JAC

Journal of Antimicrobial Chemotherapy (2004) 54, 2128

DOI: 10.1093/jac/dkh309
Advance Access publication 9 June 2004

Macrolide activities beyond their antimicrobial effects: macrolides

in diffuse panbronchiolitis and cystic fibrosis
Marcus J. Schultz1,2*
1

Laboratory of Experimental Internal Medicine and 2Department of Intensive Care Medicine, C3-329,
Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands

Keywords: erythromycin, azithromycin, clarithromycin, innate immunity, alveolar macrophages,

polymorphonuclear cells, cytokines, biofilms

prognosis of DPB was poor, but a key report by Kudoh et al.1

clearly suggested spectacular improved survival with the introduction of macrolide therapy.
DPB shares many similarities with cystic fibrosis (CF). The
triad of chronic obstructive pulmonary disease, pancreatic exocrine deficiency and abnormally high sweat electrolyte concentrations is present in most CF patients. The clinical and
pathological findings are attributable to genetic defects, leading
to an abnormality in the chloride channel. Pulmonary complications usually dominate the course of the disease, although
clinical manifestations may not appear until weeks, months or
years of age. Bronchiectasis is present in most patients by the
end of the second decade of life. Lung infections due to Staphylococcus aureus and P. aeruginosa are extremely common and
cause additional lung damage. Until now, the therapeutic
approach of CF patients included physiotherapy, DNase
and antibiotics. Successful treatment strategies with macrolides
in DPB patients have inspired researchers to introduce macrolides as immunomodulating agents in CF patients, showing some
improvements in morbidity.2,3

Introduction
Diffuse panbronchiolitis (DPB) is a condition of unknown
aetiology, usually diagnosed between the second and fifth decade. DPB is an important cause of progressive obstructive lung
disease in the Far East (mainly in Japan and Korea), but a rare
disease in non-Asian populations. The onset of DPB resembles
bronchial asthma, chronic bronchitis, and pulmonary emphysema, because it is clinically manifested by common symptoms
such as dyspnoea, cough, sputum, coarse crackles and wheeze.
The chest radiograph often shows hyperinflation. Pulmonary
function tests show decreased vital capacity (VC), and forced
expiratory volume in 1 s (FEV1). Lung histology reveals a cellular bronchiolitis, mononuclear cell proliferation and foamy
macrophages involving the bronchiolar walls, adjacent alveolar
ducts and alveoli. Narrowing and constriction of respiratory
bronchioles may develop in advanced stages. Advanced disease
is associated with chronic mucoid Pseudomonas aeruginosa
infection. Death is usually secondary to respiratory failure
and/or P. aeruginosa pneumonia. For a long time, the long-term

..........................................................................................................................................................................................................................................................................................................................................................................................................................

*Tel: +31-20-5669111; Fax: +31-20-5669568; E-mail: m.j.schultz@amc.uva.nl

..........................................................................................................................................................................................................................................................................................................................................................................................................................

21
JAC vol.54 no.1 q The British Society for Antimicrobial Chemotherapy 2004; all rights reserved.

Downloaded from http://jac.oxfordjournals.org/ at Pennsylvania State University on February 21, 2013

Diffuse panbronchiolitis (DPB) is a pulmonary disease characterized by chronic inflammation of the

bronchioles and chronic infiltration of inflammatory cells in the lungs. DPB has several features in
common with cystic fibrosis (CF). Clinical trials in patients with DPB or CF suggest a potential role for
maintenance (long-term and low-dose) macrolide therapy in the treatment of these chronic pulmonary
conditions. Indeed, these studies demonstrate improved clinical and physiological states with macrolide therapy. The beneficial effects of long-term low-dose macrolides are not related to their antimicrobial properties, since levels of macrolides with low-dose treatment are too low to have sufficient
antimicrobial effects. Data indicate that macrolides may have immunomodulatory activities: (1) in vitro
and ex vivo studies clearly show that macrolides can influence cytokine production by several cell
types; (2) furthermore, macrolides can alter polymorphonuclear cell functions in vitro and ex vivo.
Although immunomodulation may serve as one explanation for the beneficial effects of macrolides in
patients with chronic pulmonary inflammation, the effect of low-dose macrolide therapy on biofilm-formation may form a second explanation for the positive effects of long-term low-dose macrolide
therapy. In the present paper, the clinical trials on maintenance macrolide therapy in patients with DPB
or CF are reviewed. This is followed by a discussion on the immunomodulating effects of macrolides,
and the effects of macrolides on biofilm formation.

Table 1. Studies on macrolides in diffuse panbronchiolitis

Year of
publication

No. of patients

Takeda et al.
Yamamoto et al.12a

1989
1990

12
101

long-term CLR
ERY for >3 months

Nagai et al.13a

1991

19

Ichikawa et al.14a

1992

Akira et al.4

Therapy

Non-clinical findings

11

ERY 400 600 mg/day for

>2 months
long-term ERY

improvement in symptoms
improvement in dyspnoea,
amount of sputum
16 patients improved, with less
sputum production and less dyspnoea
improvement in pulmonary function

1993

19

ERY 600 mg/day

NA

Kadota et al.15a

1993

19 (?)

