antibiotics

Review
The Interplay between Antibiotics and the Host Immune
Response in Sepsis: From Basic Mechanisms to Clinical
Considerations: A Comprehensive Narrative Review
Martina Tosi 1 , Irene Coloretti 1 , Marianna Meschiari 2 , Sara De Biasi 3 , Massimo Girardis 1
and Stefano Busani 1, *

1 Anesthesia and Intensive Care Medicine, Policlinico di Modena, University of Modena and Reggio Emilia,
41124 Modena, Italy; [email protected] (M.T.); [email protected] (I.C.);
[email protected] (M.G.)
2 Infectious Diseases Unit, Policlinico di Modena, 41124 Modena, Italy; [email protected]
3 Department of Medical and Surgical Sciences for Children & Adults, University of Modena, and Reggio
Emilia, 41125 Modena, Italy; [email protected]
* Correspondence: [email protected]; Tel.: +39-059-422-4896; Fax: +39-059-422-4899

Abstract: Sepsis poses a significant global health challenge due to immune system dysregulation.
This narrative review explores the complex relationship between antibiotics and the immune system,
aiming to clarify the involved mechanisms and their clinical impacts. From pre-clinical studies,
antibiotics exhibit various immunomodulatory effects, including the regulation of pro-inflammatory
cytokine production, interaction with Toll-Like Receptors, modulation of the P38/Pmk-1 Pathway,
inhibition of Matrix Metalloproteinases, blockade of nitric oxide synthase, and regulation of caspase-
induced apoptosis. Additionally, antibiotic-induced alterations to the microbiome are associated
with changes in systemic immunity, affecting cellular and humoral responses. The adjunctive use of
antibiotics in sepsis patients, particularly macrolides, has attracted attention due to their immune-
regulatory effects. However, there are limited data comparing different types of macrolides. More
Citation: Tosi, M.; Coloretti, I.; robust evidence comes from studies on community-acquired pneumonia, especially in severe cases
Meschiari, M.; De Biasi, S.; Girardis, with a hyper-inflammatory response. While studies on septic shock have shown mixed results
M.; Busani, S. The Interplay between regarding mortality rates and immune response modulation, conflicting findings are also observed
Antibiotics and the Host Immune with macrolides in acute respiratory distress syndrome. In conclusion, there is a pressing need to tailor
Response in Sepsis: From Basic
antibiotic therapy based on the patient’s immune profile to optimize outcomes in sepsis management.
Mechanisms to Clinical
Considerations: A Comprehensive
Keywords: sepsis; immune response; antibiotic therapy; critically ill patients
Narrative Review. Antibiotics 2024, 13,
406. https://doi.org/10.3390/
antibiotics13050406

Academic Editor: Kordo Saeed 1. Introduction

Received: 1 April 2024 Sepsis has a high global prevalence and accounts for approximately 20% of the global
Revised: 23 April 2024 mortality burden [1]. The most severe forms escalate to septic shock, contributing to 10.4%
Accepted: 26 April 2024 of ICU admissions, with hospital mortality rates approaching 40% [2]. Several authors
Published: 28 April 2024 contend that the root causes of the most severe manifestations of sepsis lie in the emergence
of abnormal immune reactions within the host’s body [3].
Two opposite pathophysiological models may well summarize the wide variety of
immune response dysregulation occurring in sepsis. On the one hand, patients may develop
Copyright: © 2024 by the authors. an uncontrolled hyperinflammatory response with organ damage caused mainly by the
Licensee MDPI, Basel, Switzerland.
mechanisms intended to neutralize pathogens; on the other hand, patients may present an
This article is an open access article
unbalanced and prolonged anti-inflammatory response with failure of pathogen eradication
distributed under the terms and
(i.e., breakthrough infection) and occurrence of secondary infections [4]. The more the
conditions of the Creative Commons
immune response is skewed toward one of the models, the higher will be the risk of
Attribution (CC BY) license (https://
death. In recent years, significant efforts have been made to identify additional treatments
creativecommons.org/licenses/by/
4.0/).
for sepsis aimed at modulating the host’s immune response, for instance intravenous

Antibiotics 2024, 13, 406. https://doi.org/10.3390/antibiotics13050406 https://www.mdpi.com/journal/antibiotics

