Comments
From the Editorialists:
We appreciate the thoughtful comments by Albert and coworkers on the issues we raised in our recent editorial (1) related to their publications (2, 3). We propose a cautious view on the observed long-term macrolide benefits in chronic obstructive pulmonary disease (COPD) exacerbations.
According to the World Health Organization, an estimated 64 million people have COPD worldwide (4). Thus, the potential treated population can be astronomical. It is therefore necessary to raise a voice of caution. First, what is the effect on the microbial ecology long-term if a large proportion of patients with COPD start treatment with daily macrolides to prevent exacerbations? It is important to remember that although the placebo group had a larger proportion of colonized patients during the course of this study, the rate of macrolide-resistant pathogens significantly increased (2, 3). So, are we setting up a massive resistance problem in the community? This selective antimicrobial resistance pressure to macrolides for respiratory pathogens is currently a global concern (5). Second, what could be the ototoxic, cardiovascular, and other adverse effects when large number of patients with COPD start using macrolides for a prolonged duration of time?
We disagree with Albert and colleagues’ suggestion that azithromycin effects on decreasing COPD exacerbations might be the same as those achieved with inhaled bronchodilators. We need to remember that COPD is an obstructive airway disease and that long-active bronchodilators have been shown to improve lung function, exercise capacity, and quality of life. These effects have not been shown with macrolides.
We agree that before clinicians extrapolate these hypotheses, generating observations into clinical practice, there is a need to further validate the population that may benefit the most from azithromycin therapy. Our commitment to patients should be to identify therapies that will improve both their quality of life and their outcomes, but these therapies also have to be safe.
| 1. | Restrepo MI, Anzueto A. Macrolide antibiotics for prevention of chronic obstructive pulmonary disease exacerbations: are we there yet? [editorial]. Am J Respir Crit Care Med 2014;190:1–2. |
| 2. | Han MK, Tayob N, Murray S, Dransfield MT, Washko G, Scanlon PD, Criner GJ, Casaburi R, Connett J, Lazarus SC, et al. Predictors of chronic obstructive pulmonary disease exacerbation reduction in response to daily azithromycin therapy. Am J Respir Crit Care Med 2014;189:1503–1508. |
| 3. | Albert RK, Connett J, Bailey WC, Casaburi R, Cooper JA Jr, Criner GJ, Curtis JL, Dransfield MT, Han MK, Lazarus SC, et al.; COPD Clinical Research Network. Azithromycin for prevention of exacerbations of COPD. N Engl J Med 2011;365:689–698. |
| 4. | World Health Organization. Chronic obstructive pulmonary disease (COPD). World Health Organization fact sheet 315 [updated 2003 Oct; accessed 2014 Oct 30]. Available from: http://www.who.int/mediacentre/factsheets/fs315/en/ |
| 5. | Centers for Disease Control and Prevention. Threat report 2013: Antibiotic resistance threats in the United States, 2013. Atlanta, GA: Centers for Disease Control and Prevention; 2013 [updated 2014 Jun 2; accessed 2014 Oct 30]. Available from: http://www.cdc.gov/drugresistance/threat-report-2013/ |
Author disclosures are available with the text of this letter at www.atsjournals.org.
