Azithromycin Prophylaxis Research Articles

Recurrent Acute Rhinosinusitis Prevention by Azithromycin in Children with Nonallergic Rhinitis

Recurrent acute rhinosinusitis (RARS) is characterized by multiple episodes of acute rhinosinusitis between which symptoms and signs resolve completely. The role of antibiotic prophylaxis to prevent RARS in children with nonallergic rhinitis (NAR) has not been investigated. To evaluate the effect of azithromycin to prevent RARS in children with NAR. A randomized, double-blind, placebo-controlled study was conducted in NAR children (5-15 years) with RARS. Azithromycin (5 mg/kg/d) 3 d/wk for 12 months or placebo was assigned to the study group and the control group, respectively. Patients with allergic rhinitis were excluded. Number of rhinosinusitis episodes in 12 months, visual analog scale score of nasal symptoms, and adjunctive medication score were recorded. Forty patients were enrolled and 20 patients were assigned randomly to the azithromycin and placebo groups. IgG subclass and specific antibody deficiencies were found in 83% and 2.5% of patients, respectively. After 12 months, the number of rhinosinusitis episodes/y in the azithromycin group reduced significantly from 5 to 0.5 (P < .001) in contrast to the placebo group. Number needed to treat using azithromycin prophylaxis to prevent 1 patient from having RARS was 2. The average visual analog scale score and the average adjunctive medication score in the azithromycin (but not in the placebo) group reduced significantly compared with baseline (2.2 ± 1.4 vs 5.4 ± 1.8) and (3.9 ± 1.7 vs 5.4 ± 1.1), respectively (P < .001). Azithromycin prophylaxis can reduce the number of rhinosinusitis episodes and medication score, and improve nasal symptoms in NAR children with RARS.

Evidence appraisal of Tita ATN, Szychowski JM, Boggess K, et al. Adjunctive azithromycin prophylaxis for cesarean delivery.: N Engl J Med. 2016;375:1231-1241.

AORN JournalVolume 105, Issue 1 p. 117-122 Column Evidence appraisal of Tita ATN, Szychowski JM, Boggess K, et al. Adjunctive azithromycin prophylaxis for cesarean delivery. N Engl J Med. 2016;375:1231-1241. George Allen PhD, MS, BSN, RN, CNOR, CIC, FAPIC, George Allen PhD, MS, BSN, RN, CNOR, CIC, FAPICSearch for more papers by this author George Allen PhD, MS, BSN, RN, CNOR, CIC, FAPIC, George Allen PhD, MS, BSN, RN, CNOR, CIC, FAPICSearch for more papers by this author First published: 27 December 2016 https://doi.org/10.1016/j.aorn.2016.11.014Citations: 1Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Citing Literature Volume105, Issue1January 2017Pages 117-122 RelatedInformation

Antibiotics for preventing lower respiratory tract infections in high-risk children aged 12 years and under.

Antibiotics for preventing lower respiratory tract infections in high-risk children aged 12 years and under.

A double-blind, randomised, placebo-controlled study of roxithromycin and doxycycline combination, roxithromycin alone, or matching placebo for 12weeks in adults with frequent exacerbations of chronic obstructive pulmonary disease.