Antibiotics 2024, 13, 406 2 of 14

IgM-enriched immunoglobulins [5], but none of them has shown a significant benefit yet.
Appropriate antibiotic treatment along with source control remain the interventions with
a real and proven impact on outcome [6]. Emerging evidence shows how, beyond their
activity of microorganism killing and growth inhibition, antimicrobial drugs may also exert
direct and indirect effects on the immune system. Given the diriment role of a balanced
immune response during sepsis, the immunomodulatory effects of antibiotics must be
understood and carefully considered during the selection of antimicrobial treatment in
these patients.
This comprehensive narrative review aims to provide the latest findings on the
immune-modulating proprieties of antibiotics, to describe the mechanisms involved and to
discuss the possible clinical implications in septic patients. Most current studies retrieved
are mainly pre-clinical investigations conducted on immune cell cultures, ex-vivo sepsis
models utilizing harvested white blood cells, or animal studies. Only a few of the studies
on the immunomodulatory effects of antimicrobial drugs have advanced to the stage of
human clinical trials.
Given that the review’s objective is narrative rather than systematic, the bibliographic
research for the manuscript was conducted on journals indexed on PubMed, albeit in a
non-methodologically rigorous manner. Specifically, the following terms were employed
for the different sections:
- For the section on mechanisms of action, terms such as ‘immune dysfunction’ and
‘sepsis pathophysiology’ were paired with each class of antibiotics, with exclusion
criteria for papers related to clinical research, inflammatory/rheumatic diseases, cystic
fibrosis, and chronic respiratory diseases.
- In the microbiome section, terms such as “antibiotics”, “immunomodulation/dysfunction”,
“microbiota or microbiome”, and “sepsis” were utilized.
- Regarding the clinical studies section, the search terms included “antibiotics”, “im-
munomodulation/dysfunction”, and “clinical research”, with exclusion criteria for
studies involving animals and in-vitro and ex-vivo methodologies. However, for
each search, temporal criteria were restricted to the last 25 years of publications, from
1999 onwards.

2. Antibiotics and Immune Response: Mechanisms of Action

2.1. Regulation of Pro-Inflammatory Cytokines Production
Cytokines and chemokines are key regulators of the inflammatory response, orches-
trating both proinflammatory (interleukin (IL)-1, IL-6, IL-8, tumour necrosis factor (TNF),
and IFN-γ) and anti-inflammatory (e.g., IL-10) effects. Several studies have underscored
the impact of antimicrobial drugs on the secretion of these mediators. Among the most
well-documented immunomodulatory effects are those attributed to macrolides antibiotics,
which diminish the production of pro-inflammatory cytokines (such as TNF, IL-1, IL-6,
IL-8) through various mechanisms [7].
Intravenous administration of clarithromycin at therapeutic dosages has been shown
to reduce serum concentration of TNF and reactive oxygen species in a murine model
of sepsis caused by multi-sensitive E. coli, multidrug-resistant (MDR) P. aeruginosa, or
pan-drug-resistant K. pneumoniae, and this was associated with survival improvement [8,9].
Furthermore, an earlier study demonstrated that clarithromycin could suppress the produc-
tion of IL-8 stimulated by lipopolysaccharide (LPS) in human peripheral monocytes and
human monocytic leukaemia cell line THP-1 [10]. Similarly, in a septic shock model, the
oral administration of azithromycin reduced serum levels of TNF, which correlated with
decreased lethality [11]. Azithromycin has also been proven to suppress IL-6, IL-10, IL-12
and TNF production in human monocyte-derived dendritic cells and CD4+ T cells [12].
Dey et al. reported that azithromycin was more effective than ciprofloxacin in regulating
cytokine release from phagocytic cells [13]. In studies assessing cytokine production after
stimulation with staphylococcal toxin, Kushiya et al. observed that azithromycin exhib-
Antibiotics 2024, 13, 406 3 of 14

ited a slight suppression of pro-inflammatory cytokines production by toxin-stimulated

peripheral blood mononuclear cells [14] (Table 1).

Table 1. How antibiotics affect the immune response through different basic mechanisms of action
(see text for details).

