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Ukkonen RM, Renko M, Kuitunen I. Azithromycin for acute bronchiolitis and wheezing episodes in children - a systematic review with meta-analysis. Pediatr Res 2024; 95:1441-1447. [PMID: 38066246 PMCID: PMC11126380 DOI: 10.1038/s41390-023-02953-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 11/07/2023] [Accepted: 11/13/2023] [Indexed: 05/26/2024]
Abstract
BACKGROUND The aim of this systematic review and meta-analysis was to analyse the efficacy of azithromycin in acute bronchiolitis and wheezing. METHODS PubMed, Scopus, and Web of Science databases were searched for randomized controlled trials comparing azithromycin to placebo in children <2 years of age. Main outcomes were progress of acute wheezing episode and recurrence of wheezing. We used random-effects model to calculate mean difference (MD) with 95% confidence interval (CI) or risk ratios (RR) with CI. RESULTS We screened 1604 abstracts and included 7 studies. Risk of bias was low in three and had some concerns in four studies. Need for intensive care unit treatment was assessed in four studies (446 children) and the risk difference was 0.0% (CI -2.0 to 2.0; low quality evidence). Hospitalization duration was -0.27 days shorter in the azithromycin group (MD-0.27, CI -0.47 to -0.07; three studies; moderate quality evidence). Azithromycin did not prevent recurrence of wheezing (RR 0.84, CI 0.45-1.56; three studies), hospital readmissions (RR 1.14, CI 0.82-1.60; four studies). CONCLUSIONS We found moderate quality evidence that azithromycin may reduce hospitalization duration. Low certainty evidence suggests that azithromycin does not reduce the need for intensive care unit treatment. Furthermore, azithromycin did not prevent wheezing recurrence. IMPACT Azithromycin may reduce hospitalization time in acute bronchiolitis and wheezing episodes among children aged less than two. Azithromycin administrated during the acute wheezing period, does not have preventive effect on wheezing recurrence. Azithromycin seemed to have similar adverse event profile than placebo. Future studies with clinically relevant outcomes, and sufficient sample sizes are needed, before implementing azithromycin into clinical use.
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Affiliation(s)
- Rosa-Maria Ukkonen
- Institute of Clinical Medicine and Department of Pediatrics, University of Eastern Finland, Kuopio, Finland
| | - Marjo Renko
- Institute of Clinical Medicine and Department of Pediatrics, University of Eastern Finland, Kuopio, Finland
- Department of Pediatrics, Kuopio University Hospital, Kuopio, Finland
| | - Ilari Kuitunen
- Institute of Clinical Medicine and Department of Pediatrics, University of Eastern Finland, Kuopio, Finland.
- Department of Pediatrics, Kuopio University Hospital, Kuopio, Finland.
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Kyvsgaard JN, Ralfkiaer U, Følsgaard N, Jensen TM, Hesselberg LM, Schoos AMM, Bønnelykke K, Bisgaard H, Stokholm J, Chawes B. Azithromycin and high-dose vitamin D for treatment and prevention of asthma-like episodes in hospitalised preschool children: study protocol for a combined double-blind randomised controlled trial. BMJ Open 2022; 12:e054762. [PMID: 35418427 PMCID: PMC9014042 DOI: 10.1136/bmjopen-2021-054762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION Previous randomised controlled trials (RCTs) suggest antibiotics for treating episodes of asthma-like symptoms in preschool children. Further, high-dose vitamin D supplementation has been shown to reduce the rate of asthma exacerbations among adults with asthma, while RCTs in preschool children are lacking. The aims of this combined RCT are to evaluate treatment effect of azithromycin on episode duration and the preventive effect of high-dose vitamin D supplementation on subsequent episodes of asthma-like symptoms among hospitalised preschoolers. METHODS AND ANALYSIS Eligible participants, 1-5 years old children with a history of recurrent asthma-like symptoms hospitalised due to an acute episode, will be randomly allocated 1:1 to azithromycin (10 mg/kg/day) or placebo for 3 days (n=250). Further, independent of the azithromycin intervention participants will be randomly allocated 1:1 to high-dose vitamin D (2000 IU/day+ standard dose 400 IU/day) or standard dose (400 IU/day) for 1 year (n=320). Participants are monitored with electronic diaries for asthma-like symptoms, asthma medication, adverse events and sick-leave. The primary outcome for the azithromycin intervention is duration of asthma-like symptoms after treatment. Secondary outcomes include duration of hospitalisation and antiasthmatic treatment. The primary outcome for the vitamin D intervention is the number of exacerbations during the treatment period. Secondary outcomes include time to first exacerbation, symptom burden, asthma medication and safety. ETHICS AND DISSEMINATION The RCTs are approved by the Danish local ethical committee and conducted in accordance with the guiding principles of the Declaration of Helsinki. The Danish Medicines Agency has approved the azithromycin RCT, which is monitored by the local Unit for Good Clinical Practice. The vitamin D RCT has been reviewed and is not considered a medical intervention. Results will be published in peer-reviewed journals and presented at international conferences. TRIAL REGISTRATION NUMBERS NCT05028153, NCT05043116.
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Affiliation(s)
- Julie Nyholm Kyvsgaard
- COPSAC, Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital, University of Copenhagen, Gentofte, Denmark
- Department of Peadiatrics, Slagelse Hospital, Slagelse, Denmark
| | - Ulrik Ralfkiaer
- COPSAC, Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital, University of Copenhagen, Gentofte, Denmark
| | - Nilofar Følsgaard
- COPSAC, Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital, University of Copenhagen, Gentofte, Denmark
| | - Trine Mølbæk Jensen
- COPSAC, Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital, University of Copenhagen, Gentofte, Denmark
- Department of Peadiatrics, Slagelse Hospital, Slagelse, Denmark
| | - Laura Marie Hesselberg
- COPSAC, Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital, University of Copenhagen, Gentofte, Denmark
| | - Ann-Marie M Schoos
- COPSAC, Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital, University of Copenhagen, Gentofte, Denmark
- Department of Peadiatrics, Slagelse Hospital, Slagelse, Denmark
| | - Klaus Bønnelykke
- COPSAC, Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital, University of Copenhagen, Gentofte, Denmark
| | - Hans Bisgaard
- COPSAC, Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital, University of Copenhagen, Gentofte, Denmark
| | - Jakob Stokholm
- COPSAC, Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital, University of Copenhagen, Gentofte, Denmark
- Department of Peadiatrics, Slagelse Hospital, Slagelse, Denmark
| | - Bo Chawes
- COPSAC, Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital, University of Copenhagen, Gentofte, Denmark
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Oliver ME, Hinks TSC. Azithromycin in viral infections. Rev Med Virol 2021; 31:e2163. [PMID: 32969125 PMCID: PMC7536932 DOI: 10.1002/rmv.2163] [Citation(s) in RCA: 65] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 08/19/2020] [Accepted: 08/20/2020] [Indexed: 12/18/2022]
Abstract
Azithromycin (AZM) is a synthetic macrolide antibiotic effective against a broad range of bacterial and mycobacterial infections. Due to an additional range of anti-viral and anti-inflammatory properties, it has been given to patients with the coronaviruses SARS-CoV or MERS-CoV. It is now being investigated as a potential candidate treatment for SARS-CoV-2 having been identified as a candidate therapeutic for this virus by both in vitro and in silico drug screens. To date there are no randomised trial data on its use in any novel coronavirus infection, although a large number of trials are currently in progress. In this review, we summarise data from in vitro, murine and human clinical studies on the anti-viral and anti-inflammatory properties of macrolides, particularly AZM. AZM reduces in vitro replication of several classes of viruses including rhinovirus, influenza A, Zika virus, Ebola, enteroviruses and coronaviruses, via several mechanisms. AZM enhances expression of anti-viral pattern recognition receptors and induction of anti-viral type I and III interferon responses. Of relevance to severe coronavirus-19 disease (COVID-19), which is characterised by an over-exuberant innate inflammatory response, AZM also has anti-inflammatory properties including suppression of IL-1beta, IL-2, TNF and GM-CSF. AZM inhibits T cells by inhibiting calcineurin signalling, mammalian target of rapamycin activity and NFκB activation. AZM particularly targets granulocytes where it concentrates markedly in lysosomes, particularly affecting accumulation, adhesion, degranulation and apoptosis of neutrophils. Given its proven safety, affordability and global availability, tempered by significant concerns about antimicrobial stewardship, there is an urgent mandate to perform well-designed and conducted randomised clinical trials.
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Affiliation(s)
| | - Timothy S. C. Hinks
- Nuffield Department of Medicine Experimental Medicine, Respiratory Medicine Unit and National Institute for Health Research (NIHR), Oxford Biomedical Research Centre (BRC)University of OxfordOxfordUK
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Niu H, Chang AB, Oguoma VM, Wang Z, McCallum GB. Latent class analysis to identify clinical profiles among indigenous infants with bronchiolitis. Pediatr Pulmonol 2020; 55:3096-3103. [PMID: 32845576 DOI: 10.1002/ppul.25044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 08/22/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Better phenotyping of the heterogenous bronchiolitis syndrome may lead to targeted future interventions. This study aims to identify severe bronchiolitis profiles among hospitalized Australian Indigenous infants, a population at risk of bronchiectasis, using latent class analysis (LCA). METHODS We included prospectively collected clinical, viral, and nasopharyngeal bacteria data from 164 Indigenous infants hospitalized with bronchiolitis from our previous studies. We undertook multiple correspondence analysis (MCA) followed by LCA. The best-fitting model for LCA was based on adjusted Bayesian information criteria and entropy R2 . RESULTS We identified five clinical profiles. Profile-A's (23.8% of cohort) phenotype was previous preterm (90.7%), low birth-weight (89.2%) and weight-for-length z-score <-1 (82.7% from combining those with z-score between -1 and -2 and those in the z-score of <-2 group) previous respiratory hospitalization (39.6%) and bronchiectasis on chest high-resolution computed tomography scan (35.4%). Profile-B (25.3%) was characterized by the oxygen requirement (100%) and marked accessory muscle use (45.5%). Infants in profile-C (7.0%) had the most severe disease, with oxygen requirement and bronchiectasis in 100%, moderate accessory muscle use (85% vs 0%-51.4%) and bacteria detected (93.1% vs 56.7%-72.0%). Profile-D (11.6%) was dominated by rhinovirus (49.4%), mild accessory muscle use (73.8%), and weight-for-length z-score <-2 (36.0%). Profile-E (32.2%) included bronchiectasis (13.8%), RSV (44.0%), rhinovirus (26.3%) and any bacteria (72%). CONCLUSION Using LCA in Indigenous infants with severe bronchiolitis, we identified five clinical profiles with one distinct profile for bronchiectasis. LCA can characterize distinct phenotypes for severe bronchiolitis and infants at risk for future bronchiectasis, which may inform future targeted interventions.
