderate quality. The risk of bias of the included studies was generally low, and we did not downgrade the quality of evidence for risk of bias.The trials recruited participants with a mean age of 66 years and with at least a moderate severity of COPD. Three trials included participants with frequent exacerbations and two trials recruited participants requiring systemic steroids or antibiotics, or both, or who were at the end stage of their disease and required oxygen.The primary outcomes for this review were the number of exacerbations and quality of life.With use of continuous prophylactic antibiotics the number of patients experiencing an exacerbation was reduced (odds ratio (OR) 0.55; 95% confidence interval (CI) 0.39 to 0.77, 3 studies, 1262 participants, high quality). This represented a reduction from 69% of participants in the control group compared to 54% in the treatment group (95% CI 46% to 63%) and the number needed to treat to prevent one exacerbation (NNTb) was therefore 8 (95% CI 5 to 18). The frequency of exacerbations was also reduced with continuous prophylactic antibiotic treatment (rate ratio 0.73; 95% CI 0.58 to 0.91).Use of pulsed antibiotic treatment showed a non-significant reduction in the number of people with exacerbations (OR 0.87; 95% CI 0.69 to 1.09, 1 study, 1149 participants, moderate quality) and the test for interaction showed that this result was significantly different from the effect on exacerbations with continuous antibiotics.There was a statistically significant improvement in quality of life with both continuous and pulsed antibiotic treatment but this was smaller than the four unit improvement that is regarded as being clinically significant (MD -1.78; 95% CI -2.95 to -0.61, 2 studies, 1962 participants, moderate quality).Neither pulsed nor continuous antibiotics showed a significant effect on the secondary outcomes of frequency of hospital admissions, change in lung function, serious adverse events or all-cause mortality (moderate quality evidence).The adverse events that were recorded varied among the trials depending on the different antibiotics used. Azithromycin was associated with a significant hearing loss in the treatment group. The moxifloxacin pulsed study reported a significantly higher number of adverse events in the treatment arm due to the marked increase in gastrointestinal adverse events (P < 0.001). Some adverse events that led to drug discontinuation, such as development of long QTc or tinnitus, were not significantly more frequent in the treatment group than the placebo group but pose important considerations in clinical practice.The development of antibiotic resistance in the community is of major concern. One study found newly colonised patients to have higher rates of antibiotic resistance. Patients colonised with moxifloxacin-sensitive pseudomonas at initiation of therapy rapidly became resistant with the quinolone treatment. AUTHORS' CONCLUSIONS Use of continuous prophylactic antibiotics results in a clinically significant benefit in reducing exacerbations in COPD patients. All trials of continuous antibiotics used macrolides hence the noted benefit applies only to the use of continuous macrolide antibiotics. The impact of pulsed antibiotics remains uncertain and requires further research.The trials in this review included patients who were frequent exacerbators and needed treatment with antibiotics or systemic steroids, or who were on supplemental oxygen. There were also older individuals with a mean age of 66 years. The results of these trials apply only to the group of patients who were studied in these trials and may not be generalisable to other groups.Because of concerns about antibiotic resistance and specific adverse effects, consideration of prophylactic antibiotic use should be mindful of the balance between benefits to individual patients and the potential harms to society created by antibiotic overuse.
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Affiliation(s)
- Samantha C Herath
- Woolcock Institute of Medical Research, 431 Glebe Point Road, Sydney, New South Wales, Australia, 2037
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20
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Adriaensen GFJPM, Fokkens WJ. Chronic rhinosinusitis: an update on current pharmacotherapy. Expert Opin Pharmacother 2013; 14:2351-60. [DOI: 10.1517/14656566.2013.837450] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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21
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Wilson R, Sethi S, Anzueto A, Miravitlles M. Antibiotics for treatment and prevention of exacerbations of chronic obstructive pulmonary disease. J Infect 2013; 67:497-515. [PMID: 23973659 DOI: 10.1016/j.jinf.2013.08.010] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Revised: 08/14/2013] [Accepted: 08/16/2013] [Indexed: 11/18/2022]
Abstract
Acute exacerbations (AE) can be recurrent problems for patients with moderate-to-severe chronic obstructive pulmonary disease (COPD) increasing morbidity and mortality. Evidence suggests that ≥50% of acute exacerbations involve bacteria requiring treatment with an antibiotic which should have high activity against the causative pathogens. However, sputum analysis is not a pre-requisite for antibiotic prescription in outpatients as results are delayed and patients are likely to be colonised with bacteria in the stable state. Clinicians rely on the clinical symptoms, sputum appearance and the patient's medical history to decide if an AE-COPD should be treated with antibiotics. This article reviews the available data of antibiotic trials in AE-COPD. Management of frequent exacerbators is particularly challenging for physicians. This may include antibiotic prophylaxis, especially macrolides because of anti-inflammatory properties; though successful in reducing exacerbations, concerns about resistance development remain. Inhalation of antibiotics achieves high local concentrations and minimal systemic exposure; therefore, it may represent an attractive alternative for antibiotic prophylaxis in certain COPD patients. Inhaled antibiotic prophylaxis has been successfully used in other respiratory conditions such as non-cystic fibrosis bronchiectasis which itself might be present in COPD patients who have chronic bacterial infection, particularly with Pseudomonas aeruginosa.