Pro-Inflammatory TLRs Expression

Antibiotic’s Class MMPs and NO Apoptosis Regulation
Cytokines Production Modulation
Suppression of caspases
Modulation in TLRs and
Suppression activity resulting in
control of phagocytic Reduced production
Macrolides (Clarithromycin, enhanced bacterial
activity (all macrolides)
Azithromycin) clearance
(Erythromycin).
(Azithromycin)
Suppression in Inhibition of NO
Tigecycline concentration-dependent production induced by
manner LPS
Modulation in TLRs
Decreased MMPs activity, Inhibition of caspases
expression and regulation
Tetracyclines mitigating inflammation. against apoptosis
of phagocytic activity
Reduced NO production (Minocycline)
(Doxycycline)
Suppression in
Clindamycin concentration-dependent
manner
Suppression in
Trimethoprim-
concentration-dependent
Sulfamethoxazole
manner
Suppression in Upregulation of TLRs
Linezolid concentration-dependent expression resulting in
manner pro-inflammatory effect
Stimulation of Upregulation of TLRs
anti-inflammatory expression resulting in
Glycopeptides
cytokines pro-inflammatory effect
(Vancomycin) (Vancomycin)
Downregulation of TLRs
Reduction of
Daptomycin Suppression transcription resulting in
accumulation
anti-inflammatory effect
Modulation in TLRs
Inhibition of NO
expression and regulation
Quinolones Suppression (Ciprofloxacin) production induced by
of phagocytic activity
LPS
(Moxifloxacin)
Downregulation of TLRs
transcription resulting in
anti-inflammatory effect Reduction of nitrosative
Stimulation (Cefuroxime,
Cephalosporins (Cefuroxime, Cefotaxime) stress
Cefotaxime)
Immunostimulatory (Ceftazidime)
effects on neutrophil
phagocytosis (Ceftaroline)
Enhance macrophages’
phagocytic function
(Colistin)
Reduced NO production
Polymyxins Stimulation (Colistin) Innate immunity
(Polymyxin B)
activation via a
p38/PMK-1-pathway
(Colistin)
Decreased the expression
of TLR-4 and TNF in lung
Fosfomycin Reduction of synthesis
tissue during sepsis and
ARDS
Legenda: ROS = Reactive Oxygen Species; TLRs = Toll Like Receptors; NO = Nitric Oxide; LPS = Lipopolysaccha-
rides; MMPs = Matrix Metalloproteinases; ALI = Acute Lung Injury; ARDS = acute respiratory distress syndrome;
TNF = Tumour Necrosis Factor; LPS = Lipopolysaccharides.
Antibiotics 2024, 13, 406 4 of 14

Beyond macrolides, Pichereau et al. investigated the effects of various antibiotics on

cytokine production from peripheral blood mononuclear cells after exposure to Staphylo-
coccus aureus toxin in an in-vitro study [15]. Antimicrobials with high tissue penetration,
including tigecycline, clindamycin, trimethoprim/sulfamethoxazole, and linezolid sup-
pressed cytokines production in a concentration-dependent manner, whereas this effect
was not observed with vancomycin and daptomycin[13]. Furthermore, vancomycin ap-
pears to directly stimulate the production of anti-inflammatory mediators, as demonstrated
by measurement of LPS-stimulated IL-10 release. Other studies indeed demonstrated a
significant decrease in cytokine levels in septic patients treated with daptomycin [16,17].
Even quinolones appear to exert pronounced anti-inflammatory effects, as demonstrated in
LPS-activated human mononuclear cells with lowering of Th1 and Th2 cytokine expres-
sion [18,19]. Following ciprofloxacin, profound unresponsiveness of immune-competent
cells to LPS stimulation was observed in an ex-vivo model of sepsis [20] (Table 1). Again,
fosfomycin seems to exert an anti-inflammatory effect due to the reduction of proinflamma-
tory cytokine synthesis in mice via several mechanisms [21] (see below).
Conversely, cephalosporins, as demonstrated by Ziegeler et al., appear to induce a
shift from a balanced to an inflammatory cytokine release pattern. This study reported a
decrease in LPS-stimulated IL-10 release from all cephalosporins, with a more pronounced
effect observed with cefuroxime and cefotaxime [20]. Also, colistin seems to exert pro-
inflammatory activities, as described by Wang et al., who reported a significant increase
in the secretion of cytokines TNF, IL-1β, and IL-6 by stimulated macrophages in a murine
model [22] (Table 1).