BackgroundAzithromycin prophylaxis has been shown to reduce COPD exacerbations but there is poor evidence for other antibiotics. We compared exacerbation rates in COPD patients with a history of frequent exacerbations (at least three moderate or severe COPD exacerbations in the past two years) during a 12-week treatment course and over a subsequent 48-week follow up period.Results292 patients were randomised to one of three treatments for 12 weeks: roxithromycin 300 mg daily and doxycycline 100 mg daily (n = 101); roxithromycin 300 mg daily (n = 97); or matching placebos (n = 94). There were no differences in the annualised moderate and severe exacerbation rates after treatment with roxithromycin/doxycycline (2.83 (95 % CI 2.37-3.40)) or roxithromycin only (2.69 (2.26-3.21)) compared to placebo (2.5 (2.08-3.03)) (p = 0.352 and p = 0.5832 respectively). Furthermore, there were no differences in the annualised exacerbation rates during 12-week treatment with roxithromycin/doxycycline (1.64 (95 % CI 1.17-2.30)), roxithromycin only (1.75 (1.24-2.41)) or placebo (2.23 (1.68-3.03)) (p = 0.1709 and p = 0.2545 respectively). There were also no significant differences between groups for spirometry or quality of life scores over either the 12-week treatment or 48-week post-treatment periods. Both active treatments were associated with nausea but otherwise adverse events were comparable among treatment groups.ConclusionsTwelve-weeks of prophylaxis with roxithromycin/doxycycline combination or roxithromycin alone did not reduce COPD exacerbations in patients with history of frequent exacerbations. These findings do not support the use of these antibiotics to prevent exacerbations in COPD patients.Electronic supplementary materialThe online version of this article (doi:10.1186/s12952-015-0034-8) contains supplementary material, which is available to authorized users.

P13.13 Sexually transmitted infection care in termination of pregnancy clinics in the netherlands

Introduction Women attending termination of pregnancy (TOP) clinics are a risk group for STIs, and those with STIs are at increased risk of developing postabortal complications. We explored what STI care is provided in Dutch TOP clinics, and we compared these results with the United Kingdom (UK). Methods A qualitative study including 14 semi-structured interviews with health care professionals (HCPs) in TOP clinics (Netherlands: 9, UK: 5). Interviews were recorded, transcribed, and analysed by thematic content analysis. Results In the Netherlands, azithromycin prophylaxis is routinely prescribed after a surgical TOP, but not routinely after a medical TOP. STI tests are only offered by Dutch clinics if clients are considered at high STI risk based on the intake questionnaire. High costs of STI testing form the main barrier for clients not accepting STI testing, as costs are not covered by all health insurances. Alternatively, some clinics refer women to the Public Health Service (PHS), where STI testing is free for high-risk groups. This also involves barriers as not all women go for testing. HCPs in TOP clinics that collaborate with PHSs in the Sense program (sexual and reproductive health care) experience less barriers, as free STI testing is then offered on location of the TOP clinic. Sexual health counselling in TOP clinics is often limited to birth control conversations, also in the UK. The major difference between Dutch and UK TOP clinics is that UK clinics (who are not privately owned) offer free STI testing to all clients. Conclusion HCPs in Dutch TOP clinics consider STI testing an important part of their service, but financial barriers prevent STI testing on location. In the UK, free STI care is broadly implemented in TOP clinics. Collaboration with PHSs (in Sense program) could improve STI testing and sexual health counselling in Dutch TOP clinics. Disclosure of interest statement The study is funded by the RIVM. No pharmaceutical grants were received in the development of this study.

Widespread Bordetella parapertussis Infections-Wisconsin, 2011-2012: Clinical and Epidemiologic Features and Antibiotic Use for Treatment and Prevention.

During October 2011-December 2012, concurrent with a statewide pertussis outbreak, 443 Bordetella parapertussis infections were reported among Wisconsin residents. We examined clinical features of patients with parapertussis and the effect of antibiotic use for treatment and prevention. Patients with polymerase chain reaction results positive for B. parapertussis reported during October 2011-May 2012 were interviewed regarding presence and durations of pertussis-like symptoms and receipt of azithromycin treatment. Data regarding acute cough illnesses and receipt of azithromycin prophylaxis among parapertussis patient household members (HHMs) were also collected. Using multivariate repeated measures log-binomial regression analysis, we examined associations of treatment receipt by the HHM with the earliest illness onset and prophylaxis receipt among other HHMs with the presence of any secondary cough illnesses in the household. Among 218 patients with parapertussis, pertussis-like symptoms were frequently reported. Illness durations were significantly shorter among patients with treatment initiated 0-6 days after cough onset, compared with nonrecipients (median durations: 10 vs 19 days, P = .002). Among 361 HHMs from 120 households, compared with nonrecipients, prompt prophylaxis of HHMs was associated with no secondary cough illnesses (relative risk: 0.16; 95% confidence interval, .04-.69). Bordetella parapertussis infection causes pertussis-like illness that might be misclassified as pertussis if B. parapertussis testing is not performed. Prompt treatment might shorten illness duration, and prompt HHM prophylaxis might prevent secondary illnesses. Further study is needed to evaluate antibiotic effectiveness for preventing parapertussis and to determine risks and benefits of antibiotic use.

