Chemistry:Azithromycin

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Short description: Antibiotic
Azithromycin
Azithromycin structure.svg
Azithromycin 3d structure.png
Clinical data
Trade namesZithromax, Azithrocin, Sumamed, others[1]
Other names9-deoxy-9α-aza-9α-methyl-9α-homoerythromycin A
AHFS/Drugs.comMonograph
MedlinePlusa697037
License data
Pregnancy
category
Routes of
administration		By mouth (capsule, tablet or suspension), intravenous, eye drop
Drug classMacrolide antibiotic
ATC code
Legal status
Legal status
Pharmacokinetic data
Bioavailability38% for 250 mg capsules
MetabolismLiver
Elimination half-life11–14 h (small doses) 68 h (large or multiple dosing)
ExcretionBile duct, kidney (4.5%)
Identifiers
CAS Number
PubChem CID
IUPHAR/BPS
DrugBank
ChemSpider
UNII
KEGG
ChEBI
ChEMBL
NIAID ChemDB
Chemical and physical data
FormulaC38H72N2O12
Molar mass748.996 g·mol−1
3D model (JSmol)
  GLAH&page2=Chemistry%3AAzithromycin (verify)

Azithromycin, sold under the brand names Zithromax (in oral form) and Azasite (as an eye drop), is an antibiotic medication used for the treatment of a number of bacterial infections.[5] This includes middle ear infections, strep throat, pneumonia, traveler's diarrhea, and certain other intestinal infections.[5] Along with other medications, it may also be used for malaria.[5] It can be taken by mouth or intravenously.[5]

Common side effects include nausea, vomiting, diarrhea and upset stomach.[5] An allergic reaction, such as anaphylaxis, QT prolongation, or a type of diarrhea caused by Clostridium difficile is possible.[5] No harm has been found with its use during pregnancy.[5] Its safety during breastfeeding is not confirmed, but it is likely safe.[6] Azithromycin is an azalide, a type of macrolide antibiotic.[5] It works by decreasing the production of protein, thereby stopping bacterial growth.[5][7]

Azithromycin was discovered in Croatia in 1980 by the pharmaceutical company Pliva and approved for medical use in 1988 under the brand name Sumamed.[8][9] It is on the World Health Organization's List of Essential Medicines.[10] The World Health Organization classifies it as critically important for human medicine.[11] It is available as a generic medication[12] and is sold under many trade names worldwide.[1] In 2020, it was the 68th most commonly prescribed medication in the United States, with more than 10 million prescriptions.[13][14]

Medical uses

Azithromycin is used to treat diverse infections, including:

  • Acute bacterial sinusitis due to H. influenzae, M. catarrhalis, or S. pneumoniae, still, other agents, such as amoxicillin/clavulanate are generally preferred for these infections.[15][16]
  • Acute otitis media caused by H. influenzae, M. catarrhalis or S. pneumoniae. Azithromycin is not, however, a first-line agent for this condition. Amoxicillin or another beta-lactam antibiotic is generally preferred.[17]
  • Community-acquired pneumonia due to C. pneumoniae, H. influenzae, M. pneumoniae, or S. pneumoniae.[18]
  • Genital ulcer disease (chancroid) in men due to H. ducreyi
  • Pharyngitis or tonsillitis caused by S. pyogenes as an alternative to first-line therapy in individuals who cannot use first-line therapy[19]
  • Prevention and treatment of acute bacterial exacerbations of chronic obstructive pulmonary disease due to H. influenzae, M. catarrhalis, or S. pneumoniae. The benefits of long-term prophylaxis must be weighed on a patient-by-patient basis against the risk of cardiovascular and other adverse effects.[20]
  • Trachoma due to C. trachomatis[21]
  • Uncomplicated skin infections due to S. aureus, S. pyogenes, or S. agalactiae
  • Urethritis and cervicitis due to C. trachomatis or N. gonorrhoeae. In combination with ceftriaxone, azithromycin is part of the United States Centers for Disease Control-recommended regimen for the treatment of gonorrhea. Azithromycin is active as monotherapy in most cases, but the combination with ceftriaxone is recommended based on the relatively low barrier to resistance development in gonococci and due to frequent co-infection with C. trachomatis and N. gonorrhoeae.[22]
  • Scrub typhus caused by Orientia tsutsugamushi.[23]
Sumamed 500 mg

Bacterial susceptibility

Azithromycin has relatively broad but shallow antibacterial activity. It inhibits some Gram-positive bacteria, some Gram-negative bacteria, and many atypical bacteria.[citation needed]

A strain of gonorrhea reported to be highly resistant to azithromycin was found in the population in 2015. Neisseria gonorrhoeae is normally susceptible to azithromycin,[24] but the drug is not widely used as monotherapy due to a low barrier to resistance development.[22] Extensive use of azithromycin has resulted in growing Streptococcus pneumoniae resistance.[25]

