Azithromycin is an attractive alternative to amoxicillin-clavulanate for the management of non-severe acute exacerbations of bronchiectasis in children but should be reserved as a second-line therapy in accordance with Australian and New Zealand guidelines.
Dr Vikas Goyal, from the Department of Respiratory and Sleep Medicine at the Queensland Children’s Hospital, told the 2019 ERS Congress that the findings from a novel three-arm RCT support the guidelines.
The study compared 14 days of either treatment with placebo in 252 children with CT-proven bronchiectasis across four paediatric centres in Australian and New Zealand.
By day 14, the acute exacerbations had resolved in 65% of children in the amoxicillin–clavulanate group, 61% in the azithromycin group, and 43% in the placebo group.
The number needed to treat for benefit was five for amoxicillin-clavulanate and six for azithromycin.
The median time to resolution was seven days with amoxicillin-clavulanate, eight days with azithromycin and 10 days with placebo.
Due to the design of the study, the p value for statistical significance was lowered to p=0.025, resulting in a significant effect of amoxicillin-clavulanate compared to placebo (p=0.015) but not azithromycin (p=0.042).
Paired deep nasal swabs before and after treatment showed any pathogens decreased in both treatment groups compared to placebo.
Compared with placebo, azithromycin treatment was associated with an increased proportion of azithromycin-resistant bacteria.
Dr Goya said the findings, published recently in The Lancet Respiratory Medicine, suggested azithromycin should be reserved as a rescue antibiotic for children with genuine penicillin allergy.
“And even though we are saying it is not as good as amoxicillin-clavulanate, it definitely is better than placebo and we have actually done a non-inferiority study which was published The Lancet in 2018 which shows it is non-inferior to
amoxicillin-clavulanate.”
The researchers suggested once-daily azithromycin could also be reserved for situations in which less frequent, supervised dosing might overcome difficulties with adherence.