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Affiliation(s)
- Robert Wilson
- Host Defence Unit, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK.
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Steel HC, Theron AJ, Cockeran R, Anderson R, Feldman C. Pathogen- and host-directed anti-inflammatory activities of macrolide antibiotics. Mediators Inflamm 2012; 2012:584262. [PMID: 22778497 PMCID: PMC3388425 DOI: 10.1155/2012/584262] [Citation(s) in RCA: 77] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2012] [Accepted: 03/02/2012] [Indexed: 12/27/2022] Open
Abstract
Macrolide antibiotics possess several, beneficial, secondary properties which complement their primary antimicrobial activity. In addition to high levels of tissue penetration, which may counteract seemingly macrolide-resistant bacterial pathogens, these agents also possess anti-inflammatory properties, unrelated to their primary antimicrobial activity. Macrolides target cells of both the innate and adaptive immune systems, as well as structural cells, and are beneficial in controlling harmful inflammatory responses during acute and chronic bacterial infection. These secondary anti-inflammatory activities of macrolides appear to be particularly effective in attenuating neutrophil-mediated inflammation. This, in turn, may contribute to the usefulness of these agents in the treatment of acute and chronic inflammatory disorders of both microbial and nonmicrobial origin, predominantly of the airways. This paper is focused on the various mechanisms of macrolide-mediated anti-inflammatory activity which target both microbial pathogens and the cells of the innate and adaptive immune systems, with emphasis on their clinical relevance.
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Affiliation(s)
- Helen C Steel
- Medical Research Council Unit for Inflammation and Immunity, Department of Immunology, Faculty of Health Sciences, University of Pretoria and Tshwane Academic Division of the National Health Laboratory Service, P.O. Box 2034, Pretoria 0001, South Africa.
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Li M, Zhong X, He Z, Wen M, Li J, Peng X, Liu G, Deng J, Zhang J, Bai J. Effect of erythromycin on cigarette-induced histone deacetylase protein expression and nuclear factor-κB activity in human macrophages in vitro. Int Immunopharmacol 2012; 12:643-50. [PMID: 22265969 DOI: 10.1016/j.intimp.2011.12.022] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2011] [Revised: 11/26/2011] [Accepted: 12/29/2011] [Indexed: 01/04/2023]
Abstract
Histone deacetylases (HDACs) are families of enzymes that regulate chromatin structure and thus affect inflammatory gene expression. The anti-inflammatory properties of macrolides are well documented. However, the effects of macrolides on HDAC protein expression have not been studied. This study aimed to examine the molecular mechanism of the inflammatory responses caused by cigarette smoke extract (CSE) and the effects of erythromycin (EM) on CSE-induced HDAC protein expression in human macrophages in vitro. The cells were preincubated with EM and were then exposed to CSE. Levels of interleukin-8 (IL-8) and tumor necrosis factor-a (TNF-a) were assayed by enzyme linked immunosorbent assay (ELISA). Nuclear factor-κB (NF-κB) activity was assessed by an electrophoretic mobility shift assay. HDAC activity was measured with a colorimetric assay kit, and Western blotting was used for HDAC1, -2, -3 and NF-κB protein expression assays. The results showed that CSE causes decreases in HDAC activity and HDAC1, -2, -3 levels and upregulates NF-κB activity, resulting in increased NF-κB-dependent proinflammatory cytokine release in human macrophage cells. Moreover, EM was able to reverse the CSE-induced decline in HDAC1, -2, -3 protein expression, which was most prominent for HDAC2; these changes were associated with the suppression of both NF-κB protein expression and the production of inflammatory mediators. These results suggest that relieving inflammation with EM can be useful in therapeutic approaches for modulating intracellular nuclear signaling in chronic airway inflammatory diseases such as chronic obstructive pulmonary disease (COPD).