Aerobic and facultative Gram-positive microorganisms

Aerobic and facultative anaerobic Gram-negative microorganisms

Anaerobic microorganisms

Other microorganisms

Pregnancy and breastfeeding

No harm has been found with use during pregnancy.[5] However, there are no adequate well-controlled studies in pregnant women.[3]

The safety of the medication during breastfeeding is unclear. It was reported that because only low levels are found in breast milk and the medication has also been used in young children, it is unlikely that breastfed infants would have adverse effects.[6] Nevertheless, it is recommended that the drug be used with caution during breastfeeding.[5]

Airway diseases

Azithromycin has beneficial effects in the treatment of asthma. It possesses antibacterial, antiviral, and anti-inflammatory properties which contribute to its effectiveness. Asthma exacerbations can be caused by chronic neutrophilic inflammation, and azithromycin is known to reduce this type of inflammation due to its immunomodulatory properties. The recommended dosage for controlling asthma exacerbations with azithromycin is either 500 mg or 250 mg taken orally as tablets three times a week. In adults with severe asthma, low-dose azithromycin may be prescribed as an add-on treatment when standard therapies such as inhaled corticosteroids or long-acting beta2-agonists are not sufficient. Long-term use of azithromycin in patients with persistent symptomatic asthma aims to decrease the frequency of asthma exacerbations and improve their quality of life. While both its anti-inflammatory and antibacterial effects play crucial roles in treating asthma, studies suggest that responsiveness to azithromycin therapy depends on individual variations in lung bacterial burden and microbial composition, collectively referred to as the lung microbiome. The richness (diversity) of the lung microbiome has been identified as a key factor in determining the effectiveness of azithromycin treatment. Azithromycin has significant interactions with the patient's microbiome. Long-term use of azithromycin reduces the presence of H. influenzae bacteria in the airways but also increases resistance against macrolide antibiotics. The specific pharmacological mechanisms through which azithromycin interacts with the patient's microbiome remain unknown (As of 2024) research continues to explore how changes in microbial composition influence drug efficacy and patient outcomes.[26]

Azithromycin appears to be effective in the treatment of chronic obstructive pulmonary disease through its suppression of inflammatory processes.[27] Azithromycin is potentially useful in sinusitis via this mechanism.[28] Azithromycin is believed to produce its effects through suppressing certain immune responses that may contribute to inflammation of the airways.[29][30]

Adverse effects

Most common adverse effects are diarrhea (5%), nausea (3%), abdominal pain (3%), and vomiting. Fewer than 1% of people stop taking the drug due to side effects. Nervousness, skin reactions, and anaphylaxis have been reported.[31] Clostridium difficile infection has been reported with use of azithromycin.[5] Azithromycin does not affect the efficacy of birth control unlike some other antibiotics such as rifampin. Hearing loss has been reported.[32]

Occasionally, people have developed cholestatic hepatitis or delirium. Accidental intravenous overdose in an infant caused severe heart block, resulting in residual encephalopathy.[33][34]

In 2013 the FDA issued a warning that azithromycin "can cause abnormal changes in the electrical activity of the heart that may lead to a potentially fatal irregular heart rhythm." The FDA noted in the warning a 2012 study that found the drug may increase the risk of death, especially in those with heart problems, compared with those on other antibiotics such as amoxicillin or no antibiotic. The warning indicated people with preexisting conditions are at particular risk, such as those with QT interval prolongation, low blood levels of potassium or magnesium, a slower than normal heart rate, or those who use certain drugs to treat abnormal heart rhythms.[35][36][37]

It has been reported that azithromycin blocks autophagy and may predispose cystic fibrosis patients to mycobacterial infection.[38]

Interactions

Colchicine

Azithromycin, should not be taken with colchicine as it may lead to colchicine toxicity. Symptoms of colchicine toxicity include gastrointestinal upset, fever, myalgia, pancytopenia, and organ failure.[39][40]

Drugs metabolized by CYP3A4

CYP3A4 is an enzyme that metabolizes many drugs in the liver. Some drugs can inhibit CYP3A4, which means they reduce its activity and increase the blood levels of the drugs that depend on it for elimination. This can lead to adverse effects or drug-drug interactions.[41]

Azithromycin is a member of macrolides that are a class of antibiotics with a cyclic structure with a lactone ring and sugar moieties. Macrolides can inhibit CYP3A4 by a mechanism called mechanism-based inhibition (MBI), which involves the formation of reactive metabolites that bind covalently and irreversibly to the enzyme, rendering it inactive. MBI is more serious and long-lasting than reversible inhibition, as it requires the synthesis of new enzyme molecules to restore the activity.[42]

