Efficacy of Azithromycin-Metronidazole Induction in Mild-to-Moderate Pediatric Crohn’s Disease

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MT Fioretti et al. J Pediatr Gastroenterol Nutr. 2025;80:300–307. A decade of real-world clinical experience with 8-week azithromycin–metronidazole combined therapy in pediatric Crohn’s disease

Methods: This retrospective study over 10 years examined the efficacy of azithromycin-metronidazole for induction treatment in 44 children. All patients were given metronidazole (15–20 mg/kg/day two times daily, maximum of 1000 mg/day) administered daily for 8 weeks and azithromycin (7.5 mg/kg to a maximum of 500 mg/once a day) administered 5 days per week for the first 4 weeks, followed by 3 days per week for the final 4 weeks as per the initial publications.17, 18 

Key findings:

  • After 8 weeks, the overall remission rate was 64%.
  • Of the 38 patients who completed the CD AZCRO course, 28 patients (74%) entered remission (Group 1) and 10 (26%) did not (Group 2)
  • After 8 weeks, Group 1 showed improved CRP levels and higher albumin and hemoglobin levels than Group 2. Median FC declined significantly from 650 mcg/g at baseline to 190 mcg/g at Week 8 in Group 1 (p < 0.001).

The authors conclude that “a combination treatment of azithromycin and metronidazole represents an alternative induction therapy for mild to moderate pediatric CD, offering benefits in terms of cost and practicalities compared to EEN and in side effects compared to steroids.”

My take: There are a small number of children with mild Crohn’s disease who could benefit from this induction regimen. An alternative would be the use of a more modest dietary approach (eg. Mediterranean diet)

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2 thoughts on “Efficacy of Azithromycin-Metronidazole Induction in Mild-to-Moderate Pediatric Crohn’s Disease”

  1. Dear Dr. Hochman,

    I truly enjoy all of your content and find it very insightful.

    I found this article particularly interesting as the rates of remission overall and per protocol are much higher than typically seen with medication alone, yet not quite as strong as EEN, hinting again that microbial aspects are the largest factor in the onset and progression of CD. Further supporting the most recent data showing that EEN’s effects on microbiome by diminishing pathogenic bacterial (although all bacteria are diminished similar to antibiotics) may be the most essential aspect explaining efficacy for EEN.

    I love that you also note to consider a more modest dietary approach. I only ask if you may consider offering a therapeutic diet, like CDED or SCD for an induction approach as MED alone has never been shown to induce remission, but to help maintain it. However, perhaps you’re referring to the additional improvements in symptoms and inflammation when adding MED to medications.

    We appreciate your help and support in awareness of our nutrition conference highlights. In our next newsletters we’ll have the nutritional highlights from ECCO with links to the full review. We’d appreciate your inclusion of this review link in a future communication. Do you receive our newsletter? if so, you’ll be notified when the review is ready. If you haven’t been to the website recently, we have expanded the recipe database to over 1,000 recipes with many filterable aspects and we’ve just released a new nutrition tool, the IBD Nutrition Navigator to facilitate nutrition conversations between providers and patients to find the right nutritional starting point. This is a project led by Dr. Ananthakrishnan and a dedicated team of pediatric and adult medical advisors in a two year long development process. Many have told us this is a useful tool particularly for those less familiar with nutrition in IBD. We’re excited about it’s potential to integrate nutrition in practice, with “an option for every patient”.

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