Кларитромицин при внебольничной пневмонии у взрослых: фокус на противовоспалительную активность

Синопальников А.И., Рачина С.А., Васильева И.С., Пигусова Н.А., Карпова О.Ю. Кларитромицин при внебольничной пневмонии у взрослых: фокус на противовоспалительную активность. Терапевтический архив. 2022;94(12):1394–1400. DOI: 10.26442/00403660.2022.12.202008

© ООО «КОНСИЛИУМ МЕДИКУМ», 2022 г.

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Sinopalnikov AI, Rachina SA, Vasilyeva IS, Pigusova NA, Karpova OYu. Clarithromycin for community-acquired pneumonia in adults: focus on anti-inflammatory properties. Terapevticheskii Arkhiv (Ter. Arkh.). 2022;94(12):1394–1400. DOI: 10.26442/00403660.2022.12.202008

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Аннотация

Цель. Изучить клиническую эффективность, противовоспалительную и иммуномодулирующую активность кларитромицина у взрослых с тяжелой внебольничной пневмонией (ТВП).
Материалы и методы. В проспективное наблюдательное исследование включались взрослые госпитализированные пациенты с верифицированной ТВП. Кларитромицин назначался в качестве компонента комбинированной антибактериальной терапии (АБТ) с β-лактамным антибиотиком (АБ). Выбор β-лактамного АБ осуществлялся лечащим врачом в соответствии с национальными клиническими рекомендациями и рутинной практикой лечебного учреждения. Помимо оценки клинической эффективности регистрировалась динамика маркеров воспаления в сыворотке крови: С-реактивный белок, прокальцитонин (ПКТ), фактор некроза опухоли α, интерлейкины 1-бета (ИЛ-1) и интерлейкин 6 (ИЛ-6). Общая продолжительность АБТ составила 7–14 дней.
Результаты. Включены 20 (13 мужчин и 7 женщин) пациентов с ТВП в возрасте от 18 до 84 лет. На фоне комбинированной АБТ β-лактамным АБ и кларитромицином отмечено значимое снижение уровня С-реактивного белка к 3–5-му дню терапии (с 74,6 до 14,1 мг/л). Повышение ПКТ наблюдалось у 1/2 больных, на фоне лечения уровень ПКТ значимо снижался. Аналогичная динамика была характерна для ИЛ-6: его содержание в сыворотке крови снизилось к моменту окончания АБТ в 6,8 раза по сравнению с исходным. Снижение уровня фактора некроза опухоли α до референсного значения наблюдалось у большинства пациентов уже в ранние сроки – к 3–5-му дню АБТ. У большинства пациентов отмечалась положительная динамика на фоне АБТ с разрешением дыхательной недостаточности и других осложнений ТВП. Почти у 1/2 больных в ранние сроки достигнуты критерии клинической стабильности, позволившие осуществить переход к пероральной АБТ.
Заключение. Результаты исследования согласуются с данными литературы, свидетельствующими о быстром снижении маркеров воспаления при назначении кларитромицина больным ТВП. Его результаты могут быть отправной точкой для выполнения сравнительных рандомизированных исследований с оценкой как клинических исходов, так и иммунологических показателей при использовании разных классов АБ для лечения ТВП.

Ключевые слова: внебольничная пневмония, антибактериальная терапия, кларитромицин, С-реактивный белок, интерлейкин, прокальцитонин

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Aim. To evaluate clinical efficacy, anti-inflammatory and immunomodulatory activity of clarithromycin in adults with severe community-acquired pneumonia (sCAP).
Materials and methods. A prospective observational study recruited adult hospitalized patients with verified sCAP. Clarithromycin was prescribed as a component of combination antibiotic therapy (ABT) with a β-lactam antibiotic (AB). The choice of β-lactam AB was carried out by the attending physician in accordance with national clinical guidelines and routine practice of the medical institution. Along with assessment clinical efficacy, the dynamics of inflammatory markers in blood serum was recorded: C-reactive protein, procalcitonin (PCT), tumor necrosis factor α, interleukins 1-beta (IL-1) and interleukin 6 (IL-6). The total duration of ABT was 7–14 days.
Results. Altogether 20 patients (13 males, 7 females) aged from 18 to 84 years old were enrolled. As a result of the use of combined ABT with β-lactam AB and clarithromycin, a significant decrease in the level of C-reactive protein was noted by the 3–5th day of therapy (from 74.6 to 14.1 mg/l). An increase in serum PCT was observed in half of the patients; during treatment, the level of PCT significantly decreased. Similar dynamics was detected for IL-6 – its content in the blood serum decreased by the time of the end of ABT by 6.8 times compared with the baseline. A decrease in the level of tumor necrosis factor α to the reference value was observed in most patients already in the early stages – by 3–5 days of ABT. The majority of patients showed positive dynamics of clinical signs and symptoms with resolution of respiratory failure and other complications of sCAP. In almost half of the patients, the criteria for clinical stability were achieved in the early stages, which made it possible to switch to oral ABT.
Conclusion. The results of the study are consistent with literature data indicating a rapid decrease in inflammatory markers when clarithromycin is administered to patients with sCAP. Its results can be a starting point for comparative randomized trials assessing both clinical outcomes and immunological parameters when using different classes of antibiotics for the treatment of sCAP.