Suppressive therapy using azithromycin in 2 rare cases of recurrent staphylococcal infections

Recurrent staphylococcal skin and soft tissue infections may recur despite decontamination and multiple courses of antibiotic therapy and may dramatically impair the patient's quality of life. We report successful use of long-term azithromycin prophylaxis in a recurrent laryngitis and a scalp folliculitis due to methicillin-susceptible Staphylococcus aureus.

Incidence and Risk Factors For Pneumocystis Jirovecii pneumonia (PCP) Following Haematopoetic Stem Cell Transplant (HSCT)

Introduction Serious PCP infections are known to develop in immuno-compromised individuals. The risk and risk factors in patients with retroviral infections is well established but the data in HSCT recipients is scanty. With use of newer methods of graft versus host disease (GVHD) prevention like alemtuzumab and reduced intensity transplants (RIC) this analysis was undertaken to establish the incidence and identify the risk factors for PCP infections in HSCT patients. Methods 1129 patients (M: 732, F: 397; median age: 49yr., range: 14:73) undergoing 1149 HSCT procedures from 2002 to 2012 were analyzed (20 had more than 1 procerdure). HSCT type was autologous (n=786) or allogeneic (n=363) for malignacies [Ac. Leukaemia (n=235), chr. leukaemia (n=38), lymphoma (n=390), myeloma (n=424), aplastic anaemia (n=8) and other conditions (n= 34)]. Patients either had HSCT during this period or were alive post HSCT and at risk of PCP during the same time frame. Patients were evaluated for routine bacteriology, PCP and respiratory viruses using PCR if they had clinical signs and symptoms of respiratory infection. All patients received PCP prophylaxis (Co-trimoxazole prefereed; azithromycin, pentamidine and dapsone in cases intolerant to co-trimoxazole). Cummulative incidence rate was calculated using competing risk analysis with death as competing risk factor. Estimate of incidence was calculated per period of prophylactic drug used in cases where there was change in the medication (total 1930 spells in 1129 patients following 1149 procedures). Risk factors were analysed for the entire group and also separately for allograft and autograft population. Results In allograft group, donor was sibling (n=162) or MUD (n=201). Conditioning was full intensity (n=154) or reduced intensity (n=210). Alemtuzumab was used in conditioning in 167 procedures, ATG in 23 and TBI in 208 cases (2Gy as RIC in 26). Stem cell source was PBSC (n=1050), BM (n=78), both (n=20) and 1 had cord blood. In 275/363 (76%) donor recipient pairs where CMV status was recorded, at least one of the pair was positive in 140/275 (51%) cases. 32 patients (2.8%) developed symptomatic, PCR positive PCP infection (5yr. risk 1.02%, 95% CI: 1.01-1.03%, SE: +0.004). In all but 4 cases PCP was the only identified pathogen (4 had respiratory virus in addition to PCP). Median time to develop PCP was 765 days (range: 70-2066 days). In univariate analysis, risk of PCP was not influenced by gender (M:24/1304 vs. F:8/626, p=0.33), age at HSCT (&lt;49 yr.: 11/841 vs. &gt;49yr.: 21/1089, p=0.21), CMV status of patient (Neg: 14/ 974 vs. Pos: 16/908, p=0.70), risk category of disease (Good: 24/1401, Poor: 8/438, p=0.33), or primary diagnosis (AL: 14/539, MM: 6/707, rest: 12/684, p=0.08). The risk was significantly higher with allograft (25/887 vs. 7/1043, p&lt;0.0001), RIC (RIC: 22/541, Full: 3/350, Auto: 7/1039, p=0.0001) and use of alemtuzumab (19/388 vs. ATG: 1/69 vs. rest: 12/1473, p=0.0001). 11/537 episodes developed when patients were off PCP prophylaxis but risk was significantly higher during the period of azithromycin as PCP prophylaxis (17/321, vs. Co-trimoxazole: 3/844 vs. Pentamidine: 1/222, p=0.0001). Mutivariate analysis for the entire group showed Azithromycin use (HR: 1.6, 95% CI: 1.14-2.3, p=0.007) and RIC (HR: 3.1, 95% CI: 1.2-7.9, p=0.019) to be independently associated with risk of PCP. In autograft group, there was trend towards higher incidence with Azithromycin prophylaxis (HR: 1.74, 95% CI: 0.91-3.0, p=0.073) while in allograft group use of azithromycin (HR: 1.67, 95% CI: 1.1-2.5, p=0.013) and RIC (HR: 5.14, 95% CI: 1.2-22.1, p=0.028) were independently associated with higher risk of PCP. Maximum risk of reactivation was in patients receiving alemtuzumab conditioned RIC allograft during azithromycin prophylaxis. Out of the 11 who were off prophylaxis, 4 had stopped azithromycin in prior 6 weeks. There was no relation to lymphocyte recovery and PCP infection in allograft patients. Conclusion Even though the overall risk of PCP is small in HSCT patients, there is a significantly higher risk in alemtuzumab conditioned RIC allograft. Infections seem to develop late and azithromycin as prophylaxis may be sub-optimal in this group. Future studies need to determine the duration of PCP prophylaxis in RIC allografts. Disclosures: Cavet: Lilly: Membership on an entity’s Board of Directors or advisory committees; Celgene: Consultancy, Honoraria.