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Affiliation(s)
- Meihua Li
- Department of Respiratory Medicine, The First Affiliated Hospital of Guangxi Medical University, 6 Shuangyong Road, Nanning, Guangxi 530021, China
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Zarogoulidis P, Papanas N, Kioumis I, Chatzaki E, Maltezos E, Zarogoulidis K. Macrolides: from in vitro anti-inflammatory and immunomodulatory properties to clinical practice in respiratory diseases. Eur J Clin Pharmacol 2011; 68:479-503. [PMID: 22105373 DOI: 10.1007/s00228-011-1161-x] [Citation(s) in RCA: 187] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2011] [Accepted: 10/25/2011] [Indexed: 12/12/2022]
Abstract
BACKGROUND Macrolides have long been recognised to exert immunomodulary and anti-inflammatory actions. They are able to suppress the "cytokine storm" of inflammation and to confer an additional clinical benefit through their immunomodulatory properties. METHODS A search of electronic journal articles was performed using combinations of the following keywords: macrolides, COPD, asthma, bronchitis, bronchiolitis obliterans, cystic fibrosis, immunomodulation, anti-inflammatory effect, diabetes, side effects and systemic diseases. RESULTS Macrolide effects are time- and dose-dependent, and the mechanisms underlying these effects remain incompletely understood. Both in vitro and in vivo studies have provided ample evidence of their immunomodulary and anti-inflammatory actions. Importantly, this class of antibiotics is efficacious with respect to controlling exacerbations of underlying respiratory problems, such as cystic fibrosis, asthma, bronchiectasis, panbrochiolitis and cryptogenic organising pneumonia. Macrolides have also been reported to reduce airway hyper-responsiveness and improve pulmonary function. CONCLUSION This review provides an overview on the properties of macrolides (erythromycin, clarithromycin, roxithromycin, azithromycin), their efficacy in various respiratory diseases and their adverse effects.
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Affiliation(s)
- P Zarogoulidis
- Pulmonary Department, G. Papanikolaou Hospital, Aristotle University of Thessaloniki, Thessaloniki 57010, Greece.
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25
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Rafii R, Albertson TE, Louie S, Chan AL. Update on pharmaceutical and minimally invasive management strategies for chronic obstructive pulmonary disease. Pulm Med 2011; 2011:257496. [PMID: 21660228 PMCID: PMC3109340 DOI: 10.1155/2011/257496] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2010] [Revised: 01/21/2011] [Accepted: 02/22/2011] [Indexed: 01/01/2023] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is a debilitating pulmonary disorder with systemic effects, and it is the fourth leading cause of death in the United States. COPD patients not only develop respiratory limitations, but can also demonstrate systemic wasting, features of depression, and can succumb to social isolation. Smoking cessation is crucial, and pharmacotherapy with bronchodilators is helpful in symptom management. Inhaled corticosteroids may be beneficial in some patients. In addition, pulmonary rehabilitation and palliative care are important components under the right clinical circumstance. This review highlights current guidelines and management strategies for COPD and emphasizes novel pharmacotherapy and minimally invasive (nonsurgical) lung-volume reduction interventions that may prove to be of significant benefit in the future.
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Affiliation(s)
- Rokhsara Rafii
- Division of Pulmonary, Critical Care and Sleep Medicine, UC Davis School of Medicine and VA Northern California Health Care System, 4150 V Street, Suite 3400, Sacramento, CA 95817, USA
| | - Timothy E. Albertson
- Division of Pulmonary, Critical Care and Sleep Medicine, UC Davis School of Medicine and VA Northern California Health Care System, 4150 V Street, Suite 3400, Sacramento, CA 95817, USA
| | - Samuel Louie
- Division of Pulmonary, Critical Care and Sleep Medicine, UC Davis School of Medicine, 4150 V Street, Suite 3400, Sacramento, CA 95817, USA
| | - Andrew L. Chan
- Division of Pulmonary, Critical Care and Sleep Medicine, UC Davis School of Medicine and VA Northern California Health Care System, 4150 V Street, Suite 3400, Sacramento, CA 95817, USA
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Butorac-Petanjek B, Parnham MJ, Popovic-Grle S. Antibiotic therapy for exacerbations of chronic obstructive pulmonary disease (COPD). J Chemother 2011; 22:291-7. [PMID: 21123150 DOI: 10.1179/joc.2010.22.5.291] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) is already the world's fourth most common cause of mortality and likely to become the third in a few year's time. Because it is an inflammatory airway disease with altered host immune response, infectious complications are frequent. Acute exacerbations of COPD (AECOPD) significantly worsen the patient's general health, accelerating disability. Each exacerbation leads progressively to further deterioration of lung function. Among the various causes of AECOPD, including viruses, bacteria and air pollution, a bacterial etiology is most common (50-69%). The management of AECOPD remains extremely challenging and places a heavy economic burden on health care institutions. The decision to administer antibiotics in AECOPD is multifactorial, the most important considerations being severity of the COPD stage and patient performance status, clinical symptoms (increased dyspnea, sputum volume and sputum purulence), severity of current and previous exacerbations, comorbidity and current smoking. Exacerbations which require hospital admission are associated with significant in-patient mortality. AECOPD patients presenting with worsening dyspnea, increased sputum volume and purulence should be offered antimicrobial therapy. If treating with antibiotics, treatment must include coverage for Haemophilus influenzae, Streptococcus pneumoniae and Moraxella catarrhalis in all cases, but other bacteria (such as Gram-negatives) may need to be covered depending on the condition of the patient. Antibiotics, particularly macrolides and fluoroquinolones, when administered under suitable conditions, shorten the clinical course and prevent severe deterioration. possible complications resulting from untreated severe AECOPD surpass the potential risks from the use of antibiotic therapy. Additional anti-inflammatory and immunomodulatory actions of some antibiotics may contribute to their efficacy in AECOPD.
