JOURNAL OF PALLIATIVE MEDICINE Volume 17, Number 7, 2014 ª Mary Ann Liebert, Inc. DOI: 10.1089/jpm.2014.0068
Long-Term Macrolide Antibiotic Therapy May Prevent the Development of Pneumonia in the Elderly Hiroki Yoshikawa, MD,1 Kosaku Komiya, MD, PhD,1,2 Kenji Umeki, MD,1 and Jun-ichi Kadota, MD 1
Dear Editor: The number of elderly patients with aspiration pneumonia is increasing with the aging of society. Preventive interventions based on an improved cough reflex or weakening pathogenicity of the aspirated fluid have been reported to have beneficial effects in such people.1 However, there have so far been no reports focusing on the airway clearance system for the prevention of aspiration pneumonia. Macrolide antibiotics are known to have immunomodulatory properties, as well as antibacterial activity.2 In addition, it was reported that antibiotics can improve the mucociliary transport system.3 We therefore evaluated the possibility that long-term macrolide antibiotic use can prevent the development of pneumonia requiring hospitalization in elderly people. This was a single-center retrospective cohort study consisting of 15 patients aged 65 years and older, who were administered macrolide antibiotics for more than six months for the prevention of pneumonia between January 2006 and November 2013 at the Tenshindo Hospital. Patients with diffuse panbronchiolitis (DPB), chronic obstructive pulmo-
nary disease (COPD), and chronic sinusitis, which were previously demonstrated to be diseases responsive to long-term macrolide therapy, were excluded from this study. The study protocol was approved by the institutional ethics committee, and some patients had been included in previous studies at our institute.4,5 The patients were much older than the 65 years old we had set as the inclusion criterion (median age 82 years old; interquartile range 66–95 years old) and had a lower body mass index (20.4, 15.0–25.3 kg/m2) and a worse performance status [PS 0–2 (n = 0), PS 3 (n = 5), PS 4 (n = 5), PS 5 (n = 5)]. Of the 15 patients, 10 had histories of cerebral vascular events, four suffered from dementia, and five were fed via a tube. The type of macrolide antibiotics and the doses used were clarithromycin 200 mg/day (n = 8) or 400 mg/day (n = 1); or erythromycin 200 mg/day (n = 1), 400 mg/day (n = 2), or 600 mg/day (n = 3). No significant difference was observed in the frequency of hospitalization due to pneumonia between the first year and the previous year of treatment with longterm macrolide antibody in the patients overall. When the sample was limited to the patients with a history of pneumonia
FIG.1. Admissions due to pneumonia before and after treatment in patients with a history of one or more episodes of pneumonia.
1 2
Respiratory Medicine and Infectious Diseases, Oita University Faculty of Medicine, Oita, Japan. Clinical Research Center of Respiratory Medicine, Tenshindo Hetsugi Hospital, Oita, Japan.
749
750
requiring hospitalization within one year before the intervention (n = 11), the frequency of hospitalization due to pneumonia after treatment was significantly less than that before the intervention [median, one time (interquartile range 1–3) to one time (0–2), p = 0.035] (see Fig. 1). There were no obvious descriptions of any adverse events included in the patient records. These results seem to be compatible with those observed in patients with other respiratory diseases, such as DPB and COPD. 2 However, the sample size was small, and it could include patient selection biases due to the retrospective nature. In addition, we could not evaluate the risk for inducing resistant pathogens caused by long-term antibiotic administration. Nevertheless, long-term macrolide antibiotic therapy may prevent the development of pneumonia in elderly patients who are susceptible to developing pneumonia. A further large prospective study is needed to verify this result. References
1. Marik PE, Kaplan D: Aspiration pneumonia and dysphagia in the elderly. Chest 2003;124:328–336.
LETTERS TO THE EDITOR
2. Kanoh S, Rubin BK: Mechanisms of action and clinical application of macrolides as immunomodulatory medications. Clin Microbiol Rev 2010;23:590–615. 3. Shibuya Y, Wills PJ, Cole PJ: The effect of erythromycin on mucociliary transportability and rheology of cystic fibrosis and bronchiectasis sputum. Respiration 2001;68:615–619. 4. Komiya K, Ishii H, Umeki K, et al.: Impact of aspiration pneumonia in patients with community-acquired pneumonia and healthcare-associated pneumonia: A multicenter retrospective cohort study. Respirology 2013;18:514–521. 5. Komiya K, Ishii H, Okabe E, et al.: Risk factors for unexpected death from suffocation in elderly patients hospitalized for pneumonia. Geriatr Gerontol Int 2013;13:388–392.