Keywords: community-acquired pneumonia, antibiotic therapy, clarithromycin, C-reactive protein, interleukins, procalcitonin

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Список литературы

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3. Welte T, Torres A, Nathwani D. Clinical and economic burden of community-acquired pneumonia among adults in Europe. Thorax. 2012;67:71-9. DOI:10.1136/thx.2009.129502
4. Ramirez JA, Wiemken TL, Peyrani P, et al. Adults hospitalized with pneumonia in the United States: incidence, epidemiology, and mortality. Clin Infect Dis. 2017;65(11):1806-12. DOI:10.1093/cid/cix647
5. Teixeira-Lopes F, Cysneiros A, Dias A, et al. Intrahospital mortality for community-acquired pneumonia in mainland Portugal between 2000 and 2009. Pulmonology. 2019;25(2):66-70. DOI:10.1016/j.pulmoe.2018.06.004
6. Ferreira-Coimbra J, Sarda C, Rello J. Burden of community-acquired pneumonia and unmet clinical needs. Adv Ther. 2020;37(4):1302-18. DOI:10.1007/s12325-020-01248-7
7. Rello J, Perez A. Precision medicine for the treatment of severe pneumonia in intensive care. Expert Rev Respir Med. 2016;10(3):297-316. DOI:10.1586/17476348.2016.1144477
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DOI:10.1111/j.1365-2796.2012.02554.x
21. Sligl WI, Marrie TJ. Severe community acquired pneumonia. Crit Care Clin. 2013;29(3):563-601. DOI:10.1016/j.ccc.2013.03.009
22. Hoogewerf M, Oosterheert JJ, Hak E, et al. Prognostic factors for early clinical failure in patients with severe community-acquired pneumonia. Clin Microbiol Infect. 2006;12(11):1097-104. DOI:10.1111/j.1469-0691.2006.01535.x
23. Quah J, Jiang B, Tan PC, et al. Impact of microbial Aetiology on mortality in severe community-acquired pneumonia. BMC Infect Dis. 2018;18(1):451.
DOI:10.1186/s12879-018-3366-4
24. Liapikou A, Rosales-Mayor E, Torres A. The management of severe community acquired pneumonia in the intensive care unit. Expert Rev Respir Med. 2014;8(3):293-303. DOI:10.1586/17476348.2014.896202
25. Müller-Redetzky H, Lienau J, Suttorp N, Witzenrath M. Therapeutic strategies in pneumonia: going beyond antibiotics. Eur Respir Rev. 2015;24(137):516-24. DOI:10.1183/16000617.0034-2015
26. Anderson R, Joone G, van Rensburg CEJ. An in-vitro evaluation of the cellular mycoplasmas. Antimicrob Agents Chemother. 2000;44(7):1980-2.
DOI:10.1128/AAC.44.7.1980-1982.2000
27. Pollock J, Chalmers JD. The immunomodulatory effects of macrolide antibiotics in respiratory disease. Pulm Pharmacol Ther. 2021;71:102095. DOI:10.1016/j.pupt.2021.102095
