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Meta-Analysis
. 2015 Mar 8;2015(3):CD001954.
doi: 10.1002/14651858.CD001954.pub4.

Azithromycin for acute lower respiratory tract infections

Malinee Laopaiboon  1 , Ratana Panpanich, Kyaw Swa Mya
Affiliations
Meta-Analysis

Azithromycin for acute lower respiratory tract infections

Malinee Laopaiboon et al. Cochrane Database Syst Rev. .

Abstract

Background: Acute lower respiratory tract infections (LRTI) range from acute bronchitis and acute exacerbations of chronic bronchitis to pneumonia. Approximately five million people die from acute respiratory tract infections annually. Among these, pneumonia represents the most frequent cause of mortality, hospitalisation and medical consultation. Azithromycin is a macrolide antibiotic, structurally modified from erythromycin and noted for its activity against some gram-negative organisms associated with respiratory tract infections, particularly Haemophilus influenzae (H. influenzae).

Objectives: To compare the effectiveness of azithromycin to amoxycillin or amoxycillin/clavulanic acid (amoxyclav) in the treatment of LRTI, in terms of clinical failure, incidence of adverse events and microbial eradication.

Search methods: We searched CENTRAL (2014, Issue 10), MEDLINE (January 1966 to October week 4, 2014) and EMBASE (January 1974 to November 2014).

Selection criteria: Randomised controlled trials (RCTs) and quasi-RCTs, comparing azithromycin to amoxycillin or amoxycillin/clavulanic acid in participants with clinical evidence of an acute LRTI, such as acute bronchitis, pneumonia and acute exacerbation of chronic bronchitis.

Data collection and analysis: The review authors independently assessed all potential studies identified from the searches for methodological quality. We extracted and analysed relevant data separately. We resolved discrepancies through discussion. We initially pooled all types of acute LRTI in the meta-analyses. We investigated the heterogeneity of results using the forest plot and Chi(2) test. We also used the index of the I(2) statistic to measure inconsistent results among trials. We conducted subgroup and sensitivity analyses.

Main results: We included 16 trials involving 2648 participants. We were able to analyse 15 of the trials with 2496 participants. The pooled analysis of all the trials showed that there was no significant difference in the incidence of clinical failure on about days 10 to 14 between the two groups (risk ratio (RR), random-effects 1.09; 95% confidence interval (CI) 0.64 to 1.85). A subgroup analysis in trials with acute bronchitis participants showed significantly lower clinical failure in the azithromycin group compared to amoxycillin or amoxyclav (RR random-effects 0.63; 95% CI 0.45 to 0.88). A sensitivity analysis showed a non-significant reduction in clinical failure in azithromycin-treated participants (RR 0.55; 95% CI 0.25 to 1.21) in three adequately concealed studies, compared to RR 1.32; 95% CI 0.70 to 2.49 in 12 studies with inadequate concealment. Twelve trials reported the incidence of microbial eradication and there was no significant difference between the two groups (RR 0.95; 95% CI 0.87 to 1.03). The reduction of adverse events in the azithromycin group was RR 0.76 (95% CI 0.57 to 1.00).

Authors' conclusions: There is unclear evidence that azithromycin is superior to amoxycillin or amoxyclav in treating acute LRTI. In patients with acute bronchitis of a suspected bacterial cause, azithromycin tends to be more effective in terms of lower incidence of treatment failure and adverse events than amoxycillin or amoxyclav. However, most studies were of unclear methodological quality and had small sample sizes; future trials of high methodological quality and adequate sizes are needed.

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Conflict of interest statement

Malinee Laopaiboon: I received an honorarium from the Thailand Research Fund, which is a non‐profit organisation. Ratana Panpanich: none known. Kyaw Swa Mya: none known.

Figures

1
1
'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
2
2
'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.
3
3
Funnel plot of comparison: 1 Azithromycin versus amoxycillin or amoxycillin‐clavulanate, outcome: 1.1 Clinical failure.
1.1
1.1. Analysis
Comparison 1 Azithromycin versus amoxycillin or amoxycillin‐clavulanate, Outcome 1 Clinical failure.
1.2
1.2. Analysis
Comparison 1 Azithromycin versus amoxycillin or amoxycillin‐clavulanate, Outcome 2 Clinical failure by diagnosis.
1.3
1.3. Analysis
Comparison 1 Azithromycin versus amoxycillin or amoxycillin‐clavulanate, Outcome 3 Clinical failure by age group.
1.4
1.4. Analysis
Comparison 1 Azithromycin versus amoxycillin or amoxycillin‐clavulanate, Outcome 4 Clinical failure by dose regimen of azithromycin.
1.5
1.5. Analysis
Comparison 1 Azithromycin versus amoxycillin or amoxycillin‐clavulanate, Outcome 5 Clinical failure by type of antibiotic in control group.
1.6
1.6. Analysis
Comparison 1 Azithromycin versus amoxycillin or amoxycillin‐clavulanate, Outcome 6 Sensitivity analysis excluding one large trial.
1.7
1.7. Analysis
Comparison 1 Azithromycin versus amoxycillin or amoxycillin‐clavulanate, Outcome 7 Sensitivity analysis excluding three trials with missing data > 10%.
1.8
1.8. Analysis
Comparison 1 Azithromycin versus amoxycillin or amoxycillin‐clavulanate, Outcome 8 Sensitivity analysis with the condition of concealment.
1.9
1.9. Analysis
Comparison 1 Azithromycin versus amoxycillin or amoxycillin‐clavulanate, Outcome 9 Microbial eradication.
1.10
1.10. Analysis
Comparison 1 Azithromycin versus amoxycillin or amoxycillin‐clavulanate, Outcome 10 Adverse events.
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Update of

References

References to studies included in this review

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