The Efficacy and Safety of Inhaled Antibiotics for the Treatment of Bronchiectasis in Adults: Updated Systematic Review and Meta-Analysis

Abstract

BackgroundInhaled antibiotics are conditionally recommended by international bronchiectasis guidelines for the treatment of patients with bronchiectasis but results of individual studies are inconsistent. A previous meta-analysis demonstrated promising results regarding the efficacy and safety of inhaled antibiotics in bronchiectasis. Subsequent publications have further supplemented the existing body of evidence in this area. Research questionTo what extent do inhaled antibiotics demonstrate both efficacy and safety as a treatment option for adults with bronchiectasis? Study design And methodsSystematic review and meta-analysis of randomised controlled trials of inhaled antibiotics in adult patients with bronchiectasis. We searched MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, Web of Science, and ClinicalTrials.gov for eligible studies. Studies were included if they enrolled adults with bronchiectasis diagnosed by CT and trials had a treatment duration of at least 4 weeks. The primary endpoint was exacerbation frequency, with additional key efficacy endpoints including severe exacerbations, bacterial load, symptoms, quality of life and FEV1. Data were pooled through random-effects meta-analysis. Results20 studies involving 3468 patients were included. Inhaled antibiotics were associated with reduced number of subjects with exacerbations (risk ratio 0.85 95%CI 0.75-0.96), a slight reduction in exacerbation frequency (rate ratio 0.78 95%CI 0.68-0.91), a probable reduction in the frequency of severe exacerbations (rate ratio 0.48 95%CI 0.31-0.74) and a likely slight increase in time to first exacerbation (hazard ratio 0.80 95%CI 0.68-0.94). Inhaled antibiotics likely lead to a slight increase in the Quality of Life-Bronchiectasis Respiratory Symptom Score (2.51, 95%CI 0.44 to 4.31) and may reduce scores on the St. George’s Respiratory Questionnaire (-3.13, 95%CI -5.93 to -0.32). Bacterial load was consistently reduced but FEV1 was not changed with treatment. Evidence suggests little to no difference in adverse effects between groups (odds ratio 0.99 95%CI 0.75-1.30). Antibiotic resistant organisms were likely increased by treatment. InterpretationInhaled antibiotics result in a slight reduction in exacerbations, a probable reduction in severe exacerbations and a likely slight improvement in symptoms and quality of life in adults with bronchiectasis. Trial registrySystematic review registration number PROSPERO CRD42023384694