long-term ERY

NA

Oda et al.16

1994

13

ERY 600 mg/day

for >6 months

improved VC%, FEV1 and DLCO%

Kusano et al.5a
Fujii et al.17

1995
1995

?
28

long-term RXM
ERY 600 mg/day
for >12 months

NA
reduced sputum volume, improved
VC%, FEV1 and ABA

Kobayashi et al.20a

1995

60

AZM 250 mg 2/week

Mukae et al.18

1995

33

Tamaoki et al.19

1995

31

decrease in sputum volume

increased sputum elasticity

Kadota et al.21

1996

Sakito et al.22

1996

ERY 600 mg/day or RXM

150 mg/day, for
9.86.4 months
CLR 100 mg twice a day for 8
weeks
ERY 600 mg/day
for >3 months
long-term ERY or RXM

decrease in sputum volume,

amelioration of dyspnoea,
improved VC and FEV1
NA

?
improvement in CXR-findings, ABA,
ESR, cold coagulation titre
16 patients showed improvement
in CXR-findings
neutrophil and the neutrophil-derived
elastolytic-like activity in
BALF decreased
decreased areas of high attenuation,
no changes in peripheral areas on
CT scan
reduced BALF neutrophil cell count,
reduced neutrophil chemotactic activity
reduced BALF total cell count,
reduced BALF neutrophil cell count,
reduced neutrophil chemotactic activity
reduced BALF neutrophil cell count
reduced BALF total cell count,
reduced BALF neutrophil cell count in
pts in whom P. aeruginosa cleared
improvement in ESR, cold coagulation titre

improved FEV1, FEV1/FVC%

and FVC%
NA

Shirai et al.58a

1997

ERY for 2 3 years

improved VC%, FEV1 and PaO2

reduced BALF cell count to normal;

reduced IL-1b and IL-8 levels in BALF
reduced BALF neutrophil cell count,
reduced BALF levels of IL-1b and IL-8
NA

22

reduced lymphocyte BALF cell

count; elevated CD4/CD8 ratio

Review

Clinical symptoms

11a

Downloaded from http://jac.oxfordjournals.org/ at Pennsylvania State University on February 21, 2013

Author

Only studies with an abstract in PubMed are listed; ?, unclear or not available; pts, patients; CLR, clarithromycin; ERY, erythromycin; RXM, roxithromycin; AZM, azithromycin; NA, not applicable;
ABA, arterial blood gas analysis; BALF, bronchoalveolar lavage fluid; FVC, forced vital capacity; PaO2, arterial oxygen tension.
a
Only abstract available.

2003
Kadota et al.6

10

2003
Hiratsuka et al.25

33

ERY 600 mg/day or CLR

200 mg/day for 6 months
CLR for 4 years

long-term improved VC%, FEV1 and

ABA, and comprehensive
improvement score

improvement in the rate of survival;

more significant improvement
in the older than in the younger pts
reduced BALF total cell and
neutrophil counts and defensins levels
NA
NA
1998
Kudoh et al.1

498
(see text for details)

improved VC%, FEV1 and ABA

reduced BALF neutrophil cell

count, reduced BALF levels
of IL-8, and defensins
improved VC%, FEV1 and PaO2

ERY 600 mg/day or RXM

150 mg/day or
CLR 200 mg/day
for 6 months
long-term ERY
30
1998
Ashitani et al.23

Therapy
No. of patients
Year of
publication
Author

Table 1. (Continued)

To summarize current evidence on the effectiveness of

macrolides during treatment of DPB or CF, I carried out a systematic search in the medical literature. Here, I will review the
current literature on macrolide therapy in patients with DPB or
CF. Thereafter, mechanisms by which macrolides may achieve
their beneficial effects are discussed, focusing on the immunomodulating effects of macrolides, and their influence on biofilm
formation.

Search results
A search of the PubMed (National Library of Medicine, USA at
www.pubmed.org) for unlimited citations using the words DPB
OR diffuse panbronchiolitis found a total of 708 publications.
At the end of March 2004, a limited search using the items
macrolides AND DPB OR diffuse panbronchiolitis found 164
papers; a limited search using the items erythromycin OR azithromycin OR clarithromycin AND DPB OR diffuse panbronchiolitis listed 154 papers. Limiting these searches for
human and clinical trial, listed 10 identical papers. Only
seven papers were about macrolide therapy in DPB patients, and
only three of them were in the English language.4 6 The reference lists of these publications, and several reviews on this
topic,7 9 were used to find additional papers on macrolide
therapy in DPB. This resulted in identification of 17 additional
papers.1,10 25
A search of the PubMed database for unlimited citations
using the words CF OR cystic fibrosis found a total of 31 600
publications. At the end of March 2004, using limited search
items macrolides AND CF OR cystic fibrosis identified 325
papers; for a limited search using the items erythromycin OR
azithromycin OR clarithromycin AND CF OR cystic fibrosis
125 papers were listed. Limiting these searches for human and
clinical trial, listed eight and 14 papers, respectively. Finally,
after carefully reading the abstracts, only five papers were about
macrolide therapy in CF patients, and only three of them were in
the English language.26 28 Reviews on the topic of macrolide
therapy in chronic lung disease2,3,29 identified two additional
papers.30,31

Macrolide therapy in patients with DPB (Table 1)

The first papers reporting amelioration of signs and symptoms of
DPB by long-term low-dose macrolide therapy were all published in Japanese journals.10 12 Kudoh et al.10 were the first to
describe the beneficial effects of maintenance erythromycin
therapy in patients with DPB. Takeda et al.11 showed improvement in the symptoms of patients with DPB with long-term
clarithromycin therapy. These publications were followed by a
paper by Yamamoto et al.,12 who summarized the long-term
therapeutic effects of erythromycin or a new quinolone on DPB
in 101 patients. In this study, DPB patients treated with erythromycin showed a significant improvement in dyspnoea on exertion and sputum production. Treatment with the new quinolone
did not result in any improvement. Unfortunately, these papers
were in the Japanese language.
Since these publications, several reports in the English medical literature have confirmed the effectiveness of long-term
macrolide therapy in patients with DPB. In most of these studies,
erythromycin was used.1,4,13 18,21,23,25 Seven papers reported on
23

