Focus area: Physicians
The use of macrolide antibiotics for bronchiectasis
Bronchiectasis is a long-term respiratory condition. People are prone to infection. Moreover, bronchiectasis is associated with a mortality rate more than twice of the general population. Long-term antibiotic therapy with macrolides may reduce the cycle of reinfection, reduce symptoms, and improve quality of life. But what are the evidence on use of macrolides in people with bronchiectasis?
Bronchiectasis is a chronic respiratory disease characterised by abnormal and irreversible dilatation and distortion of the smaller airways. Bacterial colonisation of the damaged airways leads to chronic cough and sputum production, often with breathlessness and further structural damage to the airways. Long-term macrolide antibiotic therapy may suppress bacterial infection and reduce inflammation, leading to fewer exacerbations, fewer symptoms, improved lung function, and improved quality of life. A Cochrane was recently published with the aim of determining the impact of macrolide antibiotics in the treatment of adults and children with bronchiectasis. Long-term macrolide therapy may reduce the frequency of exacerbations and improve quality of life, although supporting evidence is derived mainly from studies of azithromycin, rather than other macrolides, and predominantly among adults rather than children. However, macrolides should be used with caution, as limited data indicate an associated increase in microbial resistance. Macrolides are associated with increased risk of cardiovascular death and other serious adverse events in other populations, and available data cannot exclude a similar risk among patients with bronchiectasis.
Existing studies and meta-analyses have largely taken the view that macrolide efficacy in bronchiectasis has been proven, and that additional large studies are unnecessary. The authors of this Cochrane suggest that substantial uncertainties about macrolide efficacy remain, particularly with regard to improvements in quality of life and lung function, as well as impact on antimicrobial resistance. In addition, the relative benefits of macrolides compared with those of other types of antibiotics are unknown, as they did not identify any studies that included these comparisons. Their analysis suggests that additional large, randomised, placebo controlled trials should be performed to confirm the efficacy and safety of macrolides.
Fonte: Kelly C et al. Macrolide antibiotics for bronchiectasis. Cochrane Database Syst Rev 2018 Mar 15;3:CD012406. doi: 10.1002/14651858.CD012406.pub2. [Epub ahead of print]