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Azithromycin use in Covid- 19: A tale of changing guidelines

Gupta, Harish,

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Journal of Family Medicine and Primary Care: July 2022 - Volume 11 - Issue 7 - p 3399-3400
doi: 10.4103/jfmpc.jfmpc_49_22
  • Open


A vaccine on its own will not end the Covid-19 pandemic. We will still need to continue: -Surveillance -Testing, isolating & caring for cases; Tracing & quarantining contacts; Engaging communities; Encouraging individuals to be careful.

Dr Tedros Adhanom Ghebreyesus, Director General of World Health Organization, Nov 16, 2020

Atal and colleagues make a Commentary on continued use of Azithromycin for mild Covid -19 in India by analysing evidence in support and underscoring its implications in Dec 2021 issue of the Journal.[1] Therein they recall the course of the pandemic, the way it unfolded, had an impact on the mankind and then our strategy as a countermeasure to combat by deploying various therapeutics. The authors examine if Azithromycin prescription is a correct decision in such cases. What we need to recall at this juncture is that prescribing antibiotics is something that happens commonly outside formal set up in our country when hinterlands lack qualified and trained medical experts.[2]

Before the novel mutant SARS-CoV-2 virus emerged from the woods (or still unknown place) and engulfed the globe, our prescribing habits were not up to the mark; misuse was rampant and antimicrobial drug resistance was already a challenge. On this background, SARS-CoV-2 made its appearance, upended our world when it ran roughshod, and we had to respond even when we did not know the best way and strategy.

We mounted our counterattack with the limited information we had and then updated it on a daily basis. As a regular exercise, we had to collect information from various resources (and still are), analyse trial results in real time[3] and then issue instructions to staff members. Although we did not have a tested anti-viral drug in our armamentarium then, something had to be advised to those getting infected, those being hospitalized, sometimes with falling oxygen saturation level (occasionally rapidly), developing complications and desperately gasping for breath. Under these circumstances, over-prescription was the fall out, which we now realize in retrospect. We advised patients to consume antibiotics, which were not tested, did not get positive results from trials and possibly did some (unintentional) harm.[4]

Sulis et al.[5] analysed sales data of antibiotics and hydroxychloroquine in India during the Covid-19 epidemic by conducting an interrupted time series analysis. They discovered that a significant increase in antibiotic sales, and particularly azithromycin, occurred during the peak phase of the first COVID-19 epidemic wave in India, indicating the need for urgent antibiotic stewardship measures. Simultaneously, we need to realise that as per current information antibiotics don’t work against viral infections and may not improve prognosis, rather be harmful, when consumed outside proper indications. These drugs may change our microbiome and help harmful bacteria to grow by selection pressure.[6]

Therefore when data emerged from ongoing trial results later on, guidelines were updated and antibiotics and other immunomodulators went out of favour of scientific community, although speed of the updation was not ideal at all the times. However, a few unscrupulous private practitioners and hospitals continue to muddle the water, prescribe drugs when not needed and, even when may be harmful, due to unethical financial interests. This pathology is not unique to India and privatisation and neoliberal economics maintain their status as disruptors of healthcare services.[7] Recognising these undercurrents and pre-existing realities is necessary (rather prerequisite) to appreciate use (or overuse) of Azithromycin in the Commentary. Only then can we assess its true implications on the basis of incidental evidence and thereafter rectify our mistakes and avoid them in future.

When we move forward and look in rear-view mirror, we better judge our path travelled as we have more information about the time passed. As we gather more information, in due course of time, we can better appreciate past events in a broader perspective and may even find fault in previous decisions. But, it is necessary to know the overall environment at the time of occurrence of those past events so as to know the reasons of the mistakes made as well. When available information was limited, we had to rely on the then available resources and intuitions, utilise whatever knowledge was available and move ahead. It’s unfair to make a judgement on the basis of acquired information later on. History provides us valuable lessons and one of these is that its exploration demands an understanding of the then prevailing atmosphere at the time of occurrence of a specific event and assess its characters on the basis of those criteria alone. Judging a past event on the basis of current atmosphere may yield incorrect and sometimes unjustifiable/prejudiced/inappropriate results.

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Conflicts of interest

There are no conflicts of interest.


1. Atal S, Misra S, Balakrishnan S Continued use of azithromycin for mild COVID-19 in India J Family Med Primary Care 2021 10 4341 4
2. Farooqui HH, Mehta A, Selvaraj S Outpatient antibiotic prescription rate and pattern in the private sector in India:Evidence from medical audit data PLoS One 2019 14 e0224848 doi:10.1371/journal.pone. 0224848
3. Else H How a torrent of COVID science changed research publishing-in seven charts Nature 2020 588 553
4. Hraiech S, Bourenne J, Kuteifan K, Helms J, Carvelli J, Gainnier M, et al. Lack of viral clearance by the combination of hydroxychloroquine and azithromycin or lopinavir and ritonavir in SARS-CoV-2-related acute respiratory distress syndrome Ann Intensive Care 2020 10 63
5. Sulis G, Batomen B, Kotwani A, Pai M, Gandra S Sales of antibiotics and hydroxychloroquine in India during the COVID-19 epidemic:An interrupted time series analysis PLoS Med 2021 18 e1003682 doi: 10.1371/journal.pmed. 1003682
6. Francino MP Antibiotics and the human gut microbiome:Dysbioses and accumulation of resistances Front Microbiol 2016 6 1543
7. Hospitals ignore SC and State government orders, deny admission to critical Covid patients Times of India Apr 14 2021 Available from:

Antimicrobial drug resistance; Covid-19 epidemic; medical experts; microbiome; mutant SARS-CoV-2 virus

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