Original Investigation | Critical Care Medicine

Azithromycin Treatment vs Placebo in Children With Respiratory

Syncytial Virus–Induced Respiratory Failure
A Phase 2 Randomized Clinical Trial
Michele Kong, MD; Wei Wei Zhang, MD; Kate Sewell, RN; Gregory Gorman, PhD; Hui-Chien Kuo, MS; Inmaculada Aban, PhD
Namasivayam Ambalavanan, MD; Richard J. Whitley, MD

Abstract Key Points

Question Is azithromycin (AZM) safe,
IMPORTANCE Despite a high disease burden, there is no effective treatment for respiratory
and does it reduce nasal and
syncytial virus (RSV) infection.
endotracheal matrix metalloproteinase
9 (MMP-9) levels in children with
OBJECTIVES To determine whether administration of azithromycin (AZM) to children with
respiratory syncytial virus–induced
RSV-induced respiratory failure is safe and to define the effect of AZM therapy on nasal matrix
respiratory failure?
metalloproteinase 9 (MMP-9) levels.
Findings In this randomized phase 2
DESIGN, SETTING, AND PARTICIPANTS This randomized, double-blind, placebo-controlled phase clinical trial that included 48 children
2 trial was conducted at a single tertiary pediatric intensive care unit from February 2016 to February admitted to the pediatric intensive care
2019. The study included children with RSV infection who were admitted to the pediatric intensive unit with respiratory syncytial virus lung
care unit and required respiratory support via positive pressure ventilation (invasive and disease who required positive pressure
noninvasive). A total of 147 children were screened; 90 were excluded for not meeting inclusion ventilation, AZM was safe. No difference
criteria, having an absent legal guardian, lacking pharmacy support, or having a language barrier and in nasal MMP-9 levels was observed
9 declined participation, resulting in 48 patients enrolled in the study. between treatment group, but in those
who required mechanical ventilation
INTERVENTION Receipt of standard dose AZM (10 mg/kg/d), high-dose AZM (20 mg/kg/d), or a and received a high dose of AZM,
matching placebo of normal saline intravenously for 3 days. endotracheal active and total MMP-9
levels were lower on day 3 of treatment.
MAIN OUTCOMES AND MEASURES Nasal and endotracheal samples were collected at baseline as
Meaning In this study, high doses of
well as at 24 hours and 48 hours after start of treatment. The secondary outcome was to determine
AZM were safe, reduced endotracheal
treatment effect on clinical outcome measures, including days of positive pressure ventilation and
MMP-9 levels in patients receiving
length of hospital stay.
mechanical ventilation, and potentially
improved outcomes in critically ill
RESULTS A total of 48 patients were enrolled in the trial, with a median (range) age at
children with respiratory syncytial virus
randomization of 12 (1 to 125) months; 36 participants (75.0%) were younger than 2 years. Overall, 26
infections.
participants (54.2%) were boys, and 29 (60.4%) had a comorbidity. A total of 16 patients were
randomized into each trial group (ie, placebo, standard-dose AZM, and high-dose AZM). Baseline
demographic characteristics were comparable among the 3 groups. Both doses of AZM were safe, + Visual Abstract
with no adverse events observed. No difference in nasal MMP-9 levels were observed between
treatment groups. Among those who required mechanical ventilation and received high-dose AZM,
+ Supplemental content
Author affiliations and article information are
endotracheal active and total MMP-9 levels were lower on day 3. Compared with baseline, active and
listed at the end of this article.
total MMP-9 levels in endotracheal aspirates were 1.0 log lower in the high-dose AZM group (active
MMP-9: 99.8% CI, −1.28 to −0.64; P < .001; total MMP-9: 99.8% CI, −1.37 to −0.57; P < .001).
Patients who received high-dose AZM had fewer median (interquartile range) hospital days
compared with those receiving the placebo (8 [6-14] days vs 11 [8-20] days; mean ratio estimate,
0.57; 95% CI, 0.38-0.87; P = .01).

(continued)

Open Access. This is an open access article distributed under the terms of the CC-BY License.

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Abstract (continued)

CONCLUSIONS AND RELEVANCE In this phase 2 randomized clinical trial, both doses of AZM were
safe. While nasal MMP-9 levels were unchanged among treatment groups, endotracheal MMP-9
levels were lower among those who received high-dose AZM. The positive secondary clinical
outcome, while exploratory, provides insight for end points in a multicenter randomized trial.

TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02707523

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Introduction
Respiratory syncytial virus (RSV) infection has a substantial global disease burden.1-4 Matrix
metalloproteinases (MMPs) are proteases implicated in the pathogenesis of both acute and chronic
lung disease.5-11 In 2015, we reported12 that early elevation of endotracheal MMP-9 levels was
positively associated with RSV disease severity and that MMP-9 inhibition decreased RSV replication
in a murine model, suggesting that MMP-9 might be a potential marker of disease severity and a
therapeutic target in RSV disease.
Macrolides are a class of antibiotics that are known to penetrate cells, making them active
against intracellular pathogens; azithromycin (AZM) is reported to have a long intracellular half-life.13
In addition, AZM is an immune modulator that has been reported to provide clinical benefit in
inflammatory airway diseases.14,15 Therefore, we performed a randomized, placebo-controlled phase
2 trial to test the hypothesis that AZM therapy during RSV-induced respiratory failure was safe and
would reduce nasal and lung MMP-9 levels as well as to explore preliminary effects on the disease
course for planning a subsequent definitive trial.

