in the present patent , “ biofilm modifyer ” is defined as a substance able to destroy , destructure , and disorganize the biofilm and / or to prevent or slow down its formation . for the purpose of the present invention , the terms “ antimicrobial ”, “ antiinfective ”, “ antibacterial ”, and “ antibiotic ” are synonyms and refer to substances having a bacteriostatic and / or a bactericidal effect against a given pathogen micro - organism ( bacteria , fungi , virus ). the present invention discloses the increase of efficacy of antimicrobial agents in respiratory infections associated with biofilm by the synergetic combination of at least two active agents consisting of a biofilm modifyer and an antibiotic , administered by inhalation . basically , one antibiotic , the aminoglycoside , at least , should be active against the bacteria contained in the biofilm , while the macrolide shall act on the biofilm for instance by disorganizing it , destructuring it , inhibiting the production of alginate , etc . . . . the present invention is useful to prevent the formation of biofilm in patients but also to treat patients with a formed biofilm . the present invention more precisely consists of a composition dry or liquid for inhalation comprising at least one antibiotic from the aminoglycoside group and one antibiotic from the macrolide group , the antibiotic from the macrolide family being active against biofilms (= biofilm modifyer ). the antibiotics from the aminoglycoside group comprise , but are not restricted to : tobramycin , kanamycin , streptomycin , gentamicin , amikacin , apramycin , arbekacin , bekanamycin , astromycin , dihydrostreptomycin , framycetin , neomycin , netilmicin , isepamicin , micronomicin , sisomicin or their salts and derivatives . ( see martindale , 33 rd edition , page 111 ). the macrolides from the macrolides group comprise but are not restricted to : clarithromycin , azithromycin , roxithromycin , erythromycin , telithromycin , dirithromycin , flurithromycin , josamycin , kitasamycin , midecamycin , dalfopristin , oleandomycin , midecamycin , pristinamycin , rokitamycin , spiramycin , tilmicosin , troleandomycin , tylosin , virginiamycin , or their salts and derivatives . ( see martindale , 33 rd edition , page 112 ). there are significant advantages to administer the present composition of an aminoglycoside and a macrolide directly to the lungs instead of their usual route of administration i . e . most often intravenous for aminoglycoside and oral for macrolide . first , the very significantly decrease of the systemic exposure leads to the decrease of potentially very severe adverse effects of aminoglycoside ( nephrotoxicity and ototoxicity ) and the mild adverse effects of macrolides . second , the inhalation avoids drug interactions that may occur for some macrolides that are metabolized through the cytochrome p450 3a4 ( like clarithromycin ). those interactions may again result in important adverse effects . third , the interaction with food is also avoided when the composition is inhaled rather than swallowed . and last but not least , the inhaled route produces very high local concentrations of the drugs where needed . the amount of each antibiotic and their respective ratio may vary , depending to the nature of the bacterium to eradicate , the kind of biofilm and the kind of infection to treat . the amount of aminoglycoside will be , in every case , such as to provide , locally , concentrations in aminoglycoside superior to its mic ( minimal inhibitory concentration ) against the planktonic bacterium considered . however , the preferred ratio ( w / w ) aminoglycoside / macrolide in the present invention is 0 . 2 to 5 , preferably 0 . 5 to 3 , more preferably 0 . 8 to 2 . the amount of macrolide agent inhaled shall be high enough to affect , in some way , the biofilm . it has to be noted that as the effect of macrolide derivatives on the biofilm is mediated through a non - antibacterial mechanism . therefore , the amounts required to destroy the biofilm by inhalation may be significantly lower than the one needed for antiinfective activity pre os . also importantly , the macrolide derivative does not need to possess an antiinfective activity against the targeted microorganism to acts on the biofilm . nevertheless , it is a another object of the present invention to provide a composition containing high concentrations ( or amounts ) of each of the aminoglycoside derivative and of the macrolide derivative i . e . at least more than 10 %, preferably more than 15 %, and more preferably more than 20 % of the dry powder composition . it is indeed particularly interesting to achieve high lung doses of those therapeutic agents with the minimum amounts of inhalations because it makes the administration easier and more importantly increase the patient &# 39 ; s compliance . it also decreases the nominal dose of each active ingredient and thus the adverse effects linked to these actives . in the present invention , the dry powder inhaler also provides a high fine particle dose ( fpd ) and fine particle function ( fpf ) when tested in vitro on a multistage liquid impinger ( mli , eur . pharm , 5 th edition , chapter 2 . 