Macrolide use in kids with wet cough outside guidelines


By Mardi Chapman

13 Oct 2020

Many clinicians are prescribing azithromycin in children with chronic wet cough outside current guidelines, an Australian and New Zealand survey has found.

Respondents to the web-based survey were 29 of 73 members of the TSANZ Paediatric SIG. All said they had prescribed azithromycin for chronic wet cough in the last 12 months.

“Although not a recommended first-line antibiotic for PBB [protracted bacterial bronchitis], 12 (41%) would consider using it in a short course (2–4 weeks) to treat a chronic wet cough,” the study said.

“Other indications for contemplating short courses of azithromycin were recurrent PBB (n = 9, 31%) and non-severe exacerbations in children with chronic suppurative lung disease (CSLD) (n = 10, 34%), bronchiectasis (n = 9, 31%) or chronic aspiration (n = 5, 17%).”

The study found that, in contrast, most respondents considered long-term azithromycin (>4-weeks) for CSLD (n = 23, 79%) and bronchiectasis (n = 24, 83%). And nine (31%) also used longer courses of azithromycin for PBB.

“Overall, just nine (31%) respondents would follow TSANZ guidelines by prescribing long-term azithromycin to children with either CSLD or bronchiectasis and who had experienced three non-hospitalized exacerbations in the previous 12-months, while only 12 (41%) would initiate azithromycin following two hospitalisations for these children during the same 12-month period.”

The study investigators, including Professor Anne Chang from the Queensland Children’s Hospital, found a range of investigations including sputum bacteriology (n = 27, 93%) and spirometry (n = 23, 79%) were performed where feasible prior to commencing azithromycin.

“However, only 17 (58%) requested NTM cultures when collecting sputum. Although not specifically recommended for children in the TSANZ guidelines, 10 (35%) performed a baseline electrocardiogram and two (7%) checked hearing before commencing long-term azithromycin.”

“Contraindications for commencing azithromycin identified by the responding respiratory pediatricians included hypersensitivity to macrolides (n = 27, 93%), NTM infection (n = 21, 72%) and abnormal liver function tests (n = 15, 52%).”

The most common dose prescribed was 10 mg/kg (up to 250 mg) three-times a week – used by 90% of respiratory pediatricians.

The most common benefit found in children receiving long-term azithromycin was reduced pulmonary exacerbations, which was reported by 28 (97%) respondents.

“In contrast, most (n = 17, 58%) were uncertain how long the beneficial effects persisted after ceasing the antibiotic, while seven (24%) believed beneficial effects lasted for another 3–12 months.”

Macrolide-resistant pathogens were reported by 18 (62%) respiratory pediatricians in children taking azithromycin.

“Macrolide-resistance was reported in H. influenzae by eight (28%) respondents, in S. pneumoniae and S. aureus each by another six (21%) and in M. catarrhalis by four physicians (14%).”

Respondents were more likely to prescribe azithromycin for Indigenous children, while 15 (52%) also reported being more likely to prescribe the antibiotic for those with major underlying comorbidities including congenital heart disease, neuromuscular disorder, cerebral palsy, acquired brain injury, congenital immune deficiency or immunosuppression.

The study emphasised practices that deviated from the current TSANZ guidelines for long-term azithromycin in children with CSLD and bronchiectasis.

“Only one-third of respondents prescribed azithromycin for children experiencing three exacerbations and just 41% of respondents would do so for those with two respiratory hospitalisations in the previous year. Moreover, before commencing azithromycin <60% requested NTM cultures from those capable of producing sputum,” it said.

The investigators said their findings highlighted the importance of closing knowledge gaps around azithromycin prescribing.

“Some of this has been addressed recently for acute exacerbations of CSLD and bronchiectasis, which now needs to be reflected in updated evidence-based national guidelines.”

“In parallel, increasing practitioner awareness and knowledge of appropriate azithromycin prescribing for children with chronic wet cough should continue as this is as important as developing and updating evidence-based guidelines.”

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