Methods
Participants
Eligible participants included all children admitted to the pediatric intensive care unit (PICU) at
Children’s of Alabama (Birmingham) with a diagnosis of RSV infection and requiring positive pressure
ventilation, invasive or noninvasive, including bilevel positive airway pressure (BiPAP) or high-flow
nasal cannula (HFNC) oxygen (ie, >1 L/kg/min of flow, with ⱖ5 L/min flow for children weighing <5
kg). When the trial began in February 2016, it only included patients with RSV with respiratory failure
requiring mechanical ventilation, but in December 2016, it was expanded to include patients with
respiratory failure supported on noninvasive positive pressure ventilation. This was to reflect the
overall change in the PICU’s practice whereby more patients had a trial of management using BiPAP
or HFNC before mechanical ventilation. Exclusion criteria included use of AZM within 7 days of PICU
admission, any contraindication to AZM use, cardiac arrhythmias, electrocardiogram with QT interval
corrected for heart rate of at least 450 milliseconds, history of pyloric stenosis, and receipt of
immunosuppressant.
During hospitalization, all patients were treated according to the American Academy of
Pediatrics guidelines for the management of bronchiolitis,16 primarily supportive care. The study
protocol was approved by the University of Alabama at Birmingham institutional review board, and a
data and safety monitoring board serially evaluated the study. An Investigational New Drug approval
was obtained from the US Food and Drug Administration for the use of AZM in this trial
(Investigational New Drug number, 127632). Participants’ legal guardians provided written informed
consent before randomization into the trial. The Consolidated Standards of Reporting Trials (CONSORT)
guideline was used for the reporting of this trial.17 The trial protocol is available in Supplement 1.

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Study Design and Treatment

The study was a double-masked, placebo-controlled parallel group trial with 3 treatment groups. All
participants, their families, health care professionals, and study staff were masked to study
medication allocation, with the exception of the biostatistician and the pharmacist. Participants were
randomized according to a permuted-block design to receive either placebo (saline) or AZM
(Fresenius Kabi) at 10 mg/kg/d (ie, standard dose) or 20 mg/kg/d (ie, high dose) intravenously every
24 hours for 3 days. The randomization schedule was created by the study biostatistician and
provided to the study pharmacist for implementation.
Nasal and endotracheal samples (if intubated) were collected from all participants before
treatment as well as at 24 hours and at 48 hours after treatment started. For patients who were
intubated, only nasal samples were collected once extubated. No long-term follow-up was
performed.
The study spanned 3.5 RSV seasons, from February 2016 to February 2019. Owing to the initial
age restriction placed by the Food and Drug Administration, the first 9 participants enrolled were
older than 6 months. Once this number was reached and no safety concerns were evident as
determined by the data and safety monitoring board, infants younger than 6 months were eligible for
enrollment in the study.
The primary outcomes of this trial were as follows: (1) to ascertain the safety of AZM and its
pharmacokinetics and (2) to determine whether treatment with AZM resulted in decreased nasal
MMP-9 levels. When the study protocol was expanded to include patients who were not ventilated,
the primary outcome also changed from endotracheal MMP-9 levels to nasal MMP-9 levels. The
secondary outcomes were to determine the in vivo efficacy of AZM administration on improving
clinical outcome measures, specifically duration of ventilatory support and oxygenation as well as
PICU and hospital lengths of stay.

Nasal and Endotracheal Aspirate Collection and Processing

Nasal samples were collected using a nasal swab inserted through the nares. The swab was then
immediately placed in a vial containing 3 mL of viral transport media (Quidel). Endotracheal aspirates
were collected via endotracheal tube suctioning using an 8 French suction cannula (CareFusion) and
centrifuged at 500g for 10 minutes to separate supernatant from cells and mucus (pellet). All
samples were kept at 4 °C for further analysis.

Assay of AZM and Urea Levels and Pharmacokinetic Analysis

We measured AZM and urea levels in endotracheal and plasma samples using liquid
chromatography–tandem mass spectrometric assays. Dilution estimations of endotracheal samples
were calculated using the urea dilution method.18 Peak plasma levels (Cmax) and time to Cmax (Tmax)
of AZM were determined by visual evaluation of the concentration vs time profile. The area under
the curve (AUC) values were calculated using the trapezoidal rule. The half-life (t1/2) of AZM was
calculated as natural log of 2 / ke, in which ke was the terminal elimination rate constant estimated by
linear regression analysis of the terminal portion of the concentration-time profile. Penetration ratios
for AZM in samples from the endotracheal compartment were calculated as the AUC of the
endotracheal compartment divided by the AUC of plasma.

Biologic Outcome Measurement

Measurement of active MMP-9, total MMP-9, and tissue inhibitor of metalloproteinase 1 (TIMP-1)
were done using established fluorometric assays (F9M00 and DTM100, respectively; R&D Systems).
Interleukin 1 (IL-1), IL-2, IL-4, IL-6, IL-8, IL-10, IL-12, IL-13, tumor necrosis factor α (TNF-α), and
interferon γ (IFN-γ) were analyzed via electrochemiluminescence using the Meso Scale Discovery
V-PLEX Cytokine Panel 1 Human Kit (K15049D-1; Meso Scale Diagnostics). We measured RSV loads by
reverse-transcription quantitative polymerase chain reaction using known concentrations of RSV to

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derive a standard curve.19 Standards and negative controls were included and tested with each
polymerase chain reaction assay. We reported RSV quantification as log10 copies per mL.

Clinical Data Assessment

The clinical data collected included duration of respiratory support (focusing on days of mechanical
ventilation, noninvasive positive pressure ventilation via BiPAP or HFNC, and total duration of
supplemental oxygen), PICU stay, and hospital stay. Comorbidities and the presence of multiorgan
failure20 were also identified.

Sample Size Determination and Statistical Analysis

This study was designed to have a total sample of 48 participants divided in 3 groups, with 16 per
group, to detect a 25% and 37.5% decrease in lung MMP-9 activity in the standard-dose and high-
dose groups, respectively, relative to placebo, with 80% power using analysis of variance. The
assumptions were based on MMP-9 levels found in endotracheal aspirate of children with
RSV-induced respiratory failure.13

Statistical Analysis
Means, standard deviations, medians, quartiles, and ranges (minimum, maximum) were used to
describe continuous variables, and counts and percentages were used for categorical variables. To
compare baseline characteristics among the treatment groups, we used the Kruskal-Wallis test for
age, height, and weight due to evidence of nonnormality of the distribution of the values. We used
either χ2 or Fisher exact test for categorical variables depending on expected cell counts.
We analyzed inflammatory markers by first performing log10 transformation to address the
skewedness of the distribution and extreme outliers. We then calculated the difference at each point
relative to baseline to obtain the change (ie, pretreatment and posttreatment) outcome and fitted a
generalized linear mixed model with random intercepts and assumed unequal variances across
treatment groups with change from baseline as the outcome. The Bonferroni approach was used to
adjust for multiple testing (with a 2-tailed P < .002 as the threshold for statistical significance) and
simultaneous confidence intervals (99.8% confidence level).
For clinical outcomes (measured in number of days), we used a generalized linear model
assuming a negative binomial distribution using log link function to address possible overdispersion
due to some extreme observations. For this set of analyses, a 2-tailed P < .05 was set as the level of
significance, with 95% CIs. All analyses were done using SAS version 9.4 (SAS Institute).