9 . 18 ). the fpd and fpf are the parameters that predict in vivo lung deposition . briefly , the fpf (%) is defined as the fraction ( expressed of in percent ) of the nominal dose presenting a diameter inferior to 5 μm ( maximum diameter of particles to be able to reach the lungs ) and the fine particle dose ( fpd ) is the amount ( in mg ) per inhaled unit dose composition presenting a diameter inferior to 5 μm . high lung deposition of each active ingredient from the composition of the present invention will achieve high local concentrations of the antibiotic ( generally 5 to 20 times above the minimal inhibitory concentration or mic ) in order to kill the pathogens and high local concentrations of the biofilm modifyer agent in order to destroy or destructure rapidly the biofilm . the dpi composition of the present invention provides with a fpf of at least 15 % of each active ingredient in comparison to the nominal dose , preferably superior to 20 %, more preferably superior to 35 %. the preferred ratio ( w / w ) between the active ingredients ( aminoglycoside + macrolides ) and the inactive ingredients in dry powder composition of the invention , is comprised from 0 . 2 to 90 , preferably from 0 . 3 to 5 , more preferably 0 . 4 to 2 . alternatively , the compositions may be free of excipient ( 100 % of active drugs ). in a preferred embodiment of the present invention , both antimicrobial are present under the form of a dry powder for inhalation agents and are administered in a fixed combination through inhalation . said dry powder compositions may be formulated as a single dose composition i . e . a composition to be filled individually in capsules or blisters , or as a multidose composition i . e . a composition filled in a device equipped with a reservoir containing several doses and a metering dose system . the dry powder composition of the present invention preferably contains the aminoglycoside derivative in a micronized form and the macrolide derivative in a micronized form . for the purpose of the present invention , “ micronized ” means an average particle size inferior to 20 μm , preferably inferior to 10 μm and more preferably inferior to 5 μm when measured by laser diffraction for instance . the dry powder composition of the present invention may contain more than one antibiotic and more than one biofilm modifyer the dry powder composition may further contain other excipients like buffering agents , surfactants , lubricants , chelating agents or antioxydants , aminoacids . when carbohydrate is used as main inactive ingredient , it has a role of carrier . then , the preferred process is for manufacturing the composition of the invention is a dry blending of the micronized active ingredients with the non - micronized carrier . in case of use of a non - micronized carrier , said carrier has preferably a mean particle size comprised between 50 and 250 μm , preferably between 80 and 200 μm , more preferably between 100 and 160 μm . the preferred main carrier is anhydrous lactose or lactose monohydrate but other mono - disaccharide such as dextrose , xylitol , mannitol , saccharose etc ., may be used . mixtures of two or more carriers may also be used as well as mixtures a carrier with other kinds of excipients ( lubricants , surfactants , antioxidants , etc .). the dry powder composition of the invention may contain , in addition to the main non micronized carrier described hereinabove , a second carrier which can be non - micronized or micronized . when this second carrier is micronized , the preferred mean particle size measured by laser diffraction is inferior to 20 μm , preferably inferior to 10 μm . the second carrier can be the same chemical entity as the main carrier or a different one . the dry powder composition obtained by dry blending may further comprise excipients aimed to improve the stability of the composition , the flowability of the powder or the lung deposition of both active ingredients . another composition of the invention may contain in addition to the micronized aminoglycoside and