Disseminated Mycobacterium avium intracellulare complex presenting as abdominal pain

A 50-year-old female presented with three months of progresive “sharp and gnawing” epigastric pain, fevers, and night sweats. edical history included systemic lupus erythematosus requiring mmunosuppression with prednisone and mycophenolate. Comuted tomography of the abdomen displayed upper growth of a esenteric lymph node with surrounding stranding (Fig. 1A). Endocopic ultrasound (EUS) revealed a hypoechogenic 2.2 cm lymph ode tangent to the fourth portion of the duodenum (Fig. 1B). US-guided needle aspiration showed inflammatory tissue, which tained positive for acid-fast bacilli (AFB), and culture of biopsy issue confirmed Mycobacterium avium complex (MAC). Multile sputum cultures also demonstrated MAC on Kinyoun stain Fig. 1C), and disseminated MAC was diagnosed. Patient received azithromycin, ethambutol, and rifabutin for one year and symptoms gradually resolved; azithromycin prophylaxis was continued indefinitely to prevent recurrence. MAC is a rare cause of abdominal pain and often difficult to diagnose. MAC, including M. avium and M. intracellulare, are free-living non-tubercular mycobacteria that are ubiquitous in the environment [1]. They usually cause lung disease but can cause disseminated disease in severely immunocompromised patients [1]. Diagnosis is aided by clinical, radiological, microbiological, and pathological findings [1]. Culture requires six weeks of growth before confirmed negative and has to be performed on special media, in addition, AFB staining has low sensitivity and can be falsely negative [1].

