What is the preferred antibiotic, Azithromycin (azithromycin) or Augmentin (amoxicillin-clavulanate), for a 60-year-old female with a cough lasting 1.5 weeks and a past medical history (PMH) of asthma?

From the Guidelines

For a 60-year-old female with a cough for 1.5 weeks and a history of asthma, Azithromycin is generally preferred over Augmentin due to its good coverage against common respiratory pathogens, anti-inflammatory properties, and fewer gastrointestinal side effects. The recommended regimen is Azithromycin 500mg on day 1, followed by 250mg daily for days 2-5, as suggested by the British Thoracic Society guideline for the use of long-term macrolides in adults with respiratory disease 1. This medication is typically more appropriate for respiratory infections in patients with asthma because it has good coverage against common respiratory pathogens including atypical organisms, and has anti-inflammatory properties that may benefit asthma patients, as noted in the guideline 1. Additionally, Azithromycin has fewer gastrointestinal side effects compared to Augmentin and requires less frequent dosing, which improves compliance. Augmentin (amoxicillin-clavulanate) would be a reasonable alternative if there is concern for beta-lactamase producing organisms, but it carries a higher risk of gastrointestinal side effects and may potentially worsen asthma symptoms in some patients. Before starting antibiotics, it's essential to determine if the cough is likely bacterial in nature rather than viral or related to an asthma exacerbation, as unnecessary antibiotic use contributes to resistance, as highlighted in the update of practice guidelines for the management of community-acquired pneumonia in immunocompetent adults 1. Also, ensure the patient's asthma medications are optimized, as inadequately controlled asthma could be contributing to the persistent cough.

Some key points to consider when prescribing Azithromycin include:

• Performing an ECG prior to initiation of macrolide therapy to assess QTc interval, as recommended by the British Thoracic Society guideline 1
• Counseling patients about potential adverse effects, including gastrointestinal upset, hearing and balance disturbance, cardiac effects, and microbiological resistance, as noted in the guideline 1
• Monitoring for antimicrobial resistance, as suggested by the study on the use of long-term macrolides in adults with respiratory disease 1
• Considering the risk-benefit profile of oral macrolide therapy, including the potential for gastrointestinal side effects and the need for ongoing treatment, as discussed in the guideline 1

It's also important to note that the evidence for the use of Azithromycin in patients with asthma is based on studies with varying quality, and the optimum macrolide and dosing regimen are unclear, as highlighted in the study on the use of long-term macrolides in adults with respiratory disease 1. However, the available evidence suggests that Azithromycin is a reasonable choice for the treatment of respiratory infections in patients with asthma, due to its anti-inflammatory properties and good coverage against common respiratory pathogens.

From the FDA Drug Label

For the 304 patients analyzed in the modified intent to treat analysis at the Day 21 to 24 visit, the clinical cure rate for 3 days of azithromycin was 85% (125/147) compared to 82% (129/157) for 10 days of clarithromycin The following outcomes were the clinical cure rates at the Day 21 to 24 visit for the bacteriologically evaluable patients by pathogen: PathogenAzithromycin (3 Days) Clarithromycin (10 Days) S. pneumoniae29/32 (91%)21/27 (78%) H. influenzae12/14 (86%)14/16 (88%) M catarrhalis11/12 (92%)12/15 (80%) In a randomized, double blind, double-dummy controlled clinical trial of acute bacterial sinusitis, azithromycin (500 mg once daily for 3 days) was compared with amoxicillin/clavulanate (500/125 mg tid for 10 days). Clinical response assessments were made at Day 10 and Day 28. The primary endpoint of this trial was prospectively defined as the clinical cure rate at Day 28 For the 594 patients analyzed in the modified intent to treat analysis at the Day 10 visit, the clinical cure rate for 3 days of azithromycin was 88% (268/303) compared to 85% (248/291) for 10 days of amoxicillin/clavulanate.

Azithromycin vs Augmentin:

• Clinical Cure Rates: Azithromycin has shown comparable or superior clinical cure rates to Augmentin (amoxicillin/clavulanate) in various studies, including those for acute bacterial exacerbations of chronic obstructive pulmonary disease and acute bacterial sinusitis.
• Pathogen-Specific Cure Rates: Azithromycin has demonstrated high cure rates against common pathogens such as S. pneumoniae, H. influenzae, and M. catarrhalis.
• Treatment Duration: Azithromycin is often administered for a shorter duration (3-5 days) compared to Augmentin (10 days).
• Adverse Events: Both azithromycin and Augmentin have similar adverse event profiles, with gastrointestinal symptoms being the most common.

Given the patient's presentation with a cough for 1.5 weeks and a history of asthma, azithromycin may be considered as a treatment option, especially if the cough is suspected to be due to a bacterial infection. However, it is essential to note that the patient's specific condition and medical history should be taken into account when making a treatment decision. 2

From the Research

Patient Profile

• Age: 60
• Sex: Female
• Symptoms: Cough for 1.5 weeks
• Past Medical History (PMH): Asthma

Treatment Options

• Azithromycin
• Augmentin

Relevant Studies

• According to 3, acute cough lasting less than 3 weeks may indicate an acute underlying cardiorespiratory disorder, but is most commonly caused by a self-limited viral upper respiratory tract infection.
• A study by 4 found that azithromycin may have a place in the treatment of chronic cough associated with asthma, with a significant improvement in Leicester Cough Questionnaire (LCQ) score in patients with chronic cough and a concurrent diagnosis of asthma.
• Another study by 5 found that macrolides, such as azithromycin, reduce exacerbations when added to inhaled therapy in severe asthma, and may be effective in patients treated with biologics.
• There is no direct comparison between azithromycin and augmentin in the provided studies for the treatment of cough in a patient with asthma.

Considerations

• The patient's cough duration is 1.5 weeks, which is considered acute according to 3.
• The patient's PMH of asthma may be relevant to the treatment of cough, as suggested by 4 and 5.
• Augmentin is not mentioned in the provided studies as a treatment option for cough in patients with asthma.