the micronized macrolide , a lipid derivative or a mixture of different lipid derivatives as excipients . in this case , the preferred process consists in the spray - drying the active ingredients together with the lipid . the spray - drying process requires the use of a liquid in which the active ingredients and excipients are solubilized or in suspension . the solution or suspension is homogeneized and then spray - dried to obtain a particles in the required mean particle range i . e . & lt ; 10 μm , preferably inferior to 5 μm . this spray - drying process is a well known in the pharmaceutical industry and a specific process to obtain dry powder composition may , for instance be found in ep 1 674 085 a1 . the preferred lipid excipients are either phospholipids including anionic phospholipids , cationic phospholipids , zwitterionic phospholipids and neutral phospholipids such as for example phosphatidylcholine , phosphatidylglycerol , phosphatidyl - inositol , phospatidyl - serine , or non - phospholipids such as glycerol esters ( like glycerol monostearate , glycerol behenate ), fatty alcohols ( preferably with c16 or more ), fatty acids ( preferably with c16 or more ), ethers of fatty alcohols , esters of fatty acids , hydrogenated oils , polyoxyethylenated derivatives and sterols like cholesterol and its derivatives . mixtures of two or more lipid derivatives may also be used . preferably , a combination of a phospholipid with cholesterol or a cholesterol derivative may be used in compositions of the present invention . the lipid excipients may also be combined to other lipidic or non lipidic excipients like carbohydrate , surfactant , lubricant , antioxidant , chelating agent . the dry powder composition of the present invention may additionally contain one or more chelating agent . the chelating agent useful for the present invention may include edetic acid ( edta ) or a salt thereof , but other chelating agent such as citric acid , malic acid or their salts may be used . the chelating agent will preferably be present at a concentration ( w / w ) ranging from 0 . 01 % to 5 % of the final dry powder composition . combinations of more than one chelating agents may also be used . the dry powder composition of the present invention may additionally contain one or more antioxidant agent . examples of antioxidants that can be used include derivatives of cysteine like acetylcystein and its salts , glutathion , carbocystein derivatives or ascorbic acid , derivatives of tocopherol , propylgallate , bha , bht . it is to be noted that the presence of either a chelating agent or an antioxidant agent , or both , may further increase the beneficial effect on the biofilm and may consequently result in a better efficiency that the contribution of aminoglycoside and macrolide without these agents . in a second preferred embodiment , the composition can be in the form of a liquid , comprising a carrier and both antibiotics ( macrolide and aminoglycoside ) in suspension and / or solution therein . nebulizer solutions can be formulated in a similar way to injectable macrolide solutions well - known in the art . the liquid carrier is advantageously water , or any pharmaceutically acceptable solvent , such as ethanol , dimethylsulfoxide , glycerol , propylene glycol , and mixtures thereof . the antibiotics in the liquid compositions of the present invention shall be present in the same amount ranges as defined supra for the dry powder compositions . in vitro demonstration of the activity of micronized tobramycin + micronized clarithromycin on pseudomonas aeruginosa biofilm biofilms of pseudomonas aeruginosa — strain py o 1 were formed according to the methods described by ceri et al , the calgary biofilm device : new technology for rapid determination of antibiotic susceptibilities of bacterial biofilms , journal of clinical microbiology , pp . 1771 - 1776 , 1999 and abdi - ali et al , bactericidal activity of various antibiotics against biofilm - producing pseudomonas aeruginosa , international journal of antimicrobial agents 27 , 196 - 200 , 2006 . py o 1 : is a cystic fibrosis clinical mucoid strain of pseudomonas aeruginosa received from the erasme hospital , brussels . the determination of the minimal inhibitory concentration ( mic ) is performed according to the standard of nccls ( nccls , methods for dilution antimicrobial susceptibility tests for bacteria that grow aerobically ; approved standards , sixth edition , m7 - a6 , vol . 23 no . 