Successful outcome of first paediatric renal transplant for HIV associated nephropathy

<h3>Aims</h3> Classical HIV-associated nephropathy (HIVAN) was first described before the advent of highly active anti-retroviral therapy (HAART) in late stages of HIV disease with high viral load and low CD4+ cell count. Renal transplantation guidelines for adults with HIVAN have been developed1 with comparable patient and graft survival.23 We report the successful outcome of living related renal transplantation in an 8 year old girl (AB; name changed) on haemodialysis due to HIVAN. <h3>Patients and methods</h3> AB is a vertically HIV-infected girl who was initially lost to follow-up but represented aged 5.5 years with lymphocytic interstitial pneumonitis (LIP) and CDC stage.1 She was not initially commenced on HAART but subsequently developed acute renal failure and renal biopsy confirmed HIVAN. Hemodialysis and HAART (Lopinavir/ritonavir, lamivudine and abacavir) were started at 6.5 years. <h3>Results</h3> Pre-transplantation screening showed an undetectable HIV-1 viral load and CD4 counts of 43% (=1990/mm³). She underwent living related renal transplantation from her 56-year old maternal grandmother (mismatch 1,1,1; donor and recipient both CMV negative and EBV positive). There was a historical B-cell positive cross-match, and she was therefore treated as a ‘high-risk’ transplant using induction therapy with basiliximab, tacrolimus, mycophenolate mofetil and steroids. Tacrolimus was started six weeks prior to transplantation in order to stabilise levels. HAART (Lopinavir/ritonavir, abacavir and lamivudine) was continued together with isoniazid, azithromycin, co-trimoxazole and fluconazole prophylaxis. Currently, she is 2 months post-transplant with excellent allograft function - plasma creatinine 41-48 µmol/l; estimated glomerular filtration rate 80-94 mls/min/1.73m². She has mild hypertension requiring two anti-hypertensive agents and low-grade albuminuria (25 mg/mmol). Therapeutic tacrolimus levels are achieved with once-daily tacrolimus given 5-days per week only. She has an undetectable HIV-1 viral load and CD4+ counts of 240/mm³. Protocol biopsy at 6 weeks shows mild chronic changes, no donor specific antibodies and normal transplant renal ultrasound. There have been no HIV-related complications. <h3>Conclusion</h3> This is the first reported case of successful renal transplantation in a child with HIVAN in the UK. Adult experience suggests higher risk of rejection and careful monitoring for long-term HIV-associated complications.3

A randomised controlled trial of azithromycin to prevent chronic rejection after lung transplantation

Azithromycin reduces airway inflammation and improves forced expiratory volume in 1 s (FEV₁) in chronic rejection or bronchiolitis obliterans syndrome (BOS) after lung transplantation (LTx). Azithromycin prophylaxis might prevent BOS. A double-blind randomised controlled trial of azithromycin (n = 40) or placebo (n = 43), initiated at discharge and administered three times a week for 2 yrs, was performed in 2005-2009 at the Leuven University Hospital (Leuven, Belgium). Primary end-points were BOS-free and overall survival 2 yrs after LTx; secondary end-points were acute rejection, lymphocytic bronchiolitis and pneumonitis rate, prevalence of pseudomonal airway colonisation or gastro-oesophageal reflux, and change in FEV₁, airway and systemic inflammation over time. Patients developing BOS were assessed for change in FEV₁ with open-label azithromycin. BOS occurred less in patients receiving azithromycin: 12.5 versus 44.2% (p = 0.0017). BOS-free survival was better with azithromycin (hazard ratio 0.27, 95% CI 0.092-0.816; p = 0.020). Overall survival, acute rejection, lymphocytic bronchiolitis, pneumonitis, colonisation and reflux were comparable between groups. Patients receiving azithromycin demonstrated better FEV₁ (p = 0.028), and lower airway neutrophilia (p = 0.015) and systemic C-reactive protein levels (p = 0.050) over time. Open-label azithromycin for BOS improved FEV₁ in 52.2% patients. No serious adverse events were noted. Azithromycin prophylaxis attenuates local and systemic inflammation, improves FEV₁ and reduces BOS 2 yrs after LTx.

