posted by Joelle Simpson
I was reading my AAP News and came across this article. It is a commentary on a recent article about Azithromycin prescribing written by a member of the AAP Committee on Infectious Diseases and the AAP Committee on Medical Liability and Risk Management. It struck me because I recall one of my attendings during residency who loved using Azithromycin and justified using it whenever there was not an obvious infiltrate on CXR – things that make you go hmmmmm….. (insert furrowed brow here). I pulled out the highlights of the article in bold below. Basically, the general recommendations are that Azithromycin should be used strictly for sexually transmitted infections or pertussis prophylaxis – other indications (ie community-acquired pneumonia and otitis media) are not supported in this commentary from the AAP.
What does Azithromycin study mean for pediatric prescribing?
The authors refer to a recent study that identified a small increase in the risk of cardiovascular death in adults (ages 30-74 years) treated with a five-day course of azithromycin (Ray WA, et al. N Engl J Med. 2012;366:1881-1890). This macrolide antibiotic previously had been identified as having potential for provoking ventricular arrhythmia by producing QT interval prolongation. Torsades de pointes and polymorphic ventricular tachycardia also had been described without QT prolongation. The authors noted that the risk of death was higher among patients with a higher baseline risk of cardiovascular disease, and the risk persisted only during the five days of treatment.
What is the message for pediatricians? First, in the interest of judicious antibiotic use, practitioners should bear in mind that neither azithromycin nor any other antibiotic should be given for the common cold or bronchitis.
While Food and Drug Administration indications for azithromycin include acute bacterial sinusitis, community-acquired pneumonia (CAP), pharyngitis/tonsillitis, and uncomplicated skin and skin structure infections, azithromycin is not recommended to treat otitis media or sinusitis due to the lack of coverage for the most common pathogens, Streptococcus pneumoniae or Haemophilus influenzae. Similarly, for skin and soft tissue infection caused by Staphylococcus aureus, azithromycin is not an appropriate choice.
Even for treatment of CAP due to mycoplasma, the role of antibiotics has been questioned. In at least two studies, patients who received a non-mycoplasma regimen faired equally well to those receiving a macrolide or fluoroquinolone. Macrolide-resistant group A streptococcus (GAS) has been increasingly noted, and alternatives to azithromycin are readily available for treatment of GAS pharyngitis.
Azithromycin is considered the drug of choice for treatment of sexually transmitted infections (STIs). Azithromycin also remains the drug of choice for treatment and chemoprophylaxis for pertussis.
Liability concerns
Some pediatricians are questioning whether they should avoid prescribing azithromycin to their pediatric patients due to liability concerns. Pediatricians should recall that malpractice liability arises from medical care that fails to meet prevailing practice standards. It seems unlikely that this single study, which included no pediatric patients, will be considered to have significantly changed the standard of care for pediatric practice.
Another risk management issue is whether prescribing azithromycin to parents and other household contacts of pediatric patients poses a significant liability risk.
On a related issue, the Academy has published a policy supporting immunization of parents or other adult family contacts in the pediatric office setting as a potential benefit to themselves and pediatric patients (for pertussis). With immunizations, physicians are protected by the National Childhood Vaccine Injury Act (NCVIA). Treating adult parents with azithromycin likely creates a physician-patient relationship between the pediatrician and the adult patient and imposes legal requirements to provide care consistent with prevailing medical standards. Such medical care would
not carry the liability protections of the NCVIA. Therefore, when pediatricians prescribe azithromycin for chemoprophylaxis for their patients’ household contacts, they should consider the indications, contraindications, risks and benefits and should document these considerations in a distinct medical record for each adult patient.
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