Address correspondence to: Kosaku Komiya, MD, PhD Oita University Faculty of Medicine Respiratory Medicine and Infectious Diseases 1-1 Idaigaoka, Hasama-machi, Yufu-city Oita 879-5593, Japan E-mail: [email protected]
Long-Term Macrolide Antibiotic Therapy May Prevent the Development of Pneumonia in the Elderly Hiroki Yoshikawa, MD,1 Kosaku Komiya, MD, PhD,1,2 Kenji Umeki, MD,1 and Jun-ichi Kadota, MD 1
Dear Editor: The number of elderly patients with aspiration pneumonia is increasing with the aging of society. Preventive interventions based on an improved cough reflex or weakening pathogenicity of the aspirated fluid have been reported to have beneficial effects in such people.1 However, there have so far been no reports focusing on the airway clearance system for the prevention of aspiration pneumonia. Macrolide antibiotics are known to have immunomodulatory properties, as well as antibacterial activity.2 In addition, it was reported that antibiotics can improve the mucociliary transport system.3 We therefore evaluated the possibility that long-term macrolide antibiotic use can prevent the development of pneumonia requiring hospitalization in elderly people. This was a single-center retrospective cohort study consisting of 15 patients aged 65 years and older, who were administered macrolide antibiotics for more than six months for the prevention of pneumonia between January 2006 and November 2013 at the Tenshindo Hospital. Patients with diffuse panbronchiolitis (DPB), chronic obstructive pulmo-
nary disease (COPD), and chronic sinusitis, which were previously demonstrated to be diseases responsive to long-term macrolide therapy, were excluded from this study. The study protocol was approved by the institutional ethics committee, and some patients had been included in previous studies at our institute.4,5 The patients were much older than the 65 years old we had set as the inclusion criterion (median age 82 years old; interquartile range 66–95 years old) and had a lower body mass index (20.4, 15.0–25.3 kg/m2) and a worse performance status [PS 0–2 (n = 0), PS 3 (n = 5), PS 4 (n = 5), PS 5 (n = 5)]. Of the 15 patients, 10 had histories of cerebral vascular events, four suffered from dementia, and five were fed via a tube. The type of macrolide antibiotics and the doses used were clarithromycin 200 mg/day (n = 8) or 400 mg/day (n = 1); or erythromycin 200 mg/day (n = 1), 400 mg/day (n = 2), or 600 mg/day (n = 3). No significant difference was observed in the frequency of hospitalization due to pneumonia between the first year and the previous year of treatment with longterm macrolide antibody in the patients overall. When the sample was limited to the patients with a history of pneumonia
FIG.1. Admissions due to pneumonia before and after treatment in patients with a history of one or more episodes of pneumonia.
1 2
Respiratory Medicine and Infectious Diseases, Oita University Faculty of Medicine, Oita, Japan. Clinical Research Center of Respiratory Medicine, Tenshindo Hetsugi Hospital, Oita, Japan.
749
750
requiring hospitalization within one year before the intervention (n = 11), the frequency of hospitalization due to pneumonia after treatment was significantly less than that before the intervention [median, one time (interquartile range 1–3) to one time (0–2), p = 0.035] (see Fig. 1). There were no obvious descriptions of any adverse events included in the patient records. These results seem to be compatible with those observed in patients with other respiratory diseases, such as DPB and COPD. 2 However, the sample size was small, and it could include patient selection biases due to the retrospective nature. In addition, we could not evaluate the risk for inducing resistant pathogens caused by long-term antibiotic administration. Nevertheless, long-term macrolide antibiotic therapy may prevent the development of pneumonia in elderly patients who are susceptible to developing pneumonia. A further large prospective study is needed to verify this result. References
1. Marik PE, Kaplan D: Aspiration pneumonia and dysphagia in the elderly. Chest 2003;124:328–336.
LETTERS TO THE EDITOR
2. Kanoh S, Rubin BK: Mechanisms of action and clinical application of macrolides as immunomodulatory medications. Clin Microbiol Rev 2010;23:590–615. 3. Shibuya Y, Wills PJ, Cole PJ: The effect of erythromycin on mucociliary transportability and rheology of cystic fibrosis and bronchiectasis sputum. Respiration 2001;68:615–619. 4. Komiya K, Ishii H, Umeki K, et al.: Impact of aspiration pneumonia in patients with community-acquired pneumonia and healthcare-associated pneumonia: A multicenter retrospective cohort study. Respirology 2013;18:514–521. 5. Komiya K, Ishii H, Okabe E, et al.: Risk factors for unexpected death from suffocation in elderly patients hospitalized for pneumonia. Geriatr Gerontol Int 2013;13:388–392.
Address correspondence to: Kosaku Komiya, MD, PhD Oita University Faculty of Medicine Respiratory Medicine and Infectious Diseases 1-1 Idaigaoka, Hasama-machi, Yufu-city Oita 879-5593, Japan E-mail: [email protected]