The degree of MBI by macrolides depends on the size and structure of their lactone ring. Clarithromycin and erythromycin have a 14-membered lactone ring, which is more prone to demethylation by CYP3A4 and subsequent formation of nitrosoalkenes, the reactive metabolites that cause MBI. Azithromycin, on the other hand, has a 15-membered lactone ring, which is less susceptible to demethylation and nitrosoalkene formation. Therefore, azithromycin is a weak inhibitor of CYP3A4, while clarithromycin and erythromycin are strong inhibitors which increase the area under the curve (AUC) value of co-administered drugs more than five-fold.[42] AUC it is a measure of the drug exposure in the body over time. By inhibiting CYP3A4, macrolide antibitiotics, such as erythromycin and clarithromycin, but not azithromycin, can significantly increase the AUC of the drugs that depend on it for clearance, which can lead to higher risk of adverse effects or drug-drug interactions. Azithromycin stands apart from other macrolide antibiotics because it is a weak inhibitor of CYP3A4, and does not significantly increase AUC value of co-administered drugs.[43]

The difference in CYP3A4 inhibition by macrolides has clinical implications, for example for patients who take statins, which are cholesterol-lowering drugs that are mainly metabolized by CYP3A4. Co-administration of clarithromycin or erythromycin with statins can increase the risk of statin-induced myopathy, a condition that causes muscle pain and damage. Azithromycin, however, does not significantly affect the pharmacokinetics of statins and is considered a safer alternative than other macrolide antibiotics.[42]

Pharmacology

Mechanism of action

Azithromycin prevents bacteria from growing by interfering with their protein synthesis. It binds to the 50S subunit of the bacterial ribosome, thus inhibiting translation of mRNA. Nucleic acid synthesis is not affected.[3]

Pharmacokinetics

Azithromycin is an acid-stable antibiotic, so it can be taken orally with no need of protection from gastric acids. It is readily absorbed, but absorption is greater on an empty stomach. Time to peak concentration (Tmax) in adults is 2.1 to 3.2 hours for oral dosage forms. Due to its high concentration in phagocytes, azithromycin is actively transported to the site of infection. During active phagocytosis, large concentrations are released. The concentration of azithromycin in the tissues can be over 50 times higher than in plasma due to ion trapping and its high lipid solubility.[citation needed] Azithromycin's half-life allows a large single dose to be administered and yet maintain bacteriostatic levels in the infected tissue for several days.[44]

Following a single dose of 500 mg, the apparent terminal elimination half-life of azithromycin is 68 hours.[44] Biliary excretion of azithromycin, predominantly unchanged, is a major route of elimination. Over the course of a week, about 6% of the administered dose appears as an unchanged drug in urine.

History

A team of researchers at the pharmaceutical company Pliva in Zagreb, Croatia,—Gabrijela Kobrehel, Gorjana Radobolja-Lazarevski, and Zrinka Tamburašev (sh), led by Slobodan Đokić—discovered azithromycin in 1980.[45] The company Pliva patented it in 1981.[9] In 1986, Pliva and Pfizer signed a licensing agreement, which gave Pfizer exclusive rights for the sale of azithromycin in Western Europe and the United States. Pliva put its azithromycin on the market in Central and Eastern Europe under the brand name Sumamed in 1988. Pfizer launched azithromycin under Pliva's license in other markets under the brand name Zithromax in 1991.[46] Patent protection ended in 2005.[47]

Society and culture

Zithromax (azithromycin) 250 mg tablets (CA)

Available forms

Azithromycin is available as a generic medication. Azithromycin is commonly administered in film-coated tablet, capsule, oral suspension, intravenous injection, granules for suspension in sachet, and ophthalmic solution.[1]

Usage

In 2010, azithromycin was the most prescribed antibiotic for outpatients in the US,[48] whereas in Sweden, where outpatient antibiotic use is a third as prevalent, macrolides are only on 3% of prescriptions.[49] In 2017, and 2022, azithromycin was the second most prescribed antibiotic for outpatients in the United States.[50][51]