Downloaded from http://jac.oxfordjournals.org/ at Pennsylvania State University on February 21, 2013

Clinical symptoms

Non-clinical findings

Review

Review
Table 2. Studies on macrolides in cystic fibrosis
No. of
patients

Jaffe et al.30

1998

Ordonez et al.31

2001

10

Wolter et al.26

2002

60

Equi et al.27

2002

41

AZM 250 500 mg/day

for 6 months

Saiman et al.28

2003

185

AZM 250 500 mg 3/week

for 24 weeks

Therapy

Clinical symptoms

AZM ? for >3

months
CLR 1000 mg for
6 weeks
AZM 250 mg/day
for 3 months

improvement in
FVC% and FEV1
no changes in
VC% and FEV1
improved QOL,
less antimicrobial courses,
better VC% and FEV1
no change in exercise
tolerance or subjective
well-being, modest response in
FEV1, fewer antimicrobial courses
better FEV1, less risk of
experiencing an exacerbation

Non-clinical findings
NA
no changes in BALF
neutrophil cell count
decline in CRP
no change in sputum
bacterial densities,
and inflammatory
markers

AZM, azithromycin; CLR, clarithromycin; NA, not applicable; QOL, quality of life; FVC, forced vital capacity; BALF, bronchoalveolar lavage fluid;
CRP, C-reactive protein.

the effectiveness of clarithromycin,6,11,19,25 azithromycin,20 and

roxithromycin,5,23 respectively. The vast majority of publications
reported on open, non-randomized trials evaluating the clinical
effectiveness of macrolides, with special emphasis on lung function tests.6,16,17,21,23,25 All cited studies indeed showed improved
VC and FEV1 with use of macrolides. Other studies demonstrated improvements in the diffusion capacity of lungs
(DLCO),16 and arterial oxygenation.6,17,23 Some studies also
showed improvement of radiographic findings.4,12,13
Tamaoki et al.19 carried out the one and only randomized controlled trial with macrolides in patients with DPB. In this study,
change in sputum production with macrolide therapy was determined.19 For this, patients were divided into two groups: one
group received clarithromycin (100 mg twice a day for 8 weeks),
the control group received placebo. In evaluating airway
secretion, the daily amounts of expectorated sputum, solid composition, and sputum microbiology were assessed. Clarithromycin decreased sputum production from 51 6 to 24 3 g/day
after treatment, whereas placebo had no effect. Bacterial density
and sputum flora were unaltered. These results are in line with
results from other studies.13,17,20
The largest report on macrolide therapy in patients with DPB
is the paper by Kudoh et al.1 In this retrospective, though
important analysis on almost 500 DPB patients, a significant
improvement in survival was found to be associated with longterm low-dose erythromycin treatment. Patients were clustered
in three consecutive groups: group 1 included patients diagnosed
between 1970 and 1979 (the historical control patients); group
2 included patients diagnosed between 1980 and 1984; group 3
included patients diagnosed between 1984 and 1990. In the last
group, a subgroup of patients were on long-term erythromycin
therapy. Whereas mortality rates in the first groups were
approximately 70% and 50%, respectively, the last group
showed a survival rate of approximately 90%. Survival of
patients in the subgroup receiving long-term macrolide therapy
showed a better survival, compared with patients without erythromycin therapy. Although several other mechanisms may be
responsible for the dramatic change in survival over time, the
comparison between the subgroups in group 3, showing less

mortality with erythromycin therapy, strongly suggests that

maintenance erythromycin therapy is, at least in part, responsible
for the improved survival of DPB patients.

Macrolide therapy in patients with CF (Table 2)

Based on the similarities between DPB and CF, several investigators have tried to determine the efficacy of macrolides in CF
patients.26 28,30,31
To determine whether macrolide antibiotics improve pulmonary function and decrease airway inflammation in CF, Ordonez
et al.31 treated 10 patients with 3 weeks of placebo, followed by
6 weeks of clarithromycin (500 mg twice a day) in a single-blind
prospective study. Although there was an 11% improvement in
pulmonary function, differences were not statistically significant,
nor were there significant differences in any of the inflammatory
indices measured. However, this lack of significance may have
been caused by the small number of patients studied (type 2
error). In addition, Ordonez and colleagues gave a short course
of therapy at a high dose and therefore extrapolation of results
may be difficult especially as the macrolides can initially
increase the inflammatory response. In contrast, however, Jaffe
et al.30 showed that long-term azithromycin for a period of 3
months or longer, resulted in improvement of lung function in a
small group of young CF patients, suggesting that treatment of
just 6 weeks, as used by Ordonez et al. may be too short to have
a clinical effect.
Wolter et al.26 determined if azithromycin improved clinical
parameters and reduced inflammation in patients with CF. In
their prospective randomized double-blind, placebo-controlled
study, 3 months of azithromycin (250 mg/day) was compared
with placebo in 60 adults. Monthly assessment included lung
function, weight and quality of life. Blood and sputum collection
assessed systemic inflammation and changes in bacterial flora.
Respiratory exacerbations were treated according to the policy
of the CF unit. The main results of this study were that FEV1
and forced VC were maintained in the study group, whereas in
the placebo group there was a decline in both parameters.