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Affiliation(s)
- Hongqi Niu
- Child Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Anne Bernadette Chang
- Child Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia.,Department of Respiratory and Sleep Medicine, Queensland Children's Hospital, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Victor Maduabuchi Oguoma
- Child Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Zhiqiang Wang
- Child Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Gabrielle Britt McCallum
- Child Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
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Incidence, management and outcome of respiratory syncytial virus infection in adult lung transplant recipients: a 9-year retrospective multicentre study. Clin Microbiol Infect 2020; 27:897-903. [PMID: 32827713 DOI: 10.1016/j.cmi.2020.07.050] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Revised: 06/20/2020] [Accepted: 07/30/2020] [Indexed: 01/02/2023]
Abstract
OBJECTIVES To analyse functional outcome parameters according to antimicrobial treatments after respiratory syncytial virus (RSV)-confirmed infection in adult lung transplant recipients. METHODS A 9-year retrospective multicentre cohort study (2011-19) included adult lung transplant recipients with RSV-confirmed infection. The first endpoint determined new allograft dysfunction (acute graft rejection and chronic lung allograft dysfunction (CLAD)) 3 months after infection. Then baseline and 3 months' postinfection forced expiratory volume in 1 second (FEV1) values were compared according to antimicrobial treatment. Univariate logistic regression analysis was performed. RESULTS RSV infection was confirmed in 77 of 424 lung transplant recipients (estimated incidence of 0.025 per patient per year; 95% confidence interval 0.018-0.036). At 3 months, 22 recipients (28.8%) developed allograft dysfunction: ten (13%) possible CLAD, six (7.9%) acute rejection and six (7.9%) CLAD. Recipients with the lowest preinfection FEV1 had a greater risk of developing pneumonia (median (interquartile range) 1.5 (1.1-1.9) vs. 2.2 (1.5-2.4) L/s, p 0.003) and a higher odds of receiving antibiotics (1.6 (1.3-2.3) vs. 2.3 (1.9-2.5) L/s, p 0.017; odds ratio 0.52, 95% confidence interval 0.27-0.99). Compared to tracheobronchitis/bronchiolitis, RSV-induced pneumonia led more frequently to hospitalization (91.7%, 22 vs. 58.0%, 29, p 0.003) and intensive care unit admission (33.3%, 8 vs. 0, p < 10-3). For ribavirin-treated recipients (24.7%, 19) and azithromycin prophylaxis (50.6%, 39), 3-month FEV1 values were not different from untreated recipients. The overall mortality was 2.5% at 1 month and 5.3% at 6 months, unrelated to RSV. CONCLUSIONS At 3 months after RSV-confirmed infection, 22 recipients (28.8%) had new allograft dysfunction. Ribavirin treatment and azithromycin prophylaxis did not prevent FEV1 decline.
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Binks MJ, Beissbarth J, Oguoma VM, Pizzutto SJ, Leach AJ, Smith-Vaughan HC, McHugh L, Andrews RM, Webby R, Morris PS, Chang AB. Acute lower respiratory infections in Indigenous infants in Australia's Northern Territory across three eras of pneumococcal conjugate vaccine use (2006-15): a population-based cohort study. THE LANCET CHILD & ADOLESCENT HEALTH 2020; 4:425-434. [PMID: 32450122 DOI: 10.1016/s2352-4642(20)30090-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Revised: 03/06/2020] [Accepted: 03/13/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND The burden of acute lower respiratory infection (ALRI) in Indigenous children of Australia's Northern Territory is among the highest globally. No published data exists on the effect of pneumococcal conjugate vaccine (PCV) introduction on ALRIs in this population beyond 2005. The aim of this study was to describe the rates of ALRI admissions to hospital in Indigenous infants in the Northern Territory from 2006 to 2015, across three periods of different PCV use. We hypothesised that broader valency PCVs would be more effective against hospitalisations for pneumonia. METHODS We did a retrospective population-based cohort study of Indigenous infants born in the Northern Territory followed up until age 12 months. Data were from administrative hospital and perinatal datasets. International classification of diseases codes (tenth revision, Australian modification; ICD-10AM) were used to identify respiratory hospitalisations of interest: all-cause ALRI, all-cause pneumonia, bacterial pneumonia, viral pneumonia, influenza-like illness (ILI), respiratory syncytial virus ALRI (RSV-ALRI), and pneumococcal ALRI. Incidence rates were compared between PCV eras (7-valent PCV [PCV7], 2006-09; 10-valent PCV [PCV10], 2009-11; and 13-valent PCV [PCV13], 2011-15) using interrupted time trend analysis and negative binomial regression. FINDINGS For children born between Jan 1, 2006, and Dec 31, 2015, 4138 ALRI episodes (31% of all hospitalisations) occurred among 2888 (20%) of the 14 594 infants. The overall ALRI hospitalisation rate was 29·7 episodes per 100 child-years. Prominent risk factors associated with ALRI hospitalisation were living in a remote community or the Central desert region, being born preterm or with low birthweight. ALRI rates were lowest in the PCV13 era, in association with a significant reduction in bacterial pneumonia hospitalisations in the PCV13 era compared with the PCV10 (incidence rate ratio 0·68, 95% CI 0·57-0·81) and PCV7 (0·70, 0·60-0·81) eras. In contrast, RSV-ALRI rates were 4·9 episodes per 100 child-years in each era. INTERPRETATION A 30% reduction in bacterial-coded pneumonia hospitalisations in the Northern Territory during the era of PCV13 immunisation supports its ongoing use in the region. Despite the reduction, one in five Indigenous infants born in the region continue to be hospitalised with an ALRI in their first year of life. Future gains require multifaceted environmental and biomedical approaches. FUNDING National Health and Medical Research Council of Australia.
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Affiliation(s)
- Michael J Binks
- Child Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia.
| | - Jemima Beissbarth
- Child Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
| | - Victor M Oguoma
- Child Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
| | - Susan J Pizzutto
- Child Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
| | - Amanda J Leach
- Child Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
| | - Heidi C Smith-Vaughan
- Child Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
| | - Lisa McHugh
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
| | - Ross M Andrews
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia; Research School of Population Health, Australian National University, Canberra, ACT, Australia
| | - Rosalind Webby
- Centre for Disease Control, Department of Health, Darwin, NT, Australia
| | - Peter S Morris
- Child Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia; Department of Paediatrics, Royal Darwin Hospital, Darwin, NT, Australia
| | - Anne B Chang
- Child Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia; Department of Respiratory and Sleep Medicine, Queensland Children's Hospital, Centre for Children's Health Research, Queensland University of Technology, Brisbane, QLD, Australia
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Pani A, Lauriola M, Romandini A, Scaglione F. Macrolides and viral infections: focus on azithromycin in COVID-19 pathology. Int J Antimicrob Agents 2020; 56:106053. [PMID: 32534189 PMCID: PMC7286256 DOI: 10.1016/j.ijantimicag.2020.106053] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 05/25/2020] [Accepted: 06/06/2020] [Indexed: 12/12/2022]
Abstract
It is necessary to quickly find therapeutic options for treating novel SARS-CoV2 Azithromycin has been demonstrated to have antiviral and immunomodulatory effects, which could be effective in the hyper-inflammatory syndrome caused by SARS-CoV2 Azithromycin has also shown clinical efficacy in respiratory distress syndrome and viral infections Preliminary results regarding the efficacy of the combination of azithromycin and hydroxychloroquine in COVID-19 are conflicting There are some concerns regarding the association of azithromycin and hydroxychloroquine because of QT prolongation Further studies have to be performed to investigate the safety and efficacy of azithromycin and the combination with hydroxychloroquine in COVID-19
The emergence of the new COVID-19 virus is proving to be a challenge in seeking effective therapies. Since the most severe clinical manifestation of COVID-19 appears to be a severe acute respiratory syndrome, azithromycin has been proposed as a potential treatment. Azithromycin is known to have immunomodulating and antiviral properties. In vitro studies have demonstrated the capacity of azithromycin in reducing production of pro-inflammatory cytokines such as IL-8, IL-6, TNF alpha, reduce oxidative stress, and modulate T-helper functions. At the same time there are multiple clinical evidences of the role of azithromycin in acute respiratory distress syndrome and against Middle East Respiratory syndrome (MERS). Some preliminary evidence has demonstrated controversial results regarding efficacy of azithromycin in combination with hydroxychloroquine in COVID-19. First, a French trial demonstrated 100% virological negativizing of six patients treated with azithromycin plus hydroxychloroquine vs. 57.1% of patients treated with only hydroxychloroquine and 12.5% of the control group (P < 0.05). On the other hand, another case series revealed no efficacy at all on 11 patients treated with the same combination and doses. Furthermore, there are some concerns regarding the association of azithromycin and hydroxychloroquine because of potential QT prolongation. In fact, both drugs have this as a potential side effect and evidence regarding the safe use of this combination is controversial. Despite the necessity to quickly find solutions for COVID-19, extreme caution must be used in evaluating the risk-benefit balance. However, based on preclinical and clinical evidence and some preliminary results in COVID-19, azithromycin could have potential in the fight against this new disease.
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Affiliation(s)
- Arianna Pani
- Department of Oncology and Hemato-oncology, Postgraduate School of Clinical Pharmacology and Toxicology, University of Milan, Milan, Italy; Clinical Pharmacology Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | | | - Alessandra Romandini
- Department of Oncology and Hemato-oncology, Postgraduate School of Clinical Pharmacology and Toxicology, University of Milan, Milan, Italy; Clinical Pharmacology Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Francesco Scaglione
- Department of Oncology and Hemato-oncology, Postgraduate School of Clinical Pharmacology and Toxicology, University of Milan, Milan, Italy; Clinical Pharmacology Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy.