Results
Enrollment and Baseline Characteristics
A total of 147 patients were screened, and 48 patients (32.7%) were randomized (Figure 1). All
enrolled patients completed the study. The median (range) age of patients at randomization was 12
(1-125) months, with 36 (75.0%) younger than 2 years. Overall, 26 participants (54.2%) were boys,
and 29 (60.4%) had a comorbidity. Baseline demographic characteristics were comparable among
the 3 groups (eTable in Supplement 2). At the time of randomization, 34 patients (70.8%) required
mechanical ventilation, 2 (4.2%) received BiPAP support, and the remaining 12 patients (25.0%)
received HFNC. Once extubated, 4 (11.8%) received BiPAP, and 22 (64.8%) were transitioned to
HFNC. A total of 5 of 34 patients (14.7%) were extubated before day 3. No patients who initially
received BiPAP or HFNC at randomization required intubation.

Pharmacokinetics of AZM
The pharmacokinetic parameters for AZM are listed in Table 1. A linear dose-dependent response
was observed for the mean (SD) AUC values of AZM in plasma between the standard-dose and high-
dose groups (14.8 [5.5] μg x h/mL vs 25.3 [13.2] μg x h/mL), while a nonlinear dose response was

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noted for the endotracheal samples between AZM groups (892.4 [383.7] μg x h/mL vs 807.3 [331.0]
μg x h/mL). We observed that mean (SD) Cmax values were higher in the high-dose group for plasma
than in the standard-dose group (0.34 [0.06] μg/mL vs 0.22 [0.09] μg/mL; P < .001) and
comparable for corresponding endotracheal samples (8.7 [1.1] μg/mL vs 11.0 [1.5] μg/mL; P = .008).
The times to Cmax were the same between dose groups for plasma and for endotracheal samples in
the standard-dose group, but it was prolonged for the endotracheal samples in the high-dose group.
An inverse dose-dependent penetration ratio (2:1) was observed in the endotracheal samples
between the standard-dose and high-dose groups, respectively (48 h for the standard-dose group;
96 h for the high-dose group). This observation was due to comparable endotracheal AUC values
between dose groups, while the plasma AUC values exhibited a linear dose dependent relationship.
The comparable endotracheal AUC values were likely due to extensive distribution of AZM in the
respiratory tract, resulting in drug saturation.

Safety Profile and Adverse Events

All participants were monitored daily for adverse events using National Institutes of Health event
recording21 from the time of study enrollment until discharge from the PICU. No gastrointestinal
adverse events (ie, diarrhea, vomiting, or abdominal distention), feeding intolerance, thrush,
intravenous site reactions, or rash were documented in any of the study participants. We measured
QT interval corrected for heart rate daily during the treatment phase, and all were within normal
range. There were no abnormal vital signs or arrhythmias noted during or within 4 hours of drug
administration. Finally, no abnormal laboratory values attributable to the study drug were
documented.

Figure 1. Flow Diagram of Trial

147 Children assessed for eligibility

99 Excluded
39 Met an exclusion criterion
30 Had an initial age limitation
6 Had no guardian present
14 Had no pharmacy support
1 Had a language barrier
9 Declined to participate

48 Randomized

16 Randomized to and received 16 Randomized to and received 16 Randomized to and received

high-dose AZM standard-dose AZM placebo

16 Analyzed 16 Analyzed 16 Analyzed

AZM indicates azithromycin.

Table 1. Pharmacokinetic Parameters for Standard- and High-Dose AZM Using Urea-Corrected Data

Mean (SD)
Receiving 10 mg/kg AZM Receiving 20 mg/kg AZM
Parameter Plasma Endotracheal Plasma Endotracheal
Cmax, μg/mL 0.22 (0.09) 11 (1.5) 0.34 (0.06) 8.7 (1.1)
Tmax, h 48 48 48 96
AUC, 0-144 h, μg × h/mL 14.8 (5.5) 892.4 (383.7) 25.3 (13.2) 807.3 (331)
AUCendotracheal / AUCplasma 60.3 31.9 Abbreviations: AUC, area under the curve; AZM,
azithromycin; Cmax, peak plasma levels; Tmax, time to
Half-life, h 76 (17) 78 (31) 102 (33) 385 (63)
peak plasma levels.

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Profiles of MMP-9 and Cytokine Levels at Baseline and After Treatment

In nasal secretions, compared with baseline values, no difference was noted in active and total
MMP-9 levels or the level of its natural inhibitor, TIMP-1, at hour 48 or hour 72 after treatment started
in all 3 groups (Figure 2A, Figure 2B, and Figure 2C). At 48 hours after treatment began, the
endotracheal aspirates showed that active MMP-9 was 0.4 log lower (99.8% CI, −1.07 to 0.28;
P = .051) in the placebo group, 0.3 log lower (99.8% CI, −1.42 to 0.85; P = .39) in the standard-dose
AZM group, and 0.5 log lower (99.8% CI, −1.04 to 0.14; P = .01) in the high-dose AZM group

Figure 2. Change in MMP-9 and TIMP-1 Levels

A Nasal active MMP-9 levels B Nasal total MMP-9 levels

2 1.0

0.5
1
Mean change

Mean change

–0.5

–1
–1.0

–2 –1.5
48 h 72 h 48 h 72 h 48 h 72 h 48 h 72 h 48 h 72 h 48 h 72 h
Placebo AZM 10 mg/kg AZM 20 mg/kg Placebo AZM 10 mg/kg AZM 20 mg/kg

C Nasal TIMP-1 levels D Endotracheal active MMP-9 levels

2 1

1 0
Mean change

Mean change

0 –1

–1 –2
48 h 72 h 48 h 72 h 48 h 72 h 48 h 72 h 48 h 72 h 48 h 72 h
Placebo AZM 10 mg/kg AZM 20 mg/kg Placebo AZM 10 mg/kg AZM 20 mg/kg