24

Downloaded from http://jac.oxfordjournals.org/ at Pennsylvania State University on February 21, 2013

Year of
publication

Author

Review

Cytokines and chemokines

Several studies on the effect of macrolides on production of
cytokines/chemokines have been carried out with diverse cell
types and different stimuli, including pro-inflammatory cytokines
(IL-1), bacteria (Streptococcus pneumoniae and P. aeruginosa),
or bacterial products (LPS). Macrolides suppressed IL-6 and IL8 production by IL-1-stimulated bronchial epithelial cells.45,46
Similarly, erythromycin suppressed IL-8 production by human
neutrophil cells in vitro.47 These data are in line with several in
vitro and ex vivo studies in whole blood stimulated with S. pneumoniae or P. aeruginosa, in which erythromycin dose-dependently inhibited the production of tumour necrosis factor a
(TNF), IL-6, IL-8 and IL-10.40,48,49 Comparable results have been
obtained in studies with LPS, in which macrolide antibiotics
attenuated the production of cytokines by bronchial epithelial
cells or mononuclear cells.50,51 Interestingly, one of these studies
showed that clarithromycin decreased TNF and IL-1 production,
while it increased IL-6 and IL-10 production by LPS-stimulated
mononuclear cells,51 which is different from the previously cited
studies, in which the production of all cytokines was attenuated.
But there is more inconsistency: in an ex vivo study in mice, a
short course of erythromycin or roxithromycin was associated
with increased production of TNF and IL-1 by murine cells
stimulated ex vivo,52 55 while administration of roxithromycin for
a longer period was associated with a decrease in IL-1 production.55
In a chronic inflammation model in mice, the effect of macrolides on cytokine production was determined.56 During chronic
P. aeruginosa infection, concentrations of TNF and IL-1 were
measured serially in lungs until 60 days after infection. Compared
to baseline, higher cytokine levels were found in the lungs during
the course of the disease. In this model, clarithromycin significantly inhibited pulmonary production of TNF and IL-1, and
treatment with anti-TNF antibodies significantly reduced the
number of lymphocytes in the lung, but did not change the number of viable bacteria. In another report, the same group showed
a significant decrease in the number of viable bacteria in

Immunomodulating properties of macrolides

While the exact mechanisms are unknown, anti-inflammatory
rather than antimicrobial properties of macrolides seem to be
responsible for the beneficial effects in patients with DPB or CF.
Indeed, macrolides may affect several components of pulmonary
host defence. Several papers in the medical literature reported
data from in vitro and ex vivo studies. In addition, some of the
papers cited above have focused on immunomodulating properties of macrolides as well.

Neutrophil cell infiltration and function

Macrolides can influence several neutrophil cell functions. In
numerous in vitro and ex vivo studies, it was shown that macrolides inhibit oxidant production.32 37 In addition, macrolides promote neutrophil cell degranulation in vitro,38,39 and ex vivo.40
Furthermore, macrolides reduce neutrophil cell phagocytosis
ex vivo.37 Additionally, macrolides increase neutrophil cell
migration in healthy volunteers,41 and in patients with persistently abnormal neutrophil cell chemotaxis.42
Macrolides have been found to have anti-inflammatory effects
in vivo in several animal models. A series of animal investigations have studied the effects of macrolides on pulmonary
host defence: in one study, the effect of erythromycin on intrapulmonary accumulation of neutrophil cells after intra-tracheal
challenge with interleukin (IL)-8 or lipopolysaccharide (LPS)
was studied in mice.15 Intrapulmonary neutrophil cell accumulation was significantly suppressed after intraperitoneal
25

Downloaded from http://jac.oxfordjournals.org/ at Pennsylvania State University on February 21, 2013

administration of 5 mg erythromycin per animal 2 h before intratracheal injection of IL-8 or LPS. However, administration of
erythromycin for 1 week did not alter the intrapulmonary neutrophil cell accumulation. In another animal model, LPS-induced
vascular leakage and neutrophil cell accumulation in rat trachea,
both roxithromycin and erythromycin reduced neutrophil cell
accumulation.43
Long-term macrolide treatment of patients with DPB gave
lower neutrophil cell counts in bronchoalveolar lavage fluids in
numerous studies.5,14 17,21 23,25 Although attenuation of inflammation by macrolides was not demonstrated in patients with CF,
it must be mentioned that Ordonez et al.31 gave a short course of
therapy at a high dose. Therefore extrapolation of results from
this study may be difficult especially as the macrolides can
initially increase the inflammatory response.
The mechanisms underlying the effects of macrolides on neutrophil cell functions are largely unclear. It has been suggested
that inhibition of activation of protein kinase A is responsible
for the inhibition of oxidant production.36 Another study suggests
that macrolides influence the phospholipase D phosphatidate
phosphohydrolase transduction pathway, which is essential for
neutrophil cell degranulation.44

