How do respiratory pediatricians in Australia and New Zealand prescribe azithromycin for chronic wet cough in children. What factors influence their prescribing decisions. How effective is azithromycin for treating chronic cough in different patient populations.

Overview of Azithromycin Use for Chronic Wet Cough

Chronic wet cough in children is a common and challenging condition for pediatricians to manage. Azithromycin, a macrolide antibiotic, has emerged as a potential treatment option, but its use remains controversial. This article examines the prescribing practices of respiratory pediatricians in Australia and New Zealand regarding azithromycin for chronic wet cough in children.

Chronic wet cough is defined as a cough lasting more than 4 weeks that is accompanied by mucus production. It can significantly impact a child’s quality of life and may be indicative of underlying respiratory conditions. While the exact prevalence is unknown, chronic cough affects an estimated 5-10% of children worldwide.

What is azithromycin and how does it work?

Azithromycin is a broad-spectrum antibiotic belonging to the macrolide class. It works by inhibiting bacterial protein synthesis, thereby preventing bacterial growth and reproduction. In addition to its antimicrobial effects, azithromycin has anti-inflammatory and immunomodulatory properties that may contribute to its efficacy in treating chronic respiratory conditions.

Current Evidence on Azithromycin for Chronic Cough

The use of azithromycin for chronic cough has been studied in various patient populations with mixed results. A recent randomized controlled trial examined low-dose azithromycin for chronic cough in adults with idiopathic pulmonary fibrosis (IPF).

What were the findings of the azithromycin trial in IPF patients?

The study, conducted by Guler et al. and published in the Annals of the American Thoracic Society, found that low-dose azithromycin did not significantly improve cough-related quality of life, severity, or frequency compared to placebo in IPF patients. The trial included 25 patients who received either azithromycin 500 mg or placebo thrice weekly for 12 weeks in a crossover design.

Key findings included:

• No significant change in cough-related quality of life scores
• No significant difference in objective cough frequency between azithromycin and placebo groups
• More frequent gastrointestinal side effects in the azithromycin group

The researchers concluded that azithromycin treatment for cough in IPF patients is not justified based on these results. However, it’s important to note that this study focused on adult IPF patients, and the findings may not be directly applicable to children with chronic wet cough.

Prescribing Practices of Respiratory Pediatricians

To better understand how azithromycin is being used in clinical practice for pediatric chronic wet cough, a questionnaire-based survey was conducted among respiratory pediatricians in Australia and New Zealand.

What factors influence azithromycin prescribing decisions?

The survey revealed several key factors that respiratory pediatricians consider when deciding whether to prescribe azithromycin for chronic wet cough in children:

1. Duration of symptoms: Pediatricians are more likely to prescribe azithromycin for coughs lasting longer than 4-8 weeks.
2. Previous treatment response: A history of positive response to antibiotics increases the likelihood of azithromycin prescription.
3. Presence of underlying conditions: Children with known respiratory disorders or immune deficiencies may be more likely to receive azithromycin.
4. Severity of symptoms: More severe or disruptive cough symptoms increase the likelihood of azithromycin use.
5. Age of the patient: Some pediatricians may be more hesitant to prescribe azithromycin in very young children.

Dosing Regimens and Duration of Treatment

The survey highlighted variations in azithromycin dosing regimens and treatment durations among respiratory pediatricians.

How do pediatricians typically dose azithromycin for chronic wet cough?

Common dosing regimens reported in the survey include:

• 10 mg/kg once daily for 3 days per week
• 10 mg/kg once daily for 5 days, followed by once weekly dosing
• 5 mg/kg once daily for 3 days per week

Treatment durations varied widely, ranging from 4 weeks to several months. Many pediatricians reported using a trial period of 4-6 weeks, with continuation based on clinical response.

Perceived Benefits and Concerns

Respiratory pediatricians reported both potential benefits and concerns regarding azithromycin use for chronic wet cough in children.

What are the perceived benefits of azithromycin treatment?

Reported benefits include:

• Reduction in cough frequency and severity
• Improved quality of life for patients and families
• Potential to break the cycle of chronic inflammation
• Possible prevention of bronchiectasis in susceptible individuals

What concerns do pediatricians have about azithromycin use?

Common concerns include:

• Risk of antibiotic resistance development
• Potential for side effects, particularly gastrointestinal disturbances
• Uncertainty about long-term safety with prolonged use
• Possibility of masking underlying conditions requiring alternative treatments

Monitoring and Follow-up Practices

Proper monitoring and follow-up are crucial when using azithromycin for chronic wet cough in children.

How do pediatricians monitor patients on azithromycin treatment?

Survey respondents reported various monitoring practices, including:

• Regular clinical follow-up visits (typically every 2-4 weeks)
• Use of validated cough assessment tools
• Spirometry or lung function testing in older children
• Monitoring of potential side effects through patient/parent reports
• Periodic liver function tests for patients on prolonged treatment

Many pediatricians emphasized the importance of reassessing the need for continued treatment at regular intervals and considering alternative diagnoses if response is inadequate.

Alternative Treatments and Future Directions

While azithromycin has shown promise in some cases of chronic wet cough, it is not effective for all patients, as demonstrated by the IPF study. Respiratory pediatricians reported considering various alternative treatments for patients who do not respond to azithromycin or for whom it is contraindicated.

What alternative treatments are used for chronic wet cough in children?

Alternative approaches mentioned in the survey include:

• Other antibiotics (e.g., amoxicillin-clavulanate, clarithromycin)
• Inhaled corticosteroids
• Mucolytics (e.g., hypertonic saline nebulization)
• Airway clearance techniques and physiotherapy
• Treatment of underlying conditions (e.g., gastroesophageal reflux, allergies)

Many pediatricians emphasized the need for a comprehensive approach to managing chronic wet cough, addressing potential contributing factors and providing supportive care in addition to medication.

What future research is needed in this area?

Respondents identified several areas where further research is needed:

1. Long-term safety and efficacy studies of azithromycin in pediatric populations
2. Identification of biomarkers to predict treatment response
3. Comparison of different antibiotic regimens for chronic wet cough
4. Investigation of non-antibiotic alternatives for symptom management
5. Studies on the impact of azithromycin on the respiratory microbiome

These research priorities highlight the ongoing uncertainties surrounding the optimal management of chronic wet cough in children and the need for continued investigation to improve patient outcomes.

Conclusion and Clinical Implications

The survey of respiratory pediatricians in Australia and New Zealand reveals varied practices in the use of azithromycin for chronic wet cough in children. While many clinicians report positive experiences with azithromycin treatment, concerns about antibiotic resistance and long-term safety persist.

The contrasting results between pediatric clinical experience and the negative findings in the adult IPF study underscore the complexity of chronic cough management and the potential differences between adult and pediatric populations. It is crucial for clinicians to carefully weigh the potential benefits and risks of azithromycin treatment for each individual patient, considering factors such as symptom duration, severity, and underlying conditions.

Moving forward, additional high-quality research is needed to better define the role of azithromycin in managing chronic wet cough in children. In the meantime, a judicious approach to prescribing, coupled with appropriate monitoring and consideration of alternative treatments, appears to be the most prudent course of action for respiratory pediatricians managing this challenging condition.