E Endotracheal total MMP-9 levels F Endotracheal TIMP-1 levels

1 1.0

0.5

0 Each panel shows the estimate of means with 99.8%

Mean change

Mean change

0
CIs, whereby treatment effect is defined as the change
(ie, posttreatment minus pretreatment) at each day
–0.5 for a given treatment. Therefore, a nonzero mean
–1 difference indicates a treatment effect for the given
day and treatment (placebo vs standard-dose
–1.0
azithromycin [AZM] vs high-dose AZM) for the
cytokines measured in the nasal and endotracheal
–2 –1.5 secretions. MMP-9 indicates matrix
48 h 72 h 48 h 72 h 48 h 72 h 48 h 72 h 48 h 72 h 48 h 72 h metalloproteinase–9; and TIMP-1, tissue inhibitor of
Placebo AZM 10 mg/kg AZM 20 mg/kg Placebo AZM 10 mg/kg AZM 20 mg/kg metalloproteinase–1.

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compared with baseline values (Figure 2D). At 72 hours after treatment began, active MMP-9 levels
in endotracheal aspirates were 0.4 log lower (99.8% CI, −1.45 to 0.70; P = .23) in the placebo group,
0.4 log lower (99.8% CI, −1.86 to 1.05; P = .34) in the standard-dose AZM group, and 1.0 log lower
(99.8% CI, −1.28 to −0.64; P < .001) in the high-dose AZM group compared with baseline values
(Figure 2D).
At 48 hours after treatment began, total MMP-9 levels in endotracheal aspirates were 0.4 log
lower (99.8% CI, −1.01 to 0.29; P = .06) in the placebo group, 0.5 log lower (99.8% CI, −1.98 to 0.89;
P = .20) in the standard-dose AZM group, and 0.5 log lower (99.8% CI, −0.92 to 0.02; P = .003) in
the high-dose AZM group compared with baseline values (Figure 2E). At 72 hours after treatment
began, total MMP-9 in endotracheal aspirates was 0.4 log lower (99.8% CI, −1.26 to 0.52; P = .16) in
the placebo group, 0.5 log lower (99.8% CI, −1.80 to 0.86; P = .23) in the standard-dose AZM group,
and nearly 0.97 log lower (99.8% CI, −1.37 to −0.57; P < .001) in the high-dose AZM group compared
with baseline values (Figure 2E). No significant difference was observed in endotracheal TIMP-1
values before and after treatment among the placebo and AZM groups (Figure 2F). Endotracheal
TNF-α was 1.2 log lower (TNF-α: 99.8% CI, −1.92 to −0.47; P < .001) and IL-1 was 1.1 log lower (99.8%
CI, −1.77 to −0.35; P < .001) in the high-dose AZM group 48 hours after treatment began compared
with baseline (eFigures 1A and 1B in Supplement 2). Likewise, endotracheal IL-10 was 0.84 log lower
(99.8% CI, −1.48 to −0.21; P < .001) at hour 48 and 1.2 logs lower (99.8% CI, −1.74 to −0.58; P < .001)
72 hours after treatment began compared with baseline in the high-dose AZM group (eFigure 1C in
Supplement 2). No significant differences were observed for nasal TNF-α, IL-1, and IL-10 or for nasal
and endotracheal INF-γ, IL-2, IL-6, IL-8, IL-12, and IL-13 in the placebo and both AZM groups (data not
shown). Absolute concentrations of nasal active MMP-9, total MMP-9, and TIMP-1 as well as
endotracheal active MMP-9, total MMP-9, TIMP-1, TNF-α, IL-1, and IL-10 are shown for pretreatment,
48 hours after treatment began, and 72 hours after treatment began in eFigure 2 in Supplement 2.

Viral Load
At baseline, the mean (SD) RSV load measured in the endotracheal aspirate was no different among
the 3 groups at 2.6 (1.0) log10 plaque-forming unit (PFU)/mL in the placebo group, 2.5 (1.5) log10
PFU/mL in the standard-dose AZM group, and 2.1 (0.8) log10 PFU/mL in the high-dose AZM group. On
day 2 of treatment, the mean (SD) RSV load decreased to 1.2 (0.5) log10 PFU/mL in the placebo group,
1.2 (0.5) log10 PFU/mL in the standard-dose AZM group, and 0.36 (0.2) log10 PFU/mL in the high-
dose AZM group. On day 3 of treatment, the mean (SD) RSV load was lowest in the high-dose AZM
group, at 0.1 (0.1) log10 PFU/mL compared with 1.1 (0.4) log10 PFU/mL in the standard-dose AZM
group, and 0.4 (0.3) log10 PFU/mL in the placebo group, but this did not reach statistical significance
(P = .49) (eFigure 3A and 3B in Supplement 2). Nasal RSV titer correlated positively with INF-γ on
day 3 (R2 = 0.47; P = .002). For children who were intubated, endotracheal RSV titer positively
correlated with INF-γ at randomization (R2 = 0.44; P = .01) and, for the treatment group, at 24 hours
after treatment began (R2 = 0.64; P = .004) and 48 hours after treatment began (R2 = 0.52;
P = .05). No correlation was seen between viral titer and all other measured cytokines in both the
nasal and endotracheal aspirate (data not shown).

Clinical Outcomes
Table 2 summarizes the clinical outcome findings (ie, days of ventilator support, mechanical
ventilation, BiPAP, HFNC, oxygenation, durations of PICU and hospital stay, and presence of
multiorgan failure) for the entire study cohort as well as for the placebo and AZM treatment groups
separately. Table 3 summarizes the overall treatment effect on clinical variables and by group
comparisons. Median (interquartile range) length of hospital stay was lower in the high-dose group
than the placebo group (8 [6-14] days vs 11 [8-20] days; mean ratio estimate, 0.57; 95 CI, 0.38-0.87;
P = .01).

