Impact of azithromycin on the clinical and antimicrobial effectiveness of tobramycin in the treatment of cystic fibrosis

J Cyst Fibros. 2017 May;16(3):358-366. doi: 10.1016/j.jcf.2016.12.003. Epub 2016 Dec 24.


Background: Concomitant use of oral azithromycin and inhaled tobramycin occurs in approximately half of US cystic fibrosis (CF) patients. Recent data suggest that this combination may be antagonistic.

Methods: Test the hypothesis that azithromycin reduces the clinical benefits of tobramycin by analyses of clinical trial data, in vitro modeling of P. aeruginosa antibiotic killing, and regulation of the MexXY efflux pump.

Results: Ongoing administration of azithromycin associates with reduced ability of inhaled tobramycin, as compared with aztreonam, to improve lung function and quality of life in a completed clinical trial. In users of azithromycin FEV1 (L) increased 0.8% during a 4-week period of inhaled tobramycin and an additional 6.4% during a subsequent 4-week period of inhaled aztreonam (P<0.005). CFQ-R respiratory symptom score decreased 1.8 points during inhaled tobramycin and increased 8.3 points during subsequent inhaled aztreonam (P<0.001). A smaller number of trial participants not using azithromycin had similar improvement in lung function and quality of life scores during inhaled tobramycin and inhaled aztreonam. In vitro, azithromycin selectively reduced the bactericidal effects tobramycin in cultures of clinical strains of P. aeruginosa, while up regulating antibiotic resistance through MexXY efflux.

Conclusions: Azithromycin appears capable of reducing the antimicrobial benefits of tobramycin by inducing adaptive bacterial stress responses in P. aeruginosa, suggesting that these medications together may not be optimal chronic therapy for at least some patients.

Keywords: Azithromycin; Clinical trial; Cystic fibrosis; Drug interaction; Inhaled antibiotics; MexXY; Pseudomonas aeruginosa; Tobramycin.

Publication types

  • Randomized Controlled Trial

MeSH terms

  • Anti-Bacterial Agents / administration & dosage
  • Anti-Bacterial Agents / pharmacokinetics
  • Azithromycin* / administration & dosage
  • Azithromycin* / pharmacokinetics
  • Aztreonam* / administration & dosage
  • Aztreonam* / pharmacokinetics
  • Cystic Fibrosis* / complications
  • Cystic Fibrosis* / microbiology
  • Cystic Fibrosis* / psychology
  • Drug Administration Routes
  • Drug Interactions
  • Drug Monitoring / methods
  • Female
  • Humans
  • Male
  • Pseudomonas Infections* / diagnosis
  • Pseudomonas Infections* / drug therapy
  • Pseudomonas aeruginosa / drug effects*
  • Respiratory Function Tests / methods
  • Tobramycin* / administration & dosage
  • Tobramycin* / pharmacokinetics
  • Treatment Outcome
  • Young Adult


  • Anti-Bacterial Agents
  • Azithromycin
  • Aztreonam
  • Tobramycin