Vor-Ort-Behandlung und -Chirurgie von Narbenstadien des Trachoms in Unterägypten

In spite of WHO programmes with azithromycin therapy and prophylaxis of trachoma, active and inactive stages of trachoma have not yet lost their position as one of the leading causes of blindness worldwide. For underprivileged inhabitants a specially adapted catalogue of surgical procedures was selected and for the special purposes of on-the-spot surgery and follow-up with one, two or no further examinations or removal of suture material was adapted. For 45 patients with trichiasis, trachoma scarring of upper and lower lids with entropium and different kinds of corneal damage, eight different surgical procedures with, in part, modifications were adopted. By modifications of known surgical procedures with postoperative correction of lid position, the more precise marking of trichiasis lashes, preparation to their roots for epilation or cauterisation and for minimal measurements in follow-up, essentials were found for adaptation to this purpose and the best procedures identified. Eight different surgical procedures for different scarring stages of trachoma and trichiasis including entropium at the upper and lower lids with cornea pannus led, by a selected adaptation to the particular purposes and situations, to an overall success rate of > 90 %. Visual acuity improvements in 50 % of the patients were recognised. The otherwise present threat of blindness in the further course could be avoided.

Azithromycin in the extremely low birth weight infant for the prevention of Bronchopulmonary Dysplasia: a pilot study

BackgroundAzithromycin reduces the severity of illness in patients with inflammatory lung disease such as cystic fibrosis and diffuse panbronchiolitis. Bronchopulmonary dysplasia (BPD) is a pulmonary disorder which causes significant morbidity and mortality in premature infants. BPD is pathologically characterized by inflammation, fibrosis and impaired alveolar development. The purpose of this study was to obtain pilot data on the effectiveness and safety of prophylactic azithromycin in reducing the incidence and severity of BPD in an extremely low birth weight (≤ 1000 grams) population.MethodsInfants ≤ 1000 g birth weight admitted to the University of Kentucky Neonatal Intensive Care Unit (level III, regional referral center) from 9/1/02-6/30/03 were eligible for this pilot study. The pilot study was double-blinded, randomized, and placebo-controlled. Infants were randomized to treatment or placebo within 12 hours of beginning mechanical ventilation (IMV) and within 72 hours of birth. The treatment group received azithromycin 10 mg/kg/day for 7 days followed by 5 mg/kg/day for the duration of the study. Azithromycin or placebo was continued until the infant no longer required IMV or supplemental oxygen, to a maximum of 6 weeks. Primary endpoints were incidence of BPD as defined by oxygen requirement at 36 weeks gestation, post-natal steroid use, days of IMV, and mortality. Data was analyzed by intention to treat using Chi-square and ANOVA.ResultsA total of 43 extremely premature infants were enrolled in this pilot study. Mean gestational age and birth weight were similar between groups. Mortality, incidence of BPD, days of IMV, and other morbidities were not significantly different between groups. Post-natal steroid use was significantly less in the treatment group [31% (6/19)] vs. placebo group [62% (10/16)] (p = 0.05). Duration of mechanical ventilation was significantly less in treatment survivors, with a median of 13 days (1–47 days) vs. 35 days (1–112 days)(p = 0.02).ConclusionOur study suggests that azithromycin prophylaxis in extremely low birth weight infants may effectively reduce post-natal steroid use for infants. Further studies are needed to assess the effects of azithromycin on the incidence of BPD and possible less common side effects, before any recommendations regarding routine clinical use can be made.

Feasibility of Azithromycin Prophylaxis During a Pertussis Outbreak Among Healthcare Workers in a University Hospital in Paris

The objective of the present study was to evaluate the feasibility of azithromycin prophylaxis with respect to tolerability and compliance during a pertussis outbreak among healthcare workers in a university hospital ward. Compliance with the prophylaxis regimen was 89%; compliance was 75% from intent-to-treat perspective. The rate of adverse events was 33%. Female sex was associated with reporting of adverse events. Nonstudents and healthcare workers who reported adverse events were less compliant with the prophylaxis regimen.