In addition, fewer courses of intravenous antibiotics were used

in study patients. Finally, quality of life improved over time in
study patients, and remained unchanged in patients receiving
placebo.
Equi et al.27 carried out a 15-month randomized double-blind,
placebo-controlled cross-over trial in 41 children with CF.
Patients received either azithromycin (bodyweight <_ 40 kg:
250 mg/day, >40 kg: 500 mg/day) or placebo for 6 months.
Treatments were crossed over after 2 months of washout.
Median relative difference in FEV1 between azithromycin and
placebo was 5.4% (95% CI 0.810.5). Thirteen of 41 patients
improved by more than 13% and five of 41 deteriorated by more
than 13%. Forced VC did not significantly change. Seventeen of
41 patients had 24 fewer oral antibiotic courses when on azithromycin than when taking placebo. Sputum bacterial densities,
inflammatory markers, exercise tolerance and subjective wellbeing did not change.
To determine whether an association between azithromycin
use and pulmonary function exists in patients with CF, Saiman
et al.28 carried out a multicentre, randomized, double-blind, placebo-controlled trial at 23 CF care centres in the United States.
Of 251 screened CF patients, 185 patients chronically infected
with P. aeruginosa were randomized to receive either azithromycin 3 days a week for 6 months (bodyweight <40 kg:
_ 40 kg: 500 mg/day) (n = 87) or placebo (n = 98).
250 mg/day; >
Groups were well-matched. Although there was a marked
variation in individual responses, treatment benefit was found:
the study group had a greater increase in FEV1 compared with
the placebo group. Furthermore, study patients had less risk of
experiencing an exacerbation than placebo patients, with a 40%
reduction in infective exacerbations with azithromycin therapy.

Review
an experimental murine model of chronic P. aeruginosa pneumonia.57
In clinical studies focusing on cytokine levels in lung fluids,
long-term macrolide therapy resulted in reduced IL-1b and IL-8
in patients with DPB.21,22,58 There are no data available on the
effects of maintenance macrolide therapy on cytokine production
in patients with CF.
Studies on the mechanisms underlying the effect of macrolides
on cytokine production have produced inconsistent data. Since
macrolide antibiotics exhibit their antimicrobial activity by
interfering with the protein production of microorganisms, interference with protein production may be one mechanism by which
cytokine production is influenced by macrolide antibiotics. Inhibition of cytokine production may also result from a modulation
of gene expression. Indeed, clarithromycin inhibited TNFmediated IL-8 gene expression by human bronchial epithelial
cells.59 Similarly, erythromycin inhibited the transcriptional
activity of nuclear factor kB (NFkB) in T cells,60 and clarithromycin inhibited the activation of NFkB by TNF and staphylococcal
enterotoxin A.61 In airway epithelial cells, erythromycin increases
cAMP levels.62 Elevation of cAMP has a marked effect on cytokine production induced by LPS, which includes inhibition of
TNF and up-regulation of IL-6 and IL-10.63,64 Hence, a possible
increase in cellular cAMP levels by erythromycin would only
partly explain the inhibitory effects of macrolides on cytokine
production.

and cytokine production, attenuation of biofilm formation may

be responsible for the beneficial effects of macrolides in patients
with DPB or CF.

Conclusions

References
1. Kudoh, S., Azuma, A., Yamamoto, M. et al. (1998). Improvement
of survival in patients with diffuse panbronchiolitis treated with lowdose erythromycin. American Journal of Respiratory and Critical Care
Medicine 157, 1829 32.
2. Schoni, M. H. (2003). Macrolide antibiotic therapy in patients
with cystic fibrosis. Swiss Medical Weekly 133, 297 301.
3. Spencer, H. & Jaffe, A. (2003). Newer therapies for cystic
fibrosis. Current Paediatrics 13, 259 63.
4. Akira, M., Higashihara, T., Sakatani, M. et al. (1993). Diffuse
panbronchiolitis: follow-up CT examination. Radiology 189, 559 62.
5. Kusano, S., Kadota, J., Kohno, S. et al. (1995). Effect of
roxithromycin on peripheral neutrophil adhesion molecules in patients
with chronic lower respiratory tract disease. Respiration 62, 217 22.
6. Kadota, J., Mukae, H., Ishii, H. et al. (2003). Long-term efficacy
and safety of clarithromycin treatment in patients with diffuse
panbronchiolitis. Respiratory Medicine 97, 844 50.
7. Labro, M. T. (1998). Anti-inflammatory activity of macrolides: a
new therapeutic potential? Journal of Antimicrobial Chemotherapy 41,
3746.
8. Labro, M. T. & Abdelghaffar, H. (2001). Immunomodulation by
macrolide antibiotics. Journal of Chemotherapy 13, 3 8.
9. Labro, M. T. (2002). Antibiotics as anti-inflammatory agents.
Current Opinion in Investigational Drugs 3, 61 8.
10. Kudoh, S., Uetake, T., Hagiwara, K. et al. (1987). Clinical effects
of low-dose long-term erythromycin chemotherapy on diffuse panbronchiolitis. Nihon Kyobu Shikkan Gakkai Zasshi 25, 632 42.
11. Takeda, H., Miura, H., Kawahira, M. et al. (1989). Long-term
administration study on TE-031 (A-56268) in the treatment of diffuse
panbronchiolitis. Kansenshogaku Zasshi 63, 71 8.
12. Yamamoto, M., Kondo, A., Tamura, M. et al. (1990). Long-term
therapeutic effects of erythromycin and new quinolone antibacterial
agents on diffuse panbronchiolitis. Nihon Kyobu Shikkan Gakkai Zasshi
28, 130513.
13. Nagai, H., Shishido, H., Yoneda, R. et al. (1991). Long-term lowdose administration of erythromycin to patients with diffuse panbronchiolitis. Respiration 58, 1459.
14. Ichikawa, Y., Ninomiya, H., Koga, H. et al. (1992). Erythromycin
reduces neutrophils and neutrophil-derived elastolytic-like activity in