2 , january 2003 . in the present experiment , the mic of tobramycin , clarithromycin and the combination of both antibiotics was first determined on planktonic bacteria (= probacteria i . e . free bacteria not included in a biofilm ) to prove that there is no direct additive effect of the active ingredient . the mic of tobramycin for pseudomonas aeruginosa is 3 . 9 μg / ml . the mic of clarithromycin for pseudomonas aeruginosa could not be determined since the results showed that the bacterium is not sensitive to this antibiotic . the mic of the combination of tobramycin and clarithromycin is found to be around 3 . 9 μg / ml . these results , similar to the mic value found for tobramycin alone demonstrate that there is no additional antibiotic effect of clarithromycin on planktonic pseudomonas aeruginosa . in a first attempt to measure the antibiotic activity ( mic ) of tobramycin on pseudomonas aeruginosa when incorporated in a biofilm , a culture of planktonic pseudomonas aeruginosa was prepared to produce a biofilm during a period of 24 hours . upon completion of the 24 hours the mic of tobramycin was measured using these cultures . surprisingly , it was found that the minimum inhibitory concentration ( mic ) of tobramycin on a 24 hours old biofilm of pseudomonas aeruginosa was similar to the activity of tobramycin of planktonic bacteria . in other words , tobramycin is still active on such a biofilm and there is no need to add a biofilm destroying / destructuring agent . in a second experiment using the same modus operandi as above , we measured the mic of tobramycin on a 12 day old pseudomonas aeruginosa biofilm . this situation is much closer to the situation observed in vivo in chronic respiratory diseases like cystic fibrosis . in this case , tobramycin was no longer active against said pseudomonas aeruginosa . there exists thus a significant difference between a 1 day old versus a 12 days old biofilm : it appears that a biofilm is a living entity that evolutes from the native to the mature stage . also these experiments shall warn researchers that antibiotic activity results obtained from species that form a biofilm may not be taken in consideration unless the biofilm has had sufficient time to form properly and results found in the literature have to be taken with precaution . effects of tobramycin , clarithromycin and combinations thereof on 12 - day biofilm of pseudomonas aeruginosa after having shown that the number of pseudomonas aeruginosa within the biofilms was stable after 12 days , the products listed in table 1 were added to the media for the duration of 24 hours . thereafter the biofilm was rinsed three times with a 0 . 01m phosphate buffer adjusted at ph 7 . 5 in order to remove all cells not bound to the biofilm . the microplate was then placed on ultrasonic bath at 35 ° c . for 5 minutes to allow the bacteria present in the biofilm to separate from such biofilm . a bacterial count was then performed ( number of coloning forming unit cfu / ml ). each experience was done twice and the cfu counting was also repeated twice / experience . the results are shown in table 1 and fig1 . it is concluded that neither tobramycin 4 μg / ml nor clarithromycin at 100 , 200 and 500 μg / ml alone are able to decrease the number of cfu / ml of the 12 - day biofilm versus the positive control . to the contrary all the combinations of tobramycin / clarithromycin were able to decrease the number of cfu / ml originated from the biofilm of pseudomonas aeruginosa with a maximal effect being observed for the combination tobramycin 4 μg / ml + clarithromycin 200 μg / ml which shows a number of cfu / ml of about 10 7 while tobramycin alone at 4 μg / ml shows a number of cfu / ml of around 2 . 5 × 10 8 . this means a more than 25 times decrease in the number of cfu / ml for the combination versus the reference product tobramycin . it can be seen that enhanced results are determined when at least 100 μg / ml clarithromycin is combined with tobramycin , preferably at least 200 μg / ml . the efficacy of the mixture decreases somehow for concentration in clarithromycin grater than 500 μg / ml . a dry powder composition for inhalation of tobramycin and clarithromycin was formulated using micronized tobramycin supplied by teva plantex ( israël ). clarithromycin was supplied by teva plantex ( israel ) in a non - micronized form . clarithromycin was then micronized using the micronizer mc - one ® ( jetpharma , switerland ). to obtain a product with particle size suitable to reach the respiratory tract ( i . e . 80 % of particles inferior to 10 μm , and 90 % of particles inferior to 5 μm when measured by laser diffraction ). the micronisation parameters were a pressure of 10 bars in the venturi , a pressure of 8 bars in the ring and a feeding rate of 5 g / minute . the mean particle size of the micronized clarithromycin obtained ( measured by laser diffraction ) was 1 . 