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Kong M, Zhang WW, Sewell K, Gorman G, Kuo HC, Aban I, Ambalavanan N, Whitley RJ. Azithromycin Treatment vs Placebo in Children With Respiratory Syncytial Virus-Induced Respiratory Failure: A Phase 2 Randomized Clinical Trial. JAMA Netw Open 2020; 3:e203482. [PMID: 32324238 PMCID: PMC7180420 DOI: 10.1001/jamanetworkopen.2020.3482] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
IMPORTANCE Despite a high disease burden, there is no effective treatment for respiratory syncytial virus (RSV) infection. OBJECTIVES To determine whether administration of azithromycin (AZM) to children with RSV-induced respiratory failure is safe and to define the effect of AZM therapy on nasal matrix metalloproteinase 9 (MMP-9) levels. DESIGN, SETTING, AND PARTICIPANTS This randomized, double-blind, placebo-controlled phase 2 trial was conducted at a single tertiary pediatric intensive care unit from February 2016 to February 2019. The study included children with RSV infection who were admitted to the pediatric intensive care unit and required respiratory support via positive pressure ventilation (invasive and noninvasive). A total of 147 children were screened; 90 were excluded for not meeting inclusion criteria, having an absent legal guardian, lacking pharmacy support, or having a language barrier and 9 declined participation, resulting in 48 patients enrolled in the study. INTERVENTION Receipt of standard dose AZM (10 mg/kg/d), high-dose AZM (20 mg/kg/d), or a matching placebo of normal saline intravenously for 3 days. MAIN OUTCOMES AND MEASURES Nasal and endotracheal samples were collected at baseline as well as at 24 hours and 48 hours after start of treatment. The secondary outcome was to determine treatment effect on clinical outcome measures, including days of positive pressure ventilation and length of hospital stay. RESULTS A total of 48 patients were enrolled in the trial, with a median (range) age at randomization of 12 (1 to 125) months; 36 participants (75.0%) were younger than 2 years. Overall, 26 participants (54.2%) were boys, and 29 (60.4%) had a comorbidity. A total of 16 patients were randomized into each trial group (ie, placebo, standard-dose AZM, and high-dose AZM). Baseline demographic characteristics were comparable among the 3 groups. Both doses of AZM were safe, with no adverse events observed. No difference in nasal MMP-9 levels were observed between treatment groups. Among those who required mechanical ventilation and received high-dose AZM, endotracheal active and total MMP-9 levels were lower on day 3. Compared with baseline, active and total MMP-9 levels in endotracheal aspirates were 1.0 log lower in the high-dose AZM group (active MMP-9: 99.8% CI, -1.28 to -0.64; P < .001; total MMP-9: 99.8% CI, -1.37 to -0.57; P < .001). Patients who received high-dose AZM had fewer median (interquartile range) hospital days compared with those receiving the placebo (8 [6-14] days vs 11 [8-20] days; mean ratio estimate, 0.57; 95% CI, 0.38-0.87; P = .01). CONCLUSIONS AND RELEVANCE In this phase 2 randomized clinical trial, both doses of AZM were safe. While nasal MMP-9 levels were unchanged among treatment groups, endotracheal MMP-9 levels were lower among those who received high-dose AZM. The positive secondary clinical outcome, while exploratory, provides insight for end points in a multicenter randomized trial. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02707523.
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Affiliation(s)
- Michele Kong
- Department of Pediatrics, University of Alabama at Birmingham
| | - Wei Wei Zhang
- Department of Pediatrics, University of Alabama at Birmingham
| | - Kate Sewell
- Department of Pediatrics, University of Alabama at Birmingham
| | - Gregory Gorman
- McWhorter School of Pharmacy, Samford University, Birmingham, Alabama
| | - Hui-Chien Kuo
- Department of Pediatrics, University of Alabama at Birmingham
| | - Inmaculada Aban
- Department of Pediatrics, University of Alabama at Birmingham
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Bacteremia in Children Hospitalized Due to Respiratory Syncytial Virus Infection. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2020; 1271:21-28. [PMID: 32166635 DOI: 10.1007/5584_2020_500] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The frequency of bacteremia in children hospitalized due to respiratory syncytial virus infection (RSV) rarely exceeds 1%, but a recent study reported a 10% risk of bacteremia. In this study, we set out to verify the frequency, usefulness, and costs of blood cultures in RSV infections. We addressed the issue by reviewing medical files of 512 children, aged 8 days-121 months, who were hospitalized during January 2010 and June 2017. The RSV-related diagnoses included bronchiolitis (390 patients), RSV pneumonia (65 patients), and bronchitis (57 patients). There were 212 blood cultures performed in 185 patients (36%). In 10 cultures (5.4%), the following pathogens were identified: Staphylococcus haemolyticus, 4; Staphylococcus epidermidis, 1; Staphylococcus hominis, 1; Corynebacterium, 1 Streptococcus parasanguinis, 1; Rothia mucilaginosa, 1; Micrococcus luteus, 1; and Streptococcus hominis, 1 case. However, all of these pathogens were identified as a contamination of samples only. Therefore, both positive blood cultures turned out in fact negative, and the patients having either result of blood culturing showed no clinically relevant differences. The total cost of blood cultures in the pediatric ward amounted to €1980. If performed in each and every patient, the costs would have reached €5490. In conclusion, the frank frequency of bacteremia in children with RSV infection, with no sepsis, seems exceedingly low, which confirms the earlier findings. Thus, blood culturing, generating high costs, is of negligible clinical value. The study provides no evidence supporting a routine blood culture in case of children hospitalized due to RSV infection.
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Che SY, He H, Deng Y, Liu EM. [Clinical effect of azithromycin adjuvant therapy in children with bronchiolitis: a systematic review and Meta analysis]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2019; 21:812-819. [PMID: 31416508 PMCID: PMC7389899 DOI: 10.7499/j.issn.1008-8830.2019.08.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 07/10/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To systematically evaluate the clinical effect of azithromycin (AZM) adjuvant therapy in children with bronchiolitis. METHODS Related databases were searched for randomized controlled trials (RCTs) on AZM adjuvant therapy in children with bronchiolitis published up to February 17, 2019. RevMan 5.3 was used to perform the Meta analysis. RESULTS A total of 14 RCTs were included, with 667 children in the intervention group and 651 in the control group. The pooled effect size showed that in the children with bronchiolitis, AZM adjuvant therapy did not shorten the length of hospital stay (MD=-0.29, 95%CI: -0.62 to 0.04, P=0.08) or oxygen supply time (MD=-0.33, 95%CI: -0.73 to 0.07, P=0.10), while it significantly shortened the time to the relief of wheezing (MD=-1.00, 95%CI: -1.72 to -0.28, P=0.007) and cough (MD=-0.48, 95%CI: -0.67 to -0.29, P<0.00001). The analysis of bacterial colonization revealed that AZM therapy significantly reduced the detection rates of Streptococcus pneumoniae (OR=0.24, 95%CI: 0.11-0.54, P=0.0006), Haemophilus (OR=0.28, 95%CI: 0.14-0.55, P=0.0002), and Moraxella catarrhalis (OR=0.21, 95%CI: 0.11-0.40, P<0.00001) in the nasopharyngeal region. CONCLUSIONS AZM adjuvant therapy can reduce the time to the relief of wheezing and cough in children with bronchiolitis, but it has no marked effect on the length of hospital stay and oxygen supply time.
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Affiliation(s)
- Si-Yi Che
- Department of Respiratory, Children's Hospital of Chongqing Medical University, Chongqing 400014, China.
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11
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Che SY, He H, Deng Y, Liu EM. [Clinical effect of azithromycin adjuvant therapy in children with bronchiolitis: a systematic review and Meta analysis]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2019; 21:812-819. [PMID: 31416508 PMCID: PMC7389899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 07/10/2019] [Indexed: 08/01/2024]
Abstract
OBJECTIVE To systematically evaluate the clinical effect of azithromycin (AZM) adjuvant therapy in children with bronchiolitis. METHODS Related databases were searched for randomized controlled trials (RCTs) on AZM adjuvant therapy in children with bronchiolitis published up to February 17, 2019. RevMan 5.3 was used to perform the Meta analysis. RESULTS A total of 14 RCTs were included, with 667 children in the intervention group and 651 in the control group. The pooled effect size showed that in the children with bronchiolitis, AZM adjuvant therapy did not shorten the length of hospital stay (MD=-0.29, 95%CI: -0.62 to 0.04, P=0.08) or oxygen supply time (MD=-0.33, 95%CI: -0.73 to 0.07, P=0.10), while it significantly shortened the time to the relief of wheezing (MD=-1.00, 95%CI: -1.72 to -0.28, P=0.007) and cough (MD=-0.48, 95%CI: -0.67 to -0.29, P<0.00001). The analysis of bacterial colonization revealed that AZM therapy significantly reduced the detection rates of Streptococcus pneumoniae (OR=0.24, 95%CI: 0.11-0.54, P=0.0006), Haemophilus (OR=0.28, 95%CI: 0.14-0.55, P=0.0002), and Moraxella catarrhalis (OR=0.21, 95%CI: 0.11-0.40, P<0.00001) in the nasopharyngeal region. CONCLUSIONS AZM adjuvant therapy can reduce the time to the relief of wheezing and cough in children with bronchiolitis, but it has no marked effect on the length of hospital stay and oxygen supply time.
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Affiliation(s)
- Si-Yi Che
- Department of Respiratory, Children's Hospital of Chongqing Medical University, Chongqing 400014, China.
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12
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Zhang Y, Dai J, Jian H, Lin J. Effects of macrolides on airway microbiome and cytokine of children with bronchiolitis: A systematic review and meta-analysis of randomized controlled trials. Microbiol Immunol 2019; 63:343-349. [PMID: 31283028 DOI: 10.1111/1348-0421.12726] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 06/25/2019] [Accepted: 07/01/2019] [Indexed: 12/17/2022]
Abstract
Macrolides may attenuate airway inflammation of bronchiolitis with anti-inflammatory and antiviral effects. However, the potential mechanisms of action underlying the efficiency of macrolides in treating bronchiolitis are limited. Therefore, we performed a meta-analysis to assess the effects of macrolides on airway microbiome and cytokine of children with bronchiolitis. PubMed, Embase, and Cochrane Central Register of Controlled Trials were searched until May 2018. The reference lists of included studies and pertinent reviews were investigated for supplementing our search. Randomized controlled trials (RCTs) that compared macrolides with placebo assessing the change of microbiome in airway and cytokine were included. A total of four RCTs were included in this review. Data analysis showed no significant reduction of viruses at 48 hr after azithromycin treatment (p = 0.41). There were significant reductions in Streptococcus pneumoniae (risk ratio [RR] 0.28, 95% confidence interval (CI) 0.14 to 0.6, p < 0.01), Haemophilus influenza (RR 0.35, 95% CI 0.2 to 0.62, p < 0.01), and Moraxella catarrhalis (RR 0.29, 95% CI 0.17 to 0.5, p < 0.01), but no significant reduction of Staphylococcus aureus (p = 0.28) following treatment with macrolides. There was a significant decrease in the serum interleukin-8(IL-8), interleukin-4(IL-4), and eotaxin levels following 3 weeks of clarithromycin therapy. There was no significant difference in the serum IL-8 level at Day 15 after the intervention between the azithromycin and control groups; however, a significant reduction of nasal lavage IL-8 level was found. The macrolides may reduce the IL-8 levels in the airway and plasma, but failed to demonstrate an antiviral effect in children with bronchiolitis.