2.2. Modulation of Toll-like Receptors (TLRs) and Regulation of P38/Pmk-1 Pathway

TLRs are primarily activated by bacterial pathogen-associated molecular patterns
that elicit a comprehensive inflammatory response during infections. Due to their multi-
faceted roles, TLRs have been considered suitable target molecules for immune modulatory
treatments in sepsis [23]. Several classes of antibiotics interact with the TLRs system.
Among them, erythromycin, doxycycline, and moxifloxacin exhibit the most notable activ-
ity, demonstrating significant modulation in TLRs’ expression and regulation of monocyte
phagocytic activity [24]. Linezolid, vancomycin, and daptomycin, which are largely used
in critically ill patients, were investigated on the TRL pathway in sepsis models, too [25]
(Table 1). LPS-activated THP-1 monocytes were incubated with the antibiotics and gene
expression of various cytokines, and the TLRs were monitored. The results revealed an
upregulation of the expression of all TLRs induced by linezolid and vancomycin. In con-
trast, daptomycin downregulated transcription of the TLRs responsible for the recognition
of pathogen-associated molecular patterns from Gram-positive bacteria. The authors con-
cluded that linezolid and, especially, vancomycin exhibit mainly pro-inflammatory effects,
whereas daptomycin demonstrates anti-inflammatory properties under sepsis-like condi-
tions. Moreover, cefuroxime and cefotaxime were also found to decrease the expression
density of the LPS recognition molecule CD14 on monocytes, thus downregulating, in
this way, monocytes’ response to LPS [20] (Table 1). Recent observations have examined
the impact of ceftaroline on neutrophil function, including its effects on phagocytic re-
sponse, expression of TLRs, cell survival, and apoptosis. This innate neutrophil function
was detailed in healthy patients whose cells were exposed to lipoteichoic acid (LTA) of S.
aureus, reporting that ceftaroline exerts immunostimulatory effects on phagocytosis higher
than other antibiotics on neutrophils exposed to LTA [26]. Again, fosfomycin seems to
exert an immunomodulatory effect by inhibiting TLR/NF-κb/MAPK signalling pathways.
Fosfomycin further diminishes NLRP3 inflammasome activation. In a rat model of sepsis-
induced lung injury, fosfomycin decreased the expression of TLR-4, NF-κb, and TNF in
lung tissue. Fosfomycin also exhibited antioxidative properties in this setting [27].
The increasing prevalence of MDR pathogens has prompted a reassessment of older
antibiotics such as colistin. Despite extensive research into its antibacterial properties, there
is a scarcity of data regarding colistin’s impacts on immune pathways. An animal study
Antibiotics 2024, 13, 406 5 of 14

revealed that a short, non-toxic treatment with colistin can activate the innate immunity of
C. elegans via a p38/PMK-1-dependent pathway [28]. This pathway, crucial for innate immu-
nity activation, appears to be conserved from plants to mammals [29]. Furthermore, it has
been demonstrated that colistin can induce an upregulation of specific genes and transcrip-
tional responses that closely resemble those triggered by microorganisms. A further study
on rat macrophages observed that colistin enhances the secretion of pro-inflammatory cy-
tokines and improves the macrophages’ phagocytic activity against S. aureus by modulating
the p38/MAPK pathway in a dose-dependent manner [30] (Table 1).

2.3. Inhibition of Matrix Metalloproteinases (MMPs) and Blockade of Nitric Oxide (NO) Synthase
MMPs are enzymes capable of degrading the extracellular matrix in various tissues,
and their activity is heightened during inflammation processes. Clinical studies have linked
elevated MMPs levels with tissue damage and increased mortality in septic patients [29–31].
In acute respiratory distress syndrome (ARDS), a correlation has been noted between
MMP activation, illness severity, and outcome [32,33]. Although the precise mechanisms
remain uncertain, it has been demonstrated that tetracyclines can diminish MMPs activity,
thus potentially mitigating organ damage during hyperinflammation, particularly in the
context of pulmonary infections. Hyperproduction of NO by the inducible form of NO
synthase (iNOS) may contribute to the vasoplegia and cardio-depression observed in
septic shock [34,35]. Inhibition of iNOS, either through translational or transcriptional
mechanisms leading to reduced production of NO, has been reported for macrolides and
tetracyclines [36]. Additionally, other antibiotics such as tigecycline and quinolones appear
capable of inhibiting LPS-induced nitric oxide production [37,38]. English et al. observed
that daptomycin exposure reduced the inflammatory response of macrophages to S. aureus
(reduced TNF release and reduced the accumulation of iNOS compared to those with
vancomycin or oxacillin) [39]. In an in-vitro rat model, polymyxin B was tested for its
ability to reduce LPS-induced NO production [40]. Additionally, ceftazidime significantly
decreased nitrosative stress by reducing the concentrations of pulmonary nitrotyrosine
formation in sheep with acute lung injury and sepsis [41]. All these listed properties
could potentially be valuable in clinical practice, particularly in septic shock with severe
hyperinflammatory states for limiting vasodilation and restoring hemodynamics (Table 1).

