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Objectives  Maintenance treatment with macrolide antibiotics has shown to be effective in reducing exacerbations in COPD patients. A major concern with prolonged treatment with antibiotics is the development of bacterial resistance. In this study we determined the effect of azithromycin on the development and acquisition of resistance to macrolides in the nasopharyngeal flora in COPD patients.    Methods  This study was part of the COLUMBUS trial, a randomised, double-blind, placebo-controlled trial to measure the effect of maintenance treatment with azithromycin in 92 COPD patients on the exacerbation rates during a 12-month period. In order to determine resistance to macrolides, we used a targeted metagenomic approach to measure the presence and relative abundance of specific macrolide resistance genes  ermB ,  ermF  and  mefA  in throat samples collected at different time-points during this 12-month period.    Results  There was no increased risk for acquisition of macrolide resistance genes in the azithromycin group compared to the placebo group in COPD patients. However, loss of the macrolide resistance gene  ermB  was increased overtime in the placebo treated group compared to the azithromycin group ( n  = 5 for the placebo group versus  n  = 0 for the azithromycin group at 12 months;  p  = 0.012). The change in relative abundance of the three macrolide-resistance genes showed that all but one ( ermF ) increased during treatment with azithromycin.    Conclusions  The acquisition rate of macrolide resistance genes in COPD patients treated with azithromycin maintenance therapy was limited, but the relative abundance of macrolide resistance genes increased significantly over time compared to placebo.  This study was part of the COLUMBUS trial ( Clinicaltrials.gov ,  NCT00985244 ).

Prevalence and abundance of selected genes conferring macrolide resistance genes in COPD patients during maintenance treatment with azithromycin