Speaker's Highlight

• Don Sin University of British Columbia, St. Paul Hospital (Canada)
  Kenneth R. Chapman Toronto General Hospital Research Institute (Canada)
• Parameswaran Nair McMaster University (Canada)
  Carolyn Calfee UCSF (U.S.A.)
• Gregory P. Downey University of Colorado School of Medicine (U.S.A.)
  David A. Schwartz University of Colorado School of Medicine (U.S.A.)
• Neil Schluger Tuberculosis Control Branch, California Department of Public Health (U.S.A.)
  Nick Kim Critical Care & Sleep Medicine, University of California San Diego (U.S.A.)
• Nicola Hananiah Baylor College of Medicine (U.S.A.)
  Jae-Joon Yim Seoul National University College of Medicine (Republic of Korea)
• Koichiro Asano Tokai University School of Medicine (Japan)
  Diahn-Warng Perng Taipei Veterans General Hospital (Taiwan)
• Konstantinos Kostikas University of Ioannina (Greece)
  Karin Klooster University Medical Center Groningen (Kingdom of the Netherlands)

• Macrolides in Bronchiectasis Care: Benefits, Risks and Safe Use

  Bronchiectasis is a chronic airway condition in which damaged, widened bronchi collect mucus and become prone to repeated infection. Treatment is built around airway clearance, vaccinations, pulmonary rehabilitation, prompt management of flare-ups and investigation of the underlying cause. Macrolide antibiotics can add another layer of control for carefully selected people, particularly when exacerbations remain frequent.

  Azithromycin and erythromycin are used for their antibacterial and anti-inflammatory effects. They may reduce the number of infective exacerbations, but they are not suitable for every patient and should not be treated as a routine repeat prescription. In Australia, specialist respiratory input is especially important when care involves resistant organisms, nontuberculous mycobacteria or complex medicine interactions.

  How Macrolides Work in Bronchiectasis

  Macrolides act against several respiratory bacteria and can also moderate excessive airway inflammation. This distinction matters because bronchiectasis symptoms are driven by a cycle of mucus retention, infection, inflammation and further airway damage. Long-term low-dose treatment may interrupt part of that cycle in people with recurrent exacerbations.

  The evidence is strongest for selected adults who continue to have frequent flare-ups despite good airway-clearance techniques and appropriate treatment of contributing conditions. Trials of azithromycin and erythromycin have generally shown fewer exacerbations, although improvements in lung function and day-to-day symptoms are less consistent. The aim is usually prevention rather than treating an acute chest infection.

  Selecting Patients Carefully

  A macrolide may be considered when a patient has repeated exacerbations, significant impact on quality of life and a management plan that is already being followed. Before prescribing, clinicians should review sputum results, smoking status, asthma or chronic obstructive pulmonary disease, gastro-oesophageal reflux, sinus disease and vaccination history. Regular physiotherapy remains central, whether care is delivered in a major Sydney hospital or a regional respiratory clinic.

  The decision should also reflect the patient’s goals and practical circumstances. Someone in remote Western Australia or the Northern Territory may face long travel for an ECG, audiology appointment or specialist review. A plan that looks straightforward in Melbourne may need different monitoring arrangements in a remote community, with local clinicians involved from the start.

  Checks Before Long-Term Treatment

  • Sputum culture, including testing for nontuberculous mycobacteria
  • Baseline ECG and review of QT-prolonging medicines
  • Liver function, hearing history and interaction check
  • Confirmation of airway-clearance and vaccination plans

  Testing for Nontuberculous Mycobacteria

  Macrolide monotherapy can cause serious problems when unrecognised nontuberculous mycobacterial disease is present. Organisms such as Mycobacterium avium complex may require a multi-drug regimen, and exposure to a single macrolide can encourage resistance. At least one suitable sputum sample, and often more depending on clinical findings, should be assessed before long-term therapy.

  This issue is relevant across Australia, where specialist laboratories and respiratory services may be separated by considerable distance. If sputum is difficult to produce, a respiratory physiotherapist or specialist team may arrange induced sputum or bronchoscopy. A negative result does not remove the need to reassess testing when symptoms, imaging or cultures later suggest an atypical infection.