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Berim I, Sethi S. The benefits of long-term systemic antimicrobial therapy in chronic obstructive pulmonary disease. Ther Adv Respir Dis 2011; 5:207-16. [PMID: 21378062 DOI: 10.1177/1753465811398372] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are major contributors to the morbidity and mortality associated with this disease. Current approaches that likely reduce chronic obstructive pulmonary disease (COPD) exacerbations include smoking cessation, influenza and pneumococcal vaccinations, long-acting bronchodilator and inhaled corticosteroid therapy, pulmonary rehabilitation, and mucolytic drugs. However, with optimal treatment using all of these modalities, we are only able to reduce exacerbations by about 40%. A significant proportion of COPD exacerbations are bacterial, therefore long-term antimicrobial therapy could have a role in preventing exacerbations. Long-term antibiotic treatment in COPD regimens that are being evaluated include low-dose macrolide therapy, pulsed fluoroquinolone administration and the use of inhaled antibiotics. Although initial results have been promising with significant reductions in exacerbations with these regimens, additional studies are required to identify the appropriate patient and regimen and elucidate the risk-benefit as well as cost effectiveness of long-term antibiotics in COPD.
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Affiliation(s)
- Ilya Berim
- University at Buffalo, SUNY, Buffalo, NY, USA
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Marjanović N, Bosnar M, Michielin F, Willé DR, Anić-Milić T, Culić O, Popović-Grle S, Bogdan M, Parnham MJ, Eraković Haber V. Macrolide antibiotics broadly and distinctively inhibit cytokine and chemokine production by COPD sputum cells in vitro. Pharmacol Res 2011; 63:389-97. [PMID: 21315154 DOI: 10.1016/j.phrs.2011.02.001] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2010] [Revised: 01/28/2011] [Accepted: 02/01/2011] [Indexed: 10/18/2022]
Abstract
Macrolide antibiotics are known to exert anti-inflammatory actions in vivo, including certain effects in COPD patients. In order to investigate the immunomodulatory profile of activity of macrolide antibiotics, we have studied the effects of azithromycin, clarithromycin, erythromycin and roxithromycin on the in vitro production of a panel of inflammatory mediators from cells isolated from human, steroid-naïve, COPD sputum samples. Macrolide effects were compared to three other commonly used anti-inflammatory compounds, the corticosteroid dexamethasone, the PDE4 inhibitor, roflumilast and the p38 kinase inhibitor, SB203580. Three of the four tested macrolides, azithromycin, clarithromycin and roxithromycin, exhibited pronounced, concentration-related reduction of IL-1β, IL-6, IL-10, TNF-α, CCL3, CCL5, CCL20, CCL22, CXCL1, CXCL5, and G-CSF release. Further slight inhibitory effects on IL-1α, CXCL8, GM-CSF, and PAI-1 production were also observed. Erythromycin was very weakly active. Qualitatively and quantitatively, macrolides exerted distinctive and, compared to other tested classes of compounds, more pronounced immunomodulatory effects, particularly in terms of chemokine (CCL3, CCL5, CCL20, CCL22, and CXCL5), IL-1β, G-CSF and PAI-1 release. The described modulation of inflammatory mediators could potentially contribute to further definition of biomarkers of macrolide anti-inflammatory activity in COPD.
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29
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Friedlander AL, Albert RK. Chronic macrolide therapy in inflammatory airways diseases. Chest 2011; 138:1202-12. [PMID: 21051396 DOI: 10.1378/chest.10-0196] [Citation(s) in RCA: 94] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Long-term therapy with the macrolide antibiotic erythromycin was shown to alter the clinical course of diffuse panbronchiolitis in the late 1980s. Since that time, macrolides have been found to have a large number of antiinflammatory properties in addition to being antimicrobials. These observations provided the rationale for many studies performed over the last decade to assess the usefulness of macrolides in other inflammatory airways diseases, such as cystic fibrosis, asthma, COPD, and bronchiolitis obliterans syndrome. This review summarizes the immunomodulatory properties of macrolides and the results of these recent studies demonstrating their potential for being disease-modifying agents.
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Affiliation(s)
- Adam L Friedlander
- Division of Pulmonary Sciences and Critical Care Medicine, National Jewish Health, 1400 Jackson St, Denver, CO 80206, USA.
