Prevention of Exacerbation of Non-Cystic Fibrosis Bronchiectasis With Combination of Aztreonam Lysine Inhalation and Azithromycin

Abstract

Bronchiectasis is a chronic respiratory disease characterized by bronchial dilatation leading to daily productive cough and recurrent respiratory infections.[1] Causes of bronchiectasis is broadly divided into Cystic fibrosis (CF) and non-CF. Reducing the microbial load with antibiotics and clearing secretions form the cornerstone of prophylactic and therapeutic management of exacerbations. We present a case were initiation of cyclical prophylaxis with combined Aztreonam lysine inhalation (AZLI) and azithromycin resulted in a significant increase in exacerbation free interval of a patient with non-CF bronchiectasis.CASE PRESENTATION: This is a 63-year-old female non-smoker with history of non-CF bronchiectasis who presented to the emergency department with complaints of productive cough associated with greenish brown sputum, fever and shortness of breath for 2 weeks. Her past medical history was significant for recurrent exacerbations of bronchiectasis every 2-3 months including pneumonia with pseudomonas. She was then started on prophylactic 28 day cyclical 75mg AZLI inhalation TID and oral azithromycin daily. Since then she remained exacerbation free for 19 months before this presentation. On presentation, the patient was afebrile, spo2 96% on room air. On physical examination, she was in mild respiratory distress with rhonchi present in bilateral lung fields. WBC was elevated at 14.6, Sars-Cov-19 RAT was negative. Chest x-ray demonstrated diffuse bilateral pulmonary opacities. Patient was initiated on meropenem and de-escalated to ceftazidime after sensitivities were known. She improved clinically and was discharged home after 14 days of treatment. At discharge, patient was continued on the cyclical AZLI and daily azithromycin regiment. DISCUSSION: Several clinical trials have attempted to use inhaled antibiotic treatment for CF bronchiectasis to prevent exacerbations. The inhalation of anti-pseudomonal antibiotics including aztreonam is the preferred therapeutic option. In addition, macrolides also provide benefit to reduce frequency of exacerbations.[2]With increasing prevalence of non-CF bronchiectasis, small studies have begun to address this population. Two randomized control trials utilizing AZLI demonstrated reduction in sputum Pseudomonas density but did not show reduction in bronchiectasis exacerbations or hospitalizations.[3]Thus inconsistent results from studies assessing antibiotics used in non-CF bronchiectasis leave need for further study.CONCLUSIONS: This case illustrates an effective cyclical prophylactic regiment with both a low risk of toxicity and a low risk for emergence of organisms in non-CF bronchiectasis. Further attention with a randomized control study to assess the effects on need for systemic antibiotics, hospitalization, and overall morbidity is warranted.