Antibiotic prophylaxis with azithromycin or penicillin for childhood-onset neuropsychiatric disorders

The acronym PANDAS (pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections) describes a subgroup of children with obsessive-compulsive disorder and/or tic disorder that experience symptom exacerbations following streptococcal infections. We hypothesized that the prevention of streptococcal infections among children in the PANDAS subgroup would decrease neuropsychiatric symptom exacerbations. Twenty-three subjects with PANDAS were enrolled in a double blind, randomized controlled trial. Antibiotic prophylaxis with penicillin or azithromycin was administered for 12 months. Rates of streptococcal infections and neuropsychiatric symptom exacerbations were compared between the study year and the baseline year prior to entry. Significant decreases in streptococcal infections during the study year were found with a mean of .1 (.3 SD) per subject, compared to the baseline year with 1.9 (1.2 SD) in the penicillin group and 2.4 (1.1 SD) in the azithromycin group [p<.01]. Significant decreases in neuropsychiatric exacerbations during the study year were also found with a mean of .5 (.5 SD) per subject in the penicillin group and .8 (.6 SD) in the azithromycin group, compared to the baseline year with 2.0 (.9 SD) in the penicillin group and 1.8 (.6 SD) in the azithromycin group [p<.01]. Penicillin and azithromycin prophylaxis were found to be effective in decreasing streptococcal infections and neuropsychiatric symptom exacerbations among children in the PANDAS subgroup.

Pertussis, the Pediatrician, and the Outbreak

BACKGROUND: A neonate presented with worsening gastrointestinal and respiratory distress. Pertussis isolation precautions were not initiated until 3 days after presentation. Although the initial Pertussis DFA was negative, the Pertussis culture was positive. METHODS: Surveillance for close contacts was begun. Exposed, asymptomatic healthcare workers (HCWs) were given azithromycin prophylaxis. The attending pediatrician developed a cough 9 days after the exposure and tested positive for Pertussis by PCR. Five other exposed, symptomatic HCWs met the confirmed case classification, despite negative laboratory findings. Surveillance and prophylaxis for cases exposed to the pediatrician and the five HCWs were begun. RESULTS: Two-hundred-thirty-one exposed patients and their family members were seen in the hospital setting and given prophylaxis; 51 of these individuals with a cough were tested for Pertussis by PCR and culture. The one positive contact was linked to an unrelated Pertussis case. The five exposed HCWs also spent clinical time in various outpatient settings. Ninety days after the index case presented, the pediatrician remains the only laboratory-confirmed secondary case. CONCLUSIONS: Pertussis should be part of the differential diagnosis in all patients < 6 months of age who present with an upper respiratory illness or distress. Droplet precautions should be initiated promptly in these patients. The current case definition when applied to individuals with negative laboratory findings can lead to expensive diagnostic testing, inappropriate antibiotic use, unneeded school/work furlough, and over-taxing of healthcare resources. Further investigation into the safety of immunizing adults with a Pertussis vaccine is needed.

An Outbreak of Pneumococcal Pneumonia among Military Personnel at High Risk: Control by Low-Dose Azithromycin Postexposure Chemoprophylaxis

In the winter of 1998-1999 an outbreak of pneumococcal pneumonia occurred among Ranger students undergoing high-intensity training. Thirty pneumonia cases (attack rate = 12.6%) were identified among a group of 239 students. Eighteen students were hospitalized; Streptococcus pneumoniae-positive cultures were detected in 11 (61.1%) of these 18 hospitalized cases. Pneumococci were also identified in throat swabs of 30 (13.6%) of 221 nonhospitalized students surveyed. Serum antipneumolysin seroconversions were detected in 30 (18.3%) of 164 students tested. An association between development of serum antipneumolysin antibody and pneumococcal pharyngeal carriage/colonization was found. Of 30 seroconverters, eight (26.7%) had S. pneumoniae-positive cultures compared with only 17 (12.7%) of 134 nonseroconverters (relative risks = 2.02, 95% confidence interval = 1.02-4.02, p = 0.05). The outbreak was controlled by administrating lowdose, oral azithromycin prophylaxis (250 mg weekly for 2 weeks) and was associated with a 69% reduction in pneumococcal carriage and a 94% reduction in pneumonia rates.