2.4. Regulation of Apoptosis Induced by Caspases

The significance of apoptosis in lymphoid organs and parenchymal tissues has gar-
nered heightened attention in the understanding of sepsis pathophysiology, particularly
concerning organ and immune dysfunction [42]. Many studies have highlighted the pivotal
role of the caspase pathway in apoptosis, pyroptosis, and necroptosis during infections, par-
ticularly in conditions of sepsis [43]. Indeed, both caspase inhibitors and caspase deficiency
have shown significant improvements in survival and overall disease outcome in sepsis,
and with protection from high-dose endotoxin shock and sepsis-related cardiac dysfunc-
tion in animal models [44,45]. A potential interaction between certain antibiotics and this
apoptotic pathway has been observed in other disease models: for instance, minocycline
has demonstrated protection against apoptosis by inhibiting caspases in various conditions
such as ischemia-reperfusion injury and stroke [46,47], although there is a shortage of
data on the effects of antimicrobial drugs on caspases in sepsis (Table 1). Azithromycin
appears to enhance bacterial clearance and attenuate lung injury in mice chronically in-
fected with Pseudomonas aeruginosa by inhibiting caspase-1-dependent IL-1ß and IL-18
secretion [48], as previously highlighted in our report on the inflammasome pathway in
MDR pathogens [49]. A recent study examined the effects of tetracyclines on a murine
model of acute lung injury (ALI) and inflammation. Tetracyclines were found to signifi-
cantly reduce ALI and pulmonary infiltrations, primarily through the selective inhibition of
caspase-1-dependent IL-1β and IL-18 production, ultimately leading to improved survival
rates. Additional experiments demonstrated that tetracyclines also decrease the production
of IL-1β and IL-18 by ex-vivo-studied alveolar leukocytes from patients with direct ARDS,
Antibiotics 2024, 13, 406 6 of 14

suggesting a potential role for tetracyclines in the treatment of ARDS associated with
elevated caspase-1 activity [50] (Table 1).

3. Antibiotics and Sepsis Impact on Microbiome Disruption

The administration of broad-spectrum antibiotics disrupts the composition of the gut
with a loss of commensal bacteria and an overgrowth of potential pathogenic microorgan-
isms. These alterations also extend to nonbacterial intestinal inhabitants. Disruptions of
these intestinal communities are associated with both an increased susceptibility to develop
sepsis as well as a higher risk of adverse outcomes [51].

3.1. Animal Studies

Several investigations indicate a connection between the preservation of gut micro-
biome balance and the effectiveness of systemic immunity, encompassing both innate and
adaptive cellular and molecular pathways. Signals emanating from the microbiome appear
to impact not only the generation of neutrophil granulocytes in the bone marrow but also
that of macrophages and monocytes [52,53]. Additional reports indicated a decrease in
circulating neutrophil granulocytes, their precursors, and factors and cytokines essential for
haematopoiesis stimulation in mice subjected to antibiotic administration or in germ-free
mice [52]. In addition to the production of immunity cells, their functionality is affected as
well: neutrophil cells’ extravasation capacity from the bloodstream to the site of infection
is impaired together with the bacterial killing capacity of neutrophils and macrophages
as a consequence of lower production of ROS [54,55]. Besides the Pattern Recognition
Receptors pathway, there are many cytokines whose production seems to be altered in
microbiota-depleted animal models: IFN-1 [56], TNF, IL-6 [55], IL-18, IL-1β, IFN-γ, and
IL-17 [57]. Yet, another intriguing study demonstrated the significant influence of micro-
biome composition on the generation of adaptive immune cells, including T CD4+ and
CD8+ lymphocytes, as well as specific antibodies following infection with the Influenza
A respiratory virus [58]. In this study, mice who received a combined antibiotic therapy
of ampicillin, vancomycin, metronidazole, and neomycin, as well as those who received
only neomycin, had extremely pronounced immune-suppressive effects on cytotoxic T
lymphocytes, whereas in mice treated with ampicillin, vancomycin, or metronidazole alone
the observed effects were variable and of average entity.
Other mechanisms have been observed by Clarke et al., who reported a reduced
clearance capacity of K. pneumoniae in the lungs of microbiota-depleted mice [55], while
Schuijt et al. observed, in the same pre-clinical setting, a reduced phagocytosis capacity,
increased systemic dissemination, inflammation, organ dysfunction, and higher mortality
rates [59]. Similarly, Chen et al. showed increased mortality rates in microbiota-depleted
mice with pneumonia sustained by E. coli infection [60].