Macrolides and biofilms

Biofilm-forming bacteria, such as P. aeruginosa, resist phagocytosis by host immune cells and the actions of antimicrobial
agents. P. aeruginosa recovered from the lungs of patients with
DPB or CF is often encased in mucoid-alginate biofilm. Biofilms
bind cells and organic and inorganic materials to each other.
Their tightly-formed structure reduces antimicrobial activity,
promotes bacterial adhesion to lung epithelia, and prevents bacterial dehydration. Interference with biofilm formation may play
a part in the effect of macrolides in patients with DPB or CF.
The major component of biofilm is alginate. Alginate induces
a continuous antigen antibody reaction on the surface of small
airways. Through inhibition of alginate production, macrolides
decrease the viscosity of media containing P. aeruginosa.65 67
Alginate production is inhibited in a dose-dependent manner by
erythromycin, clarithromycin or azithromycin, through inhibition
of enzymes in the alginate system that activate the alginate production inside P. aeruginosa. Importantly, alginate production is
inhibited by macrolides at concentrations well below the MIC.
Perhaps of more importance is the effect of macrolides on flagellin-induced inflammation. Flagellin induces a stronger inflammatory response, and macrolides have been found to inhibit
twitching motility of P. aeruginosa.68,69
The interaction of neutrophil cells with P. aeruginosa biofilms treated with macrolides is markedly enhanced compared
with the untreated biofilms.67 As with the effect of macrolides on
alginate production, this effect is also dose-dependent.
These findings indicate that biofilm is involved in impairment
of phagocytosis of P. aeruginosa, and inhibiting its formation
with macrolides may enhance clearance of bacteria by the
patients own pulmonary host defence. Next to the abovementioned effects of macrolides on neutrophil cell function

26

Downloaded from http://jac.oxfordjournals.org/ at Pennsylvania State University on February 21, 2013

In conclusion, in nearly all reports, long-term low-dose macrolide therapy resulted in, sometimes dramatic, improvements in
pulmonary function in patients with DPB. Before introduction of
maintenance macrolide therapy, the 10-year survival rate was
below 50%. After introduction of macrolide therapy, the 10-year
survival rate improved impressively, and is now above 90%.
Although almost all studies were not randomized controlled
trials, data presented in the peer-reviewed journals are convincing enough to justify recommendations for the general use of
long-term macrolide therapy in DPB.
Similar to DPB, there seems to be some role for macrolides
in the treatment of CF. However, data presented in peerreviewed journals are sparse, and there seems to be considerable
variation in response. At present, it is recommended to use maintenance macrolide therapy for individual patients who do not
respond to conventional therapy.3

Review

27

Downloaded from http://jac.oxfordjournals.org/ at Pennsylvania State University on February 21, 2013

burst of human neutrophils. Journal of Antimicrobial Chemotherapy 24,

561 72.
34. Joone, G. K., Van Rensburg, C. E. & Anderson, R. (1992).
Investigation of the in vitro uptake, intraphagocytic biological activity
and effects on neutrophil superoxide generation of dirithromycin
compared with erythromycin. Journal of Antimicrobial Chemotherapy
30, 50923.
35. Labro, M. T., el Benna, J. & Abdelghaffar, H. (1993). Modulation
of human polymorphonuclear neutrophil function by macrolides:
preliminary data concerning dirithromycin. Journal of Antimicrobial
Chemotherapy 31, 51 64.
36. Mitsuyama, T., Tanaka, T., Hidaka, K. et al. (1995). Inhibition by
erythromycin of superoxide anion production by human polymorphonuclear leukocytes through the action of cyclic AMP-dependent protein
kinase. Respiration 62, 26973.
37. Wenisch, C., Parschalk, B., Zedtwitz-Liebenstein, K. et al.
(1996). Effect of single oral dose of azithromycin, clarithromycin, and
roxithromycin on polymorphonuclear leukocyte function assessed
ex vivo by flow cytometry. Antimicrobial Agents and Chemotherapy 40,
203942.
38. Abdelghaffar, H., Mtairag, E. M. & Labro, M. T. (1994).
Effects of dirithromycin and erythromycylamine on human neutrophil
degranulation. Antimicrobial Agents and Chemotherapy 38,
154854.
39. Abdelghaffar, H., Vazifeh, D. & Labro, M.T. (1996). Comparison
of various macrolides on stimulation of human neutrophil degranulation
in vitro. Journal of Antimicrobial Chemotherapy 38, 81 93.
40. Schultz, M. J., Speelman, P., Hack, C. E. et al. (2000).
Intravenous infusion of erythromycin inhibits CXC chemokine production, but augments neutrophil degranulation in whole blood
stimulated with Streptococcus pneumoniae. Journal of Antimicrobial
Chemotherapy 46, 235 40.
41. Anderson, R., Fernandes, A. C. & Eftychis, H. E. (1984). Studies
on the effects of ingestion of a single 500 mg oral dose of erythromycin
stearate on leucocyte motility and transformation and on release in
vitro of prostaglandin E2 by stimulated leucocytes. Journal of
Antimicrobial Chemotherapy 14, 41 50.
42. Ras, G. J. & Anderson, R. (1986). An in vitro study of oral
therapeutic doses of co-trimoxazole and erythromycin stearate on
abnormal polymorphonuclear leucocyte migration. Journal of Antimicrobial Chemotherapy 17, 18593.
43. Tamaoki, J., Sakai, N., Tagaya, E. et al. (1994). Macrolide
antibiotics protect against endotoxin-induced vascular leakage and
neutrophil accumulation in rat trachea. Antimicrobial Agents and
Chemotherapy 38, 16413.
44. Abdelghaffar, H., Vazifeh, D. & Labro, M. T. (1997). Erythromycin A-derived macrolides modify the functional activities of human
neutrophils by altering the phospholipase D-phosphatidate phosphohydrolase transduction pathway: L -cladinose is involved both in alterations of neutrophil functions and modulation of this transductional
pathway. Journal of Immunology 159, 3995 4005.
45. Takizawa, H., Desaki, M., Ohtoshi, T. et al. (1995). Erythromycin
suppresses interleukin 6 expression by human bronchial epithelial
cells: a potential mechanism of its anti-inflammatory action. Biochemical and Biophysical Research Communications 210, 781 6.
46. Takizawa, H., Desaki, M., Ohtoshi, T. et al. (1997). Erythromycin
modulates IL-8 expression in normal and inflamed human bronchial
epithelial cells. American Journal of Respiratory and Critical Care
Medicine 156, 266 71.
47. Oishi, K., Sonoda, F., Kobayashi, S. et al. (1994). Role of
interleukin-8 (IL-8) and an inhibitory effect of erythromycin on IL-8
release in the airways of patients with chronic airway diseases.
Infection and Immunity 62, 414552.
48. Schultz, M. J., Speelman, P., Zaat, S. et al. (1998). Erythromycin inhibits tumor necrosis factor alpha and interleukin 6 production
induced by heat-killed Streptococcus pneumoniae in whole blood.
Antimicrobial Agents and Chemotherapy 42, 16059.