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Affiliation(s)
- Yin Zhang
- Respiratory Department, Children's Hospital of Chongqing Medical University, Chongqing, China.,Ministry of Education Key Laboratory of Child Development and Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Jihong Dai
- Respiratory Department, Children's Hospital of Chongqing Medical University, Chongqing, China.,Ministry of Education Key Laboratory of Child Development and Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Hui Jian
- Department of Pediatrics, Sichuan Provincial Hospital for Women and Children, Chengdu, Sichuan, China
| | - Jilei Lin
- Respiratory Department, Children's Hospital of Chongqing Medical University, Chongqing, China.,Ministry of Education Key Laboratory of Child Development and Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China
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Chang AB, Fong SM, Yeo TW, Ware RS, McCallum GB, Nathan AM, Ooi MH, de Bruyne J, Byrnes CA, Lee B, Nachiappan N, Saari N, Torzillo P, Smith-Vaughan H, Morris PS, Upham JW, Grimwood K. HOspitalised Pneumonia Extended (HOPE) Study to reduce the long-term effects of childhood pneumonia: protocol for a multicentre, double-blind, parallel, superiority randomised controlled trial. BMJ Open 2019; 9:e026411. [PMID: 31023759 PMCID: PMC6502017 DOI: 10.1136/bmjopen-2018-026411] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 12/06/2018] [Accepted: 01/08/2019] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Early childhood pneumonia is a common problem globally with long-term complications that include bronchiectasis and chronic obstructive pulmonary disease. It is biologically plausible that these long-term effects may be minimised in young children at increased risk of such sequelae if any residual lower airway infection and inflammation in their developing lungs can be treated successfully by longer antibiotic courses. In contrast, shortened antibiotic treatments are being promoted because of concerns over inducing antimicrobial resistance. Nevertheless, the optimal treatment duration remains unknown. Outcomes from randomised controlled trials (RCTs) on paediatric pneumonia have focused on short-term (usually <2 weeks) results. Indeed, no long-term RCT-generated outcome data are available currently. We hypothesise that a longer antibiotic course, compared with the standard treatment course, reduces the risk of chronic respiratory symptoms/signs or bronchiectasis 24 months after the original pneumonia episode. METHODS AND ANALYSIS This multicentre, parallel, double-blind, placebo-controlled randomised trial involving seven hospitals in six cities from three different countries commenced in May 2016. Three-hundred-and-fourteen eligible Australian Indigenous, New Zealand Māori/Pacific and Malaysian children (aged 0.25 to 5 years) hospitalised for community-acquired, chest X-ray (CXR)-proven pneumonia are being recruited. Following intravenous antibiotics and 3 days of amoxicillin-clavulanate, they are randomised (stratified by site and age group, allocation-concealed) to receive either: (i) amoxicillin-clavulanate (80 mg/kg/day (maximum 980 mg of amoxicillin) in two-divided doses or (ii) placebo (equal volume and dosing frequency) for 8 days. Clinical data, nasopharyngeal swab, bloods and CXR are collected. The primary outcome is the proportion of children without chronic respiratory symptom/signs of bronchiectasis at 24 months. The main secondary outcomes are 'clinical cure' at 4 weeks, time-to-next respiratory-related hospitalisation and antibiotic resistance of nasopharyngeal respiratory bacteria. ETHICS AND DISSEMINATION The Human Research Ethics Committees of all the recruiting institutions (Darwin: Northern Territory Department of Health and Menzies School of Health Research; Auckland: Starship Children's and KidsFirst Hospitals; East Malaysia: Likas Hospital and Sarawak General Hospital; Kuala Lumpur: University of Malaya Research Ethics Committee; and Klang: Malaysian Department of Health) have approved the research protocol version 7 (13 August 2018). The RCT and other results will be submitted for publication. TRIAL REGISTRATION ACTRN12616000046404.
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Affiliation(s)
- Anne B Chang
- Child Health Division, Menzies School of Health Research, Charles Darwin Univ, Darwin, Northern Territory, Australia
- Qld Children's Hospital, Brisbane, Queensland, Australia
| | | | - Tsin Wen Yeo
- Global and Tropical Health Division, Menzies School of Health Research, Darwin, Northern Territory, Australia
| | - Robert S Ware
- School of Population Health, The University of Queensland, Brisbane, Queensland, Australia
| | - Gabrielle B McCallum
- Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | | | - Mong H Ooi
- Universiti Malaysia Sarawak, Kuching, Malaysia
| | | | | | - Bilawara Lee
- Charles Darwin University, Darwin, Northern Territory, Australia
| | | | | | - Paul Torzillo
- Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Heidi Smith-Vaughan
- Child Health Division, Menzies School of Health Research, Darwin, Northern Territory, Australia
| | - Peter S Morris
- Menzies School of Health Research, Darwin, Northern Territory, Australia
| | - John W Upham
- School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Keith Grimwood
- Menzies Health Institute Queensland, Griffith University, Southport, Queensland, Australia
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14
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Macrolides in critically ill patients with Middle East Respiratory Syndrome. Int J Infect Dis 2019; 81:184-190. [PMID: 30690213 PMCID: PMC7110878 DOI: 10.1016/j.ijid.2019.01.041] [Citation(s) in RCA: 84] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 01/18/2019] [Accepted: 01/21/2019] [Indexed: 01/16/2023] Open
Abstract
More than one-third of critically ill patients with Middle East Respiratory Syndrome Coronavirus (MERS-CoV) received empiric therapy with macrolides. Macrolide therapy is not significantly associated with a reduction in 90-day mortality of critically ill patients with MERS-CoV. Macrolide therapy is not significantly associated with improvement in MERS-CoV RNA clearance of critically ill patients with MERS-CoV.
Objectives Macrolides have been reported to be associated with improved outcomes in patients with viral pneumonia related to influenza and other viruses, possibly because of their immune-modulatory effects. Macrolides have frequently been used in patients with Middle East Respiratory Syndrome (MERS). This study investigated the association of macrolides with 90-day mortality and MERS coronavirus (CoV) RNA clearance in critically ill patients with MERS. Methods This retrospective analysis of a multicenter cohort database included 14 tertiary-care hospitals in five cities in Saudi Arabia. Multivariate logistic-regression analysis was used to determine the association of macrolide therapy with 90-day mortality, and the Cox-proportional hazard model to determine the association of macrolide therapy with MERS-CoV RNA clearance. Results Of 349 critically ill MERS patients, 136 (39%) received macrolide therapy. Azithromycin was most commonly used (97/136; 71.3%). Macrolide therapy was commonly started before the patient arrived in the intensive care unit (ICU) (51/136; 37.5%), or on day1 in ICU (53/136; 39%). On admission to ICU, the baseline characteristics of patients who received and did not receive macrolides were similar, including demographic data and sequential organ failure assessment score. However, patients who received macrolides were more likely to be admitted with community-acquired MERS (P = 0.02). Macrolide therapy was not independently associated with a significant difference in 90-day mortality (adjusted odds ratio [OR]: 0.84; 95% confidence interval [CI] :0.47–1.51; P = 0.56) or MERS-CoV RNA clearance (adjusted HR: 0.88; 95% CI:0.47–1.64; P = 0.68). Conclusions These findings indicate that macrolide therapy is not associated with a reduction in 90-day mortality or improvement in MERS-CoV RNA clearance.
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Hansen MP, Scott AM, McCullough A, Thorning S, Aronson JK, Beller EM, Glasziou PP, Hoffmann TC, Clark J, Del Mar CB. Adverse events in people taking macrolide antibiotics versus placebo for any indication. Cochrane Database Syst Rev 2019; 1:CD011825. [PMID: 30656650 PMCID: PMC6353052 DOI: 10.1002/14651858.cd011825.pub2] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Macrolide antibiotics (macrolides) are among the most commonly prescribed antibiotics worldwide and are used for a wide range of infections. However, macrolides also expose people to the risk of adverse events. The current understanding of adverse events is mostly derived from observational studies, which are subject to bias because it is hard to distinguish events caused by antibiotics from events caused by the diseases being treated. Because adverse events are treatment-specific, rather than disease-specific, it is possible to increase the number of adverse events available for analysis by combining randomised controlled trials (RCTs) of the same treatment across different diseases. OBJECTIVES To quantify the incidences of reported adverse events in people taking macrolide antibiotics compared to placebo for any indication. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), which includes the Cochrane Acute Respiratory Infections Group Specialised Register (2018, Issue 4); MEDLINE (Ovid, from 1946 to 8 May 2018); Embase (from 2010 to 8 May 2018); CINAHL (from 1981 to 8 May 2018); LILACS (from 1982 to 8 May 2018); and Web of Science (from 1955 to 8 May 2018). We searched clinical trial registries for current and completed trials (9 May 2018) and checked the reference lists of included studies and of previous Cochrane Reviews on macrolides. SELECTION CRITERIA We included RCTs that compared a macrolide antibiotic to placebo for any indication. We included trials using any of the four most commonly used macrolide antibiotics: azithromycin, clarithromycin, erythromycin, or roxithromycin. Macrolides could be administered by any route. Concomitant medications were permitted provided they were equally available to both treatment and comparison groups. DATA COLLECTION AND ANALYSIS Two review authors independently extracted and collected data. We assessed the risk of bias of all included studies and the quality of evidence for each outcome of interest. We analysed specific adverse events, deaths, and subsequent carriage of macrolide-resistant bacteria separately. The study participant was the unit of analysis for each adverse event. Any specific adverse events that occurred in 5% or more of any group were reported. We undertook a meta-analysis when three or more included studies reported a specific adverse event. MAIN RESULTS We included 183 studies with a total of 252,886 participants (range 40 to 190,238). The indications for macrolide antibiotics varied greatly, with most studies using macrolides for the treatment or prevention of either acute respiratory tract infections, cardiovascular diseases, chronic respiratory diseases, gastrointestinal conditions, or urogynaecological problems. Most trials were conducted in secondary care settings. Azithromycin and erythromycin were more commonly studied than clarithromycin and roxithromycin.Most studies (89%) reported some adverse events or at least stated that no adverse events were observed.Gastrointestinal adverse events were the most commonly reported type of adverse event. Compared to placebo, macrolides caused more diarrhoea (odds ratio (OR) 1.70, 95% confidence interval (CI) 1.34 to 2.16; low-quality evidence); more abdominal pain (OR 1.66, 95% CI 1.22 to 2.26; low-quality evidence); and more nausea (OR 1.61, 95% CI 1.37 to 1.90; moderate-quality evidence). Vomiting (OR 1.27, 95% CI 1.04 to 1.56; moderate-quality evidence) and gastrointestinal disorders not otherwise specified (NOS) (OR 2.16, 95% CI 1.56 to 3.00; moderate-quality evidence) were also reported more often in participants taking macrolides compared to placebo.The number of additional people (absolute difference in risk) who experienced adverse events from macrolides was: gastrointestinal disorders NOS 85/1000; diarrhoea 72/1000; abdominal pain 62/1000; nausea 47/1000; and vomiting 23/1000.The number needed to treat for an additional harmful outcome (NNTH) ranged from 12 (95% CI 8 to 23) for gastrointestinal disorders NOS to 17 (9 to 47) for abdominal pain; 19 (12 to 33) for diarrhoea; 19 (13 to 30) for nausea; and 45 (22 to 295) for vomiting.There was no clear consistent difference in gastrointestinal adverse events between different types of macrolides or route of administration.Taste disturbances were reported more often by participants taking macrolide antibiotics, although there were wide confidence intervals and moderate heterogeneity (OR 4.95, 95% CI 1.64 to 14.93; I² = 46%; low-quality evidence).Compared with participants taking placebo, those taking macrolides experienced hearing loss more often, however only four studies reported this outcome (OR 1.30, 95% CI 1.00 to 1.70; I² = 0%; low-quality evidence).We did not find any evidence that macrolides caused more cardiac disorders (OR 0.87, 95% CI 0.54 to 1.40; very low-quality evidence); hepatobiliary disorders (OR 1.04, 95% CI 0.27 to 4.09; very low-quality evidence); or changes in liver enzymes (OR 1.56, 95% CI 0.73 to 3.37; very low-quality evidence) compared to placebo.We did not find any evidence that appetite loss, dizziness, headache, respiratory symptoms, blood infections, skin and soft tissue infections, itching, or rashes were reported more often by participants treated with macrolides compared to placebo.Macrolides caused less cough (OR 0.57, 95% CI 0.40 to 0.80; moderate-quality evidence) and fewer respiratory tract infections (OR 0.70, 95% CI 0.62 to 0.80; moderate-quality evidence) compared to placebo, probably because these are not adverse events, but rather characteristics of the indications for the antibiotics. Less fever (OR 0.73, 95% 0.54 to 1.00; moderate-quality evidence) was also reported by participants taking macrolides compared to placebo, although these findings were non-significant.There was no increase in mortality in participants taking macrolides compared with placebo (OR 0.96, 95% 0.87 to 1.06; I² = 11%; low-quality evidence).Only 24 studies (13%) provided useful data on macrolide-resistant bacteria. Macrolide-resistant bacteria were more commonly identified among participants immediately after exposure to the antibiotic. However, differences in resistance thereafter were inconsistent.Pharmaceutical companies supplied the trial medication or funding, or both, for 91 trials. AUTHORS' CONCLUSIONS The macrolides as a group clearly increased rates of gastrointestinal adverse events. Most trials made at least some statement about adverse events, such as "none were observed". However, few trials clearly listed adverse events as outcomes, reported on the methods used for eliciting adverse events, or even detailed the numbers of people who experienced adverse events in both the intervention and placebo group. This was especially true for the adverse event of bacterial resistance.
