Are inhaled antibiotics, such as aztreonam (aztreonam) and colistin (colistin), approved for non-cystic fibrosis (non-CF) bronchiectasis?

Inhaled Antibiotics for Non-Cystic Fibrosis Bronchiectasis

Currently, there are no inhaled antibiotics specifically approved by regulatory agencies for non-cystic fibrosis bronchiectasis, though several are used off-label based on clinical evidence and guideline recommendations. 1

Current Status of Inhaled Antibiotics in Non-CF Bronchiectasis

Recommended Inhaled Antibiotics (Off-Label Use)

• Inhaled colistin (1 MU twice daily) is recommended as first-line therapy for patients with bronchiectasis and chronic Pseudomonas aeruginosa infection who experience three or more exacerbations per year 2
• Inhaled gentamicin is recommended as a second-line alternative to colistin for patients with bronchiectasis and chronic P. aeruginosa infection 2
• Both inhaled colistin and gentamicin have demonstrated clinical benefits in extending time to exacerbation, reducing exacerbation rates, and improving quality of life in patients with non-CF bronchiectasis 2

Antibiotics Not Recommended

• Inhaled aztreonam is not recommended for non-CF bronchiectasis as it has not been associated with clinically significant benefits in quality of life or time to first exacerbation, and has a higher incidence of treatment-related adverse events 2
• Inhaled ciprofloxacin (dry powder formulation) has shown some positive signals in clinical trials (RESPIRE studies) but has not been granted marketing authorization for non-CF bronchiectasis 2

Patient Selection for Inhaled Antibiotics

Inhaled antibiotics should be considered for:

• Patients experiencing three or more exacerbations per year 2
• Specific patient populations based on bacterial colonization:
  • P. aeruginosa colonized patients: Inhaled colistin as first-line therapy 2
  • Patients with chronic infection with potentially pathogenic microorganisms and frequent exacerbations 2

Safety Considerations

Before initiating inhaled aminoglycosides:

• Avoid use if creatinine clearance is <30 mL/min 2
• Use with caution in patients with significant hearing loss requiring hearing aids or significant balance issues 2
• Avoid concomitant nephrotoxic medications 2
• Perform a suitable challenge test when the patient is stable before starting inhaled antibiotics 2
• Counsel patients about potential major side effects with long-term antibiotics 2

Monitoring and Follow-up

• Prophylactic antibiotics should only be initiated by respiratory specialists 2
• Review patients on long-term antibiotics every 6 months to assess:
  • Efficacy
  • Toxicity
  • Continuing need
• Monitor sputum culture and sensitivity regularly, although in vitro resistance may not affect clinical efficacy 2

Alternative Approaches

• Macrolides (azithromycin, erythromycin) can be considered:
  • As an alternative to inhaled antibiotics for patients who cannot tolerate them 2
  • As an additive treatment to inhaled antibiotics for patients with high exacerbation frequency 2
• Cyclical intravenous antibiotics may be considered in patients with ≥5 exacerbations and subjective ill health between exacerbations 2

Future Prospects

• Several inhaled antibiotics are currently under investigation for non-CF bronchiectasis 3, 4
• Liposomal ciprofloxacin formulations have shown promise in clinical trials 3
• A more targeted approach could help identify specific populations of non-CF bronchiectasis patients who benefit most from inhaled antibiotics 3, 5

Despite the lack of formal regulatory approval, the British Thoracic Society and European Respiratory Society guidelines support the use of certain inhaled antibiotics in specific patient populations with non-CF bronchiectasis based on available clinical evidence 2.