the lower respiratory tract of bronchiolitis patients. American Review of

Respiratory Disease 146, 196 203.
15. Kadota, J., Sakito, O., Kohno, S. et al. (1993). A mechanism of
erythromycin treatment in patients with diffuse panbronchiolitis. American Review of Respiratory Disease 147, 153 9.
16. Oda, H., Kadota, J., Kohno, S. et al. (1994). Erythromycin
inhibits neutrophil chemotaxis in bronchoalveoli of diffuse panbronchiolitis. Chest 106, 111623.
17. Fujii, T., Kadota, J., Kawakami, K. et al. (1995). Long term effect
of erythromycin therapy in patients with chronic Pseudomonas
aeruginosa infection. Thorax 50, 1246 52.
18. Mukae, H., Kadota, J., Kohno, S. et al. (1995). Increase in
activated CD8+ cells in bronchoalveolar lavage fluid in patients with
diffuse panbronchiolitis. American Journal of Respiratory and Critical
Care Medicine 152, 613 8.
19. Tamaoki, J., Takeyama, K., Tagaya, E. et al. (1995). Effect
of clarithromycin on sputum production and its rheological properties
in chronic respiratory tract infections. Antimicrobial Agents and
Chemotherapy 39, 168890.
20. Kobayashi, H., Takeda, H., Sakayori, S. et al. (1995). Study on
azithromycin in treatment of diffuse panbronchiolitis. Kansenshogaku
Zasshi 69, 711 22.
21. Kadota, J., Matsubara, Y., Ishimatsu, Y. et al. (1996).
Significance of IL-1b and IL-1 receptor antagonist (IL-1Ra) in
bronchoalveolar lavage fluid (BALF) in patients with diffuse panbronchiolitis (DPB). Clinical and Experimental Immunology 103,
461 6.
22. Sakito, O., Kadota, J., Kohno, S. et al. (1996). Interleukin 1b,
tumor necrosis factor a, and interleukin 8 in bronchoalveolar lavage
fluid of patients with diffuse panbronchiolitis: a potential mechanism of
macrolide therapy. Respiration 63, 428.
23. Ashitani, J., Mukae, H., Nakazato, M. et al. (1998). Elevated
concentrations of defensins in bronchoalveolar lavage fluid in diffuse
panbronchiolitis. European Respiratory Journal 11, 104 11.
24. Shirai, R., Abe, K., Yoshinaga, R. et al. (1998). Evaluation of the
duration of medication with erythromycin for treatment of diffuse
panbronchitisa comparison between interruption of medication and
continued administration. Japanese Journal of Antibiotics 51, 903.
25. Hiratsuka, T., Mukae, H., Iiboshi, H. et al. (2003). Increased
concentrations of human b-defensins in plasma and bronchoalveolar
lavage fluid of patients with diffuse panbronchiolitis. Thorax 58,
425 30.
26. Wolter, J., Seeney, S., Bell, S. et al. (2002). Effect of long term
treatment with azithromycin on disease parameters in cystic fibrosis: a
randomised trial. Thorax 57, 212 6.
27. Equi, A., Balfour-Lynn, I.M., Bush, A. et al. (2002). Long term
azithromycin in children with cystic fibrosis: a randomised, placebocontrolled crossover trial. Lancet 360, 978 84.
28. Saiman, L., Marshall, B. C., Mayer-Hamblett, N. et al. (2003).
Azithromycin in patients with cystic fibrosis chronically infected with
Pseudomonas aeruginosa: a randomized controlled trial. Journal of the
American Medical Association 290, 1749 56.
29. Gaylor, A. S. & Reilly, J. C. (2002). Therapy with macrolides in
patients with cystic fibrosis. Pharmacotherapy 22, 227 39.
30. Jaffe, A., Francis, J., Rosenthal, M. et al. (1998). Long-term
azithromycin may improve lung function in children with cystic fibrosis.
Lancet 351, 420.
31. Ordonez, C. L., Stulbarg, M., Grundland, H. et al. (2001). Effect
of clarithromycin on airway obstruction and inflammatory markers in
induced sputum in cystic fibrosis: a pilot study. Pediatric Pulmonology
32, 29 37.
32. Anderson, R. (1989). Erythromycin and roxithromycin potentiate
human neutrophil locomotion in vitro by inhibition of leukoattractantactivated superoxide generation and autooxidation. Journal of Infectious Diseases 159, 966 73.
33. Labro, M. T., el Benna, J. & Babin-Chevaye, C. (1989).
Comparison of the in vitro effect of several macrolides on the oxidative