Brand names

Brand name listings

It is sold under many trade names worldwide including 3-Micina, A Sai Qi, Abacten, Abbott, Acex, Acithroc, Actazith, Agitro, Ai Mi Qi, Amixef, Amizin, Amovin, An Mei Qin, Ao Li Ping, Apotex, Lebanon, Aratro, Aruzilina, Arzomicin, Arzomidol, Asizith, Asomin, Astidal, Astro, Athofix, Athxin, Atizor, Atromizin, Avalon, AZ, AZA, Azacid, Azadose, Azalid, Azalide, AzaSite, Azath, Azatril, Azatril, Azax, Azee, Azeecor, Azeeta, Azelide, Azeltin, Azenil, Azeptin, Azerkym, Azi, Aziact, Azibact, Azibactron, Azibay, Azibect, Azibest, Azibiot, Azibiotic, Azicare, Azicin, Azicine, Aziclass, Azicom, Azicure, Azid, Azidose, Azidraw, Azifam, Azifarm, Azifast, Azifine, Azigen, Azigram, Azigreat, Azikare, Azilide, Azilife, Azilip, Azilup, Azimac, Azimax, Azimed, Azimepha, Azimex, Azimit, Azimix, Azimon, Azimore, Azimycin, Azimycine, Azin, Azindamon, Azinew, Azinex, Azinif, Azinil, Azintra, Aziom, Azipar, Aziped, Aziphar, Azipin, Azipro, Aziprome, Aziquilab, Azirace, Aziram, Aziresp, Aziride, Azirol, Azirom, Azirox, Azirute, Azirutec, Aziset, Azisis, Azison, Azissel, Aziswift, Azit, Azita, Azitam, Azitex, Azith, Azithral, Azithrin, Azithro, Azithrobeta, Azithrocin, Azithrocine, Azithromax, Azithromed, Azithromicina, Azithromycin, Azithromycine, Azithromycinum, Azithrovid, Azitic, Azitive, Azitome, Azitrac, Azitral, Azitrax, Azitredil, Azitrex, Azitrim, Azitrin, Azitrix, Azitro, Azitrobac, Azitrocin, Azitroerre, Azitrogal, Azitrolabsa, Azitrolid, Azitrolit, Azitrom, Azitromac, Azitromax, Azitromek, Azitromicin, Azitromicina, Azitromycin, Azitromycine, Azitrona, Azitropharma, Azitroteg, Azitrox, Azitsa, Azitus, Azivar, Azivirus, Aziwill, Aziwok, Azix, Azizox, Azmycin, Azo, Azobat, Azocin, Azoget, Azoheim, Azoksin, Azom, Azomac, Azomax, Azomex, Azomycin, Azomyne, Azores, Azorox, Azostar, Azot, Azoxin, Azras, Azro, Azrocin, Azrolid, Azromax, Azrosin, Aztin, Aztrin, Aztro, Aztrogecin, Azvig, Azycin, Azycyna, Azydrop, Azypin, Azytact, Azytan, Azyter, Azyter, Azyth, Azywell, Azza, Ba Qi, Bactizith, Bactrazol, Bai Ke De Rui, Batif, Bazyt, Bezanin, Bin Qi, Binozyt, BinQi, Biocine, Biozit, Bo Kang, Canbiox, Cetaxim, Charyn, Chen Yu, Cinalid, Cinetrin, Clamelle, Clearsing, Corzi, Cozith, Cronopen, Curazith, Delzosin, Dentazit, Disithrom, Doromax, Doyle, Elzithro, Eniz, Epica, Ethrimax, Ezith, Fabodrox, Fabramicina, Feng Da Qi, Figothrom, Floctil, Flumax, Fu Qi-Hua Yuan, Fu Rui Xin, Fuqixing, Fuxin-Hai Xin Pharm, Geozif, Geozit, Gitro, Goldamycin, Gramac, Gramokil, Hemomicin, Hemomycin, I-Thro, Ilozin, Imexa, Inedol, Infectomycin, Iramicina, Itha, Jin Nuo, Jin Pai Qi, Jinbo, Jun Jie, Jun Wei Qing, Kai Qi, Kang Li Jian, Kang Qi, Katrozax, Ke Lin Da, Ke Yan Li, Koptin, Kuai Yu, L-Thro, Laz, Legar, Lg-Thral, Li Ke Si, Li Li Xing, Li Qi, Lin Bi, Lipuqi, Lipuxin, Lizhu Qile, Loromycin, Lu Jia Kang, Luo Bei Er, Luo Qi, Maazi, Macroazi, Macromax, Macrozit, Maczith, Makromicin, Maxmor, Mazit, Mazitrom, Medimacrol, Meithromax, Mezatrin, Ming Qi Xin, Misultina, Na Qi, Nadymax, Naxocina, Neblic, Nemezid, Neofarmiz, Nifostin, Nobaxin, Nokar, Novatrex, Novozithron, Novozitron, Nurox, Odaz, Odazyth, Onzet, Oranex, Oranex, Ordipha, Orobiotic, Pai Fen, Pai Fu, Paiqi, Pediazith, Portex, Pu He, Pu Le Qi, Pu Yang, Qi Gu Mei, Qi Mai Xing, Qi Nuo, Qi Tai, Qi Xian, Qili, Qiyue, Rarpezit, Razimax, Razithro, Rezan, Ribotrex, Ribozith, Ricilina, Rizcin, Romycin, Rothin (Rakaposhi), Rozalid, Rozith, Ru Shuang Qi, Rui Qi, Rui Qi Lin, Rulide, Sai Jin Sha, Sai Le Xin, Sai Qi, Selimax, Sheng Nuo Ling, Shu Luo Kang, Simpli-3, Sisocin, Sitrox, Sohomac, Stromac, Su Shuang, Sumamed, Sumamox, Tailite, Talcilina, Tanezox, Te Li Xin, Tetris, Texis, Thoraxx, Throin, Thromaxin, Tong Tai Qi Li, Topt, Toraseptol, Tremac, Trex, Tri Azit, Triamid, Tridosil, Trimelin, Tritab, Tromiatlas, Tromix, Trozamil, Trozin, Trozocina, Trulimax, Tuoqi, Udox, Ultreon, Ultreon, Vectocilina, Vinzam, Visag, Vizicin, Wei Li Qinga, Wei Lu De, Wei Zong, Weihong, Xerexomair, Xi Le Xin, Xi Mei, Xin Da Kang, Xin Pu Rui, Xithrone, Ya Rui, Yan Sha, Yanic, Yi Nuo Da, Yi Song, Yi Xina, Yin Pei Kang, Yong Qi, You Ni Ke, Yu Qi, Z-3, Z-PAK, Zady, Zaiqi, Zaret, Zarom, Zathrin, Zedbac, Zeemide, Zenith, Zentavion, Zetamac, Zetamax, Zeto, Zetron, Zevlen, Zibramax, Zicho, Zigilex, Zikti, Zimacrol, Zimax, Zimicina, Zindel, Zinfect, Zirom, Zisrocin, Zistic, Zit-Od, Zitab, Zitax, Zithrax, Zithrin, Zithro-Due, Zithrobest, Zithrodose, Zithrogen, Zithrokan, Zithrolide, Zithromax, Zithrome, Zithromed, Zithroplus, Zithrotel, Zithrox, Zithroxyn, Zithtec, Zitinn, Zitmac, Zitraval, Zitrax, Zitrex, Zitric, Zitrim, Zitrobid, Zitrobiotic, Zithrolect, Zitrocin, Zitrocin, Zitrogram, Zitrolab, Zitromax, Zitroneo, Zitrotek, Ziyoazi, Zmax, Zocin, Zomax, Zotax, Zycin, and Zythrocin.[1]