6 μm . 400 g of anhydrous lactose ( 100 - 160 μm ) were put in a planetary mixer together with 50 g of micronized lactose monohydrate . the two lactoses were blended at 40 rpm for 10 minutes . 200 g of micronized tobramycin and 100 g of micronized clarithromycin were added to the mix of lactoses using the “ sandwich technique ”, i . e . by alternating the layer of lactoses and the layer of active ingredients to obtain a final mix as homogeneous as possible . the mix was blended for 10 minutes at a speed of 40 rpm . samples were taken from this powder blend to assure both active ingredients were homogeneously blended . 50 mg of the powder mix was then filled into number 3 hydroxypropylmethylcellulose ( hpmc ) capsules . these capsules are ready for use with a dry powder inhaled device such as the miat monodose inhaler , or any other suitable capsule based inhalation device . edetic acid in an amount of 0 . 5 % ( weight / weight ) was added to the blend of example 2 . the powder was thereafter filled in a miat multidose inhaler device . 400 g of anhydrous lactose ( 100 - 160 μm ) was introduced in a planetary mixer and 150 g of micronized tobramycin , 150 g of micronized clarithromycin and 20 g of n - acetylcysteinate lysine ( as antioxidant ) were added using the “ sandwich technique ”, i . e . by alternating the layer of lactose and the layer of active ingredients to obtain a final blend as homogeneous as possible . the blend was mixed for 10 minutes at a speed of 40 rpm . the blend was then filled in size 3 hard gelatine capsules ( 40 mg of powder / capsule ). 10 g of micronized tobramycin , 5 g of clarithromycin were dissolved in a 80 / 20 ( w / w ) water / ethanol mixture . 300 mg of phospholipon 90h ® and 1 . 2 g of cholesterol were added and dissolved in said solution containing the active ingredients . the solution was thereafter spray - dried to obtain a powder consisting of micrometric spherical lipidic particles with a very high content in active ingredients . this powder was filled in hpmc capsules for inhalation ( 20 mg of powder / capsule ). 400 g of anhydrous lactose ( 100 - 160 μm ) was mixed in a planetary mixer ( 40 rpm for 10 minutes ) with 200 g of micronized tobramycin and 200 g of micronized clarithromycin . 40 mg of the blend obtained was filled into size 3 hydroxypropylmethylcellulose capsules . this produced capsules each containing 10 mg of micronized tobramycin and 10 mg of micronized clarithromycin that may be used for inhalation the determination of the fine particle fraction ( fpf ) i . e . the fraction ( expressed in percent ) of the nominal dose presenting a diameter inferior to 5 μm ( maximum diameter to reach the lungs ) and the fine particle dose ( fpd ) i . e . the amount ( in mg ) per capsule presenting a diameter inferior to 5 μm , has been performed on the capsules using the axahaler device as powder inhaler device . the in vitro lung deposition test was performed using equipment and conditions as described in the european pharmacopoeia ( 5 th edition , chapter 2 . 9 . 18 — apparatus c ). this equipment consists of a multistage liquid impinger ( mli ) and was operated with an air flow of 100 l / min during a period of time of 2 . 4 seconds to simulate inhalation capabilities of patients . the quantification of the deposition of each drug on each stage of the mli was performed by hplc equipped with a a corona detector . the results are presented in table 2 . the fpf of tobramycin and clarithromycin obtained are 42 . 5 % and 36 . 3 % respectively . the fpd / capsule of tobramycin and clarithromycin are 4 . 26 mg and 3 . 63 mg respectively . those results clearly demonstrate that the compositions of the invention allow to reach very high lung deposition of both the antibiotic and the biofilm modifyer . such high lung deposition is suitable for use in vivo . indeed , the volume of epithelial liquid in the lung is generally estimated at about 100 ml . and lung deposition results show that each capsule of the composition of example 6 allows thus to obtain a lung concentration of respectively 42 . 6 μg / ml of tobramycin and 36 . 3 μg / ml of clarithromycin . different compositions ( f1 to f5 ) were manufactured using the blending process as described in example 6 .
an anti - infective composition for inhalation , containing , at least an effective amount of an antimicrobial aminoglycoside compound or a salt thereof ; and an effective amount of a biofilm modifier which is a macrolide compound or salt thereof .