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Affiliation(s)
| | - Anna M Scott
- Bond UniversityCentre for Research in Evidence‐Based Practice (CREBP)14 University DriveGold CoastQueenslandAustralia4229
| | - Amanda McCullough
- Bond UniversityCentre for Research in Evidence‐Based Practice (CREBP)14 University DriveGold CoastQueenslandAustralia4229
| | - Sarah Thorning
- Gold Coast Hospital and Health ServiceGCUH LibraryLevel 1, Block E, GCUHSouthportQueenslandAustralia4215
| | - Jeffrey K Aronson
- Oxford UniversityNuffield Department of Primary Care Health SciencesOxfordOxonUKOX26GG
| | - Elaine M Beller
- Bond UniversityCentre for Research in Evidence‐Based Practice (CREBP)14 University DriveGold CoastQueenslandAustralia4229
| | - Paul P Glasziou
- Bond UniversityCentre for Research in Evidence‐Based Practice (CREBP)14 University DriveGold CoastQueenslandAustralia4229
| | - Tammy C Hoffmann
- Bond UniversityCentre for Research in Evidence‐Based Practice (CREBP)14 University DriveGold CoastQueenslandAustralia4229
| | - Justin Clark
- Bond UniversityCentre for Research in Evidence‐Based Practice (CREBP)14 University DriveGold CoastQueenslandAustralia4229
| | - Chris B Del Mar
- Bond UniversityCentre for Research in Evidence‐Based Practice (CREBP)14 University DriveGold CoastQueenslandAustralia4229
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Effects of Macrolide Treatment during the Hospitalization of Children with Childhood Wheezing Disease: A Systematic Review and Meta-Analysis. J Clin Med 2018; 7:jcm7110432. [PMID: 30423980 PMCID: PMC6262331 DOI: 10.3390/jcm7110432] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Revised: 10/28/2018] [Accepted: 11/07/2018] [Indexed: 11/29/2022] Open
Abstract
Children are susceptible to a variety of respiratory infections. Wheezing is a common sign presented by children with respiratory infections. Asthma, bronchiolitis, and bronchitis are common causes of childhood wheezing disease (CWD) and are regarded as overlapping disease spectra. Macrolides are common antimicrobial agents with anti-inflammatory effects. We conducted a comprehensive literature search and a systematic review of studies that investigated the influences of macrolide treatment on CWD. The primary outcomes were the impact of macrolides on hospitalization courses of patients with CWD. Data pertaining to the study population, macrolide treatment, hospital courses, and recurrences were analyzed. Twenty-three studies with a combined study population of 2210 patients were included in the systematic review. Any kind of benefit from macrolide treatment was observed in approximately two-thirds of the studies (15/23). Eight studies were included in the meta-analysis to investigate the influence of macrolides on the length of stay (LOS), duration of oxygen demand (DOD), symptoms and signs of respiratory distress, and re-admission rates. Although the benefits of macrolide treatment were reported in several of the studies, no significant differences in LOS, DOD, symptoms and signs of respiratory distress, or re-admission rates were observed in patients undergoing macrolide treatment. In conclusion, any kind of benefit of macrolide treatment was observed in approximately two-thirds of the studies; however, no obvious benefits of macrolide treatment were observed in the hospitalization courses of children with CWD. The routine use of macrolides to improve the hospitalization course of children with CWD is not suggested.
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Lei WT, Lin HH, Tsai MC, Hung HH, Cheng YJ, Liu SJ, Lin CY, Yeh TL. The effects of macrolides in children with reactive airway disease: a systematic review and meta-analysis of randomized controlled trials. DRUG DESIGN DEVELOPMENT AND THERAPY 2018; 12:3825-3845. [PMID: 30510399 PMCID: PMC6231435 DOI: 10.2147/dddt.s183527] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Purpose Childhood reactive airway diseases (RADs) are concerning problems in children’s airways and may be preceded by bronchiolitis and may progress to childhood asthma. The severity of the disease is indicated by deterioration in pulmonary functions, increased usage of rescue medications, and recurrent wheezing episodes. Macrolides have both antimicrobial and anti-inflammatory functions and have been used as adjunctive therapy in childhood RADs. Patients and methods We conducted a meta-analysis to evaluate the effect of macrolides in children with RAD. Literature searches were systematically conducted using an electronic database from inception to August 2018. The Cochrane review risk of bias assessment tool was used to assess the quality of each randomized controlled trial. Results Sixteen randomized controlled trials comprising 1,415 participants were investigated in this meta-analysis. Children treated with macrolide therapy showed significantly better pulmonary functions in both forced expiratory volume in one second (% predicted) (difference in means=−9.77, 95% CI=−14.18 to −5.35, P<0.001; I2=0%) and forced expiratory flow 25–75 (% predicted) (difference in means=−14.14, 95% CI=−26.11 to −2.18, P=0.02; I2=29.56%). In addition, the short-acting β-agonist usage days and recurrent wheezing risk were significantly lowered in children with macrolide treatment (standardized difference in means=−0.34, 95% CI=−0.59 to −0.09, P=0.007, I2=27.05% and standardized difference in means=−0.53, 95% CI=−0.81 to −0.26, P<0.001, I2=0%, respectively). Furthermore, the growth of Moraxella catarrhalis from nasal swabs was less in children treated with macrolides (odds ratio=0.19, 95% CI=0.11–0.35, P<0.001). Children who took macrolides had a lower risk of adverse events (risk ratio=0.83, 95% CI=0.70–0.98, P=0.024, I2=0%). Conclusion This current meta-analysis suggested that adjunctive therapy with macrolides is safe and effective for achieving better outcomes in childhood RAD.
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Affiliation(s)
- Wei-Te Lei
- Department of Pediatrics, Hsinchu MacKay Memorial Hospital, Hsinchu, Taiwan
| | - Hsin Hui Lin
- Department of Family Medicine, Taipei Mackay Memorial Hospital, Taipei, Taiwan
| | - Mu-Chieh Tsai
- Department of Pediatrics, Hsinchu MacKay Memorial Hospital, Hsinchu, Taiwan
| | - Hua-His Hung
- Department of Pediatrics, Hsinchu MacKay Memorial Hospital, Hsinchu, Taiwan
| | - Yu-Jyun Cheng
- Department of Pediatrics, Hsinchu MacKay Memorial Hospital, Hsinchu, Taiwan
| | - Shu-Jung Liu
- Department of Medical Library, MacKay Memorial Hospital, Tamsui Branch, New Taipei City, Taiwan
| | - Chien Yu Lin
- Department of Pediatrics, Hsinchu MacKay Memorial Hospital, Hsinchu, Taiwan
| | - Tzu-Lin Yeh
- Department of Family Medicine, Hsinchu MacKay Memorial Hospital, Hsinchu, Taiwan,
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18
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Midulla F, Petrarca L, Frassanito A, Di Mattia G, Zicari AM, Nenna R. Bronchiolitis clinics and medical treatment. Minerva Pediatr 2018; 70:600-611. [PMID: 30334624 DOI: 10.23736/s0026-4946.18.05334-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Bronchiolitis is the most common acute lower respiratory tract infection in infants and the first cause of hospitalization in this age group. Despite it has been studied for over 70 years, its management remains controversial and nowadays the treatment is only supportive. Pediatricians should be well acquainted with the clinical course of the disease. In particular, they should know that the severity of respiratory symptoms peaks between days 3-7 of the disease and dehydration is a key sign to consider for the management. In this review, we will discuss the most controversial points in the management of bronchiolitis according to six evidence-based guidelines, six clinical practice guidelines and five consensus-based reviews.