It is sold as a combination drug with cefixime as Anex-AZ, Azifine-C, Aziter-C, Brutacef-AZ, Cezee, Fixicom-AZ, Emtax-AZ, Olcefone-AZ, Starfix-AZ, Zeph-AZ, Zicin-CX, and Zifi-AZ.[1]

It is also sold as a combination drug with nimesulide as Zitroflam; in a combination with tinidazole and fluconazole as Trivafluc, and in a combination with ambroxol as Zathrin-AX, Laz-AX and Azro-AM.[1]

Research

Azithromycin is researched for its supposed anti-inflammatory and immunomodulatory properties, which are believed to be exhibited through its suppression of proinflammatory cytokines and enhancing the production of anti-inflammatory cytokines, which is important in dampening inflammation. Cytokines are small proteins that are secreted by immune cells and play a key role in the immune response. Studies suggest that azithromycin can decrease the release of pro-inflammatory cytokines such as TNF-alpha, IL-1β, IL-6, and IL-8 while increasing the levels of anti-inflammatory cytokine IL-10. By decreasing the number of pro-inflammatory cytokines, azithromycin probably controls potential tissue damage during inflammation. These effects are believed to be due to azithromycin's ability to suppress a transcription factor called nuclear factor-kappa B (NF-κB) resulting in blockade of inflammatory response pathways downstream from NF-κB activation leading to decreased chemokine receptor CXCR4 signaling causing reduced inflammation.[52][53][54][55][56] Despite the efficiency of treating rosacea with azithromycin, the exact mechanism of why azithromycin is effective in treating rosacea are not completely understood.[57] It is unclear whether its antibacterial or immunomodulatory properties or a combination of both mechanisms contribute to its efficacy. Azithromycin may prevent mast cell degranulation and thus can suppress inflammation of dorsal root ganglia through various signaling pathways such as decreased numbers of CD4+ T cells which are particularly relevant since they mediate the response of hair follicle antigens.[58] Inflammation in rosacea is thought to be associated with increased production of reactive oxygen species (ROS) by inflammatory cells. The ability of azithromycin to decrease ROS production can help reduce oxidative stress and inflammation, but this remains speculation.[57]

The therapeutic role of azithromycin has been explored in various diseases such as cystic fibrosis exacerbation, burn injury-induced lung injury, asthma, chronic obstructive pulmonary disease, and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in COVID-19 infection.[59][60][61][62][63] Despite early evidence showing azithromycin slowed down coronavirus multiplication in laboratory settings, further research indicates it to be ineffective as a treatment for COVID-19 in humans.[64] After a large-scale trial showed no benefit of using azithromycin in treating COVID-19, the UK's National Institute for Health and Care Excellence (NICE) updated its guidance and no longer recommends the medication for COVID-19.[65][66]

