SOURCE: Gibson PG, Yang IA, Upham JW, et al. Lancet 2017;390:659-668.

In my early years of training, I was tempted occasionally to consider an antibiotic during an asthma exacerbation, but was quickly advised about the basic foolhardiness of such a consideration. After all, asthma exacerbations essentially are induced exclusively by viral infections (as well as thermal and atopic stimuli). Is it time to reconsider that posture?

In the AMAZES clinical trial, symptomatic adult asthmatics (n = 420) on a long-acting bronchodilator and inhaled steroid were randomized to azithromycin 500 mg thrice weekly vs. placebo for 48 weeks. The primary outcome was number of asthma exacerbations. In a previous similarly designed trial of COPD patients receiving azithromycin 250 mg/day for one year, a decrement in hearing function was noted in the azithromycin treatment arm; hence, patients with any hearing impairment were excluded from this trial.

At 48 weeks, subjects on azithromycin experienced a 61% reduction in asthma exacerbations, as well as a statistically significant improvement in quality of life. Tolerability of azithromycin was very good, although diarrhea was twice as common in the azithromycin group as the placebo group (34% vs. 19%, respectively; P < 0.05). The authors reminded us that macrolides, in addition to antibacterial effects, also possess anti-inflammatory and antiviral activity.