28. Синопальников А.И., Рачина С.А., Захаренков И.А. Антибактериальная терапия тяжелой внебольничной пневмонии у взрослых: возможности макролидов. Клиническая микробиология и антимикробная химиотерапия. 2019;21(3):217-23 [Sinopal'nikov AI, Rachina SA, Zaharenkov IA. Antibacterial therapy for severe community-acquired pneumonia in adults: the potential of macrolides. Clinical Microbiology and Antimicrobial Chemotherapy. 2019;21(3):217-23 (in Russian)].
29. Zarogoulidis P, Papanas N, Kioumis I, et al. Macrolides: from in vitro anti-inflammatory and immunomodulatory properties to clinical practice in respiratory diseases. Eur J Clin Pharmacol. 2012;68(5):479-503. DOI:10.1007/s00228-011-1161-x
30. Anderson R, Steel HC, Cockeran R, et al. Clarithromycin alone and in combination with ceftriaxone inhibits the production of pneumolysin by both macrolide-susceptible and macrolide-resistant strains of Streptococcus pneumoniae. J Antimicrob Chemother. 2007;59(2):224-9. DOI:10.1093/jac/dkl479
31. Kanoh S, Rubin BK. Mechanisms of action and clinical application of macrolides as immunomodulatory medications. Clin Microbiol Rev. 2010;23(3):590-615. DOI:10.1128/CMR.00078-09
32. Bosnar M, Bosnjak B, Cuzic S, et al. Azithromycin and clarithromycin inhibit lipopolysaccharide-induced murine pulmonary neutrophilia mainly through effects on macrophage-derived granulocyte-macrophage colony-stimulating factor and interleukin-1beta. J Pharmacol Exp Ther. 2009;331(1):104-13. DOI:10.1124/jpet.109.155838
33. Demartini G, Esposti D, Marthyn P, et al. Effect of multiple doses of clarithromycin and amoxicillin on IL-6, IFN gamma and IL-10 plasma levels in patients with community acquired pneumonia. J Chemother. 2004;16(1):82-5. DOI:10.1179/joc.2004.16.1.82
34. Sligl WI, Asadi L, Eurich DT, et al. Macrolides and mortality in critically ill patients with community-acquired pneumonia: a systematic review and meta-analysis. Crit Care Med. 2014;42(2):420-32. DOI:10.1097/CCM.0b013e3182a66b9b
35. Martin-Loeches I, Lisboa T, Rodriguez A, et al. Combination antibiotic therapy with macrolides improves survival in intubated patients with community-acquired pneumonia. Intensive Care Med. 2010;36(4):612-20. DOI:10.1007/s00134-009-1730-y
36. Restrepo MI, Mortensen EM, Waterer GW, et al. Impact of macrolide therapy on mortality for patients with severe sepsis due to pneumonia. Eur Respir J. 2009;33(1):153-9. DOI:10.1183/09031936.00054108
37. Lee JH, Kim HJ, Kim YH. Is β-Lactam Plus Macrolide More Effective than β-Lactam Plus Fluoroquinolone among Patients with Severe Community-Acquired Pneumonia?: a Systemic Review and Meta-Analysis. J Korean Med Sci. 2017;32(1):77-84. DOI:10.3346/jkms.2017.32.1.77
38. Kyriazopoulou E, Sinapidis D, Halvatzis S, et al. Survival benefit associated with clarithromycin in severe community-acquired pneumonia: A matched comparator study. Int J Antimicrob Agents. 2020;55(1):105836. DOI:10.1016/j.ijantimicag.2019.10.017