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Affiliation(s)
- Fabio Midulla
- Department of Pediatrics, Sapienza University, Rome, Italy -
| | - Laura Petrarca
- Department of Pediatrics, Sapienza University, Rome, Italy
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Alharbi AS, Alqwaiee M, Al-Hindi MY, Mosalli R, Al-Shamrani A, Alharbi S, Yousef A, Al Aidaroos A, Alahmadi T, Alshammary A, Miqdad A, Said Y, Alnemri A. Bronchiolitis in children: The Saudi initiative of bronchiolitis diagnosis, management, and prevention (SIBRO). Ann Thorac Med 2018; 13:127-143. [PMID: 30123331 PMCID: PMC6073791 DOI: 10.4103/atm.atm_60_18] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2018] [Accepted: 05/09/2018] [Indexed: 12/19/2022] Open
Abstract
Bronchiolitis is the leading cause of admissions in children less than two years of age. It has been recognized as highly debated for many decades. Despite the abundance of literature and the well-recognized importance of palivizumab in the high risk groups, and despite the existence of numerous, high-quality, recent guidelines on bronchiolitis, the number of admissions continues to increase. Only supportive therapy and few therapeutic interventions are evidence based and proved to be effective. Since Respiratory Syncytial Virus (RSV) is the major cause of bronchiolitis, we will focus on this virus mostly in high risk groups like the premature babies and children with chronic lung disease and cardiac abnormalities. Further, the prevention of RSV with palivizumab in the high risk groups is effective and well known since 1998; we will discuss the updated criteria for allocating infants to this treatment, as this medication is expensive and should be utilized in the best condition. Usually, diagnosis of bronchiolitis is not challenging, however there has been historically no universally accepted and validated scoring system to assess the severity of the condition. Severe RSV, especially in high risk children, is unique because it can cause serious respiratory sequelae. Currently there is no effective curative treatment for bronchiolitis. The utility of different therapeutic interventions is worth a discussion.
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Affiliation(s)
- Adel S. Alharbi
- Department of Pediatrics, Prince Sultan Military City, Ministry of Defense, Riyadh, Saudi Arabia
| | - Mansour Alqwaiee
- Department of Pediatrics, Prince Sultan Military City, Ministry of Defense, Riyadh, Saudi Arabia
| | - Mohammed Y Al-Hindi
- King Abdullah International Medical Research Center/King Saud bin Abdulaziz University for Health Sciences, Department of Pediatric, Ministry of National Guard, Jeddah, Saudi Arabia
| | - Rafat Mosalli
- Department of Pediatrics, Umm Al Qura university, Makkah, Saudi Arabia
| | - Abdullah Al-Shamrani
- Department of Pediatrics, Prince Sultan Military City, Ministry of Defense, Riyadh, Saudi Arabia
| | - Saleh Alharbi
- Department of Pediatrics, Umm Al Qura university, Makkah, Saudi Arabia
| | - Abdullah Yousef
- Department of Pediatrics, College of Medicine, Imam Abdulrahman bin Faisal University, Dammam, Saudi Arabia
| | - Amal Al Aidaroos
- Department of Pediatrics, Prince Sultan Military City, Ministry of Defense, Riyadh, Saudi Arabia
| | - Turki Alahmadi
- King Abdulaziz University, College of Medicine, Department of Pediatrics, Jeddah, Saudi Arabia
| | | | - Abeer Miqdad
- Department of Pediatrics, Security forces hospital, Riyadh, Saudi Arabia
| | - Yazan Said
- King Fahad Specialist Hospital, Ministry of Health, Dammam, Saudi Arabia
| | - Abdulrahman Alnemri
- College of Medicine, Peadiatric Department, King Saud University, Riyadh, Saudi Arabia
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Mosquera RA, De Jesus-Rojas W, Stark JM, Yadav A, Jon CK, Atkins CL, Samuels CL, Gonzales TR, McBeth KE, Hashmi SS, Garolalo R, Colasurdo GN. Role of prophylactic azithromycin to reduce airway inflammation and mortality in a RSV mouse infection model. Pediatr Pulmonol 2018; 53:567-574. [PMID: 29405608 DOI: 10.1002/ppul.23956] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Accepted: 12/31/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND Respiratory syncytial virus (RSV) infection is an important cause of morbidity and mortality in vulnerable populations. Macrolides have received considerable attention for their anti-inflammatory actions beyond their antibacterial effect. We hypothesize that prophylactic azithromycin will be effective in reducing the severity of RSV infection in a mouse model. METHODS Four groups of BALB/c mice were studied for 8 days: Control (C), RSV-infected (R), early prophylaxis with daily azithromycin from days 1 to 8, (E), and late prophylaxis with daily azithromycin from days 4 to 8 (L). Mice were infected with RSV on day 4, except for the control group. All groups were followed for a total of 8 days when bronchoalveolar lavage cell count and cytokines levels were measured. Mouse weight, histopathology, and mortality data were obtained. RESULTS Prophylactic azithromycin significantly attenuated post-viral weight loss between group R and both groups E and L (P = 0.0236, 0.0179, respectively). IL-6, IL-5, and Interferon-Gamma were significantly lower in group L (P = 0.0294, 0.0131, and 0.0056, respectively) compared with group R. The total cell count was significantly lower for group L as compared with group R (P < 0.05). Mortality was only observed in group R (8%). Lung histology in the prophylactic groups showed diminished inflammatory infiltrates and cellularity when compared with group R. CONCLUSION Prophylactic azithromycin effectively reduced weight loss, airway inflammation, cytokine levels and mortality in RSV-infected mice. These results support the rationale for future clinical trials to evaluate the effects of prophylactic azithromycin for RSV infection.
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Affiliation(s)
- Ricardo A Mosquera
- Department of Pediatrics, University of Texas Health Science Center, McGovern Medical School, Houston, Texas
| | - Wilfredo De Jesus-Rojas
- Department of Pediatrics, University of Texas Health Science Center, McGovern Medical School, Houston, Texas
| | - James M Stark
- Department of Pediatrics, University of Texas Health Science Center, McGovern Medical School, Houston, Texas
| | - Aravind Yadav
- Department of Pediatrics, University of Texas Health Science Center, McGovern Medical School, Houston, Texas
| | - Cindy K Jon
- Department of Pediatrics, University of Texas Health Science Center, McGovern Medical School, Houston, Texas
| | - Constance L Atkins
- Department of Pediatrics, University of Texas Health Science Center, McGovern Medical School, Houston, Texas
| | - Cheryl L Samuels
- Department of Pediatrics, University of Texas Health Science Center, McGovern Medical School, Houston, Texas
| | - Traci R Gonzales
- Department of Pediatrics, University of Texas Health Science Center, McGovern Medical School, Houston, Texas
| | - Katrina E McBeth
- Department of Pediatrics, University of Texas Health Science Center, McGovern Medical School, Houston, Texas
| | - Syed S Hashmi
- Department of Pediatrics, University of Texas Health Science Center, McGovern Medical School, Houston, Texas
| | - Roberto Garolalo
- Department of Microbiology and Immunology, The University of Texas Medical Branch at Galveston, Galveston, Texas
| | - Giuseppe N Colasurdo
- Department of Pediatrics, University of Texas Health Science Center, McGovern Medical School, Houston, Texas
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Kwong CG, Bacharier LB. Microbes and the Role of Antibiotic Treatment for Wheezy Lower Respiratory Tract Illnesses in Preschool Children. Curr Allergy Asthma Rep 2017; 17:34. [PMID: 28456910 DOI: 10.1007/s11882-017-0701-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE OF REVIEW Antibiotics are commonly used to treat wheezy lower respiratory tract illnesses in preschoolers, although these infections have been traditionally thought to be predominantly of viral origin. Our purpose is to review recent research pertaining to the role of antibiotics in lower respiratory tract illnesses and on subsequent asthma development, as well as the possible mechanisms of their effects. RECENT FINDINGS Increasing evidence suggests that asthma pathogenesis is associated with events during infancy and early childhood, particularly respiratory tract infections. While viruses are frequently detected in children with lower respiratory tract infections, the presence of potentially pathogenic bacteria is also often detected and may play a role in asthma pathogenesis. Recent evidence suggests that use of macrolides, particularly azithromycin, may decrease the risk of and duration of lower respiratory tract illnesses and prevent future episodes in specific high-risk populations. Infants and preschoolers who have wheezy lower respiratory tract illnesses have a higher risk of asthma development. Alterations in the microbiome are thought to be influential. While several recent studies identify azithromycin as a therapeutic option in these illnesses, additional research is needed.
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Affiliation(s)
- Christina G Kwong
- Division of Allergy, Immunology and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine in St. Louis, St. Louis Children's Hospital, One Children's Place, St. Louis, MO, 63110, USA
| | - Leonard B Bacharier
- Division of Allergy, Immunology and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine in St. Louis, St. Louis Children's Hospital, One Children's Place, St. Louis, MO, 63110, USA.
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McCallum GB, Plumb EJ, Morris PS, Chang AB. Antibiotics for persistent cough or wheeze following acute bronchiolitis in children. Cochrane Database Syst Rev 2017; 8:CD009834. [PMID: 28828759 PMCID: PMC6483479 DOI: 10.1002/14651858.cd009834.pub3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Bronchiolitis is a common acute respiratory condition with high prevalence worldwide. This clinically diagnosed syndrome is manifested by tachypnoea (rapid breathing), with crackles or wheeze in young children. In the acute phase of bronchiolitis (≤ 14 days), antibiotics are not routinely prescribed unless the illness is severe or a secondary bacterial infection is suspected. Although bronchiolitis is usually self-limiting, some young children continue to have protracted symptoms (e.g. cough and wheezing) beyond the acute phase and often re-present to secondary care. OBJECTIVES To compare the effectiveness of antibiotics versus controls (placebo or no treatment) for reducing or treating persistent respiratory symptoms following acute bronchiolitis within six months of acute illness. SEARCH METHODS We searched the following databases: the Cochrane Airways Group Register of Trials, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid), Embase (Ovid), the World Health Organization (WHO) trial portal, the Australian and New Zealand Clinical Trials Registry, and ClinicalTrials.gov, up to 26 August 2016. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing antibiotics versus controls (placebo or no treatment) given in the post-acute phase of bronchiolitis (> 14 days) for children younger than two years with a diagnosis of bronchiolitis. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies against predefined criteria, and selected, extracted, and assessed data for inclusion. We contacted trial authors for further information. MAIN RESULTS In this review update, we added one study with 219 children. A total of two RCTs with 249 children (n = 240 completed) were eligible for inclusion in this review. Both studies contributed to our primary and secondary outcomes, but we assessed the quality of evidence for our three primary outcomes as low, owing to the small numbers of studies and participants; and high attrition in one of the studies. Data show no significant differences between treatment groups for our primary outcomes: proportion of children (n = 249) who had persistent symptoms at follow-up (odds ratio (OR) 0.69, 95% confidence interval (CI) 0.37 to 1.28; fixed-effect model); and number of children (n = 240) rehospitalised with respiratory illness within six months (OR 0.54, 95% CI 0.05 to 6.21; random-effects model). We were unable to analyse exacerbation rate because studies used different methods to report this information. Data showed no significant differences between treatment groups for our secondary outcome: proportion of children (n = 240) with wheeze at six months (OR 0.47, 95% CI 0.06 to 3.95; random-effects model). One study reported bacterial resistance, but only at 48 hours (thus with limited applicability for this review). Another study reported adverse events from which all children recovered and remained in the study. AUTHORS' CONCLUSIONS Current evidence is insufficient to inform whether antibiotics should be used to treat or prevent persistent respiratory symptoms in the post-acute bronchiolitis phase. Future RCTs are needed to evaluate the efficacy of antibiotics for reducing persistent respiratory symptoms. This is particularly important in populations with high acute and post-acute bronchiolitis morbidity (e.g. indigenous populations in Australia, New Zealand, and the USA).
