Azithromycin use during RSV not useful in preventing recurrent wheezing, may cause harm: NEJM

Findings from a recent study evaluating the impact of the antibiotic azithromycin during severe respiratory syncytial virus (RSV) bronchiolitis overwhelmingly support current national bronchiolitis guidelines, which recommend against antibiotics during acute bronchiolitis due to lack of effect on the acute illness.

There is also substantial evidence that severe RSV bronchiolitis in early life increases the likelihood of repeated wheezing episodes in early childhood, often leading to asthma.

"The major message is that antibiotics don't have a role, either in the management of acute RSV bronchiolitis or to reduce subsequent wheezing," said co-corresponding author Leonard Bacharier, MD, professor of Pediatrics at Monroe Carell Jr. Children's Hospital at Vanderbilt. "As a matter of fact, we found that antibiotics in general in our study of severe RSV bronchiolitis increased the risk of subsequent recurrent wheezing over the following two to four years."

"We need to discourage the use of this therapy, as it is potentially harmful," he said.

"Azithromycin to Prevent Recurrent Wheeze Following Severe RSV Bronchiolitis," published in NEJM Evidence, a new digital journal from the New England Journal of Medicine, looks at children hospitalized with RSV bronchiolitis during a single-center, double-blind, placebo-controlled trial.

The most recent study follows an earlier pilot trial of 40 infants hospitalized with RSV bronchiolitis where treatment with azithromycin showed a reduction in the likelihood of recurrent wheeze over the following year.

In the current study, 200 otherwise healthy 1- to 18-month-old children who were hospitalized for RSV bronchiolitis were prospectively randomized to receive either oral azithromycin or a placebo for 14 days. A total of 188 completed the study — 96 in the azithromycin group and 92 in the placebo group. The group was broadly representative of the population of children who experience severe RSV bronchiolitis.

Bacharier said it is not infrequent that antibiotics are used in the treatment of RSV because of co-occurring complications that lead medical teams to prescribe them, thinking there is a bacterial component to the illness, including fever, ear infection and pneumonia.

"This condition can be managed by supportive care — oxygen, fluids, observation, time and love," he stressed. "If a clinician is going to use an antibiotic in the setting of RSV bronchiolitis, there needs to be a very strong rationale for doing so. There is substantial evidence to suggest that children who receive antibiotics early in life are at an increased risk of developing asthma, and this study is consistent with that evidence."