Jan 182017

Adding azithromycin to usual treatment for asthma exacerbations in adults did not improve asthma symptoms or speed their resolution, investigators reported in the AZALEA randomized clinical trial. Patients getting azithromycin also had no improvement in lung function.

Azithromycin is known to have some activity against viruses that infect bronchial cells; viruses are causative or contributory in many asthma exacerbations. An earlier study (TELICAST) showed benefits from telithromycin, a macrolide similar to azithromycin but with more associated toxicity.

Although experts advise against prescribing antibiotics for asthma exacerbations, it's a common practice among physicians. In fact, recruitment for the AZALEA study was almost impossible because thousands of the patients screened had received antibiotics in the previous 4 weeks. The U.K.-based investigators could only randomize 199 of 4,582 patients screened; they had intended to enroll 380.

Adults with known asthma presenting with <48 hours of symptoms of an asthma exacerbation considered severe enough to justify corticosteroid treatment received azithromycin 500 mg or placebo for 3 days in addition to steroids and other usual treatments for asthma exacerbations.

Asthma scores were not improved at 10 days in the azithromycin group, nor was lung function (FEV1) or time to 50% reduction in symptom score.

There is no established benefit or professional recommendation for antibiotics in asthma attacks. This study does not suggest changing that in any way, but it does provide confirmation of antibiotic overuse for asthma exacerbations in U.K. adults. Previous studies have shown similar high rates of antibiotic prescription by pediatricians in Belgium and the U.S.

Of course, it's one thing to issue edicts and guidelines from a cushy committee chair or from behind a governmental logo. It's much harder for an individual physician to deny an antibiotic prescription to the coughing asthmatic in her office, who wants and expects it based on past experience and a fear (however unfounded) of an impending or worsening infection.

Unless stronger disincentives materialize (on physicians, patients, or both), there's no reason to expect a reduction in the tens of millions of antibiotic prescriptions written for asthma exacerbations around the Western world each year.

Read more: Azithromycin for Acute Exacerbations of Asthma : The AZALEA Randomized Clinical Trial. JAMA Intern Med. 2016 Nov 1;176(11):1630-1637.

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Azithromycin was no help in asthma exacerbations (AZALEA)