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Affiliation(s)
- Gabrielle B McCallum
- Menzies School of Health Research, Charles Darwin UniversityChild Health DivisionDarwinNorthern TerritoryAustralia0810
| | - Erin J Plumb
- Menzies School of Health Research, Charles Darwin UniversityChild Health DivisionDarwinNorthern TerritoryAustralia0810
| | - Peter S Morris
- Menzies School of Health Research, Charles Darwin UniversityChild Health DivisionDarwinNorthern TerritoryAustralia0810
| | - Anne B Chang
- Menzies School of Health Research, Charles Darwin UniversityChild Health DivisionDarwinNorthern TerritoryAustralia0810
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Treatment of preschool children presenting to the emergency department with wheeze with azithromycin: A placebo-controlled randomized trial. PLoS One 2017; 12:e0182411. [PMID: 28771627 PMCID: PMC5542589 DOI: 10.1371/journal.pone.0182411] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 07/17/2017] [Indexed: 12/18/2022] Open
Abstract
Background Antibiotics are frequently used to treat wheezing children. Macrolides may be effective in treating bronchiolitis and asthma. Method We completed a prospective, double-blinded, randomized placebo-control trial of azithromycin among pre-school children (12 to 60 months of age) presenting to the emergency department with wheeze. Patients were randomized to receive either five days of azithromycin or placebo. Primary outcome was time to resolution of respiratory symptoms after treatment initiation. Secondary outcomes included the number of days children used a Short-Acting Beta-Agonists during the 21 day follow-up and time to disease exacerbation during the following six months (unscheduled health care visit or treatment with an oral corticosteroid for acute respiratory symptoms). Results Of the 300 wheezing children recruited, 222 and 169 were analyzed for the primary and secondary outcomes, respectively. The treatment groups had similar demographics and clinical parameters at baseline. Median time to resolution of respiratory symptoms was four days for both treatment arms (interquartile range (IQR) 3,6; p = 0.28). Median number of days of Short-Acting Beta-Agonist use among those who received azithromycin was four and a half days (IQR 2, 7) and five days (IQR 2, 9; p = 0.22) among those who received placebo. Participants who received azithromycin had a 0.91 hazard ratio for time to six-month exacerbation compared to placebo (95% CI 0.61, 1.36, p = 0.65). A pre-determined subgroup analysis showed no differences in outcomes for children with their first or repeat episode of wheezing. There was no significant difference in the proportion of participants experiencing an adverse event. Conclusion Azithromycin neither reduced duration of respiratory symptoms nor time to respiratory exacerbation in the following six months after treatment among wheezing preschool children presenting to an emergency department. There was no significant effect among children with either first-time or prior wheezing.
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Abstract
Viral bronchiolitis is a common clinical syndrome affecting infants and young children. Concern about its associated morbidity and cost has led to a large body of research that has been summarised in systematic reviews and integrated into clinical practice guidelines in several countries. The evidence and guideline recommendations consistently support a clinical diagnosis with the limited role for diagnostic testing for children presenting with the typical clinical syndrome of viral upper respiratory infection progressing to the lower respiratory tract. Management is largely supportive, focusing on maintaining oxygenation and hydration of the patient. Evidence suggests no benefit from bronchodilator or corticosteroid use in infants with a first episode of bronchiolitis. Evidence for other treatments such as hypertonic saline is evolving but not clearly defined yet. For infants with severe disease, the insufficient available data suggest a role for high-flow nasal cannula and continuous positive airway pressure use in a monitored setting to prevent respiratory failure.
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Affiliation(s)
- Todd A Florin
- Division of Pediatric Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
| | - Amy C Plint
- Division of Emergency Medicine, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada; Department of Pediatrics, University of Ottawa, Ottawa, ON, Canada
| | - Joseph J Zorc
- Division of Emergency Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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McCallum GB, Chatfield MD, Morris PS, Chang AB. Risk factors for adverse outcomes of Indigenous infants hospitalized with bronchiolitis. Pediatr Pulmonol 2016; 51:613-23. [PMID: 26575201 PMCID: PMC7167668 DOI: 10.1002/ppul.23342] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Revised: 10/18/2015] [Accepted: 11/01/2015] [Indexed: 11/06/2022]
Abstract
BACKGROUND Hospitalized bronchiolitis imposes a significant burden among infants, particularly among Indigenous children. Traditional or known risk factors for severe disease are well described, but there are limited data on risks for prolonged hospitalization and persistent symptoms. Our aims were to determine factors (clinical and microbiological) associated with (i) prolonged length of stay (LOS); (ii) persistent respiratory symptoms at 3 weeks; (iii) bronchiectasis up to ∼24 months post-hospitalisation; and (iv) risk of respiratory readmissions within 6 months. METHODS Indigenous infants hospitalized with bronchiolitis were enrolled at Royal Darwin Hospital between 2008 and 2013. Standardized forms were used to record clinical data. A nasopharyngeal swab was collected at enrolment to identify respiratory viruses and bacteria. RESULTS The median age of 232 infants was 5 months (interquartile range 3-9); 65% male. On multivariate regression, our 12 point severity score (including accessory muscle use) was the only factor associated with prolonged LOS but the effect was modest (+3.0 hr per point, 95%CI: 0.7, 5.1, P = 0.01). Presence of cough at 3 weeks increased the odds of bronchiectasis (OR 3.0, 95%CI: 1.1, 7.0, P = 0.03). Factors associated with respiratory readmissions were: previous respiratory hospitalization (OR 2.3, 95%CI: 1.0, 5.4, P = 0.05) and household smoke (OR 2.6, 95%CI: 1.0, 6.3, P = 0.04). CONCLUSION Increased severity score is associated with prolonged LOS in Indigenous children hospitalized with bronchiolitis. As persistent symptoms at 3 weeks post-hospitalization are associated with future diagnosis of bronchiectasis, optimising clinical care beyond hospitalization is needed to improve long-term respiratory outcomes for infants at risk of respiratory disease. Pediatr Pulmonol. 2016;51:613-623. © 2015 Wiley Periodicals, Inc.
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Affiliation(s)
- Gabrielle B McCallum
- Child Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, 0811, Northern Territory, Australia
| | - Mark D Chatfield
- Child Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, 0811, Northern Territory, Australia
| | - Peter S Morris
- Child Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, 0811, Northern Territory, Australia.,Department of Paediatrics, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Anne B Chang
- Child Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, 0811, Northern Territory, Australia.,Queensland Children's Medical Research Institute, Children's Health Queensland, Queensland University of Technology, Brisbane, Queensland, Australia
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Silva Filho LVRFD, Pinto LA, Stein RT. Use of macrolides in lung diseases: recent literature controversies. J Pediatr (Rio J) 2015; 91:S52-60. [PMID: 26354869 DOI: 10.1016/j.jped.2015.08.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Accepted: 06/12/2015] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE To review the mechanisms of action of macrolides in pediatric respiratory diseases and their clinical indications. SOURCES Review in the PubMed database, comprising the following terms in English: "macrolide and asthma"; "macrolide and cystic fibrosis"; "macrolide bronchiolitis and viral acute"; "macrolide and bronchiolitis obliterans" and "macrolide and non-CF bronchiectasis". SUMMARY OF THE FINDINGS The spectrum of action of macrolides includes production of inflammatory mediators, control of mucus hypersecretion, and modulation of host-defense mechanisms. The potential benefit of macrolide antibiotics has been studied in a variety of lung diseases, such as cystic fibrosis (CF), bronchiectasis, asthma, acute bronchiolitis, and non-CF bronchiectasis. Several studies have evaluated the benefits of macrolides in asthma refractory to therapy, but the results are controversial and indications should be limited to specific phenotypes. In viral bronchiolitis, there is no consistent benefit in acute conditions, although recent data have shown an effect in recurrent wheezing prevention. In patients with CF results are also contradictory, but the consensus states there is a small clinical benefit, especially for patients infected with P. aeruginosa. There was also no positive action of macrolides in patients with post-infectious bronchiolitis obliterans. Children with non-CF bronchiectasis seem to have clear benefits regarding the use of macrolides, which showed clinical advantages in parenchyma protection and lung function. CONCLUSIONS The long-term use of macrolides should be limited to highly selected situations, especially in patients with bronchiectasis. Careful evaluation of the benefits and potential damage are tools for their indication in specific groups.
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Affiliation(s)
- Luiz Vicente Ribeiro Ferreira da Silva Filho
- Pneumology Unit, Instituto da Criança, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil; Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | - Leonardo Araujo Pinto
- Pediatric Pneumology Unit, Hospital São Lucas, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, RS, Brazil; Postgraduate Program in Pediatrics/Child Health, Faculdade de Medicina, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, RS, Brazil
| | - Renato Tetelbom Stein
- Pediatric Pneumology Unit, Hospital São Lucas, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, RS, Brazil; Postgraduate Program in Pediatrics/Child Health, Faculdade de Medicina, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, RS, Brazil.
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Use of macrolides in lung diseases: recent literature controversies. JORNAL DE PEDIATRIA (VERSÃO EM PORTUGUÊS) 2015. [DOI: 10.1016/j.jpedp.2015.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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McCallum GB, Chang AB, Grimwood K. Further clinical trials on macrolides for bronchiolitis in infants are unnecessary. J Allergy Clin Immunol 2015; 136:1134-5. [DOI: 10.1016/j.jaci.2015.07.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Accepted: 07/16/2015] [Indexed: 01/27/2023]
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Beigelman A, Bacharier LB. Reply: To PMID 25458910. J Allergy Clin Immunol 2015; 136:1135-6. [PMID: 26309182 DOI: 10.1016/j.jaci.2015.07.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Accepted: 07/16/2015] [Indexed: 11/25/2022]
Affiliation(s)
- Avraham Beigelman
- Division of Allergy, Immunology and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine and St Louis Children's Hospital, St Louis, Mo.