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Table 2. Clinical Outcome Measures

AZM
Outcome All (N = 48) Placebo (n = 16) 10 mg/kg (n = 16) 20 mg/kg (n = 16) P value for treatment effecta
b
Ventilator support, d
Mean (SD) 8.3 (8.7) 11.6 (13.1) 8.4 (6.1) 4.9 (2.9)
.06
Median (IQR) [range] 6 (3-11) [1-56] 7 (4-14) [2-56] 7 (3-14) [1-20] 5 (3-7) [1-11]
Mechanical ventilation, dc
Mean (SD) 4.3 (4.2) 4.8 (3.4) 5.6 (5.5) 2.6 (2.8)
.54
Median (IQR) [range] 4 (0-7) [0-16] 4 (3-8) [0-11] 5 (0-10) [0-16] 2 (0-5) [0-8]
BiPAP, dd
Mean (SD) 1.4 (7.7) 3.6 (13.2) 0.4 (1.5) 0.1 (0.3)
.02e
Median (IQR) [range] 0 (0-0) [0-53] 0 (0-0) [0-53] 0 (0-0) [0-6] 0 (0-0) [0-1]
HFNC, df
Mean (SD) 2.6 (3.1) 3.3 (4.9) 2.4 (2.0) 2.3 (1.7)
.81
Median (IQR) [range] 2 (1-3) [0-18] 2 (0-3) [0-18] 2 (1-5) [0-6] 2 (1-3) [0-6]
Oxygen, d
Mean (SD) 9.1 (6.6) 11.0 (8.7) 9.6 (5.8) 6.6 (4.0)
.10
Median (IQR) [range] 7 (4-13) [2-31] 8 (5-16) [2-31] 8 (5-16) [2-20] 6 (4-8) [2-15]
PICU stay, d
Mean (SD) 7.1 (4.6) 7.7 (4.4) 8.1 (5.8) 5.4 (2.7)
.09
Median (IQR) [range] 5 (4-10) [2-19] 7 (5-10) [2-19] 6 (4-13) [2-19] 5 (4-7) [2-11]
Hospital stay, d
Mean (SD) 12.2 (9.1) 15.8 (13.1) 11.8 (6.5) 9.1 (4.7)
.04
Median (IQR) [range] 10 (6-16) [2-57] 11 (8-20) [3-57] 10 (7-17) [4-25] 8 (6-14) [2-16]
Multiorgan failure
Yes 3 (6.3) 2 (12.5) 1 (6.2) 0
No 45 (93.7) 14 (87.5) 15 (93.8) 16 (100)

Abbreviations: AZM, azithromycin; BiPAP, bilevel positive airway pressure; HFNC, high- tracheostomy before discharge home on positive pressure ventilation. When this
flow nasal cannula; IQR, interquartile range; PICU, pediatric intensive care unit. outlier was removed, revised analyses changed BiPAP treatment effect (P = .13), with
a
P value and estimates with 95% confidence intervals for ratio of means based on fitting pairwise comparison P values of .05 (AZM 20 vs AZM 10), .61 (AZM 10 vs placebo) and
a generalized linear model assuming negative binomial distribution. .13 (AZM 20 vs placebo); and ventilation support treatment effect (P = .03), with
b pairwise comparison P values of .02 (AZM 20 vs AZM 10), .93 (AZM 10 vs placebo), and
Ventilator support days is the sum of mechanical ventilation, BiPAP, and HFNC days.
.02 (AZM 20 vs placebo).
c
At randomization, there were 34 intubated patients (70.8%); 13 (81.3%) in the placebo f
At randomization, there were 12 patients (25.0%) receiving HFNC; 2 (12.5%) in the
group, 11 (68.8%) in the group receiving AZM 10 mg/kg, and 10 (62.5%) in the group
placebo group, 5 (31.3%) in the group receiving AZM 10 mg/kg, and 5 (31.3%) in the
receiving AZM 20 mg/kg.
group receiving AZM 20 mg/kg.
d
At randomization, there were 2 patients (4.2%) receiving BiPAP; 1 (6.3%) in the
placebo group and 1 (6.3%) in the group receiving AZM 20 mg/kg.
e
There was an outlier in the placebo group who received BiPAP for 53 days. This patient
had congenital myopathy and was unable to wean off BiPAP and received a

Table 3. Mean Ratio Estimates for Clinical Outcomes

AZM 20 mg/kg vs AZM 10 mg/kg AZM 10 mg/kg vs Placebo AZM 20 mg/kg vs Placebo
Mean ratio estimate Mean ratio estimate Mean ratio estimate
Outcome (95% CI)a P valuea (95% CI)a P valuea (95% CI)a P valuea
Ventilator support 0.59 (0.15-2.35) .44 0.73 (0.17-3.13) .67 0.43 (0.21-0.86) .02
Mechanical ventilation 0.47 (0.07-2.98) .41 1.18 (0.20-7.10) .85 0.55 (0.17-1.80) .32
BiPAP 0.14 (0.02-1.18) .07 0.12 (0.00-4.49) .25 0.02 (0.00-0.44) .02
HFNC 0.95 (0.30-3.04) .93 0.73 (0.17-3.21) .67 0.69 (0.22-2.20) .52
Oxygen 0.69 (0.43-1.10) .12 0.87 (0.55-1.37) .54 0.60 (0.38-0.97) .04
PICU stay 0.67 (0.45-1.02) .06 1.05 (0.69-1.60) .82 0.71 (0.49-1.02) .07
Hospital stay 0.77 (0.53-1.13) .18 0.74 (0.49-1.14) .17 0.57 (0.38-0.87) .01
a
Abbreviations: AZM, azithromycin; BiPAP, bilevel positive airway pressure; HFNC, high- P value and estimates with 95% confidence intervals for ratio of means based on fitting
flow nasal cannula; PICU, pediatric intensive care unit. a generalized linear model assuming negative binomial distribution.

