Gallium Maltolate as an Alternative to Macrolides for Treatment of Presumed Rhodococcus equi Pneumonia in Foals

BACKGROUND: Macrolide‐resistant isolates of Rhodococcus equi are emerging, prompting the search for clinically effective alternative antimicrobials. HYPOTHESIS: The proportion of foals with ultrasonographic evidence of pneumonia presumed to be caused by R. equi that had a successful outcome when administered gallium maltolate (GaM) PO would not be more than 10% inferior (ie, lower) than that of foals receiving standard treatment. ANIMALS: Fifty‐four foals with subclinical pulmonary abscesses among 509 foals at 6 breeding farms in Kentucky. METHODS: Controlled, randomized, prospective noninferiority study. Foals with ultrasonographic lesions >1 cm in diameter (n = 54) were randomly allocated to receive per os either clarithromycin combined with rifampin (CLR+R) or GaM, and followed up for 28 days by daily physical inspections and weekly (n = 1 farm) or biweekly (n = 4 farms) thoracic ultrasound examinations by individuals unaware of treatment‐group assignments. Treatment success was defined as resolution of ultrasonographically identified pulmonary abscesses within 28 days of initiating treatment. Noninferiority was defined as a 90% confidence interval for the observed difference in CLR+R minus GaM that was ≤10%. RESULTS: The proportion of GaM‐treated foals that resolved (70%; 14/20) was similar to that of foals treated with CLR+R (74%; 25/34), but we failed to demonstrate noninferiority for GaM relative to CLR+R; however, GaM was noninferior to CLR+R treatment when results from a noncompliant farm were excluded. CONCLUSIONS AND CLINICAL IMPORTANCE: Gallium maltolate is not inferior to macrolides for treating foals with subclinical pneumonia. Use of GaM might reduce pressure for macrolide‐resistance in R. equi.