| | - Leonard B Bacharier
- Division of Allergy, Immunology and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine and St Louis Children's Hospital, St Louis, Mo
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McCallum GB, Morris PS, Grimwood K, Maclennan C, White AV, Chatfield MD, Sloots TP, Mackay IM, Smith-Vaughan H, McKay CC, Versteegh LA, Jacobsen N, Mobberley C, Byrnes CA, Chang AB. Three-weekly doses of azithromycin for indigenous infants hospitalized with bronchiolitis: a multicentre, randomized, placebo-controlled trial. Front Pediatr 2015; 3:32. [PMID: 25954737 PMCID: PMC4404864 DOI: 10.3389/fped.2015.00032] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Accepted: 04/05/2015] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Bronchiolitis is a major health burden in infants globally, particularly among Indigenous populations. It is unknown if 3 weeks of azithromycin improve clinical outcomes beyond the hospitalization period. In an international, double-blind randomized controlled trial, we determined if 3 weeks of azithromycin improved clinical outcomes in Indigenous infants hospitalized with bronchiolitis. METHODS Infants aged ≤24 months were enrolled from three centers and randomized to receive three once-weekly doses of either azithromycin (30 mg/kg) or placebo. Nasopharyngeal swabs were collected at baseline and 48 h later. Primary endpoints were hospital length of stay (LOS) and duration of oxygen supplementation monitored every 12 h until judged ready for discharge. Secondary outcomes were: day-21 symptom/signs, respiratory rehospitalizations within 6 months post-discharge and impact upon nasopharyngeal bacteria and virus shedding at 48 h. RESULTS Two hundred nineteen infants were randomized (n = 106 azithromycin, n = 113 placebo). No significant between-group differences were found for LOS (median 54 h for each group, difference = 0 h, 95% CI: -6, 8; p = 0.8), time receiving oxygen (azithromycin = 40 h, placebo = 35 h, group difference = 5 h, 95% CI: -8, 11; p = 0.7), day-21 symptom/signs, or rehospitalization within 6 months (azithromycin n = 31, placebo n = 25 infants, p = 0.2). Azithromycin reduced nasopharyngeal bacterial carriage (between-group difference 0.4 bacteria/child, 95% CI: 0.2, 0.6; p < 0.001), but had no significant effect upon virus detection rates. CONCLUSION Despite reducing nasopharyngeal bacterial carriage, three large once-weekly doses of azithromycin did not confer any benefit over placebo during the bronchiolitis illness or 6 months post hospitalization. Azithromycin should not be used routinely to treat infants hospitalized with bronchiolitis. CLINICAL TRIAL REGISTRATION The trial was registered with the Australian and New Zealand Clinical Trials Register: Clinical trials number: ACTRN1261000036099.
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Affiliation(s)
- Gabrielle B McCallum
- Child Health Division, Menzies School of Health Research, Charles Darwin University , Darwin, NT , Australia
| | - Peter S Morris
- Child Health Division, Menzies School of Health Research, Charles Darwin University , Darwin, NT , Australia ; Department of Paediatrics, Royal Darwin Hospital , Darwin, NT , Australia
| | - Keith Grimwood
- Menzies Health Institute Queensland, Griffith University and Gold Coast University Hospital , Gold Coast, QLD , Australia
| | - Carolyn Maclennan
- Department of Paediatrics, Royal Darwin Hospital , Darwin, NT , Australia
| | - Andrew V White
- Department of Paediatrics, Townsville Hospital , Townsville, QLD , Australia
| | - Mark D Chatfield
- Child Health Division, Menzies School of Health Research, Charles Darwin University , Darwin, NT , Australia
| | - Theo P Sloots
- Queensland Paediatric Infectious Diseases Laboratory, Queensland Children's Medical Research Institute, Sir Albert Sakzewski Virus Research Centre, Children's Health Queensland Hospital and Health Service, University of Queensland , Herston, QLD , Australia
| | - Ian M Mackay
- Queensland Paediatric Infectious Diseases Laboratory, Queensland Children's Medical Research Institute, Sir Albert Sakzewski Virus Research Centre, Children's Health Queensland Hospital and Health Service, University of Queensland , Herston, QLD , Australia ; Clinical Medical Virology Centre, School of Chemistry and Molecular Biosciences, University of Queensland , St Lucia, QLD , Australia
| | - Heidi Smith-Vaughan
- Child Health Division, Menzies School of Health Research, Charles Darwin University , Darwin, NT , Australia
| | - Clare C McKay
- Child Health Division, Menzies School of Health Research, Charles Darwin University , Darwin, NT , Australia
| | - Lesley A Versteegh
- Child Health Division, Menzies School of Health Research, Charles Darwin University , Darwin, NT , Australia
| | - Nerida Jacobsen
- Department of Paediatrics, Townsville Hospital , Townsville, QLD , Australia
| | - Charmaine Mobberley
- The University of Auckland and Starship Children's Hospital , Auckland , New Zealand
| | - Catherine A Byrnes
- The University of Auckland and Starship Children's Hospital , Auckland , New Zealand
| | - Anne B Chang
- Child Health Division, Menzies School of Health Research, Charles Darwin University , Darwin, NT , Australia ; Queensland Children's Medical Research Institute, Children's Health Queensland, Queensland University of Technology , Brisbane, QLD , Australia
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Sabroe I, Dockrell DH, Culley FJ. Editorial: RSV: a new box of delights for an old enemy. J Leukoc Biol 2014; 96:945-7. [PMID: 25452617 DOI: 10.1189/jlb.4ce0714-341r] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Ian Sabroe
- Academic Units of Respiratory Medicine and
| | - David H Dockrell
- Immunology and Infectious Diseases, Department of Infection and Immunity, Faculty of Medicine, Dentistry and Health, University of Sheffield, United Kingdom; and
| | - Fiona J Culley
- Respiratory Infections Section, National Heart and Lung Institute, Faculty of Medicine, Imperial College London, United Kingdom
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Chang AB, Brown N, Toombs M, Marsh RL, Redding GJ. Lung disease in indigenous children. Paediatr Respir Rev 2014; 15:325-32. [PMID: 24958089 DOI: 10.1016/j.prrv.2014.04.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Accepted: 04/29/2014] [Indexed: 12/20/2022]
Abstract
Children in indigenous populations have substantially higher respiratory morbidity than non-indigenous children. Indigenous children have more frequent respiratory infections that are, more severe and, associated with long-term sequelae. Post-infectious sequelae such as chronic suppurative lung disease and bronchiectasis are especially prevalent among indigenous groups and have lifelong impact on lung function. Also, although estimates of asthma prevalence among indigenous children are similar to non-indigenous groups the morbidity of asthma is higher in indigenous children. To reduce the morbidity of respiratory illness, best-practice medicine is essential in addition to improving socio-economic factors, (eg household crowding), tobacco smoke exposure, and access to health care and illness prevention programs that likely contribute to these issues. Although each indigenous group may have unique health beliefs and interfaces with modern health care, a culturally sensitive and community-based comprehensive care system of preventive and long term care can improve outcomes for all these conditions. This article focuses on common respiratory conditions encountered by indigenous children living in affluent countries where data is available.
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Affiliation(s)
- A B Chang
- Child Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Brisbane, Australia; Queensland Respiratory Centre, Royal Children's Hospital, Brisbane, Queensland Medical Research Institute, Queensland University of Technology, Brisbane, Australia.
| | - N Brown
- National Aboriginal Community Controlled Health Organisation and University of Wollongong, Wollongong, New South Wales, Australia
| | - M Toombs
- Child Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Brisbane, Australia; Indigenous Health, Toowoomba Rural Clinical School, University of Queensland
| | - R L Marsh
- Child Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Brisbane, Australia
| | - G J Redding
- University of Washington School of Medicine, Pediatric Pulmonary Division, Children's Hospital and Regional Medical Center, Seattle, Washington, USA
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Farley R, Spurling GKP, Eriksson L, Del Mar CB. Antibiotics for bronchiolitis in children under two years of age. Cochrane Database Syst Rev 2014; 2014:CD005189. [PMID: 25300167 PMCID: PMC10580123 DOI: 10.1002/14651858.cd005189.pub4] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Bronchiolitis is a serious, potentially life-threatening respiratory illness commonly affecting babies. It is often caused by respiratory syncytial virus (RSV). Antibiotics are not recommended for bronchiolitis unless there is concern about complications such as secondary bacterial pneumonia or respiratory failure. Nevertheless, they are often used. OBJECTIVES To evaluate the effectiveness of antibiotics for bronchiolitis in children under two years of age compared to placebo or other interventions. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL 2014, Issue 6), which includes the Cochrane Acute Respiratory Infection Group's Specialised Register, and the Database of Abstracts of Reviews of Effects, MEDLINE (1966 to June 2014), EMBASE (1990 to June 2014) and Current Contents (2001 to June 2014). SELECTION CRITERIA Randomised controlled trials (RCTs) comparing antibiotics to placebo in children under two years diagnosed with bronchiolitis, using clinical criteria (including respiratory distress preceded by coryzal symptoms with or without fever). Primary clinical outcomes included time to resolution of signs or symptoms (pulmonary markers included respiratory distress, wheeze, crepitations, oxygen saturation and fever). Secondary outcomes included hospital admissions, length of hospital stay, readmissions, complications or adverse events and radiological findings. DATA COLLECTION AND ANALYSIS Two review authors independently analysed the search results. MAIN RESULTS We included seven studies with a total of 824 participants. The results of these seven included studies were often heterogeneous, which generally precluded meta-analysis, except for deaths, length of supplemental oxygen use and length of hospital admission.In this update, we included two new studies (281 participants), both comparing azithromycin with placebo. They found no significant difference for length of hospital stay, duration of oxygen requirement and readmission. These results were similar to an older study (52 participants) that demonstrated no significant difference comparing ampicillin and placebo for length of illness.One small study (21 participants) with higher risk of bias randomised children with proven RSV infection to clarithromycin or placebo and found a trend towards a reduction in hospital readmission with clarithromycin.The three studies providing adequate data for days of supplementary oxygen showed no difference between antibiotics and placebo (pooled mean difference (MD) (days) -0.20; 95% confidence interval (CI) -0.72 to 0.33). The three studies providing adequate data for length of hospital stay, similarly showed no difference between antibiotics (azithromycin) and placebo (pooled MD (days) -0.58; 95% CI -1.18 to 0.02).Two studies randomised children to intravenous ampicillin, oral erythromycin and control and found no difference for most symptom measures.There were no deaths reported in any of the arms of the seven included studies. No other adverse effects were reported. AUTHORS' CONCLUSIONS This review did not find sufficient evidence to support the use of antibiotics for bronchiolitis, although research may be justified to identify a subgroup of patients who may benefit from antibiotics. Further research may be better focused on determining the reasons that clinicians use antibiotics so readily for bronchiolitis, how to reduce their use and how to reduce clinician anxiety about not using antibiotics.
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Affiliation(s)
- Rebecca Farley
- The University of QueenslandDiscipline of General PracticeHerstonBrisbaneQueenslandAustralia4029
| | - Geoffrey KP Spurling
- The University of QueenslandDiscipline of General PracticeHerstonBrisbaneQueenslandAustralia4029
| | - Lars Eriksson
- University of Queensland LibraryHerston Health Sciences LibraryBrisbaneQueenslandAustralia4029
| | - Chris B Del Mar
- Bond UniversityCentre for Research in Evidence‐Based Practice (CREBP), Faculty of Health Sciences and MedicineUniversity DriveRobinaGold CoastQueenslandAustralia4229
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