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Discussion
To the best of our knowledge, this is the first randomized placebo-controlled trial of AZM at multiple
doses in children with severe RSV infection and lung disease who required PICU management and
positive pressure ventilation. We demonstrated preliminary efficacy of AZM, specifically at a higher
dose, in the reduction of biomarkers modulated by RSV infection and in reducing duration of
hospitalization in a critically ill cohort of hospitalized children.
Disease severity in RSV infection has been linked with excessive release of cytokines.22-27
Previous studies have shown that AZM attenuates cytokine production, which may reduce the
disease severity seen in respiratory viral infections.28 Furthermore, preclinical studies have shown
the antiviral effects of AZM.29,30 Given these properties, AZM has been studied for its potential use
as targeted therapy for a wide spectrum of viral respiratory infections, including RSV. However,
clinical trials of AZM and other macrolides in RSV infection have yielded conflicting results. In the first
trial by Tahan et al,31 the investigators reported that treatment with clarithromycin reduced hospital
length of stay and supplemental oxygen need compared with placebo. In contrast, subsequent trials
using enteral AZM failed to demonstrate any clinical benefit.32-35 In previously reported negative
trials, the study design, including patient population (non-ICU patients), macrolide dosing (1-3 doses
during 1-14 days), and route of AZM administration (enteral) likely contributed to the difference seen
in the findings of this trial. In a 2015 trial,15 treatment of RSV bronchiolitis with AZM reduced overall
respiratory morbidity and, in another,36 decreased the progression to severe lower respiratory tract
infection in preschool children.
Given the uncertainty regarding optimal dosing to achieve anti-inflammatory activity, we
included a high-dose AZM group to maximize the likelihood of achieving adequate and sustained
AZM levels. Others have suggested increased effectiveness of high-dose AZM in Ureaplasma
urealyticum clearance in preterm infants.37-39 In this study, we demonstrated that high doses of AZM
were safe. Although the nasal levels of MMP-9, TIMP-1, and the other RSV-related cytokines were
similar among the placebo and AZM treatment groups, endotracheal active and total MMP-9, TNF-α,
IL-1, and IL-10 were lower after treatment in the high-dose AZM group compared with baseline
values. We also observed that RSV titer in the nasal and lung compartment decreased among all
patients, and although those treated with high doses of AZM had the lowest viral burden at the end
of the third dose, this finding was not significant. Although exploratory in nature, we also found that
the median number of hospital days was approximately 3 days less in the high-dose group compared
with the placebo group.

Limitations
This study has limitations, including its small sample size. Although we observed decreased numbers
of ventilator support and oxygen days as well as shorter duration of PICU stay in the high-dose AZM
group, future studies will need to be powered to detect changes in these clinical outcome measures
based on the findings of this trial. Also, it is possible that practice variation might have contributed
to the clinical differences seen between the placebo vs treatment group. However, the masking of
the study ensured no biases toward any particular group, and practice variation was also limited
given that our unit in general follows the same respiratory weaning protocol. Furthermore,
sensorineural hearing loss is a possible, although rare, adverse effect of AZM use and was not tested
in our patients.

Conclusions
We found that both doses of AZM were safe. No difference was observed in nasal MMP-9 levels
across all groups. Patients who received high-dose AZM had lower endotracheal MMP-9 levels and
had fewer hospitalization days. This trial provides the necessary foundation to plan a larger,

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multicenter randomized clinical trial that will be critical in determining the clinical effectiveness of
high-dose AZM among children with severe RSV lung disease.

ARTICLE INFORMATION
Accepted for Publication: February 21, 2020.
Published: April 23, 2020. doi:10.1001/jamanetworkopen.2020.3482
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Kong M et al.
JAMA Network Open.
Corresponding Author: Michele Kong, MD, Department of Pediatrics, University of Alabama at Birmingham, 1600
Fifth Ave S, PPS 102, Birmingham, AL 35233 (mkong@peds.uab.edu).
Author Affiliations: Department of Pediatrics, University of Alabama at Birmingham (Kong, Zhang, Sewell, Kuo,
Aban, Ambalavanan, Whitley); McWhorter School of Pharmacy, Samford University, Birmingham,
Alabama (Gorman).
Author Contributions: Dr Kong had full access to all of the data in the study and takes responsibility for the
integrity of the data and the accuracy of the data analysis. Drs Ambalavanan and Whitley contributed equally to
this work.
Concept and design: Kong, Aban, Ambalavanan, Whitley.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Kong, Sewell, Gorman, Aban, Ambalavanan.
Critical revision of the manuscript for important intellectual content: Kong, Zhang, Gorman, Kuo, Aban,
Ambalavanan, Whitley.
Statistical analysis: Kong, Kuo, Aban.
Obtained funding: Kong.
Administrative, technical, or material support: Kong, Zhang, Sewell, Gorman, Ambalavanan, Whitley.
Supervision: Whitley.
Conflict of Interest Disclosures: Dr Aban reported receiving grants from the National Institutes of Health, the
Myasthenia Gravis Foundation of America, Alexion, argenx, Catalyst Pharmaceutical, RA Pharmaceutical, and the
Transverse Myelitis Association outside the submitted work. Dr Amabalavanan reported receiving grants from the
National Institutes of Health during the conduct of the study. Dr Whitley reported receiving grants from the
National Institutes of Health during the conduct of the study and receiving personal fees from Gilead Sciences
outside the submitted work. No other disclosures were reported.
Funding/Support: This work was funded by grant UL1TR003096 from the University of Alabama at Birmingham
Center for Clinical and Translational Science.
Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection,
management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and
decision to submit the manuscript for publication.
Data Sharing Statement: See Supplement 3.
Additional Contributions: We thank the members of the data and safety monitoring board, Nancy Tofil, MD
(chair; University of Alabama at Birmingham), Kim Benner, PharmD (McWhorter School of Pharmacy), Stephen
Robert, MD (Cedars Sinai), Charity Morgan, PhD (University of Alabama at Birmingham), and David Kimberlin, MD
(University of Alabama at Birmingham), for their time and oversight. We thank the Department of Pediatrics
Research Office and the University of Alabama at Birmingham Center for Clinical and Translational Science for their
ongoing support of this work. Finally, we thank the members of the scientific oversight committee, David Redden,
PhD (University of Alabama at Birmingham), and Steven Rowe, MD (University of Alabama at Birmingham), for
their insights. None of these individuals were compensated for their time.
Additional Information: Because of a data entry oversight in ClinicalTrials.gov, the primary outcomes were
originally listed only as azithromycin pharmacokinetics, oxygen support, and multiorgan system failure scores. No
secondary outcomes were listed. We provided regulatory documentation, including institutional review board
and Investigational New Drug submissions and approvals that confirmed studies performed prospectively on
these children, with the primary and secondary outcomes as stated in the manuscript.

