Risks of population antimicrobial resistance associated with chronic macrolide use for inflammatory airway diseases

Lancet Respir Med. 2013 May;1(3):262-74. doi: 10.1016/S2213-2600(13)70038-9. Epub 2013 Mar 29.


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.

Publication types

  • Personal Narrative

MeSH terms

  • Anti-Bacterial Agents / adverse effects
  • Anti-Bacterial Agents / classification
  • Anti-Bacterial Agents / therapeutic use
  • Bacterial Physiological Phenomena / drug effects*
  • Bronchiolitis / complications*
  • Bronchiolitis / physiopathology
  • Bronchiolitis / therapy
  • Cystic Fibrosis / complications*
  • Cystic Fibrosis / physiopathology
  • Cystic Fibrosis / therapy
  • Disease Progression
  • Drug Resistance, Microbial*
  • Haemophilus Infections / complications*
  • Haemophilus Infections / physiopathology
  • Haemophilus Infections / therapy
  • Humans
  • Macrolides* / adverse effects
  • Macrolides* / classification
  • Macrolides* / therapeutic use
  • Medication Therapy Management
  • Respiratory System / physiopathology
  • Respiratory Tract Infections* / drug therapy
  • Respiratory Tract Infections* / etiology
  • Respiratory Tract Infections* / microbiology
  • Respiratory Tract Infections* / transmission
  • Risk Adjustment
  • Risk Assessment


  • Anti-Bacterial Agents
  • Macrolides

Supplementary concepts

  • Diffuse panbronchiolitis