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Risks of population antimicrobial resistance associated with chronic macrolide use for inflammatory airway diseases
1Department of Respiratory Medicine, Mater Adult Hospital, South Brisbane, QLD, Australia; University of Queensland and Mater Medical Research Institute, Mater Health Services, South Brisbane, QLD, Australia.
Abstract:
Macrolide antibiotics have established efficacy in the management of cystic fibrosis and diffuse panbronchiolitis-uncommon lung diseases with substantial morbidity and the potential for rapid progression to death. Emerging evidence suggests benefits of maintenance macrolide treatment in more indolent respiratory diseases including chronic obstructive pulmonary disease and non-cystic fibrosis bronchiectasis. In view of the greater patient population affected by these disorders (and potential for macrolide use to spread to disorders such as chronic cough), widespread use of macrolides, particularly azithromycin, has the potential to substantially influence antimicrobial resistance rates of a range of respiratory microbes. In this Personal View, I explore theories around population (rather than patient) macrolide resistance, appraise evidence linking macrolide use with development of resistance, and highlight the risks posed by injudicious broadening of their use, particularly of azithromycin. These risks are weighed against the potential benefits of macrolides in less aggressive inflammatory airway disorders. A far-sighted approach to maintenance macrolide use in non-cystic fibrosis inflammatory airway diseases is needed, which minimises risks of adversely affecting community macrolide resistance: combining preferential use of erythromycin and restriction of macrolide use to those patients at greatest risk represents an appropriately cautious management approach.
Insights
Widespread macrolide antibiotic use for chronic lung diseases may increase antimicrobial resistance. A cautious approach, prioritizing erythromycin and limiting use to high-risk patients, is needed to balance benefits against resistance risks.
Area of Science:
- Respiratory Medicine
- Infectious Diseases
- Pharmacology
Background:
- Macrolide antibiotics are effective for cystic fibrosis and diffuse panbronchiolitis.
- Emerging evidence supports their use in chronic obstructive pulmonary disease and non-cystic fibrosis bronchiectasis.
- Widespread use, especially azithromycin, may impact respiratory microbe resistance.
Purpose of the Study:
- To explore population-level macrolide resistance theories.
- To appraise evidence linking macrolide use to resistance development.
- To highlight risks of expanding macrolide use in inflammatory airway diseases.
Main Methods:
- Review of existing literature on macrolide use and antimicrobial resistance.
- Analysis of population versus individual patient resistance mechanisms.
- Risk-benefit assessment of macrolide therapy in various respiratory conditions.
Main Results:
- Broadening macrolide use, particularly azithromycin, poses a significant risk to community antimicrobial resistance.
- Potential benefits in less aggressive inflammatory airway disorders must be weighed against resistance concerns.
- Injudicious use can lead to widespread resistance affecting various respiratory microbes.
Conclusions:
- A cautious, far-sighted approach to maintenance macrolide therapy is essential for non-cystic fibrosis inflammatory airway diseases.
- Preferential use of erythromycin and restricting macrolide use to high-risk patients can mitigate resistance risks.
- Balancing therapeutic benefits with the imperative to preserve antimicrobial efficacy is crucial for long-term respiratory health management.
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