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Re: Antibiotic Prophylaxis for Aspiration: The Limits of Extrapolation

Dear Editor(s):

In the May edition of ADC, Dr. Kirk provides a helpful synopsis of the paucity of evidence to help guide the management of neurologically- impaired (NI) children with recurrent chest infections. In the absence of direct evidence, a synthesis of the data from the cystic fibrosis (CF) literature is presented that shows a decrease in the number of pulmonary exacerbations in children with CF with prophylactic azithromycin. Unfortunately, there are important differences between these populations of children which make application of this extrapolated evidence problematic. In NI children, aspiration of oropharyngeal flora containing both aerobic and anaerobic organisms rather than intraparenchymal colonization is thought to be the primary cause of lung disease (1) (2). Azithromycin is not known to be particularly effective against many anaerobic micro-organisms (3). Further, bacterial superinfection following inhalation of colonized oropharyngeal material is thought to cause bacterial pneumonia in these children. Antimicrobial prophylaxis can potentially eliminate some of these bacteria, but can also potentially lead to the selection of multidrug resistant oropharyngeal organisms. Last, azithromycin absorbtion may also be decreased in patients taking antacid drugs (4), a class of medications frequently used in the treatment of gastro-oesophageal reflux in NI children. More direct rather than extrapolated evidence is needed to help guide clinicians in the challenging management of these children.

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