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REFERENCES
1. Nair H, Nokes DJ, Gessner BD, et al. Global burden of acute lower respiratory infections due to respiratory
syncytial virus in young children: a systematic review and meta-analysis. Lancet. 2010;375(9725):1545-1555. doi:
10.1016/S0140-6736(10)60206-1
2. Shi T, Balsells E, Wastnedge E, et al. Risk factors for respiratory syncytial virus associated with acute lower
respiratory infection in children under five years: systematic review and meta-analysis. J Glob Health. 2015;5(2):
020416. doi:10.7189/jogh.05.020416
3. Buckingham SC, Quasney MW, Bush AJ, DeVincenzo JP. Respiratory syncytial virus infections in the pediatric
intensive care unit: clinical characteristics and risk factors for adverse outcomes. Pediatr Crit Care Med. 2001;2(4):
318-323. doi:10.1097/00130478-200110000-00006
4. Franklin D, Fraser JF, Schibler A. Respiratory support for infants with bronchiolitis, a narrative review of the
literature. Paediatr Respir Rev. 2019;30:16-24.
5. Kong MY, Gaggar A, Li Y, Winkler M, Blalock JE, Clancy JP. Matrix metalloproteinase activity in pediatric acute
lung injury. Int J Med Sci. 2009;6(1):9-17. doi:10.7150/ijms.6.9
6. Zinter MS, Delucchi KL, Kong MY, et al. Early plasma matrix metalloproteinase profiles: a novel pathway in
pediatric acute respiratory distress syndrome. Am J Respir Crit Care Med. 2019;199(2):181-189. doi:10.1164/rccm.
201804-0678OC
7. Devereux G, Steele S, Jagelman T, et al. An observational study of matrix metalloproteinase (MMP)-9 in cystic
fibrosis. J Cyst Fibros. 2014;13(5):557-563. doi:10.1016/j.jcf.2014.01.010
8. Cederqvist K, Sorsa T, Tervahartiala T, et al. Matrix metalloproteinases-2, -8, and -9 and TIMP-2 in tracheal
aspirates from preterm infants with respiratory distress. Pediatrics. 2001;108(3):686-692. doi:10.1542/peds.
108.3.686
9. Ma HP, Li W, Liu XM. Matrix metalloproteinase 9 is involved in airway inflammation in cough variant asthma. Exp
Ther Med. 2014;8(4):1197-1200. doi:10.3892/etm.2014.1903
10. Culpitt SV, Rogers DF, Traves SL, Barnes PJ, Donnelly LE. Sputum matrix metalloproteases: comparison
between chronic obstructive pulmonary disease and asthma. Respir Med. 2005;99(6):703-710. doi:10.1016/j.
rmed.2004.10.022
11. Cataldo DD, Bettiol J, Noël A, Bartsch P, Foidart JM, Louis R. Matrix metalloproteinase-9, but not tissue inhibitor
of matrix metalloproteinase-1, increases in the sputum from allergic asthmatic patients after allergen challenge.
Chest. 2002;122(5):1553-1559. doi:10.1378/chest.122.5.1553
12. Kong MY, Whitley RJ, Peng N, et al. Matrix metalloproteinase-9 mediates RSV infection in vitro and in vivo.
Viruses. 2015;7(8):4230-4253. doi:10.3390/v7082817
13. Labro MT. Intraphagocytic penetration of macrolides antibiotics. In: Bryskier J, Butzler JP, Neu HC, Tulkens PM,
eds. Macrolides: Chemistry, Pharmacology, and Clinical Use. Arnette Blackwell; 1993:379-388.
14. Cameron EJ, McSharry C, Chaudhuri R, Farrow S, Thomson NC. Long-term macrolide treatment of chronic
inflammatory airway diseases: risks, benefits and future developments. Clin Exp Allergy. 2012;42(9):1302-1312.
doi:10.1111/j.1365-2222.2012.03979.x
15. Beigelman A, Isaacson-Schmid M, Sajol G, et al. Randomized trial to evaluate azithromycin’s effects on serum
and upper airway IL-8 levels and recurrent wheezing in infants with respiratory syncytial virus bronchiolitis.
J Allergy Clin Immunol. 2015;135(5):1171-8.e1. doi:10.1016/j.jaci.2014.10.001
16. American Academy of Pediatrics Subcommittee on Diagnosis and Management of Bronchiolitis. Diagnosis and
management of bronchiolitis. Pediatrics. 2006;118(4):1774-1793. doi:10.1542/peds.2006-2223
17. Schulz KF, Altman DG, Moher D; CONSORT Group. CONSORT 2010 statement: updated guidelines for
reporting parallel group randomized trials. Ann Intern Med. 2010;152(11):726-732. doi:10.7326/0003-4819-152-11-
201006010-00232
18. Rennard SI, Basset G, Lecossier D, et al. Estimation of volume of epithelial lining fluid recovered by lavage using
urea as marker of dilution. J Appl Physiol (1985). 1986;60(2):532-538. doi:10.1152/jappl.1986.60.2.532
19. Bouzas ML, Oliveira JR, Queiroz A, et al; Acute Respiratory Infection and Wheeze Study Group Phase I and II.
Diagnostic accuracy of digital RNA quantification versus real-time PCR for the detection of respiratory syncytial
virus in nasopharyngeal aspirates from children with acute respiratory infection. J Clin Virol. 2018;106:34-40. doi:
10.1016/j.jcv.2018.07.003
20. Goldstein B, Giroir B, Randolph A; International Consensus Conference on Pediatric Sepsis. International
Pediatric Sepsis Consensus Conference: definitions for sepsis and organ dysfunction in pediatrics. Pediatr Crit Care
Med. 2005;6(1):2-8. doi:10.1097/01.PCC.0000149131.72248.E6

JAMA Network Open. 2020;3(4):e203482. doi:10.1001/jamanetworkopen.2020.3482 (Reprinted) April 23, 2020 11/13

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 JAMA Network Open | Critical Care Medicine Azithromycin (AZM) Treatment in Children With Respiratory Syncytial Virus (RSV)–Induced Respiratory Failure