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30
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Nakanishi Y, Kobayashi D, Asano Y, Sakurai T, Kashimura M, Okuyama S, Yoneda Y, Shapiro SD, Takayama K. Clarithromycin prevents smoke-induced emphysema in mice. Am J Respir Crit Care Med 2008; 179:271-8. [PMID: 19060231 DOI: 10.1164/rccm.200806-905oc] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Modulating the low-grade chronic inflammation in chronic obstructive pulmonary disease remains challenging. Clarithromycin (CAM), a macrolide antibiotic, reportedly ameliorates chronic inflammation via mechanisms independent of its antibacterial activity. OBJECTIVES The aim of this study was to examine whether CAM can prevent or reduce emphysema induced by chronic cigarette smoke exposure. METHODS Mice were exposed to cigarette smoke daily for 6 months and treated with orally administered CAM at doses of 25 to 100 mg/kg twice a day throughout the course of the experiment to test the preventive effects. The administration of CAM at 50 or 100 mg/kg was performed during the second half of a 6-month exposure period to assess the therapeutic effects. Histologic analysis was performed to evaluate the effect of CAM. MEASUREMENTS AND MAIN RESULTS CAM treatment for 6 months decreased airspace enlargement and the destruction of the alveolar walls and impaired the accumulation of macrophages in bronchoalveolar lavage fluid in a dose-related fashion. The administration of clarithromycin at 100 mg/kg in the therapeutic protocol reduced emphysema compared with the smoke-exposed group without treatment. An immunohistologic analysis revealed that CAM reduced the number of F4/80-positive macrophages in the lung parenchyma. In an in vitro test, CAM at 5 to 20 microM directly suppressed the activation of macrophages stimulated with tumor necrosis factor-alpha. CONCLUSIONS Our data demonstrated that CAM at a clinically achievable dose prevented cigarette smoke-induced emphysema by modulating lung inflammation. This study supports the possibility that low-dose CAM treatment might provide a new therapeutic strategy for chronic obstructive pulmonary diseases.
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Affiliation(s)
- Yutaka Nakanishi
- Research Center, Taisho Pharmaceutical Co., Ltd., 403, Yoshino-Cho 1-Chome, Kita-Ku, Saitama City, Saitama, Japan
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31
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Anthonisen NR. Macrolide therapy in airways disease. Can Respir J 2008; 15:177-8. [PMID: 18666342 PMCID: PMC2677945 DOI: 10.1155/2008/692495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Martinez FJ, Curtis JL, Albert R. Role of macrolide therapy in chronic obstructive pulmonary disease. Int J Chron Obstruct Pulmon Dis 2008; 3:331-50. [PMID: 18990961 PMCID: PMC2629987 DOI: 10.2147/copd.s681] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is a leading cause of death and disability worldwide. The Global Burden of Disease study has concluded that COPD will become the third leading cause of death worldwide by 2020, and will increase its ranking of disability-adjusted life years lost from 12th to 5th. Acute exacerbations of COPD (AECOPD) are associated with impaired quality of life and pulmonary function. More frequent or severe AECOPDs have been associated with especially markedly impaired quality of life and a greater longitudinal loss of pulmonary function. COPD and AECOPDs are characterized by an augmented inflammatory response. Macrolide antibiotics are macrocyclical lactones that provide adequate coverage for the most frequently identified pathogens in AECOPD and have been generally included in published guidelines for AECOPD management. In addition, they exert broad-ranging, immunomodulatory effects both in vitro and in vivo, as well as diverse actions that suppress microbial virulence factors. Macrolide antibiotics have been used to successfully treat a number of chronic, inflammatory lung disorders including diffuse panbronchiolitis, asthma, noncystic fibrosis associated bronchiectasis, and cystic fibrosis. Data in COPD patients have been limited and contradictory but the majority hint to a potential clinical and biological effect. Additional, prospective, controlled data are required to define any potential treatment effect, the nature of this effect, and the role of bronchiectasis, baseline colonization, and other cormorbidities.
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Affiliation(s)
- Fernando J Martinez
- Division of Pulmonary and Critical Care Medicine, University of Michigan Health System, Ann Arbor, MI 48109-0360, USA.
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33
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He Z, Li B, Yu L, Liu Q, Zhong N, Ran P. Suppression of oxidant-induced glutathione synthesis by erythromycin in human bronchial epithelial cells. Respiration 2007; 75:202-9. [PMID: 18032881 DOI: 10.1159/000111569] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2007] [Accepted: 07/18/2007] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Macrolide antibiotics have anti-inflammatory effects which are utilized for the treatment of chronic inflammatory airway diseases. Recently, their anti-inflammatory effects have been proposed to be beneficial in patients with chronic obstructive pulmonary disease (COPD). OBJECTIVES Since the molecular mechanisms of anti-inflammatory effects are associated with inhibition of activator protein 1 (AP-1) and nuclear factor (NF)-kappaB, and both are reported to be involved in the expression of gamma-glutamylcysteine synthetase (gamma-GCS), we set out to determine if these drugs influence the oxidant-antioxidant balance in human bronchial epithelial (HBE) cells. METHODS 16HBE cells were preincubated with erythromycin (EM) at different concentrations and times and then exposed to hydrogen peroxide (0.01 mM). Levels of interleukin (IL)-8 and glutathione (GSH), and activity of gamma-GCS and gamma-GCS heavy subunit (gamma-GCS-HS) protein production were assayed. AP-1 and NF-kappaB binding to the 5'-flanking region of IL-8 and gamma-GCS-HS genes was assessed by electrophoretic mobility-shift assay. RESULTS The increase in IL-8 levels and activity of AP-1 induced by H(2)O(2) were abrogated by preincubation of the cells with EM (5 mug/ml) for 36 h. We also showed that preincubation with EM for 48 h inhibited H(2)O(2)-induced GSH levels, gamma-GCS activity and expression of gamma-GCS-HS, and decreased AP-1 binding to the gamma-GCS-HS 5'-flanking region. CONCLUSIONS The confirmation of antioxidants maintaining enzyme suppression by EM raised concerns on whether this drug could disrupt the oxidant/ antioxidant balance during long-term use. These data provide important insights into the treatment of inflammatory lung diseases with macrolide antibiotics.