3.2. Human Studies

Besides antibiotics, the development of sepsis itself can alter microbiota. Sun et al.
evaluated the microbiome of septic patients showing a destruction of symbiotic flora [61].
Patients with a high burden of Bacteroides, especially B. vulgatus, had higher severity scores
and longer stays in the intensive care unit (ICU). The alteration of the gut microbiome also
seems to be involved in sepsis myocardial injury; the mechanisms by which gut microbiota
affects myocardial health include small-chains fatty acids, cytokines, and mitochondrial
damage [62,63]. Various clinical studies in critically ill patients suggest that alterations
in the richness and diversity of the microbiome may result in dysregulation of systemic
immune responses to invasive pathogens [53]. A recent study part of the Human Func-
tional Genomics Project investigated 500 healthy volunteers as to how differences in the
composition of microbiome communities may affect the production of cytokines in answer
to microbial stimuli [64]. Patients enrolled in the study of Lankelma et al. highlighted how
the disruption of the microbiome, consequent to the administration of broad-spectrum
antibiotics, leads to a reduced capacity of systemic cellular response, in terms of ex-vivo
Antibiotics 2024, 13, 406 7 of 14

production of TNF, IL-1β, and IL-6 after stimulation with LPS [65]. Dufour et al. demon-
strated a pronounced reduction of serum immunoglobulin G titers as a consequence of
administration of amoxicillin/clavulanate [66].
Shimizu and colleagues reported how a variation in the composition of the gut mi-
crobial community, particularly a decrease of anaerobic forced bacteria and an increase of
pathogen microorganisms, is associated with the development of septic complications and
superior mortality rates among patients with systemic inflammatory response syndrome
(SIRS) [67]. Another interesting signal in this direction is provided by a sub-analysis of
an American large-scale study that identified in hospitalized patients a correlation be-
tween some conditions known to cause dysbiosis and re-hospitalization for severe sepsis in
the following 90 days. Namely, patients hospitalized for infective events and even more
patients with C. difficile infection, compared to patients with non-infective diseases, had
subsequent higher re-admission rates for severe sepsis but comparable re-admission rates
for non-sepsis-related diseases [68]. A remarkable study conducted by Shimizu et al. on
critically ill patients analysed the outcomes of 52 patients with SIRS by dividing them into
three groups based on the composition pattern of their faecal microbiome. The phenotypes
may be classed as either differentiated, meaning with richness of bacteria of different taxa;
single, in which a specific microorganism predominated on the others; or depleted, in which
a general lack of bacteria can be observed. The observed mortality in the three groups
was, respectively, 6%, 52%, and 64% [69]. A recent study conducted on 71 mechanically
ventilated patients demonstrated that the administration of broad-spectrum antibiotics and
disease severity may be associated with gut dysbiosis in the ICU. The progression of gut
dysbiosis occurring in these patients was associated with higher mortality [70].
Regrettably, comparative studies are scarce, with only a handful of exceptions in small-
scale inquiries that would allow us to accurately outline the unique immune-modulating
characteristics of different antibiotic compounds and their actual effects on the microbiome.

4. Clinical Studies on Antibiotics and Immunity

The majority of the trials available on the use of antibiotic drugs as adjunctive treat-
ment in patients with sepsis are focused on the use of macrolides, drugs whose immune-
regulatory effects are better known and whose use is already an established practice in the
framework of chronic inflammatory diseases [71]. Data comparing different macrolides
are largely lacking. Here, we delve into a comprehensive examination of investigations
concerning various clinical scenarios.

4.1. Community-Acquired Pneumonia (CAP) and Ventilator-Associated Pneumonia (VAP)

Several studies have indicated an improvement in survival and other clinical outcomes
associated with the adjunctive use of macrolide therapy in CAP [72]. Nie et al. conducted
a meta-analysis published on the treatment of CAP, comparing β-lactam monotherapy
with the addition of a macrolide [73]. The results consistently showed a superior effect
on patients’ survival with the combination therapy, regardless of whether they were in an
intensive or non-ICU setting and irrespective of the degree of severity of the pneumonia.
Garin et al. conducted a randomized controlled trial (RCT) of non-inferiority involving
580 patients to compare β-lactam monotherapy with β-lactam–macrolide combination
therapy for the treatment of moderately severe CAP [74]. In contrast with the previously
cited studies, they observed a difference in the rate of achieving clinical stability at day 7
only among patients with more severe forms of CAP. A prospective study on 52 patients
with non-responding CAP demonstrated that macrolide treatment significantly altered
cytokines expression in both plasma and bronchoalveolar lavage (BAL). IL-6 and TNF
levels in BAL fluid were significantly lower in patients treated with macrolide regimens,
showing a tendency towards decreased IL-8 levels. Interestingly, lower IL-6 levels in BAL
were confirmed even after excluding patients receiving concomitant inhaled or systemic
corticosteroid treatment. Additionally, circulating interleukins 8 and 10 were notably lower
in patients receiving macrolide regimens, with a trend towards decreased IL-6 levels. In
Antibiotics 2024, 13, 406 8 of 14

the subgroup of patients without concomitant corticosteroid treatment, lower levels of

