Prolonged antibiotics for non-cystic fibrosis bronchiectasis in children and adults

• Published in: Cochrane database of systematic reviews 2015-08, Vol.2015 (8), p.CD001392, Article CD001392
• Main Authors: Hnin, Khin, Nguyen, Chau, Carson, Kristin V, Evans, David J, Greenstone, Michael, Smith, Brian J
• Format: Article
• Language: English
• Subjects: Adult; Anti-Bacterial Agents - administration & dosage; Anti-Bacterial Agents - adverse effects; Bronchiectasis; Bronchiectasis - drug therapy; Bronchiectasis - microbiology; Child; Child health; Diarrhea - chemically induced; Disease Progression; Drug Resistance, Bacterial; Hospitalization - statistics & numerical data; Humans; Lungs & airways; Middle Aged; Odds Ratio; Randomized Controlled Trials as Topic; Time Factors
• ISSN: 1469-493X; 1469-493X
• DOI: 10.1002/14651858.cd001392.pub3

The vicious cycle hypothesis for bronchiectasis predicts that bacterial colonisation of the respiratory tract perpetuates inflammatory change. This damages the mucociliary escalator, preventing bacterial clearance and allowing persistence of pro-inflammatory mediators. Conventional treatment with physiotherapy and intermittent antibiotics is believed to improve the condition of people with bronchiectasis, although no conclusive data show that these interventions influence the natural history of the condition. Various strategies have been tried to interrupt this cycle of infection and inflammation, including prolonging antibiotic treatment with the goal of allowing the airway mucosa to heal. To determine the benefits of prolonged antibiotic therapy in the treatment of patients with bronchiectasis. We searched the Cochrane Airways Group Trials Register and reference lists of identified articles. Searches were current as of February 2014. Randomised trials examining the use of prolonged antibiotic therapy (for four or more weeks) in the treatment of bronchiectasis compared with placebo or usual care. Two review authors independently assessed trial quality and extracted data. We contacted study authors to ask for missing information. Eighteen trials met the inclusion criteria, randomly assigning a total of 1157 participants. Antibiotics were given for between four weeks and 83 weeks. Limited meta-analysis was possible because of the diversity of outcomes reported in these trials. Based on the number of participants with at least one exacerbation, the meta-analysis showed significant effects in favour of the intervention (odds ratio (OR) 0.31, 95% confidence interval (CI) 0.19 to 0.52; P value < 0.00001), with events occurring in 271 per 1000 people in the intervention arm (95% CI 126 to 385) and in 546 per 1000 in the control population, based on evidence of moderate quality. A non-statistically significant reduction in hospitalisation favoured the use of prolonged antibiotics with a moderate quality grade of supporting evidence (37 per 1000 in the intervention arm (95% CI 13 to 96) and 87 per 1000 in control (OR 0.40, 95% CI 0.14 to 1.11; P value = 0.08). Drug resistance developed in 36 of 220 participants taking antibiotics compared with 10 of 211 participants given placebo or standard therapy (OR 3.48, 95% CI 1.20 to 10.07; P value = 0.02), translating to natural frequencies of 155 per 1000 in the intervention arm (95% CI 59 to 346) and 50 per 1000 in the c