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Viewpoint: Azithromycin Always the Wrong Respiratory Drug

Mosley, Mark MD

doi: 10.1097/01.EEM.0000470686.95089.f0

Dr. Mosleyis the medical director for residency education at HCA/Wesley Medical Center in Wichita, KS.



The most common bacterial organisms for upper respiratory illness — sinusitis and otitis — in childhood and adults are Streptococcus pneumoniae and nontypeable Haemophilus influenzae. Even in diseases like bullous myringitis, the primary organism is S. pneumoniae, not Mycoplasma. (JPed Infect Dis 2004;23[5]:465; Pediatrics 1980;65[4]:761.)

Azithromycin may have streptococcal resistance higher than 25 percent in many places because of its overuse, and it performs no better than placebo in treating Haemophilus. (Ann Pharmacother 2010;44[3]:471; Cochrane Databse Syst Rev 2008; Apr 16[2]:CD000243; Am J Med Sci 1998;316[1]:13.) Cephalexin or clindamycin are better choices for penicillin-allergic patients with GABHS, not azithromycin. (Clin Infect Dis 2002;35[2]:113.) The majority of patients with sinusitis, otitis, and pharyngitis require no antibiotics, even when the infection is bacterial, but azithromycin is the wrong choice even when a decision is made to treat.

The majority of lower respiratory tract disease is viral. Bronchitis in a nonsmoker should not justify the use of azithromycin or any antibiotic. (“Get Smart: Know When Antibiotics Work,” Centers for Disease Control and Prevention; Calling it walking pneumonia is a shameful excuse. An antibiotic should not be automatic in smoker's bronchitis-chronic bronchitis-COPD, but reserved for severe cases with significant changes in sputum production. (Curr Opin Pulm Med 2015;21[2]:142.) Even here, one is only beating back colonization, so any antibiotic can be used with equal success. If one is fearful of the dreaded early pneumonia, amoxicillin would make more microbiological and financial sense.

The drug of choice for young children and adolescents with community-acquired pneumonia is amoxicillin (Clin Infect Dis 2011;53[7]:e25), and no advantage is conferred by adding a macrolide like azithromycin. (Pediatrics 2014;133[6]:1081.) The same appears to be true in adults. The non-ICU patient can usually be treated with monotherapy with ceftriaxone and no macrolide. (New Engl J Med 2015;372[14]:1312.) Even in the ICU, no advantage is seen for empirically covering for the rare case of Legionella.

Some claim they know they are overtreating and even mistreating with azithromycin, but they fear the patient will be dissatisfied that he didn't get his Z-Pak or that they will be written up for not meeting their hospital's pneumonia metrics. They shrug, and say, “What is the harm?”

There is great harm. While rare, prolonged QT leading to torsades can kill. Patients on SSRIs, methadone, and other drugs are placed at greater risk when prescribed azithromycin. (Clin Infect Dis 2006;43[12]:1603; Can J Hosp Pharm 2013;66[5]:328.) Overuse of azithromycin also increases streptococcal resistance, making it useless when the drug is necessary. And azithromycin is $40 for tablets and $50 for suspension, a significant cost to many ED patients (compared with $4 for amoxicillin). Finally, it harms our scientific and professional integrity. When we cost the patient money and potentially cause harm primarily to alleviate our own fears of missing something or getting a bad score, we have sacrificed what makes us a sacred profession. If we do not set ourselves apart with better medicine, then we become just another employed provider.

For the doc-in-a-box, the mall midlevel, or any provider who would rather “just treat 'em so no one will worry,” the Z-Pak has been a blockbuster one-size-fits-all drug for any upper or lower respiratory tract illness. Since 2011, azithromycin is the most commonly prescribed drug in the United States. Unfortunately, it is the wrong drug for almost everything respiratory in the ED.

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