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 "Azithromycin International Brands". Drugs.com. https://www.drugs.com/international/azithromycin.html. 
  2. ↑ "Azithromycin Use During Pregnancy". 2 May 2019. https://www.drugs.com/pregnancy/azithromycin.html. 
  3. ↑ 3.0 3.1 3.2 "Zithromax- azithromycin dihydrate tablet, film coated". 29 September 2023. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=fb3d03d8-c7c1-48c4-b5ac-91ed0398f0d2. 
  4. ↑ "List of nationally authorised medicinal products Active substance: azithromycin (systemic use formulations)". European Medicine Agency. 14 January 2021. https://www.ema.europa.eu/en/documents/psusa/azithromycin-list-nationally-authorised-medicinal-products-psusa/00010491/202004_en.pdf. 
  5. ↑ 5.00 5.01 5.02 5.03 5.04 5.05 5.06 5.07 5.08 5.09 5.10 5.11 "Azithromycin". The American Society of Health-System Pharmacists. https://www.drugs.com/monograph/azithromycin.html. 
  6. ↑ 6.0 6.1 "Azithromycin use while Breastfeeding". https://www.drugs.com/breastfeeding/azithromycin.html. 
  7. ↑ "Azithromycin Stops The Growth of Bacteria" (in de). https://deutschemedz.de/azithromycin/. 
  8. ↑ Greenwood, David (2008). Antimicrobial drugs : chronicle of a twentieth century medical triumph (1. publ. ed.). Oxford: Oxford University Press. p. 239. ISBN 9780199534845. https://books.google.com/books?id=i4_FZHmzjzwC&pg=PA239. 
  9. ↑ 9.0 9.1 "Table of Selected Analogue Classes". Analogue-based Drug Discovery. Weinheim: Wiley-Vch Verlag GmbH & Co. KGaA. 2006. p. 498. ISBN 978-3-527-31257-3. https://books.google.com/books?id=FjKfqkaKkAAC&pg=PA498. Retrieved 2 April 2020. 
  10. ↑ World Health Organization model list of essential medicines: 21st list 2019. Geneva: World Health Organization. 2019. WHO/MVP/EMP/IAU/2019.06. License: CC BY-NC-SA 3.0 IGO. 
  11. ↑ Critically important antimicrobials for human medicine (6th revision ed.). Geneva: World Health Organization. 2018. License: CC BY-NC-SA 3.0 IGO. ISBN 9789241515528. https://www.who.int/foodsafety/publications/antimicrobials-sixth/en/. 
  12. ↑ Hamilton, Richart (2015). Tarascon Pocket Pharmacopoeia 2015 Deluxe Lab-Coat Edition. Jones & Bartlett Learning. ISBN 9781284057560. 
  13. ↑ "The Top 300 of 2020". https://clincalc.com/DrugStats/Top300Drugs.aspx. 
  14. ↑ "Azithromycin – Drug Usage Statistics". https://clincalc.com/DrugStats/Drugs/Azithromycin. 
  15. ↑ "Clinical practice guideline (update): adult sinusitis". Otolaryngology–Head and Neck Surgery 152 (2 Suppl): S1–S39. April 2015. doi:10.1177/0194599815572097. PMID 25832968. 
  16. ↑ "AAP releases guideline on diagnosis and management of acute bacterial sinusitis in children one to 18 years of age". American Family Physician 89 (8): 676–81. April 2014. PMID 24784128. 
  17. ↑ "AAP, AAFP release guideline on diagnosis and management of acute otitis media". American Family Physician 69 (11): 2713–5. June 2004. PMID 15202704. 
  18. ↑ "Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults". Clinical Infectious Diseases 44 (Suppl 2): S27-72. March 2007. doi:10.1086/511159. PMID 17278083. 
  19. ↑ "IDSA Updates Guideline for Managing Group A Streptococcal Pharyngitis". American Family Physician 88 (5): 338–40. September 2013. PMID 24010402. 
  20. ↑ "Azithromycin for the Prevention of COPD Exacerbations: The Good, Bad, and Ugly". The American Journal of Medicine 128 (12): 1362.e1–6. December 2015. doi:10.1016/j.amjmed.2015.07.032. PMID 26291905. 
  21. ↑ "Interventions for trachoma trichiasis". The Cochrane Database of Systematic Reviews 11 (11): CD004008. November 2015. doi:10.1002/14651858.CD004008.pub3. PMID 26568232. 
  22. ↑ 22.0 22.1 "Gonococcal Infections – 2015 STD Treatment Guidelines". https://www.cdc.gov/std/tg2015/gonorrhea.htm. 
  23. ↑ "Doxycycline vs azithromycin in patients with scrub typhus: a systematic review of literature and meta-analysis". BMC Infect Dis 23 (1): 884. December 2023. doi:10.1186/s12879-023-08893-7. PMID 38110855. 
  24. ↑ "'Super-gonorrhoea' outbreak in Leeds". 17 September 2015. https://www.bbc.com/news/health-34269315. 