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Affiliation(s)
- Zhiyi He
- Guangzhou Institute of Respiratory Diseases, First Affiliated Hospital, Guangzhou Medical College, Guangzhou, PR China
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34
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Simpson JL, Powell H, Boyle MJ, Scott RJ, Gibson PG. Clarithromycin targets neutrophilic airway inflammation in refractory asthma. Am J Respir Crit Care Med 2007; 177:148-55. [PMID: 17947611 DOI: 10.1164/rccm.200707-1134oc] [Citation(s) in RCA: 344] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Patients with refractory asthma have persistent symptoms despite maximal treatment with inhaled corticosteroids and long-acting bronchodilators. The availability of add-on therapies is limited, and effective add-on therapies that target noneosinophilic airway inflammation are needed. Macrolide antibiotics, such as clarithromycin, have in vitro efficacy against IL-8 and neutrophils, key inflammatory mediators in noneosinophilic asthma. OBJECTIVES To determine the efficacy of clarithromycin in patients with severe refractory asthma and specifically in a subgroup of patients with noneosinophilic asthma. METHODS Subjects with severe refractory asthma (n = 45) were randomized to receive clarithromycin (500 mg twice daily) or placebo for 8 weeks. MEASUREMENTS AND MAIN RESULTS The primary outcome for this study was sputum IL-8 concentration. Other inflammatory outcomes assessed included sputum neutrophil numbers and concentrations of neutrophil elastase and matrix metalloproteinase (MMP)-9. Clinical outcomes were also assessed, including lung function, airway hyperresponsiveness to hypertonic saline, asthma control, quality of life, and symptoms. Clarithromycin therapy significantly reduced airway concentrations of IL-8 and neutrophil numbers and improved quality-of-life scores compared with placebo. Reductions in neutrophil elastase and MMP-9 concentrations were also observed. These reductions in inflammation were most marked in those with refractory noneosinophilic asthma. CONCLUSIONS Clarithromycin therapy can modulate IL-8 levels and neutrophil accumulation and activation in the airways of patients with refractory asthma. Macrolide therapy may be an important additional therapy that could be used to reduce noneosinophilic airway inflammation, particularly neutrophilic inflammation, in asthma. Clinical trial registered with the Australian Clinical Trials Registry www.actr.org.au (No. 12605000318684).
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Affiliation(s)
- Jodie L Simpson
- NHMRC Centre for Respiratory and Sleep Medicine, School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
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35
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Siddiqui S, Brightling CE. Airways disease: phenotyping heterogeneity using measures of airway inflammation. ALLERGY, ASTHMA, AND CLINICAL IMMUNOLOGY : OFFICIAL JOURNAL OF THE CANADIAN SOCIETY OF ALLERGY AND CLINICAL IMMUNOLOGY 2007; 3:60-9. [PMID: 20525145 PMCID: PMC2873624 DOI: 10.1186/1710-1492-3-2-60] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
: Despite asthma and chronic obstructive pulmonary disease being widely regarded as heterogeneous diseases, a consensus for an accurate system of classification has not been agreed. Recent studies have suggested that the recognition of subphenotypes of airway disease based on the pattern of airway inflammation may be particularly useful in increasing our understanding of the disease. The use of non-invasive markers of airway inflammation has suggested the presence of four distinct phenotypes: eosinophilic, neutrophilic, mixed inflammatory and paucigranulocytic asthma. Recent studies suggest that these subgroups may differ in their etiology, immunopathology and response to treatment. Importantly, novel treatment approaches targeted at specific patterns of airway inflammation are emerging, making an appreciation of subphenotypes particularly relevant. New developments in phenotyping inflammation and other facets of airway disease mean that we are entering an era where careful phenotyping will lead to targeted therapy.
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Banning M. Chronic obstructive pulmonary disease: clinical signs and infections. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2006; 15:874-80. [PMID: 17108859 DOI: 10.12968/bjon.2006.15.16.21852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
Chronic obstructive pulmonary disease (COPD) is a pathological condition that involves excessive production of mucus, chronic cough and inflammatory changes leading to airway limitation. The most common cause of COPD is cigarette smoking. COPD can be categorized into either chronic bronchitis or emphysema; both conditions can be differentiated by age and the production of copious, tenacious sputum. Patients with COPD are susceptible to pulmonary infections of bacterial or viral origin. Nurses should be aware of the subtle differences in conditions and the usefulness of antibiotics in the treatment of acute bacterial exacerbations of chronic bronchitis.