Azithromycin prophylaxis for Mycobacterium avium complex during the era of highly active antiretroviral therapy: evaluation of a provincial program.

Mycobacterium avium complex (MAC) disease was evaluated in a provincial program of azithromycin prophylaxis. Highly active antiretroviral therapy (HAART) was prescribed to 383 (65%) of 587 patients eligible for MAC prophylaxis (CD4 <75 cells/mm3). By use of an intent-to-treat analysis, MAC disease was observed in 21 of 271 patients who did not receive prophylaxis (incidence rate, 8 events per 100 person-years). MAC events occurred in 10 of 316 patients who received azithromycin (2.37 events per 100 person-years). Localized lymphadenitis compatible with immune reconstitution disease accounted for 23% of all MAC events, in contrast to studies in the pre-HAART era, where almost all cases were disseminated. None of the MAC isolates from the 10 prophylaxis failures were resistant to azithromycin. Azithromycin appeared to be protective against disseminated MAC in patients who were either unresponsive or nonadherent to HAART, but it did not prevent the development of immune reconstitution disease due to MAC.

Azithromycin prophylaxis during a hospitalwide outbreak of a pertussis-like illness.

A questionnaire regarding tolerability and adherence was administered for 5 days to hospital employees who received azithromycin prophylaxis during a hospitalwide outbreak of a pertussis-like illness. Analysis of the 239 responses from those having received prophylactic azithromycin determined that it was well tolerated and accounted for a minimal loss of days worked; 81.5% were fully adherent with the regimen.

THE COST-EFFECTIVENESS OF PROPHYLAXIS FOR MYCOBACTERIUM AVIUM COMPLEX IN AIDS

To develop a simulation model to project costs, life expectancy, and cost-effectiveness in discounted dollars per quality-adjusted life-year (QALY) saved for clinical strategies to prevent Mycobacterium avium complex (MAC) in patients with AIDS. We used natural history data from the Multicenter AIDS Cohort Study, efficacy and toxicity data from randomized clinical trials, and cost data from the AIDS Cost and Services Utilization Survey. The model permits timing of prophylaxis to be stratified by CD4 count (201-300, 101-200, 51-100, and < or = 50/mm3), and allows combinations of prophylaxis, crossover to second- and third-line agents for toxicity, and consideration of adherence, resistance, and quality of life. The model projects that the average HIV-infected patient with a beginning CD4 count between 201 and 300/mm3 has total lifetime costs of approximately $43,150 and a quality-adjusted life expectancy of 42.35 months. If azithromycin prophylaxis for M. avium complex is begun after the CD4 declines to 50/mm3, costs and quality-adjusted survival increase to approximately $44,040 and 42.78 months, respectively, for an incremental cost-effectiveness ratio of $25,000/QALY compared with no M. avium complex prophylaxis. Other prophylaxis options (i.e., rifabutin, clarithromycin, and combination therapies) either cost more but offer shorter survival, or have cost-effectiveness ratios above $260,000/QALY. Sensitivity analysis reveals that, for reasonable assumptions about quality of life, risk of infection, prophylaxis cost, adherence, and resistance, azithromycin remains the most cost-effective prophylaxis option. Azithromycin prophylaxis, begun after the CD4 count has declined to 50/mm3, is the most cost-effective M. avium complex prophylaxis strategy. Consistent with new United States Public Health Service guidelines, it should be the first-line prophylaxis option.