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Azithromycin is the answer in paediatric respiratory medicine, but what was the question?

Abstract

The first clinical indication of non-antibiotic benefits of macrolides was in the Far East, in adults with diffuse panbronchiolitis. This condition is characterised by chronic airway infection, often with Pseudomonas aeruginosa, airway inflammation, bronchiectasis and a high mortality. Low dose erythromycin, and subsequently other macrolides, led in many cases to complete remission of the condition, and abrogated the neutrophilic airway inflammation characteristic of the disease. This dramatic finding sparked a flurry of interest in the many hundreds of macrolides in nature, especially their anti-inflammatory and immunomodulatory effects. The biggest subsequent trials of azithromycin were in cystic fibrosis, which has obvious similarities to diffuse panbronchiolitis. There were unquestionable improvements in lung function and pulmonary exacerbations, but compared to diffuse panbronchiolitis, the results were disappointing. Case reports, case series and some randomised controlled trials followed in other conditions. Three trials of azithromycin in preschool wheeze gave contradictory results; a trial in pauci-inflammatory adult asthma, and a trial in non-cystic fibrosis bronchiectasis both showed a significant reduction in exacerbations, but none matched the dramatic results in diffuse panbronchiolitis. There is clearly a huge risk of antibacterial resistance if macrolides are used widely and uncritically in the community. In summary, Azithromycin is not the answer to anything in paediatric respiratory medicine; the paediatric respiratory community needs to refocus on the dramatic benefits of macrolides in diffuse panbronchiolitis, use modern - omics technologies to determine the endotypes of inflammatory diseases and discover in nature or synthesise designer macrolides to replicate the diffuse panbronchiolitis results. We must now find out how to do better!

Authors+Show Affiliations

Professor of Paediatrics and Paediatric Respirology, Imperial College Consultant Paediatric Chest Physician, Royal Brompton & Harefield NHS Foundation Trust, National Heart and Lung Institute, UK; Paediatric Chest Physician, Royal Brompton Harefield NHS Foundation Trust, UK. Electronic address: a.bush@imperial.ac.uk.

Pub Type(s)

Journal Article
Review

Language

eng

PubMed ID

31629643

Citation

Bush, Andrew. "Azithromycin Is the Answer in Paediatric Respiratory Medicine, but what Was the Question?" Paediatric Respiratory Reviews, 2019.
Bush A. Azithromycin is the answer in paediatric respiratory medicine, but what was the question? Paediatr Respir Rev. 2019.
Bush, A. (2019). Azithromycin is the answer in paediatric respiratory medicine, but what was the question? Paediatric Respiratory Reviews, doi:10.1016/j.prrv.2019.07.002.
Bush A. Azithromycin Is the Answer in Paediatric Respiratory Medicine, but what Was the Question. Paediatr Respir Rev. 2019 Aug 16; PubMed PMID: 31629643.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Azithromycin is the answer in paediatric respiratory medicine, but what was the question? A1 - Bush,Andrew, Y1 - 2019/08/16/ PY - 2019/07/30/received PY - 2019/07/30/accepted PY - 2019/10/21/entrez PY - 2019/10/21/pubmed PY - 2019/10/21/medline KW - Asthma KW - Bronchiectasis KW - Bronchiolitis KW - Cystic fibrosis KW - Interstitial lung disease KW - Preschool wheeze KW - Primary ciliary dyskinesia JF - Paediatric respiratory reviews JO - Paediatr Respir Rev N2 - The first clinical indication of non-antibiotic benefits of macrolides was in the Far East, in adults with diffuse panbronchiolitis. This condition is characterised by chronic airway infection, often with Pseudomonas aeruginosa, airway inflammation, bronchiectasis and a high mortality. Low dose erythromycin, and subsequently other macrolides, led in many cases to complete remission of the condition, and abrogated the neutrophilic airway inflammation characteristic of the disease. This dramatic finding sparked a flurry of interest in the many hundreds of macrolides in nature, especially their anti-inflammatory and immunomodulatory effects. The biggest subsequent trials of azithromycin were in cystic fibrosis, which has obvious similarities to diffuse panbronchiolitis. There were unquestionable improvements in lung function and pulmonary exacerbations, but compared to diffuse panbronchiolitis, the results were disappointing. Case reports, case series and some randomised controlled trials followed in other conditions. Three trials of azithromycin in preschool wheeze gave contradictory results; a trial in pauci-inflammatory adult asthma, and a trial in non-cystic fibrosis bronchiectasis both showed a significant reduction in exacerbations, but none matched the dramatic results in diffuse panbronchiolitis. There is clearly a huge risk of antibacterial resistance if macrolides are used widely and uncritically in the community. In summary, Azithromycin is not the answer to anything in paediatric respiratory medicine; the paediatric respiratory community needs to refocus on the dramatic benefits of macrolides in diffuse panbronchiolitis, use modern - omics technologies to determine the endotypes of inflammatory diseases and discover in nature or synthesise designer macrolides to replicate the diffuse panbronchiolitis results. We must now find out how to do better! SN - 1526-0550 UR - https://www.unboundmedicine.com/medline/citation/31629643/Azithromycin_is_the_answer_in_paediatric_respiratory_medicine,_but_what_was_the_question L2 - https://linkinghub.elsevier.com/retrieve/pii/S1526-0542(19)30065-X DB - PRIME DP - Unbound Medicine ER -