Bronchiectasis exacerbation study on azithromycin and amoxycillin-clavulanate for respiratory exacerbations in children (BEST-2) : study protocol for a randomized controlled trial

Chang, Anne B., Grimwood , Keith, Wilson, Andrew C., van Asperen, Peter P., Byrnes, Catherine A., O'Grady, Kerry-Ann, Sloots, Theo P., Robertson, Colin F., Torzillo, Paul J., McCallum, Gabrielle B., Masters, Ian B., Buntain, Helen M., Mackay, Ian M., Ungerer, Jacobus, Tuppin, Joanne, & Morris, Peter S. (2013) Bronchiectasis exacerbation study on azithromycin and amoxycillin-clavulanate for respiratory exacerbations in children (BEST-2) : study protocol for a randomized controlled trial. Trials, 14(53).

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Bronchiectasis unrelated to cystic fibrosis (CF) is being increasingly recognized in children and adults globally, both in resource-poor and in affluent countries. However, high-quality evidence to inform management is scarce. Oral amoxycillin-clavulanate is often the first antibiotic chosen for non-severe respiratory exacerbations, because of the antibiotic-susceptibility patterns detected in the respiratory pathogens commonly associated with bronchiectasis. Azithromycin has a prolonged half-life, and with its unique anti-bacterial, immunomodulatory, and anti-inflammatory properties, presents an attractive alternative. Our proposed study will test the hypothesis that oral azithromycin is non-inferior (within a 20% margin) to amoxycillin-clavulanate at achieving resolution of non-severe respiratory exacerbations by day 21 of treatment in children with non-CF bronchiectasis.


This will be a multicenter, randomized, double-blind, double-dummy, placebo-controlled, parallel group trial involving six Australian and New Zealand centers. In total, 170 eligible children will be stratified by site and bronchiectasis etiology, and randomized (allocation concealed) to receive: 1) azithromycin (5 mg/kg daily) with placebo amoxycillin-clavulanate or 2) amoxycillin-clavulanate (22.5 mg/kg twice daily) with placebo azithromycin for 21 days as treatment for non-severe respiratory exacerbations. Clinical data and a parent-proxy cough-specific quality of life (PC-QOL) score will be obtained at baseline, at the start and resolution of exacerbations, and on day 21. In most children, blood and deep-nasal swabs will also be collected at the same time points. The primary outcome is the proportion of children whose exacerbations have resolved at day 21. The main secondary outcome is the PC-QOL score. Other outcomes are: time to next exacerbation; requirement for hospitalization; duration of exacerbation, and spirometry data. Descriptive viral and bacteriological data from nasal samples and blood inflammatory markers will be reported where available.


Currently, there are no published randomized controlled trials (RCT) to underpin effective, evidence-based management of acute respiratory exacerbations in children with non-CF bronchiectasis. To help address this information gap, we are conducting two RCTs. The first (bronchiectasis exacerbation study; BEST-1) evaluates the efficacy of azithromycin and amoxycillin-clavulanate compared with placebo, and the second RCT (BEST-2), described here, is designed to determine if azithromycin is non-inferior to amoxycillin-clavulanate in achieving symptom resolution by day 21 of treatment in children with acute respiratory exacerbations.

Trial registration

Australia and New Zealand Clinical Trials Register (ANZCTR) number ACTRN12612000010897.

Impact and interest:

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ID Code: 64695
Item Type: Journal Article
Refereed: Yes
Additional Information: 099MF-- Times Cited:0-- Cited References Count:80-- http://WOS:000315624900001
Keywords: amoxycillin-clavulanate, azithromycin, bronchiectasis, placebo, pulmonary exacerbations, randomized controlled trial, cystic fibrosis bronchiectasis, obstructive pulmonary-disease, suppurative lung-disease, placebo-controlled trial, non-cf bronchiectasis, indigenous children, viral-infections, chronic cough, otitis-media, pseudomonas-aeruginosa
DOI: 10.1186/1745-6215-14-53
ISSN: 1745-6215
Subjects: Australian and New Zealand Standard Research Classification > MEDICAL AND HEALTH SCIENCES (110000)
Divisions: Current > QUT Faculties and Divisions > Faculty of Health
Current > Institutes > Institute of Health and Biomedical Innovation
Copyright Owner: Copyright 2013 Chang et al.
Copyright Statement: licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Deposited On: 26 Nov 2013 03:23
Last Modified: 29 Jan 2015 00:06

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