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Clinician Article

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Azithromycin for acute lower respiratory tract infections.

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• Laopaiboon M
• Panpanich R
• Swa Mya K

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Clinical Comments

Emergency Medicine

Important implications to provide clinical alternatives in an era of frequent drug shortages.

Emergency Medicine

The meta-analysis comparing azithromycin vs amoxicillin +/- clavulante for treating lower respiratory infections (acute bronchitis, exacerbation of chronic bronchitis and pneumonia) is well done. However, most of the original articles are small and have significant risk of bias. Although the authors report that the funnel plot shows no publication bias, visual inspection of the plot seems to indicate that small studies that showed a large treatment benefit for azithromycin are missing, a finding with uncertain implications. Overall, effectiveness of azithromycin is similar to that of amoxicillin-containing antibiotics. However, for acute bronchitis (not exacerbation of chronic bronchitis or pneumonia), azithromycin is superior. Azithromycin shows borderline increased adverse events (risk ratio 0.76, CI 0.57, 1.00). The authors conclude that future trials of high methodological quality and adequate sizes are needed to more definitely answer the clinical question posed.

Family Medicine (FM)/General Practice (GP)

The level of the evidence from the studies included in the review is low and one major theme - the potential for antibiotic resistance - is not covered in this review.

General Internal Medicine-Primary Care(US)

The results are not surprising or particularly helpful. Sputum cultures in LRTIs are infrequent and misleading, not to mention the fact that many episodes of bronchitis are viral. It probably makes no difference which antibiotic you choose; unfortunately, everyone gets treated.

Infectious Disease

It's nice to know that good old amoxicillin is just as effective as the macrolide. The subgroup analysis of presumed bacterial bronchitis patients is interesting in showing a trend for azithromycin, presumably due to Chlamydia and Pertussis infections in that group.

Pediatric Emergency Medicine

I was hopeful that this Cochrane review would look into the question of whether the addition of azithromycin to standard anti-pneumococcal therapy would be helpful in community-acquired pneumonia. Unfortunately, most of the studies included were in adults with bronchitis, not a particularly relevant population for the PEM practitioner, and those studies including children randomized children with CAP to either azithromycin alone or standard care (which in many cases included erythromycin - uncertain whether this is really a different treatment than azithromycin). Overall, this is not particularly relevant to today`s CAP treatment, as current guidelines recommend monotherapy with beta lactam antibiotics to cover pneumococcus, which is the most prevalent pathogen in children.

Pediatric Emergency Medicine

Emergency physicians commonly evaluate and treat patients with acute lower respiratory tract infections, and many receive antibiotic therapy. Amoxicillin, amoxyclav, and azithromycin are common drugs prescribed by physicians. This review shows that evidence is insufficient to state conclusively that azithromycin is superior to amoxycillin or amoxyclav in treating acute LRTI.

Pediatric Emergency Medicine

The review findings are interesting, particularly given the swing towards azithromycin use that appears to be happening. There is no separation of paediatric cases, however, which limits its applicability to paediatric LRTIs.

Respirology/Pulmonology

Cochrane review of available literature finds that azithromycin is as effective as amoxicillin and amoxicillin/clavulante for treating lower respiratory tract infections, with perhaps fewer adverse effects. The quality of the data was poor so it`s not clear to me that the review provides any meaningful results nor should it have any impact on clinical practice.

Respirology/Pulmonology

Cochrane meta-analysis finding that azithromycin did not differ from amoxicillin or amoxicillin-clavulanate for LRTI, but did reduce risk for clinical failure in acute bronchitis specifically. The Outcome lumps 3 different diagnoses (acute bronchitis, AECB, and pneumonia) with different patterns of microbial ethology and different natural histories together. Why did they do this in the first place? Not surprising that diagnosis partly explained high heterogeneity, which remained unexplained in the AECB subgroup, precluding any meaningful interpretation in that subgroup. Individual trials are small and mostly non-significant, so meta-analysis adds new information.