  Choosing a Regimen and Duration

  Azithromycin is commonly used because it has convenient dosing and a relatively long half-life. Erythromycin is another option, although gastrointestinal effects and medicine interactions can be more troublesome. The appropriate dose and schedule depend on local protocols, patient factors and specialist judgement; long-term treatment should not be started from an old prescription or borrowed course of antibiotics.

  A defined review period is preferable to open-ended therapy. Many clinicians assess response after several months and continue only when the reduction in exacerbations justifies the risks. Treatment should sit alongside sputum-guided antibiotics for acute flare-ups, rather than replacing cultures or encouraging repeated empirical prescribing through a GP clinic.

  Managing Cardiac and Hearing Risks

  Macrolides can prolong the QT interval and, rarely, trigger a dangerous rhythm disturbance. Risk increases with existing heart disease, low potassium or magnesium, bradycardia and other QT-prolonging medicines. A baseline ECG is sensible, with repeat testing when risk changes or symptoms develop. Patients should report fainting, palpitations or unexplained dizziness promptly.

  Hearing and balance effects are less common but clinically important, especially during prolonged treatment. Patients may notice tinnitus, muffled hearing or unusual imbalance. Liver injury, diarrhoea and abdominal discomfort are other possible adverse effects. A medication review should include anticoagulants, antiarrhythmics and other regular medicines, including products supplied by different doctors or purchased over the counter.

  Symptoms That Need Prompt Review

  • New palpitations, fainting or severe dizziness
  • Tinnitus, hearing loss or persistent imbalance
  • Yellowing of the skin, dark urine or marked abdominal pain
  • Severe or ongoing diarrhoea

  Antimicrobial Stewardship in Australia

  Long-term macrolide use has a population-level cost as well as an individual one: resistant bacteria become harder to treat. Australia’s antimicrobial stewardship approach supports using antibiotics only when the expected benefit is clear, with regular reassessment and accurate documentation. PBS supply arrangements and specialist prescribing requirements may affect access, so patients need a practical plan for repeats and follow-up rather than assuming automatic renewal.

  Culture results should guide treatment wherever possible. During a flare-up, increased breathlessness, purulent sputum, fever or a noticeable change in cough may require a fresh sample before antibiotics are started. The local climate also matters clinically: people living in humid tropical Queensland may have different environmental exposures and comorbidities from those in Tasmania, although the principles of culture and review remain the same.

  Combining Medication With Airway Clearance

  Macrolides work best as part of a broader bronchiectasis program. Active cycle of breathing techniques, positive expiratory pressure devices, exercise and adequate hydration can help move retained mucus. A respiratory physiotherapist can tailor the approach, particularly when fatigue, chest wall pain or coexisting COPD makes clearance difficult.

  Vaccination against influenza, COVID-19 and pneumococcal disease should be reviewed according to current Australian recommendations. Smoking cessation, treatment of reflux or rhinosinusitis and attention to nutrition can also reduce respiratory burden. In Aboriginal and Torres Strait Islander communities, culturally safe care and reliable access to follow-up are essential parts of any prevention strategy.

  Reviewing Whether Treatment Is Working

  Success should be measured with more than a single spirometry result. Useful outcomes include the number of exacerbations, hospital admissions, courses of rescue antibiotics, sputum burden, exercise tolerance and the patient’s confidence managing symptoms. A written action plan can help distinguish a stable day from a flare-up and clarify when to contact the care team.

  Macrolides should be stopped or reconsidered when adverse effects outweigh benefit, cultures reveal a different treatment priority, or exacerbations do not meaningfully decrease. Shared decision-making is particularly valuable for people who work remotely, travel between regional towns or find regular monitoring difficult. The safest long-term plan is one that can actually be followed.

  For practical care, treat macrolides as a monitored preventive strategy: confirm the indication, exclude nontuberculous mycobacteria, check cardiac and hearing risks, maintain airway clearance, and review the benefit at an agreed date.

  Richard Russell Nuffield Department of Clinical Medicine, University of Oxford (United Kingdom)
• Mona Bafadhel King’s College London (United Kingdom)
  David Jackson Guy’s and St Thomas’ Hospital, King’s College London (United Kingdom)
• James Chalmers University of Dundee (United Kingdom)
  David Price University of Aberdeen (United Kingdom)