Azithromycin in Bronchiolitis Obliterans Syndrome (AZI001)

• Prevalence of Bronchiolitis Obliterans Syndrome (BOS) [ Time Frame: 2 years post-transplant ] [ Designated as safety issue: No ]
  BOS was defined as a sustained decrease in forced Expiratory Volume in one second (FEV1) of at least 20% from the patient's maximum post-operative values in the absence of other causes.
• Overall Survival [ Time Frame: 2 years post-transplant ] [ Designated as safety issue: No ]
  Survival data were obtained using all-cause mortality information in the Leuven University Hospital transplant database, in which all our lung transplant recipients since 1991 are registered. For the end-point of all-cause mortality, survival times were not censored at retransplantation or at study-discontinuation if these preceded death, or else at 2 years after transplantation.

• Prevalence of Bronchiolitis Obliterans Syndrome [ Time Frame: at 1 and 2 years post-transplant ] [ Designated as safety issue: No ]
• Overall survival [ Time Frame: at 1 and 2 years post-transplant ] [ Designated as safety issue: No ]

• Acute Rejection Incidence Rate [ Time Frame: 2 years post-transplant ] [ Designated as safety issue: No ]
  Bronchoscopy and broncho-alveolar lavage (BAL) was routinely performed at discharge, 3, 6, 12, 18, 24 months post-transplantation and later at intervals of 1 year, or in case of clinically suspected acute allograft rejection, infection or chronic rejection. Transbronchial biopsies were routinely performed at discharge and 3 months post-transplant or in case of suspected acute rejection, infection or chronic rejection. Biopsies were graded according to the 1996 ISHLT-guidelines (grade A0-4 with concomitant B0-4), as well as assessed for other interstitial lesions of the pulmonary graft.
• Infection Incidence Rate [ Time Frame: 2 years post-transplant ] [ Designated as safety issue: No ]
  Cytomegalovirus (CMV)-status was assessed on on every broncho-alevolar lavage sample and by serum CMV DNA at weekly intervals during hospitalization and thereafter at each outpatient evaluation or hospital admission. Immunohistochemical staining for CMV was performed on transbronchial biopsies in case of clinical suspicion of infection (i.e. dyspnea, cough, sputum, fever, increased plasma C-reactive protein, new chest radiograph infiltrates, or a decrease of at least 10% in peak expiratory flow (PEF) as measured by patient's peak flow measurements.
• Pulmonary Function [ Time Frame: during first two years post-transplant ] [ Designated as safety issue: No ]
  Spirometry (Masterscreen, Jaeger, Hoechberg, Germany) was performed at twice weekly intervals for the first 2 postoperative months, thereafter at weekly to biweekly intervals until 6 months post-transplantation, then every 2 to 4 weeks until the first postoperative year and afterwards life-long at intervals of 2 to 3 months according to American Thoracic Society standards and forced expiratory volume in one second (FEV1) expressed in terms of the percentage of predicted values.
• Broncho-alveolar (BAL) Neutrophilia [ Time Frame: during first two years post-transplant ] [ Designated as safety issue: No ]
  BAL was performed with two 50 mL aliquots of sterile saline at room temperature. Five mL of the recovered BAL fluid was sent for microbiological and virological assessment, whereas the remaining fluid was analysed for cell counts after a cytospin was made in a Shandon cytocentrifuge and stained with May-Grünwald-Giemsa. Differential cell counts were determined by counting at least 300 cells.
• Plasma C-reactive Protein (CRP) Levels [ Time Frame: during the first two years post-transplant ] [ Designated as safety issue: No ]
  Plasma C-reactive protein (CRP) levels were assessed using Tina-quant CRP latex assay, Roche, Mannheim, Germany; sensitivity threshold of 1 mg/L, upper limit of normal 5 mg/L.

• Acute rejection rate [ Time Frame: at 1 and 2 years post-transplant ] [ Designated as safety issue: No ]
• Infection rate [ Time Frame: at 1 and 2 years post-transplant ] [ Designated as safety issue: No ]
• Pulmonary function evolution [ Time Frame: during first and second year post-transplant ] [ Designated as safety issue: No ]
• Evolution of BAL cellularity, protein levels and microbiology [ Time Frame: during first and second year post-transplant ] [ Designated as safety issue: No ]

Preventive treatment with azithromycin reduces the prevalence fo Bronchiolitis Obliterans Syndrome after lung transplantation.

• Prospective, interventional, randomized, double-blind, placebo-controlled trial.
• Clinical setting (tertiary University Hospital).
• Investigator-driven, no pharmaceutical sponsor.
• Lung transplant recipients.
• Add-on of study-drug (placebo or azithromycin) to 'standard of care' (standardized, routine immunosuppressive and infectious prophylactic protocol).
• 1:1 inclusion ratio (placebo:azithromycin).
• Randomisation at discharge after informed consent.

• Bronchiolitis Obliterans Syndrome
• Graft Rejection
• Lymphocytic Bronchiolitis
• Respiratory Infection

• Drug: Azithromycin
  Azithromycin 250 mg daily during 5 days followed by 250 mg three times a week on Mon., Wed. and Fri. during study-period.
  Other Name: Zitromax (Azithromycin Dihydrate, Pfizer, ZTM250)
• Drug: Placebo
  Placebo once daily during 5 days, followed by one placebo three times a week on Mon., Wed. and Fri during rest of study-period.
  Other Name: Lactose monohydricum Ph.Eur. (Fagron)

• Experimental: Azithromycin
  250 mg daily for 5 days, followed by 250 mg three times a week (Mon.-Wed.-Fri.) until the end of study
  Intervention: Drug: Azithromycin
• Placebo Comparator: Placebo
  PLacebo daily for 5 days, followed by placebo three times a week (Mon.-Wed.-Fri.) until end of study.
  Intervention: Drug: Placebo

Inclusion Criteria:

• Stable LTx recipients at discharge after transplantation.
• Signed informed consent
• Adult (age at least 18 years old at moment of transplantation)
• Able to take oral medication

Exclusion Criteria:

• Prolonged and/or complicated ICU-course after transplantation.
• Early (<30 days post-transplant) post-operative death
• Major suture problems (airway stenosis or stent)
• Retransplantation (lung)
• Previous transplantation (solid organ)
• Multi-organ transplantation (lung+ other solid organ)

• University Hospital, Gasthuisberg
• Fund for Scientific Research, Flanders, Belgium