Cystic fibrosis azithromycin

Pneumonia - Do not use oral azithromycin in patients with pneumonia who are judged to be inappropriate for oral therapy because of moderate to severe illness or risk factors such as any of the following nosocomially acquired infections known or suspected bacteremia conditions requiring hospitalization cystic fibrosis significant underlying health problems that may compromise patients ability to respond to their illness (including immunodeficiency or functional asplenia) elderly or debilitated patients. 

Anti-infectious agents also play a key role in the treatment of cystic fibrosis, and respiratory infections are treated with appropriate antibiotic agents.16 89 In particular, azithromycin has shown considerable... 

Jaffe A, Francis J, Rosenthal M, Bush A. Long-term azithromycin may improve lung function in children with cystic fibrosis. Lancet 1998 351(9100) 420. 

Altschuler EL. Azithromycin, the multidrug-resistant protein, and cystic fibrosis. Lancet 1998 351(9111) 1286. 

Saiman L, Marshall BC, Mayer-Hamblett N, et al. Azithromycin in patients with cystic fibrosis chronically infected with Pseudomonas aeruginosa A randomized controlled trial. JAMA 2003 290 1749-1756. 

A meta-analysis of azithromycin for greater than 6 months in chronic lung disease was associated with a 2.7-fold increase in resistant pathogens (95% Cl 1.249-5.211) [105 ]. High rates of macrolide-resistant pathogens were also seen in controlled trials of Tanzanian children treated with Mass Distribution of Azithromycin for endemic Chlamydia trachomatis [lOh ] and in paediatric cystic fibrosis patients [107 ]. A French case-control study did not find an association between long-term Azithromycin use and M. abscessus in adult and paediatric cystic fibrosis patients [lOS ]. 

Wong C, Jayaram L, Karalus N, Eaton T, Tong C, Hockey H, et al. Azithromycin for prevention of exacerbations in non-cystic fibrosis bronchiectasis (EMBRACE) a randomised, double-blind, placebo-controlled trial. Lancet 2012 380(9842) 660-7. 

Altenburg J, de Graaff CS, Stienstra Y, Sloos JH, van Haren EH, Koppers RJ, et al. Effect of azithromycin maintenance treatment on infectious exacerbations among patients with non-cystic fibrosis bronchiectasis the BAT randomized controlled trial. JAMA 2013 309(12) 1251-9. 

Catherinot E, Roux AL, Vibet MA, Beilis G, Lemonnier L, Le Roux E, et al. Inhaled therapies, azithromycin and Mycobacterium abscessus in cystic fibrosis patients. Eur Respir J 2013 41(5) 1101-6. 

Table 6.1 Observations of cystic fibrosis patients treated with azithromycin for 168 days and selected according to the presence of Pseudomonas aeruginosa.

Similarly, there is a very clear systemic response of plasma inflammatory markers to azithromycin soon after commencement of therapy in cystic fibrosis patients that is sustained for 3 to 6 months. The most notable feature of this response is a decline in circulating neutrophils that may correspond to changes in neutrophil infiltration in airways. 

Although various studies demonstrate these benefits, each example can be countered. For example, reductions in circulating neutrophils can also simply indicate the reduction of an infection. Similarly, cryptic infection may underlie many inflammatory conditions and these cryptic infections are by definition difficult to demonstrate. In both COPD and cystic fibrosis there is a plateau in response to azithromycin after one to three years that may relate to either some change in flora that has not yet been observed or accommodation by the immune system. 

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