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Affiliation(s)
- Maggi Banning
- Brunel University, School of Health Sciences and Social Care, Mary Seacole Building, Uxbridge, Middlesex
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37
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Beeh KM, Beier J. Handle with care: targeting neutrophils in chronic obstructive pulmonary disease and severe asthma? Clin Exp Allergy 2006; 36:142-57. [PMID: 16433851 DOI: 10.1111/j.1365-2222.2006.02418.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Neutrophils play an important role in the pathogenesis of airway inflammation in both chronic obstructive pulmonary disease (COPD) and severe asthma. Currently available drugs have only limited effects on neutrophilic airway inflammation, particularily in COPD. Therefore, great efforts are undertaken to address neutrophilic inflammation in chronic respiratory disorders, in particular COPD. This review summarizes the rationale for anti-neutrophilic treatment in COPD and asthma and gives a critical overview of current developments in drug therapy. Moreover, unanswered questions and limitations of clinical trial design and choice of outcome parameters for proof-of-concept studies with novel anti-neutrophilic drugs are discussed as well as potential safety issues.
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Affiliation(s)
- K M Beeh
- Insaf Respiratory Research Institute, Wiesbaden, Germany.
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38
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Abstract
Macrolide antibiotics have been licensed since the 1950s and have an important role in the treatment of a diverse range of infectious diseases. Macrolide antibiotics have antibacterial activity against gram-positive bacteria, some gram-negative bacteria and intracellular pathogens. The spectrum of antibacterial activity combined with excellent intracellular and tissue penetration has led to the extensive use of this class of drugs in respiratory disease. Macrolide antibiotics also have demonstrated anti-inflammatory properties in various in vitro and in vivo model systems. Novel antimicrobial and anti-inflammatory properties of macrolide may result in clinical benefits, particularly in conditions where the infectious agent is inherently resistant to macrolides. Three randomized control trials have demonstrated improved lung function in patients treated with the macrolide antibiotic, azithromycin. Azithromycin was generally well tolerated and resulted in reduction in the inflammatory response which may be due to an immunomodulatory role. Short term studies (three to six months) have not demonstrated the development of increased bacterial resistance or the emergence of new pathogens following azithromycin.
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Affiliation(s)
- S C Bell
- Adult Cystic Fibrosis Unit, Department of Thoracic Medicine, The Prince Charles Hospital, Brisbane, Australia.
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39
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Roche N, Huchon G. Reducing airways inflammation to prevent exacerbations in chronic obstructive pulmonary disease. Allergy 2005; 60:1350-6. [PMID: 16197465 DOI: 10.1111/j.1398-9995.2005.00947.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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40
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Abstract
Chronic obstructive pulmonary disease (COPD) is a major and increasing global health problem that is now a leading cause of death. COPD is associated with a chronic inflammatory response, predominantly in small airways and lung parenchyma, which is characterized by increased numbers of macrophages, neutrophils, and T lymphocytes. The inflammatory mediators involved in COPD have not been clearly defined, in contrast to asthma, but it is now apparent that many lipid mediators, inflammatory peptides, reactive oxygen and nitrogen species, chemokines, cytokines, and growth factors are involved in orchestrating the complex inflammatory process that results in small airway fibrosis and alveolar destruction. Many proteases are also involved in the inflammatory process and are responsible for the destruction of elastin fibers in the lung parenchyma, which is the hallmark of emphysema. The identification of inflammatory mediators and understanding their interactions is important for the development of anti-inflammatory treatments for this important disease.
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Affiliation(s)
- Peter J Barnes
- National Heart and Lung Institute, Imperial College School of Medicine, Dovehouse St, London SW3 6LY, United Kingdom.
