Long-Term Macrolides in Chronic Respiratory Diseases: Dusk or a New Dawn? A Narrative Review

Macrolides—especially azithromycin—have long been used in chronic respiratory dis-eases for their combined antimicrobial, anti-inflammatory, and immunomodulatory properties. Their role has been investigated across a range of conditions, including bronchiectasis, COPD, asthma, and less common entities such as chronic lung allograft dysfunction (CLAD), bronchiolitis obliterans syndrome (BOS), and diffuse panbron-chiolitis. In this narrative review, we analyze the evidence for macrolide therapy in these diseases, considering not only prevention of exacerbation but also outcomes such as lung function, quality of life, microbiological response, and long-term safety. We also examine their use in the light of alternative or emerging options, including biologics and novel anti-inflammatory agents, with careful attention to patient selection and safety concerns. With a clinical and practical approach, this review evaluates the current role of long-term macrolide therapy across different respiratory conditions, identifying the patient phenotypes most likely to benefit and exploring whether, in the era of new treatments, macrolides are heading toward dusk or opening to a new dawn.