________________________________________________

1. World Health Organization. Disease burden and mortality estimates. 2000–2016, June 2018, Geneva. Available at: https://www.who.int/healthinfo/global_burden_ disease/ estimates/en/index1.html. Accessed: 24.06.2019.
2. Vallés J, Diaz E, Martín-Loeches I, et al. Evolution over a 15-year period of the clinical characteristics and outcomes of critically ill patients with severe community-acquired pneumonia. Med Intensiva. 2016;40(4):238-45. DOI:10.1016/j.medin.2015.07.005
3. Welte T, Torres A, Nathwani D. Clinical and economic burden of community-acquired pneumonia among adults in Europe. Thorax. 2012;67:71-9. DOI:10.1136/thx.2009.129502
4. Ramirez JA, Wiemken TL, Peyrani P, et al. Adults hospitalized with pneumonia in the United States: incidence, epidemiology, and mortality. Clin Infect Dis. 2017;65(11):1806-12. DOI:10.1093/cid/cix647
5. Teixeira-Lopes F, Cysneiros A, Dias A, et al. Intrahospital mortality for community-acquired pneumonia in mainland Portugal between 2000 and 2009. Pulmonology. 2019;25(2):66-70. DOI:10.1016/j.pulmoe.2018.06.004
6. Ferreira-Coimbra J, Sarda C, Rello J. Burden of community-acquired pneumonia and unmet clinical needs. Adv Ther. 2020;37(4):1302-18. DOI:10.1007/s12325-020-01248-7
7. Rello J, Perez A. Precision medicine for the treatment of severe pneumonia in intensive care. Expert Rev Respir Med. 2016;10(3):297-316. DOI:10.1586/17476348.2016.1144477
8. Ranzani OT, Prina E, Menéndez R, et al. New sepsis definition (Sepsis-3) and community-acquired pneumonia mortality. A validation and clinical decision-making study. Am J Respir Crit Care Med. 2017;196(10):1287-97. DOI:10.1164/rccm.201611-2262OC
9. Nair GB, Niederman MS. Updates on community-acquired pneumonia management in the ICU. Pharmacol Ther. 2021;217:107663. DOI:10.1016/j.pharmthera.2020.10766.
10. Frei CR, Attridge RT, Mortensen EM, et al. Guideline-concordant antibiotic use and survival among patients with community-acquired pneumonia admitted to the intensive care unit. Clin Ther. 2010;32(2):293-9. DOI:10.1016/j.clinthera.2010.02.006
11. Morgan AJ, Glossop AJ. Severe community-acquired pneumonia. BJA Educ. 2016;16(5):167-72. DOI:10.1093/bjaed/mkv052
12. Kumar A, Roberts D, Wood KE, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med. 2006;34(6):1589-96. DOI:10.1097/01.CCM.0000217961.75225.E9
13. Leroy O, Santré C, Beuscart C, et al. A five-year study of severe community-acquired pneumonia with emphasis on prognosis in patients admitted to an intensive care unit. Intensive Care Med. 1995;21(1):24-31. DOI:10.1007/BF02425150
14. Chuchalin AG, Sinopal'nikov AI, Kozlov RS, et al. Clinical guidelines for the diagnosis, treatment and prevention of severe community-acquired pneumonia in adults. Clinical Microbiology and Antimicrobial Chemotherapy. 2015;17(2):84-125 (in Russian).
15. Avdeev SN, Dekhnich AV, Zaytsev AA, et al. Federal guidelines on diagnosis and treatment of community-acquired pneumonia. Pulmonologiya. 2022;32(3):295-355 (in Russian). DOI:10.18093/0869-0189-2022-32-3-295-355
16. Avdeev SN, Beloborodov VB, Belotserkovskiy BZ, et al. Severe community-acquired pneumonia in adults. Clinical recommendations from Russian Federation of Anaesthesiologists and Reanimatologists. Anesteziologiya i reanimatologiya. 2022;1:6‑35 (in Russian). DOI:10.17116/anaesthesiology20220116
17. Metlay JP, Waterer GW, Long AC, et al. Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019;200(7):e45-67. DOI:10.1164/rccm.201908-1581ST
18. Torres A, Chalmers JD, Dela Cruz CS, et al. Challenges in severe community-acquired pneumonia: a point-of-view review. Intensive Care Med. 2019;45(2):159-71. DOI:10.1007/s00134-019-05519-y
19. Asadi L, Sligl WI, Eurich DT, et al. Macrolide-based regimens and mortality in hospitalized patients with community-acquired pneumonia: a systematic review and meta-analysis. Clin Infect Dis. 2012;55(3):371-80. DOI:10.1093/cid/cis414
20. Meijvis SC, van de Garde EM, Rijkers GT, Bos WJ. Treatment with anti-inflammatory drugs in community-acquired pneumonia. J Intern Med. 2012;272(1):25-35.
DOI:10.1111/j.1365-2796.2012.02554.x
21. Sligl WI, Marrie TJ. Severe community acquired pneumonia. Crit Care Clin. 2013;29(3):563-601. DOI:10.1016/j.ccc.2013.03.009
22. Hoogewerf M, Oosterheert JJ, Hak E, et al. Prognostic factors for early clinical failure in patients with severe community-acquired pneumonia. Clin Microbiol Infect. 2006;12(11):1097-104. DOI:10.1111/j.1469-0691.2006.01535.x