  25. ↑ Lippincott Illustrated Reviews : Pharmacology Sixth Edition. pp. 506. 
  26. ↑ "Exploring the influence of the microbiome on the pharmacology of anti-asthmatic drugs". Naunyn Schmiedebergs Arch Pharmacol 397 (2): 751–762. February 2024. doi:10.1007/s00210-023-02681-5. PMID 37650889. 
  27. ↑ "Preventing COPD exacerbations with macrolides: a review and budget impact analysis". Respiratory Medicine 107 (5): 637–48. May 2013. doi:10.1016/j.rmed.2012.12.019. PMID 23352223. 
  28. ↑ "Macrolides for the treatment of chronic sinusitis, asthma, and COPD". Chest 125 (2 Suppl): 52S-60S; quiz 60S-61S. February 2004. doi:10.1378/chest.125.2_suppl.52S. PMID 14872001. https://journal.chestnet.org/article/S0012-3692(15)32220-0/fulltext. Retrieved 22 March 2020. 
  29. ↑ "Macrolides: from in vitro anti-inflammatory and immunomodulatory properties to clinical practice in respiratory diseases". European Journal of Clinical Pharmacology 68 (5): 479–503. May 2012. doi:10.1007/s00228-011-1161-x. PMID 22105373. 
  30. ↑ "Pathogen- and host-directed anti-inflammatory activities of macrolide antibiotics". Mediators of Inflammation 2012: 584262. 2012. doi:10.1155/2012/584262. PMID 22778497. 
  31. ↑ "Azithromycin anaphylaxis in children". International Journal of Immunopathology and Pharmacology 27 (1): 121–6. 2014. doi:10.1177/039463201402700116. PMID 24674687. 
  32. ↑ Medical Toxology. Lippincott Williams & Wilkins. 2004. pp. 23. 
  33. ↑ "Life-threatening bradyarrhythmia after massive azithromycin overdose". Pharmacotherapy 26 (1): 147–50. January 2006. doi:10.1592/phco.2006.26.1.147. PMID 16506357. 
  34. ↑ Disposition of Toxic Drugs and Chemicals in Man (8th ed.). Foster City, CA: Biomedical Publications. 2008. pp. 132–133. 
  35. ↑ Grady, Denise (16 May 2012). "Popular Antibiotic May Raise Risk of Sudden Death". The New York Times. https://www.nytimes.com/2012/05/17/health/research/popular-antibiotic-may-raise-risk-of-sudden-death.html. 
  36. ↑ "Azithromycin and the risk of cardiovascular death". The New England Journal of Medicine 366 (20): 1881–90. May 2012. doi:10.1056/NEJMoa1003833. PMID 22591294. 
  37. ↑ "FDA Drug Safety Communication: Azithromycin (Zithromax or Zmax) and the risk of potentially fatal heart rhythms". FDA. 12 March 2013. https://www.fda.gov/Drugs/DrugSafety/ucm341822.htm. 
  38. ↑ "Azithromycin blocks autophagy and may predispose cystic fibrosis patients to mycobacterial infection". J Clin Invest 121 (9): 3554–63. Sep 2011. doi:10.1172/JCI46095. PMID 21804191. 
  39. ↑ "Life Threatening Colchicine Drug Interactions. Drug Interactions: Insights and Observations". 2006. http://www.hanstenandhorn.com/hh-article05-06.pdf. 
  40. ↑ "Colchicine and macrolides: a cohort study of the risk of adverse outcomes associated with concomitant exposure". Rheumatol Int 42 (12): 2253–2259. December 2022. doi:10.1007/s00296-022-05201-5. PMID 36104598. 
  41. ↑ "A Review: Effects of Macrolides on CYP450 Enzymes". Curr Drug Metab 21 (12): 928–937. 2020. doi:10.2174/1389200221666200817113920. PMID 32807049. 
  42. ↑ 42.0 42.1 42.2 "Interaction potential between clarithromycin and individual statins-A systematic review". Basic Clin Pharmacol Toxicol 126 (4): 307–317. April 2020. doi:10.1111/bcpt.13343. PMID 31628882. 
  43. ↑ "Macrolide - induced clinically relevant drug interactions with cytochrome P-450A (CYP) 3A4: an update focused on clarithromycin, azithromycin and dirithromycin". Br J Clin Pharmacol 50 (4): 285–95. October 2000. doi:10.1046/j.1365-2125.2000.00261.x. PMID 11012550. 
  44. ↑ 44.0 44.1 "Zithromax – FDA prescribing information, side effects and uses". https://www.drugs.com/pro/zithromax.html. 
  45. ↑ "The Story of Azithromycin". Kemija U Industriji: Časopis Kemičara I Kemijskih Inženjera Hrvatske. 60 (12): 603–17. December 2011. https://www.researchgate.net/publication/286136408. 
  46. ↑ "The Story of Azithromycin". Kemija U Industriji 60 (12): 603–617. 2011. ISSN 0022-9830. http://pierre.fkit.hr/hdki/kui/en/vol60/abstracts/617.html. Retrieved 15 April 2013. 
  47. ↑ "Azithromycin: A world best-selling Antibiotic". World Intellectual Property Organization. https://www.wipo.int/ipadvantage/en/details.jsp?id=906. 