IL-6, IL-8, and IL-10 in those on macrolide regimens were observed [75]. The benefits of
using a macrolide-containing antimicrobial regimen for the treatment of CAP were once
again reaffirmed by two large retrospective studies conducted by a Spanish group. They
observed a reduction in 30-day mortality among patients who received macrolides, with
a more pronounced effect seen in those with high levels of inflammation, as indicated by
CRP levels > 15 mg/dL, and in those with Pneumococcal pneumonia. The reduction in
30-day mortality was even greater when both criteria were met. Importantly, this benefit
was consistently observed irrespective of whether the causative strain was resistant to
macrolides [76,77].
Very recently, Giamarellos-Borboulis and co-workers published the results of the AC-
CESS trial, a multicentre RCT enrolling 278 hospitalized patients with CAP who presented
with SIRS, a Sequential Organ Failure Assessment (SOFA) score of two or higher, and
procalcitonin titre above 0.25 ng/mL [78]. Patients were randomly assigned to receive oral
placebo or oral clarithromycin. In the clarithromycin group, 68% of patients met a compos-
ite endpoint, compared to 38% in the placebo group. Interestingly, there was no observed
difference in the odds of achieving this composite outcome between patients with and
without microbiologically documented infection, whether with bacterial or non-bacterial
pathogens. These differences were accompanied by significant modifications in the expres-
sion of pro- and anti-inflammatory cytokines and in the ability of circulating peripheral
blood mononuclear cells (PBMCs) to produce TNF between the two groups. Patients who
received clarithromycin appeared to experience a less pronounced immune-paralysis effect
in response to infection, as evidenced by an improved capacity of circulating PBMCs to
produce TNF, a decrease in circulating IL-10 levels, and a decrease in the IL-8 to IL-10 ratio.
While these observations do not directly provide evidence, they indirectly suggest an effect
of clarithromycin on immune function [78]. Additionally, some benefits were observed in
viral pneumonia as well. In a RCT involving 48 children with respiratory failure caused
by respiratory syncytial virus infection, treatment with high-dose azithromycin reduced the
length of ventilatory support and oxygen therapy as well as the length of hospital stay.
Those benefits appeared to be mediated by a reduction of MMP-9, TNF, IL-1β, and IL-10
levels [79].
Only a few reports have been published about VAP and macrolides; a secondary anal-
ysis of an older RCT trial explained the observed outcome benefit by reporting differences
in the pattern of molecular response among patients who received clarithromycin: the
use of clarithromycin resulted in the restoration of the balance between pro-inflammatory
and anti-inflammatory mediators, evidenced by significantly lower TNF levels, higher
IL-6 levels, a more balanced TNF/IL-10 ratio, and more efficient processes of antigen
presentation and apoptosis [80]. Notably, these differences were more pronounced among
patients who developed septic shock. These findings seem to witness clarithromycin’s
ability to reverse immune suppression and endotoxin tolerance and accelerate the return to
homoeostasis from immune suppression and maintenance of innate immune cell function
against invading pathogens, although evidence is not as strong as those for CAP.

4.2. Sepsis, Septic Shock, and ARDS

A recent secondary analysis of the MARS (Molecular Assessment and Risk Stratifica-
tion in Sepsis) study assessed the effects of low-dose erythromycin on 235 patients, with
470 patients serving as controls. The study found no significant differences in mortality
rates up to day 90 between patients treated with low-dose erythromycin and the control
group, with a matching hazard ratio (HR) of 0.89 (95% CI 0.64–1.24) and a weighted HR of
0.95 (95% CI 0.66–1.36). Additionally, there were no disparities observed in secondary clini-
cal outcomes. The alteration in levels of host response biomarkers from admission to day 4
showed similar patterns between erythromycin-treated patients and controls [81]. A recent
meta-analysis including three RCTs involving a total of 910 patients did not reveal an im-
provement in short-term outcomes in patients with sepsis treated with clarithromycin [82].
Antibiotics 2024, 13, 406 9 of 14

