The Thoracic Society of Australia and New Zealand
Recommendations from The Thoracic Society of Australia and New Zealand. The Thoracic Society of Australia and New Zealand (TSANZ) is the only health peak body representing a range of professions (medical specialists, scientists, researchers, academics, nurses, physiotherapists, students and others) across various disciplines within the respiratory/sleep medicine field in Australia and New Zealand.
Do not prescribe antibiotics for exacerbation of asthma.
The most recent Global Initiative for Asthma (GINA) report does not recommend a role for antibiotics in management of asthma exacerbation unless there is strong evidence of lung infection, such as fever and purulent sputum or radiographic evidence of pneumonia. This is supported by recent trials involving azithromycin (a commonly prescribed antibiotic for management of asthma), which found that this drug had no statistically significant impacts on severity of symptoms during an exacerbation. One small randomised controlled trial (RCT) in young children with recurrent asthma-like symptoms showed that azithromycin reduced the duration of asthma-like symptoms. No RCT has been conducted in children who have a diagnosis of asthma to determine if the rate of severe asthma exacerbation or the severity of asthma symptoms or duration of an asthma exacerbation is reduced by azithromycin. A potential role for azithromycin in reducing the duration of an episode of asthma-like symptoms in children less than 3 years of age requires further investigation. Antibiotic treatment in addition to its lack of efficacy also increases the risk of bacteria resistance for those on long term treatment regimes.
- Brusselle GG, Vanderstichele C, Jordens P, et al. Azithromycin for prevention of exacerbations in severe asthma (AZISAST): a multicentre randomised double-blind placebo-controlled trial. Thorax. 2013;68(4):322-9.
- 2018 GINA Report, Global Strategy for Asthma Management and Prevention.
- Li H, Liu DH, Chen LL, et al. Meta-analysis of the adverse effects of long-term azithromycin use in patients with chronic lung diseases. Antimicrob Agents Chemother. 2014;58(1):511-7.
- Johnston SL, Szigeti M, Cross M, et al. Azithromycin for Acute Exacerbations of Asthma The AZALEA Randomized Clinical Trial. JAMA Intern Med. 2016;176(11):1630–1637.
- Stokholm J, Chawes BL, Vissing NH, et al. Azithromycin for episodes with asthma-like symptoms in young children aged 1-3 years: a randomised, double-blind, placebo-controlled trial. Lancet Respir Med. 2016;4(1):19-26.
The Royal Australasian College of Physicians worked with a Lead Fellow nominated by TSANZ to review evidence for 12 paediatric thoracic recommendations on low-value care in paediatric thoracic medicine. These recommendations were the subject of email discussions and deliberation by members of the Paediatric Special Interest Group (SIG) of the TSANZ. They were further discussed at a workshop held at a meeting of the Asia Pacific Society of Respirology in 2017, which included TSANZ members. Based on the feedback provided at this workshop and through email discussions with members of the SIG, four were removed and two of the original 12 were considered for inclusion in the final recommendations with overwhelming support. Members of the Paediatric SIG were then invited to choose three out of the remaining six through an email based poll. This served as the basis for final recommendations, which were further refined and developed through successive drafts based on the input of the Lead Fellow, the results of consultation with other specialty groups and the views of the TSANZ Board.
- 1 Do not prescribe combination therapy (inhaled corticosteroids with long-acting beta2 agonist) as initial therapy in mild to moderate asthma before a trial of inhaled corticosteroids alone.
- 2 Do not prescribe antibiotics for exacerbation of asthma.
- 3 Do not use oral beta2 agonists as bronchodilators in asthma, wheeze or bronchiolitis.
- 4 For children with bronchiolitis without other co-morbidities, do not delay discharge from an inpatient admission based on oxygen saturations alone if saturations are ≥90%.
- 5 Do not delay immunisation/s based on presence of mild respiratory symptoms in the absence of fever.