Clinical Edge

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Azithromycin and Preschool Children

Can antibiotics lessen onset of severe LRTIs?

The use of azithromycin early during an apparent respiratory tract illness (RTI) reduced the likelihood of severe lower respiratory tract illness (LRTI) among young children with histories of recurrent severe LRTIs when compared with placebo, according to a study of 607 children aged 12 through 71 months. Participants were randomized in a 1:1 ratio to receive either azithromycin (12 mg/kg once daily for 5 days) or matching placebo at the start of an RTI. Researchers found:

• A total of 937 treated RTIs were experienced by 443 children, including 92 severe LRTIs (azithromycin group, 35; placebo group, 57).

• Azithromycin significantly reduced the risk of progressing to severe LRTI relative to placebo (HR, 0.64).

• Induction of azithromycin-resistant organisms and adverse events were infrequent.

Citation: Bacharier LB, Guilbert TW, Mauger DT, et al. Early administration of azithromycin and prevention of severe lower respiratory tract illnesses in preschool children with a history of such illnesses: A randomized clinical trial. JAMA. 2015;314(19):2034-2044. doi: 10.1001/jama.2015.13896.

Commentary: Recurrent severe wheezing episodes occurring with RTI are an important and common occurrence, affecting up to 15% to 20% of children prior to 6 years of age.1 LRTI was defined in this study as RTI that required the use of additional rescue medication. The current approach to RTI is to try to minimize the use of antibiotics unless an infection is clearly bacterial in origin, and to treat severe LRTI when it occurs. The results of this trial suggest that in children at high risk of severe LRTI, identified by their episodes of recurrent wheezing, early treatment of RTI with azithromycin may decrease the development of severe LRTI by over 35%, an important result. It is important to recognize that this study does not suggest treating all RTI with antibiotics, but rather that the use of a macrolide antibiotic may be considered, perhaps, in the select group of children similar to those studied with a history of recurrent wheezing with previous RTIs. —Neil Skolnik, MD

1. Ly NP, Gold DR, Weiss ST, Celedón JC. Recurrent wheeze in early childhood and asthma among children at risk for atopy. Pediatrics. 2006;117(6): e1132-e1138.