In the recent INCLASS trial, 110 patients with sepsis and moderate hypoxia, along with
more than three SOFA points derived from systems other than respiratory function, were
randomly assigned to receive either intravenous adjunctive treatment with clarithromycin
or a placebo over 4 days. The trial encompassed patients with sepsis in critical conditions,
as witnessed by the 90% of patients requiring vasopressors. The results showed no discrep-
ancy in survival rates at both 28 and 90 days between the two treatment groups, although,
notably, patients administered with clarithromycin exhibited a more than half reduction in
the risk of developing secondary infections. Moreover, the subgroup analysis demonstrated
a favourable impact on 90-day mortality among those with a SOFA score exceeding 12 at
enrolment. These subgroups’ clinical benefits observed in the clarithromycin group could
potentially be attributed to the modulation of the host immune response, aiding in the
recovery from sepsis-induced immunosuppression. This is evidenced by the observed
increase in mHLA-DR expression and expansion of non-classical monocytes in the cohort
of patients who received clarithromycin [83].
In a comprehensive retrospective secondary analysis conducted by Simonis et al. [84],
the impact of macrolide usage was evaluated in a cohort comprising 873 ARDS patients.
The study found that patients who received macrolide therapy, primarily erythromycin,
during their ICU stay experienced a decrease of nearly 10% in mortality at the 30-day mark.
Upon further examination of the study population, it was observed that the survival ad-
vantage was evident predominantly in ARDS cases stemming from non-pulmonary causes.
Notably, subgroup analysis unveiled a more significant benefit of macrolide exposure in
ARDS cases exhibiting biological phenotype I, identified as the less inflamed type. This
observation poses a challenge as it appears to contradict the presumed mechanism of action
of macrolides [67].

5. Conclusions
We have entered a new phase to fight infections, one that focuses on boosting the
interaction between sepsis and the immune system. We know that the inflammatory-
immune response can vary greatly, influenced by factors such as microbial load, virulence,
host genetics, and existing health conditions [3]. Given the diverse phenotypes seen in septic
patients, customizing treatment approaches could be immensely beneficial. Antibiotics,
being central to sepsis treatment, offer not only the means to fight the infection but also
the potential to modulate the immune response (Figure 1). In this context, the selection of
antibiotics should not solely depend on the source, location, and cause of the infection but
also on the specific immune profile of the patient [85] (Figure 1). This idea gains support
from research on macrolides, which have demonstrated the ability to dampen inflammation.
The positive outcomes observed in patients with CAP could be attributed to considering
the immunological state of these patient groups. Further basic and clinical investigations
are imperative to delve deeper into this area, given the current limited evidence.
 fection but also on the specific immune profile of the patient [85] (Figure 1). This idea
support from research on macrolides, which have demonstrated the ability to da
inflammation. The positive outcomes observed in patients with CAP could be attri
to considering the immunological state of these patient groups. Further basic and c
Antibiotics 2024, 13, 406 investigations are imperative to delve deeper into this area, given the10current
of 14 limite
dence.

Figure 1. The figure depicts antibiotics that may have beneficial, detrimental, or neutral effects
Figure
concerning the two 1. The
phases figure
of the depicts
host’s antibiotics
(hyper- or hypo)that may have beneficial,
inflammatory detrimental,
response in or neutral effec
sepsis. Legenda:
IL: Interleukin, cerning the two phases
IFN: Interferon, of the host’s
TNF: Tumour (hyper-
Necrosis or hypo)
Factor, CCL:inflammatory
Chemokine response in sepsis. Legen
Ligand, CXCL:
Interleukin,
C-X-C motif chemokine IFN: Interferon, TNF: Tumour Necrosis Factor, CCL: Chemokine Ligand, CXCL:
ligand.
motif chemokine ligand.
Author Contributions: M.T., I.C. and S.B. are the study primary investigators for the design and
concepts of the Authors’ contributions:
review. M.T., I.C., M.M.M.T.,
andI.C. andwere
S.D.B. S.B. are the studyfor
responsible primary investigators
the collection for the desig
and the
analysis of manuscripts with which the review was completed. M.T., I.C. and S.B. drafted the original and th
concepts of the review. M.T., I.C., M.M. and S.D.B. were responsible for the collection
ysis was
manuscript, which of manuscripts
subsequently with which the
reviewed review
by M.G. was
All completed.
authors M.T.,and
have read I.C.agreed
and S.B.todrafted
the the o
manuscript, which
published version of the manuscript. was subsequently reviewed by M.G. All authors have read and agreed
published version of the manuscript.
Funding: This research received no external funding.
Funding: This research received no external funding.
Informed Consent Statement: Due to the nature of the manuscript informed consent was not collected.
Informed Consent Statement: Due to the nature of the manuscript informed consent was n
lected.The study group declares no conflicts of interest in relation to this academic
Conflicts of Interest:
research study.
Conflicts of Interest: The study group declares no conflicts of interest in relation to this aca
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