Study design and patient’s selection
We conducted a single-blind, randomized, controlled clinical trial from February 2016 to May 2017 at the bone marrow transplantation center, Taleghani Teaching Hospital affiliated to Shahid Beheshti University of Medical Sciences, Tehran, Iran. The study was conducted in accordance to the declaration of Helsinki and was approved by the board of ethics committee in Shahid Beheshti University of Medical Sciences and registered in the Iranian Registry of Clinical Trials (IRCT201603093210N13). Written informed consent was signed by all participants or their legal guardians before enrollment.The inclusion criteria were defined as followed. Patients aged 15 years and older, being a nonsmoker, able to gargle mouthwash solution, with no history of liver disease and capability of reading and communicating with staff and able to sign the informed consents included to the study.Exclusion criteria included any serious adverse effect of azithromycin or allergic reaction to azithromycin suspension, and failure to follow the instruction to use oral protocol due to any variation of the patient’s health condition.All included patients were randomly assigned into two groups of azithromycin suspension and control. Randomization of patients was stratified with respect to age, gender, type of transplantation, and malignancy
Intervention
On the first day of hospitalization, patients are provided with instructions to maintain good oral hygiene. Based on bone marrow transplant (BMT) ward protocol, during the hospitalization time, patients in both groups received sodium chloride 0.9% and chlorhexidine mouthwash 5 mL three times daily to reduce the risk of oral infections.By adding 30 mL pre-boiled water to the bottle of Azithromycin (Tehran Cheimie Pharmaceutical Company, Tehran, Iran) powder up to the marked line, the suspension is ready to use by the concentration of 200mg/5mL. The prepared medication should be consumed by the patients in 48 hours 7.5 mL twice daily. On the first day of chemotherapy patients in the test group, received Azithromycin suspension. They were requested to shake well and gargle 7.5 mL suspension for 30 seconds or more and then swallow twice daily. The therapy continued to the engraftment day or mucositis resolution.Oral examination was performed from the first day of chemotherapy before intervention and daily thereafter. To control and manage the symptoms of OM after the occurrence, chlorhexidine mouthwash discontinued and symptoms were managed using a mouthwash containing diphenhydramine 12.5mg/5mL, lidocaine 2%, aluminum hydroxide 225mg/5mL, magnesium hydroxide 200mg/5mL, and nystatin 100000IU/12mL was prescribed. Refractory episodes of pain were controlled using opioids as patient control analgesia (PCA) administration in both groups until engraftment day or recovery of the mucosa. Also, patients in the intervention group were instructed to use Azithromycin suspension until the engraftment day or resolution of OM. Moreover, the standard protocol of the BMT ward continued for managing mucositis.
Assessment and outcome measures
For each patient, basic demographics and clinical data including age, gender, type of malignancy, type of transplantation, and any history of allergy to drugs were recorded in prepared sheets. laboratory data consisting of White Blood Cell (WBC), platelet count, blood culture before and after the intervention, time of total parenteral nutrition (PN) initiation and its duration (if any), need to opioid analgesic and dose of it (if any), need to receive antibiotics and length of hospital stay were recorded until discharge from the ward.All patients were assessed for OM episode incidence as the primary outcome. The patients were visited by the same practitioner to be examined in accordance with the mucositis and the practitioner was blinded to the allocation. Patients who were not excluded from the study and finished the protocol were analyzed. The secondary outcomes measured in both groups as the time of mucositis occurrence, duration of OM episodes, maximum grade and, average daily degree of mucositis, the necessity to receive other mucositis therapies, need to receive and duration of PN, antibiotics utilization, length of hospital stay, days with fever, first episode of infection and engraftment time. Also, patients were assessed for severity of the symptoms and pain, dryness of oral cavity, dysphagia and alteration taste perception, serum glutamate-pyruvate transaminase (SGPT), and serum glutamic-oxaloacetic transaminase (SGOT) (due to azithromycin side effect), Serum creatinine, were assessed and recorded for each patient during the study period.Engraftment time was represented as the day on which the absolute neutrophil count was greater than 500 per microliter for 3 days in a row and platelet count of 20000 per microliter for 3 consecutive days (16). Infection was considered as a positive blood culture and fever was defined as a single oral temperature equal, or more than a based on National Comprehensive Cancer Network (NCCN) guideline.National Cancer Institute Common Toxicity Criteria (NCI-CTC) version 4 mucositis scale was used to measure the OM severity (Table 1) (17). In patients developing OM, the Oral Mucositis Daily Assessment Worksheet was completed and the severity of symptoms was evaluated using the Numerical Rating Scale (NRS: 0-10).
Statistical analysis
Intention-to-treat analysis was considered. In the case of quantitative variables, the results were calculated as the mean ±standard deviation, and in the nominal and qualitative variables, the results were expressed as percentages. To compare quantitative variables with normal distribution, we used paired and unpaired t-test, and to compare quantitative variables with non-normal distribution, use Mann-U-Whitney test. Chi-square was used to compare qualitative and nominal variables. Whenever the chi-square test was more than 25% of the expected values less than 5, we used Fisher Exact test instead of the chi-square test. All tests were of two-tailed type. The normal distribution of the variables was evaluated using the Kolmogorov-Smirnov test. P-value less than 0.05 was considered statistically significant. Statistical analysis was performed using SPSS Version 22 software and Minitab software. The 2-sided p-value less than 0.05 is considered as significant.