Antibiotics for persistent cough or wheeze following acute bronchiolitis in children
Abstract
Background
Bronchiolitis is a common acute respiratory infectious condition, with a high prevalence worldwide. It is a clinically diagnosed syndrome, manifested by tachypnoea (rapid breathing), with crackles or wheeze in young children. In the acute phase of bronchiolitis (< 14 days), antibiotics have only been recommended when a secondary bacterial infection is suspected. Although bronchiolitis is usually a self‐limiting condition, a number of children have persistent respiratory symptoms such as cough and wheezing in post‐acute bronchiolitis, and they present or re‐present to secondary care.
Objectives
To determine the effectiveness of antibiotics compared to a control (no treatment or placebo) for persistent respiratory symptoms (within six months), following acute bronchiolitis.
Search methods
The following databases were searched, The Cochrane Airways Group Register of Trials, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid), EMBASE (Ovid) and ClinicalTrials.gov. We searched all databases from their inception to the present, and did not impose restriction on language of publication. The search was performed in October 2012.
Selection criteria
All randomised controlled trials (RCTs) comparing antibiotics with controls (placebo or no treatment) given in the post‐acute phase of bronchiolitis (> 14 days) for children younger than two years of age diagnosed with bronchiolitis were included.
Data collection and analysis
Two review authors independently assessed studies against pre‐defined criteria; and selected, extracted and assessed the data for inclusion. Several subgroup analyses were planned and this included when antibiotics commenced (early commencement classified as preventing; later commencement as treatment for post‐bronchiolitis symptoms).
Main results
A single study met the inclusion criteria but had a high attrition rate. Thirty infants with respiratory syncytial virus (RSV)‐confirmed bronchiolitis were randomised to receive either a daily dose of oral clarithromycin 15 mg/kg or placebo for three weeks. Using an intention‐to‐treat (ITT) analysis, there was no significant difference between groups for the proportion of children who had persistent symptoms (odds ratio (OR) 0.20; 95% confidence interval (CI) 0.02 to 2.02) or re‐hospitalisation within six months (OR 0.11; 95% CI 0.01 to 1.29). There were no treatment studies of later commencement of antibiotics.
Authors' conclusions
There is currently insufficient evidence to inform whether antibiotics should be used to treat or prevent persistent respiratory symptoms in the post‐acute bronchiolitis phase. Future RCTs that evaluate the efficacy of antibiotics to reduce persistent respiratory symptoms are required, especially in areas where both acute and post‐bronchiolitis morbidity is high such as in Indigenous communities in the US, New Zealand and Australia.
PICOs
Plain language summary
Antibiotics for persistent cough or wheeze following acute bronchiolitis in children
Bronchiolitis is a common lung infection, affecting children across the world. It is usually caused by a virus called RSV (respiratory syncytial virus) but other viruses can cause this too. Young children with bronchiolitis normally have a cough, fast and difficult breathing, and poor feeding. Antibiotics are not normally prescribed to children with bronchiolitis unless there is concern of a secondary bacterial infection. However, some children continue to have ongoing problems (i.e. wheeze, cough) after the acute viral infection (> 14 days); increasing the risk of burden of disease and cost to the health system. These children often re‐present for further medical care in the community (general practitioners and health providers) or in hospital (emergency departments). Antibiotics may help treat these ongoing symptoms and get rid of the bacteria in the lungs.
This review found only one eligible study looking at antibiotics compared to placebo for children in the post‐acute bronchiolitis phase. This randomised controlled trial was from Turkey and enrolled 30 infants aged seven months or younger. There is currently not enough evidence to inform whether antibiotics should be used to treat or prevent persistent respiratory symptoms in the post‐acute bronchiolitis phase. Randomised controlled trials that evaluate the efficacy of antibiotics to reduce persistent respiratory symptoms are needed, especially in countries where the morbidity of acute bronchiolitis is high such as in Indigenous populations.
