[CIS PIDD] [cis-pidd] Long term Azithromycin for IgA deficiency & recurrent bronchitis

Tue Aug 29 16:44:43 EDT 2017

Hi Stan,

Admittedly I am a 'low-but-not-undetectable-IgA-deficiency' skeptic.  In other words, in these situations I believe there are other factors contributing as much or moreso than the IgA.  Truth be told, even with undetectable serum IgA, I am always searching for additional contributing factors rather than looking to antibiotics to solve all.

My approach to these patients is to thoroughly re-evaluate things from an allergic rhintis, chronic rhinosinusitis and asthma standpoint and maximize therapy based on history, exam and diagnostics (PFTs, , allergy testing, sinus CT if applicable).  Once this has been re-visited and a consistent management plan (e.g. nasal saline irrigation, intranasal steroids, ICS, AIT, etc.) is in place I will work to discontinue the azithromycin or other prophylactic antibiotics.

I am not sure if anyone has determined a finite length of azithromycin prophylaxis at which adverse events start to occur.   I have seen children and adults on azithromycin fpr years.  Admittedly I do not routinely do hearing tests or ECGs.  Perhaps I should?  I alos would like to hear others' approaches.

-j

jason raasch, md

Midwest Immunology Clinic

Minnesota

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From: cis-pidd at lyris.dundee.net <cis-pidd at lyris.dundee.net> on behalf of CIS-PIDD <cis-pidd at lists.clinimmsoc.org>
Sent: Tuesday, August 29, 2017 2:14:48 PM
To: CIS-PIDD
Subject: [cis-pidd] Long term Azithromycin for IgA deficiency & recurrent bronchitis

Dear Colleagues,

I've followed a 16 year-old adolescent since 2014 with mild IgA deficiency 0.36 (0.6-3.0) & low IgG4 (0.01). She had severe bronchitis aged 9 years and thereafter she has had recurrent annual viral infections with bronchitis. She has allergic rhinitis treated with nasal steroids and recently has been on a steroid MDI for asthma under the care of a pulmonologist. Prior to steroid therapy for the asthma she was on prophylactic Azithromycin from January to November 2015. In February 2016 she developed bronchitis requiring 2 antibiotic courses,  and went back on Azithromycin 3 times a week thereafter. In May 2016 she had normal lymphocyte subsets and total memory B-cells, but class-switched B-cells were low at 6.4%. Serum MBL, classical & alternate complement pathways, and lymphocyte proliferation were all normal, and there was a strong response to vaccination with tetanus & pneumovax 23 with protective specific IgG levels. I have not seen her since May 2016 but I understand she has now been diagnosed clinically with bacterial tonsillitis by her family physician (but no lab evidence), and is still on Azithromycin AB 3 times a week.

My concern is for how long can one continue AB prophylaxis in this scenario? I usually prescribe it only for 6 months over winter in young scholars with IgA deficiency and recurrent infections, to help them cope with school.  Also, what sort of routine precautions are advisable (annual hearing tests? 6 monthly ECG for QT interval prolongation?)

I’d appreciate any advice and hearing what others do & about routine monitoring protocols.

Thanks,

Stan

Stanley Ress
Emeritus Associate Professor of Medicine, UCT
Specialist physician & Clinical Immunologist,
UCT Private Academic hospital, Anzio Road, Observatory,
Cape Town, 7925 South Africa
TEL:INTERN<file://localhost/tel/INTERN>. + 2721-4421966 or 4421816 FAX:   "    + 2721-(0)865173095
Cell: 0833115482
email: stan.ress at uct.ac.za<mailto:stan.ress at uct.ac.za>

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