Effect of long-term, low-dose erythromycin on pulmonary exacerbations among patients with non-cystic fibrosis bronchiectasis: the BLESS randomized controlled trial.

Abstract

IMPORTANCE:

Macrolide antibiotics such as erythromycin may improve clinical outcomes in non-cystic fibrosis (CF) bronchiectasis, although associated risks of macrolide resistance are poorly defined.

OBJECTIVE:

To evaluate the clinical efficacy and antimicrobial resistance cost of low-dose erythromycin given for 12 months to patients with non-CF bronchiectasis with a history of frequent pulmonary exacerbations.

DESIGN, SETTING, AND PARTICIPANTS:

Twelve-month, randomized (1:1), double-blind, placebo-controlled trial of erythromycin in currently nonsmoking, adult patients with non-CF bronchiectasis with a history of 2 or more infective exacerbations in the preceding year. This Australian study was undertaken between October 2008 and December 2011 in a university teaching hospital, with participants also recruited via respiratory physicians at other centers and from public radio advertisements.

INTERVENTIONS:

Twice-daily erythromycin ethylsuccinate (400 mg) or matching placebo.

MAIN OUTCOME MEASURES:

The primary outcome was the annualized mean rate of protocol-defined pulmonary exacerbations (PDPEs) per patient. Secondary outcomes included macrolide resistance in commensal oropharyngeal streptococci and lung function.

RESULTS:

Six-hundred seventy-nine patients were screened, 117 were randomized (58 placebo, 59 erythromycin), and 107 (91.5%) completed the study. Erythromycin significantly reduced PDPEs both overall (mean, 1.29 [95% CI, 0.93-1.65] vs 1.97 [95% CI, 1.45-2.48] per patient per year; incidence rate ratio [IRR], 0.57 [95% CI, 0.42-0.77]; P = .003), and in the prespecified subgroup with baseline Pseudomonas aeruginosa airway infection (mean difference, 1.32 [95% CI, 0.19-2.46]; P = .02). Erythromycin reduced 24-hour sputum production (median difference, 4.3 g [interquartile range [IQR], 1 to 7.8], P = .01) and attenuated lung function decline (mean absolute difference for change in postbronchodilator forced expiratory volume in the first second of expiration, 2.2 percent predicted [95% CI, 0.1% to 4.3%]; P = .04) compared with placebo. Erythromycin increased the proportion of macrolide-resistant oropharyngeal streptococci (median change, 27.7% [IQR, 0.04% to 41.1%] vs 0.04% [IQR, -1.6% to 1.5%]; difference, 25.5% [IQR,15.0% to 33.7%]; P < .001).

CONCLUSION AND RELEVANCE:

Among patients with non-CF bronchiectasis, the 12-month use of erythromycin compared with placebo resulted in a modest decrease in the rate of pulmonary exacerbations and an increased rate of macrolide resistance.

TRIAL REGISTRATION:

anzctr.org.au Identifier: ACTRN12609000578202.

• Authors: David J Serisier, Megan L Martin, Michael A McGuckin, Rohan Lourie, Alice C Chen, Barbara Brain, Sally Biga, Sanmarié Schlebusch, Peter Dash, Simon D Bowler
• Journal: JAMA (JAMA) Vol. 309 Issue 12 Pg. 1260-7 (Mar 27 2013) ISSN: 1538-3598 [Electronic] United States
• PMID: 23532242 (Publication Type: Journal Article, Randomized Controlled Trial, Research Support, Non-U.S. Gov't)

Chemical References

• Anti-Bacterial Agents
• Erythromycin

Topics

• Aged
• Anti-Bacterial Agents (administration & dosage, pharmacology)
• Bronchiectasis (complications)
• Dose-Response Relationship, Drug
• Double-Blind Method
• Drug Administration Schedule
• Drug Resistance, Bacterial
• Erythromycin (administration & dosage, pharmacology)
• Female
• Humans
• Lung (physiopathology)
• Male
• Middle Aged
• Pseudomonas Infections (etiology, prevention & control)
• Pseudomonas aeruginosa (isolation & purification)
• Respiratory Tract Infections (etiology, prevention & control)
• Sputum (microbiology)
• Streptococcus (isolation & purification)
• Treatment Outcome