Review

28

Downloaded from http://jac.oxfordjournals.org/ at Pennsylvania State University on February 21, 2013

protein-1 binding site in human bronchial epithelial cells. American

Journal of Respiratory Cell and Molecular Biology 22, 51 60.
60. Aoki, Y. & Kao, P. N. (1999). Erythromycin inhibits
transcriptional activation of NF-kB, but not NFAT, through calcineurinindependent signaling in T cells. Antimicrobial Agents and Chemotherapy 43, 267884.
61. Ichiyama, T., Nishikawa, M., Yoshitomi, T. et al. (2001).
Clarithromycin inhibits NF-kB activation in human peripheral blood
mononuclear cells and pulmonary epithelial cells. Antimicrobial Agents
and Chemotherapy 45, 44 7.
62. Takeyama, K., Tamaoki, J., Chiyotani, A. et al. (1993). Effect of
macrolide antibiotics on ciliary motility in rabbit airway epithelium
in vitro. Journal of Pharmacy and Pharmacology 45, 7568.
63. van der Poll, T., Coyle, S. M., Barbosa, K. et al. (1996).
Epinephrine inhibits tumor necrosis factor-a and potentiates interleukin
10 production during human endotoxemia. Journal of Clinical Investigations 97, 713 9.
64. Bailly, S., Ferrua, B., Fay, M. et al. (1990). Differential regulation
of IL 6, IL 1 A, IL 1 b and TNF a production in LPS-stimulated human
monocytes: role of cyclic AMP. Cytokine 2, 205 10.
65. Kobayashi, H. (1995). Biofilm disease: its clinical manifestation
and therapeutic possibilities of macrolides. American Journal of
Medicine 99, 26S 30S.
66. Ichimiya, T., Takeoka, K., Hiramatsu, K. et al. (1996). The
influence of azithromycin on the biofilm formation of Pseudomonas
aeruginosa in vitro. Chemotherapy 42, 186 91.
67. Takeoka, K., Ichimiya, T. & Yamasaki, T. (1998). The in vitro
effect of macrolides on the interaction of human polymorphonuclear
leukocytes with Pseudomonas aeruginosa in biofilm. Chemotherapy
44, 190 7.
68. Kawamura-Sato, K., Iinuma, Y., Hasegawa, T. et al. (2000).
Effect of subinhibitory concentrations of macrolides on expression of
flagellin in Pseudomonas aeruginosa and Proteus mirabilis. Antimicrobial Agents and Chemotherapy 44, 2869 72.
69. Kawamura-Sato, K., Iinuma, Y., Hasegawa, T. et al. (2001).
Postantibiotic suppression effect of macrolides on the expression of
flagellin in Pseudomonas aeruginosa and Proteus mirabilis. Journal of
Infection and Chemotherapy 7, 51 4.

49. Schultz, M. J., Speelman, P., van der Poll, T. et al. (2001).
Erythromycin inhibits Pseudomonas aeruginosa induced tumor necrosis factor-a production in human whole blood. Journal of Antimicrobial
Chemotherapy 48, 2758.
50. Khair, O.A., Devalia, J. L., Abdelaziz, M. M. et al. (1995). Effect
of erythromycin on Haemophilus influenzae endotoxin-induced release
of IL-6, IL-8 and sICAM-1 by cultured human bronchial epithelial cells.
European Respiratory Journal 8, 1451 7.
51. Morikawa, K., Watabe, H., Araake, M. et al. (1996). Modulatory
effect of antibiotics on cytokine production by human monocytes
in vitro. Antimicrobial Agents and Chemotherapy 40, 136670.
52. Hirakata, Y., Kaku, M., Mizukane, R. et al. (1992). Potential
effects of erythromycin on host defense systems and virulence of
Pseudomonas aeruginosa. Antimicrobial Agents and Chemotherapy
36, 19227.
53. Kita, E., Sawaki, M., Nishikawa, F. et al. (1990). Enhanced
interleukin production after long-term administration of erythromycin
stearate. Pharmacology 41, 177 83.
54. Kita, E., Sawaki, M., Mikasa, K. et al. (1993). Alterations of
host response by a long-term treatment of roxithromycin. Journal of
Antimicrobial Chemotherapy 32, 28594.
55. Konno, S., Adachi, M., Asano, K. et al. (1992). Influences of
roxithromycin on cell-mediated immune responses. Life Sciences 51,
L107 12.
56. Yanagihara, K., Tomono, K., Kuroki, M. et al. (2000). Intrapulmonary concentrations of inflammatory cytokines in a mouse model of
chronic respiratory infection caused by Pseudomonas aeruginosa.
Clinical and Experimental Immunology 122, 6771.
57. Yanagihara, K., Tomono, K., Imamura, Y. et al. (2002). Effect of
clarithromycin on chronic respiratory infection caused by Pseudomonas
aeruginosa with biofilm formation in an experimental murine model.
Journal of Antimicrobial Chemotherapy 49, 86770.
58. Shirai, R., Abe, K., Yoshinaga, M. et al. (1997). Analysis of cases
allowed to cease erythromycin therapy for diffuse panbronchiolitis
comparative study between patients with cessation of the therapy and
patients continuing the therapy. Kansenshogaku Zasshi 71, 115561.
59. Abe, S., Nakamura, H., Inoue, S. et al. (2000). Interleukin-8
gene repression by clarithromycin is mediated by the activator