An old antibiotic class still has a role in asthma. In JACI, Ologundudu and colleagues pooled the randomized trial evidence on macrolides for asthma — a systematic review and meta-analysis done for the upcoming AAAAI/ACAAI severe-asthma guidelines.
The evidence base. 19 randomized trials, 1,825 participants, macrolides versus placebo or standard care, with certainty rated by GRADE.
Control and exacerbations. Macrolides improved asthma control — ACQ-6 mean difference −0.23 (95% CI −0.32 to −0.13, high certainty), with 40.6% vs 21.6% of patients improving by the 0.5-point minimally important difference. They likely reduced severe exacerbations: incidence rate ratio 0.75, or 0.26 fewer events per patient-year (moderate certainty). Quality of life improved modestly.
Not T2-restricted, and no safety signal. The benefit was similar in type 2–high and type 2–low asthma, which sets macrolides apart from most add-on options that are phenotype-specific. There was little to no effect on serious adverse events or mortality.
The takeaway. The average effects are modest — the ACQ-6 gain sits below the 0.5-point MID — but the exacerbation reduction is real and phenotype-independent.
That makes macrolides a guideline-relevant option to weigh in severe asthma, balanced against the usual stewardship concern of antimicrobial resistance with long-term antibiotic use.
References:
Ologundudu LM, et al. J Allergy Clin Immunol. 2026;158(4):970-981.