21. National Heart, Lung, and Blood Institute. NHLBI adverse event and unanticipated problem reporting policy.
Accessed March 17, 2020. https://www.nhlbi.nih.gov/grants-and-training/policies-and-guidelines/nhlbi-adverse-
event-and-unanticipated-problem-reporting-policy
22. Kong MY, Clancy JP, Peng N, et al. Pulmonary matrix metalloproteinase-9 activity in mechanically ventilated
children with respiratory syncytial virus. Eur Respir J. 2014;43(4):1086-1096. doi:10.1183/09031936.00105613
23. Gern JE, Martin MS, Anklam KA, et al. Relationships among specific viral pathogens, virus-induced
interleukin-8, and respiratory symptoms in infancy. Pediatr Allergy Immunol. 2002;13(6):386-393. doi:10.1034/j.
1399-3038.2002.01093.x
24. Lee IT, Lin CC, Wu YC, Yang CM. TNF-alpha induces matrix metalloproteinase-9 expression in A549 cells: role
of TNFR1/TRAF2/PKCalpha-dependent signaling pathways. J Cell Physiol. 2010;224(2):454-464. doi:10.1002/
jcp.22142
25. Rutigliano JA, Graham BS. Prolonged production of TNF-α exacerbates illness during respiratory syncytial virus
infection. J Immunol. 2004;173(5):3408-3417. doi:10.4049/jimmunol.173.5.3408
26. Murai H, Terada A, Mizuno M, et al. IL-10 and RANTES are elevated in nasopharyngeal secretions of children
with respiratory syncytial virus infection. Allergol Int. 2007;56(2):157-163. doi:10.2332/allergolint.O-06-454
27. Tripp RA, Oshansky C, Alvarez R. Cytokines and respiratory syncytial virus infection. Proc Am Thorac Soc.
2005;2(2):147-149. doi:10.1513/pats.200502-014AW
28. Mosquera RA, De Jesus-Rojas W, Stark JM, et al. Role of prophylactic azithromycin to reduce airway
inflammation and mortality in a RSV mouse infection model. Pediatr Pulmonol. 2018;53(5):567-574. doi:10.1002/
ppul.23956
29. Gielen V, Johnston SL, Edwards MR. Azithromycin induces anti-viral responses in bronchial epithelial cells. Eur
Respir J. 2010;36(3):646-654. doi:10.1183/09031936.00095809
30. Schögler A, Kopf BS, Edwards MR, et al. Novel antiviral properties of azithromycin in cystic fibrosis airway
epithelial cells. Eur Respir J. 2015;45(2):428-439. doi:10.1183/09031936.00102014
31. Tahan F, Ozcan A, Koc N. Clarithromycin in the treatment of RSV bronchiolitis: a double-blind, randomised,
placebo-controlled trial. Eur Respir J. 2007;29(1):91-97. doi:10.1183/09031936.00029206
32. Kneyber MC, van Woensel JB, Uijtendaal E, Uiterwaal CS, Kimpen JL; Dutch Antibiotics in RSV Trial (DART)
Research Group. Azithromycin does not improve disease course in hospitalized infants with respiratory syncytial
virus (RSV) lower respiratory tract disease: a randomized equivalence trial. Pediatr Pulmonol. 2008;43(2):142-149.
doi:10.1002/ppul.20748
33. Pinto LA, Pitrez PM, Luisi F, et al. Azithromycin therapy in hospitalized infants with acute bronchiolitis is not
associated with better clinical outcomes: a randomized, double-blinded, and placebo-controlled clinical trial.
J Pediatr. 2012;161(6):1104-1108. doi:10.1016/j.jpeds.2012.05.053
34. McCallum GB, Morris PS, Chatfield MD, et al. A single dose of azithromycin does not improve clinical outcomes
of children hospitalised with bronchiolitis: a randomised, placebo-controlled trial. PLoS One. 2013;8(9):e74316.
doi:10.1371/journal.pone.0074316
35. McCallum GB, Morris PS, Grimwood K, et al. Three-weekly doses of azithromycin for indigenous infants
hospitalized with bronchiolitis: a multicentre, randomized, placebo-controlled trial. Front Pediatr. 2015;3:32. doi:
10.3389/fped.2015.00032
36. Bacharier LB, Guilbert TW, Mauger DT, et al. Early administration of azithromycin and prevention of severe
lower respiratory tract illnesses in preschool children with a history of such illnesses: a randomized clinical trial.
JAMA. 2015;314(19):2034-2044. doi:10.1001/jama.2015.13896
37. Hassan HE, Othman AA, Eddington ND, et al. Pharmacokinetics, safety, and biologic effects of azithromycin in
extremely preterm infants at risk for ureaplasma colonization and bronchopulmonary dysplasia. J Clin Pharmacol.
2011;51(9):1264-1275. doi:10.1177/0091270010382021
38. Viscardi RM, Othman AA, Hassan HE, et al. Azithromycin to prevent bronchopulmonary dysplasia in
ureaplasma-infected preterm infants: pharmacokinetics, safety, microbial response, and clinical outcomes with a
20-milligram-per-kilogram single intravenous dose. Antimicrob Agents Chemother. 2013;57(5):2127-2133. doi:10.
1128/AAC.02183-12
39. Merchan LM, Hassan HE, Terrin ML, et al. Pharmacokinetics, microbial response, and pulmonary outcomes of
multidose intravenous azithromycin in preterm infants at risk for Ureaplasma respiratory colonization. Antimicrob
Agents Chemother. 2015;59(1):570-578. doi:10.1128/AAC.03951-14

SUPPLEMENT 1.
Trial Procotol

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SUPPLEMENT 2.
eFigure 1. Endotracheal TNF-α, IL-1 and IL-10 Levels in the High-Dose Azithromycin Group After Treatment
eFigure 2. Cytokine Levels Measured in the Nasal and Endotracheal Compartment Among All Groups at Baseline
(Day 1), Day 2, and Day 3
eFigure 3. RSV Titer Measured Over Time for Patients in All 3 Groups
eTable. Demographic and Clinical Characteristics at Baseline

SUPPLEMENT 3.
Data Sharing Statement

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