Citation: Bacharier LB, Guilbert TW, Maugeret DT, al. Early administration of azithromycin and prevention of severe lower respiratory tract illnesses in preschool children with a history of such illnesses. JAMA. 2015;314:2034-2044.

Reviewed by: Michael B. Weinstock, MD
Background/question: The authors wanted to know if antibiotics administered early in the course of a respiratory tract infection (RTI) in children with recurrent, severe RTIs decreased progression of disease.

Study: This is a randomized, double-blind, placebo-controlled trial at nine academic medical centers in the US between 2011 and 2014 examining 607 children between the ages of 12 months and 71 months with a history of recurrent, severe lower RTI (LRTI). Participants deemed to be beginning a lower RTI were randomized to receive azithromycin 12 mg/kg/day for 5 days or matching placebo.

Outcomes and conclusions: There were a total of 473 RTIs in the azithromycin group and 464 RTIs in the placebo group. The azithromycin group had a statistically significant reduction in the risk of severe LRTIs relative to placebo with a low induction of azithromycin-resistant organisms. The number needed to treat (NNT) to prevent one severe LRTI fell with each subsequent episode: NNT for one RTI = 33, NNT for two RTIs = 14, NNT for three RTIs = 10. Swabs for azithromycin resistance were performed and did not show a significant increase.

Reviewer discussion: Urgent care providers see many pediatric patients with RTIs, and the conventional teaching has been that antibiotics should not be given for viral infections. This study does suggest that in a select population, azithromycin decreases the risk of progression of illness, though it did not show a change in hospitalizations or mortality. One possibility for the efficacy of azithromycin is the antibacterial effect, though another hypothesis is its antiinflammatory properties. There was a large NNT to prevent progression of illness (33 patients with the first episode), but this was likely at the expense of known side effects and drawbacks of azithromycin, which include gastrointestinal effects, resistance, cost, interactions, and inconvenience. Though there may be a minimal decrease in progression of illness in a select population, this single study should not change practice.
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LITERATURE REVIEW: Early Administration of Azithromycin and Prevention of Severe Lower RTI

Michael B. Weinstock, MD

Associate Program Director, Adena Emergency Medicine Residency; Director of Research and CME, Adena Health System; Professor of Emergency Medicine, Adjunct, Department of Emergency Medicine, Wexner Medical Center at The Ohio State University; Senior Clinical Editor, The Journal of Urgent Care Medicine (JUCM)
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