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Parnham MJ, Culić O, Eraković V, Munić V, Popović-Grle S, Barisić K, Bosnar M, Brajsa K, Cepelak I, Cuzić S, Glojnarić I, Manojlović Z, Novak-Mircetić R, Oresković K, Pavicić-Beljak V, Radosević S, Sucić M. Modulation of neutrophil and inflammation markers in chronic obstructive pulmonary disease by short-term azithromycin treatment. Eur J Pharmacol 2005; 517:132-43. [PMID: 15964564 DOI: 10.1016/j.ejphar.2005.05.023] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2004] [Revised: 05/18/2005] [Accepted: 05/24/2005] [Indexed: 10/25/2022]
Abstract
The anti-inflammatory potential of azithromycin in chronic obstructive pulmonary disease (COPD) patients was explored following a standard oral dosing regimen. Patients with moderate and severe COPD were treated with azithromycin (500 mg, n=16) or placebo (n=8) once daily for 3 days in a randomized, double blind design, to compare effects on inflammation markers with those seen in a previous study in healthy volunteers. A battery of tests was made on serum, blood neutrophils and sputum on days 1 (baseline), 3, 4, 11, 18 and 32. In comparison to placebo, azithromycin resulted in an early transient increase in serum nitrites plus nitrates (day 3), associated with a tendency towards an increase in the blood neutrophil oxidative burst to phorbol myristic acetate. Subsequently, prolonged decreases in blood leukocyte and platelet counts, serum acute phase protein (including C reactive protein) and soluble E-selectin and blood neutrophil lactoferrin concentrations and a transient decrease in serum interleukin-8 were observed. Blood neutrophil glutathione peroxidase activity showed a prolonged increase after azithromycin treatment. The biphasic facilitatory-then-inhibitory response to azithromycin seen in healthy volunteers is not so clearly detectable in COPD patients, only potential anti-inflammatory effects. Treatment for longer periods may give therapeutic anti-inflammatory benefit in these patients.
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Affiliation(s)
- Michael J Parnham
- PLIVA Research Institute Ltd, Prilaz baruna Filipovića 29, HR-10 000 Zagreb, Croatia.
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Parnham MJ. Immunomodulatory effects of antimicrobials in the therapy of respiratory tract infections. Curr Opin Infect Dis 2005; 18:125-31. [PMID: 15735416 DOI: 10.1097/01.qco.0000160901.71813.fe] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Several classes of antibiotics, particularly macrolides and to some extent quinolones, exert modulatory effects on inflammatory cells. With a growing number of experimental and clinical studies being performed, the relevance of the immunomodulatory actions of antibiotics to the therapy of respiratory infections is discussed in the light of recent reports. RECENT FINDINGS Antibiotics, particularly macrolides, exert both stimulatory and inhibitory effects on leukocytes. These effects seem to be related to the activation state of the leukocytes, facilitating bacterial killing as well as the resolution of local inflammation. In community-acquired pneumonia, this may account for the therapeutic benefit of macrolides, even when bacterial eradication is not complete. A variety of effects of macrolides on Pseudomonas aeruginosa, including the inhibition of biofilm matrix, contribute with immunomodulation to the improvement of respiratory function seen with macrolides in cystic fibrosis. SUMMARY Macrolides can facilitate the killing of microorganisms in acute respiratory infections through the stimulation of neutrophil activation. On long-term administration, anti-inflammatory, T helper type 1 lymphocyte-enhancing and biofilm-thinning actions, among others, make macrolides valid therapeutic options in chronic infectious/inflammatory disorders, even for infections with microorganisms that are not completely eradicated.
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Basyigit I, Yildiz F, Ozkara SK, Yildirim E, Boyaci H, Ilgazli A. The Effect of Clarithromycin on Inflammatory Markers in Chronic Obstructive Pulmonary Disease: Preliminary Data. Ann Pharmacother 2004; 38:1400-5. [PMID: 15252191 DOI: 10.1345/aph.1d634] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND: Clarithromycin is an antimicrobial agent that can be used for treatment of chronic obstructive pulmonary disease (COPD) exacerbations with bronchodilator therapy. However, it has also been shown that clarithromycin has antiinflammatory effects by the inhibition of cytokine production. OBJECTIVE: To evaluate the antiinflammatory effect of clarithromycin on serum and sputum interleukin-8 (IL-8), tumor necrosis factor-α (TNF-α), and leukotriene B4 levels in patients with COPD. METHODS: Thirty men with mild to moderate COPD were enrolled in this prospective, single-center, double-blind, placebo-controlled study. None of the patients was receiving systemic or inhaled corticosteroids during the study. Subjects received either clarithromycin or placebo for 14 days. Before and after this treatment period, spirometric tests and arterial blood gas analysis were performed, blood was drawn for measurement of serum inflammatory markers, and sputum was induced. RESULTS: There were no statistically significant differences in baseline clinical or laboratory parameters between the groups. After the treatment, the induced sputum total cell counts, and IL-8 and TNF-α levels decreased significantly in the clarithromycin group compared with pretreatment levels (mean ± SD IL-8 1606 ± 367.3 vs 882 ± 143.6 pg/mL, p = 0.001; TNF-α 638.2 ± 287.5 vs 390 ± 235 pg/mL, p = 0.001). Similarly, decreases in serum inflammatory markers were found in the clarithromycin group while there was no significant change in the placebo group. CONCLUSIONS: This study demonstrated that the decrease in IL-8 and TNF-α levels might be related to the antiinflammatory effect of clarithromycin. Thus, we suggest that the use of clarithromycin in COPD exacerbations may either treat the infection or help control the inflammation. Future studies are needed to determine the clinical significance of these findings.
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Affiliation(s)
- Ilknur Basyigit
- Chest Disease Department, Faculty of Medicine, Kocaeli University, Kocaeli, Turkey.
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