23. Quah J, Jiang B, Tan PC, et al. Impact of microbial Aetiology on mortality in severe community-acquired pneumonia. BMC Infect Dis. 2018;18(1):451.
DOI:10.1186/s12879-018-3366-4
24. Liapikou A, Rosales-Mayor E, Torres A. The management of severe community acquired pneumonia in the intensive care unit. Expert Rev Respir Med. 2014;8(3):293-303. DOI:10.1586/17476348.2014.896202
25. Müller-Redetzky H, Lienau J, Suttorp N, Witzenrath M. Therapeutic strategies in pneumonia: going beyond antibiotics. Eur Respir Rev. 2015;24(137):516-24. DOI:10.1183/16000617.0034-2015
26. Anderson R, Joone G, van Rensburg CEJ. An in-vitro evaluation of the cellular mycoplasmas. Antimicrob Agents Chemother. 2000;44(7):1980-2.
DOI:10.1128/AAC.44.7.1980-1982.2000
27. Pollock J, Chalmers JD. The immunomodulatory effects of macrolide antibiotics in respiratory disease. Pulm Pharmacol Ther. 2021;71:102095. DOI:10.1016/j.pupt.2021.102095
28. Sinopal'nikov AI, Rachina SA, Zaharenkov IA. Antibacterial therapy for severe community-acquired pneumonia in adults: the potential of macrolides. Clinical Microbiology and Antimicrobial Chemotherapy. 2019;21(3):217-23 (in Russian).
29. Zarogoulidis P, Papanas N, Kioumis I, et al. Macrolides: from in vitro anti-inflammatory and immunomodulatory properties to clinical practice in respiratory diseases. Eur J Clin Pharmacol. 2012;68(5):479-503. DOI:10.1007/s00228-011-1161-x
30. Anderson R, Steel HC, Cockeran R, et al. Clarithromycin alone and in combination with ceftriaxone inhibits the production of pneumolysin by both macrolide-susceptible and macrolide-resistant strains of Streptococcus pneumoniae. J Antimicrob Chemother. 2007;59(2):224-9. DOI:10.1093/jac/dkl479
31. Kanoh S, Rubin BK. Mechanisms of action and clinical application of macrolides as immunomodulatory medications. Clin Microbiol Rev. 2010;23(3):590-615. DOI:10.1128/CMR.00078-09
32. Bosnar M, Bosnjak B, Cuzic S, et al. Azithromycin and clarithromycin inhibit lipopolysaccharide-induced murine pulmonary neutrophilia mainly through effects on macrophage-derived granulocyte-macrophage colony-stimulating factor and interleukin-1beta. J Pharmacol Exp Ther. 2009;331(1):104-13. DOI:10.1124/jpet.109.155838
33. Demartini G, Esposti D, Marthyn P, et al. Effect of multiple doses of clarithromycin and amoxicillin on IL-6, IFN gamma and IL-10 plasma levels in patients with community acquired pneumonia. J Chemother. 2004;16(1):82-5. DOI:10.1179/joc.2004.16.1.82
34. Sligl WI, Asadi L, Eurich DT, et al. Macrolides and mortality in critically ill patients with community-acquired pneumonia: a systematic review and meta-analysis. Crit Care Med. 2014;42(2):420-32. DOI:10.1097/CCM.0b013e3182a66b9b
35. Martin-Loeches I, Lisboa T, Rodriguez A, et al. Combination antibiotic therapy with macrolides improves survival in intubated patients with community-acquired pneumonia. Intensive Care Med. 2010;36(4):612-20. DOI:10.1007/s00134-009-1730-y
36. Restrepo MI, Mortensen EM, Waterer GW, et al. Impact of macrolide therapy on mortality for patients with severe sepsis due to pneumonia. Eur Respir J. 2009;33(1):153-9. DOI:10.1183/09031936.00054108
37. Lee JH, Kim HJ, Kim YH. Is β-Lactam Plus Macrolide More Effective than β-Lactam Plus Fluoroquinolone among Patients with Severe Community-Acquired Pneumonia?: a Systemic Review and Meta-Analysis. J Korean Med Sci. 2017;32(1):77-84. DOI:10.3346/jkms.2017.32.1.77
38. Kyriazopoulou E, Sinapidis D, Halvatzis S, et al. Survival benefit associated with clarithromycin in severe community-acquired pneumonia: A matched comparator study. Int J Antimicrob Agents. 2020;55(1):105836. DOI:10.1016/j.ijantimicag.2019.10.017

Авторы

А.И. Синопальников1, С.А. Рачина*2, И.С. Васильева2, Н.А. Пигусова3, О.Ю. Карпова2

1 ФГБОУ ДПО «Российская медицинская академия непрерывного профессионального образования» Минздрава России, Москва, Россия;
2 ФГАОУ ВО «Первый Московский государственный медицинский университет им. И.М. Сеченова» Минздрава России (Сеченовский Университет), Москва, Россия;
3 ФГБУЗ «Клиническая больница №8» ФМБА России, Обнинск, Россия
*rachina_s_a@staff.sechenov.ru

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Alexander I. Sinopalnikov1, Svetlana A. Rachina*2, Irina S. Vasilyeva2, Nina A. Pigusova3, Olga Yu. Karpova2

1 Russian Medical Academy of Continuous Professional Education, Moscow, Russia;
2 Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia;
3 Clinical Hospital №8, Obninsk, Russia
*rachina_s_a@staff.sechenov.ru

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