  48. ↑ "U.S. outpatient antibiotic prescribing, 2010". The New England Journal of Medicine 368 (15): 1461–2. April 2013. doi:10.1056/NEJMc1212055. PMID 23574140. 
  49. ↑ "More on U.S. outpatient antibiotic prescribing, 2010". The New England Journal of Medicine 369 (12): 1175–6. September 2013. doi:10.1056/NEJMc1306863. PMID 24047077. 
  50. ↑ "Outpatient Antibiotic Prescriptions — United States, 2017". 26 March 2020. https://www.cdc.gov/antibiotic-use/community/programs-measurement/state-local-activities/outpatient-antibiotic-prescriptions-US-2017.html. 
  51. ↑ "Outpatient Antibiotic Prescriptions — United States, 2022". 15 November 2023. https://www.cdc.gov/antibiotic-use/data/report-2022.html. 
  52. ↑ "Azithromycin and ciprofloxacin inhibit interleukin-8 secretion without disrupting human sinonasal epithelial integrity in vitro". Int Forum Allergy Rhinol 11 (2): 136–143. February 2021. doi:10.1002/alr.22656. PMID 32725797. 
  53. ↑ "Azithromycin alters Colony Stimulating Factor-1R (CSF-1R) expression and functional output of murine bone marrow-derived macrophages: A novel report". Int Immunopharmacol 123: 110688. October 2023. doi:10.1016/j.intimp.2023.110688. PMID 37499396. 
  54. ↑ "Clinical significance of serum microRNA-146a and inflammatory factors in children with Mycoplasma pneumoniae pneumonia after azithromycin treatment". J Pediatr (Rio J) 100 (1): 108–115. September 2023. doi:10.1016/j.jped.2023.06.004. PMID 37778397. 
  55. ↑ "The effect of azithromycin on sputum inflammatory markers in bronchiectasis". BMC Pulm Med 23 (1): 151. April 2023. doi:10.1186/s12890-023-02444-1. PMID 37118704. 
  56. ↑ "Azithromycin attenuates wheezing after pulmonary inflammation through inhibiting histone H3K27me3 hypermethylation mediated by EZH2". Clin Epigenetics 15 (1): 12. January 2023. doi:10.1186/s13148-023-01430-y. PMID 36691058. 
  57. ↑ 57.0 57.1 "The effect of azithromycin on reactive oxygen species in rosacea". Clin Exp Dermatol 32 (2): 197–200. March 2007. doi:10.1111/j.1365-2230.2006.02322.x. PMID 17244346. 
  58. ↑ "The anti-inflammatory effects of erythromycin, clarithromycin, azithromycin and roxithromycin on histamine-induced otitis media with effusion in guinea pigs". J Laryngol Otol 132 (7): 579–583. July 2018. doi:10.1017/S0022215118000610. PMID 29888693. 
  59. ↑ "Wastewater surveillance of pharmaceuticals during the COVID-19 pandemic in Mexico City and the Mezquital Valley: A comprehensive environmental risk assessment". Sci Total Environ 900: 165886. November 2023. doi:10.1016/j.scitotenv.2023.165886. PMID 37524191. Bibcode: 2023ScTEn.900p5886D. 
  60. ↑ "Azithromycin for cystic fibrosis". Eur Respir J 24 (5): 834–8. November 2004. doi:10.1183/09031936.04.00084304. PMID 15516680. 
  61. ↑ "Azithromycin and cystic fibrosis". Arch Dis Child 107 (8): 739. August 2022. doi:10.1136/archdischild-2022-324569. PMID 35853636. 
  62. ↑ "Azithromycin for Poorly Controlled Asthma in Children: A Randomized Controlled Trial". Chest 161 (6): 1456–1464. June 2022. doi:10.1016/j.chest.2022.02.025. PMID 35202621. 
  63. ↑ "Effect of azithromycin on asthma exacerbations and quality of life in adults with persistent uncontrolled asthma (AMAZES): a randomised, double-blind, placebo-controlled trial". Lancet 390 (10095): 659–668. August 2017. doi:10.1016/S0140-6736(17)31281-3. PMID 28687413. 
  64. ↑ "Intervention Antibiotics for the treatment of COVID-19". Cochrane Database of Systematic Reviews 10 (10): CD015025. 22 October 2021. doi:10.1002/14651858.CD015025. PMID 34679203. 
  65. ↑ "Doxycycline for community treatment of suspected COVID-19 in people at high risk of adverse outcomes in the UK (PRINCIPLE): a randomised, controlled, open-label, adaptive platform trial". The Lancet. Respiratory Medicine 9 (9): 1010–1020. September 2021. doi:10.1016/S2213-2600(21)00310-6. PMID 34329624. 
  66. ↑ Platform trial rules out treatments for COVID-19. 31 May 2022. doi:10.3310/nihrevidence_50873. https://evidence.nihr.ac.uk/alert/platform-trial-rules-out-covid-treatments/. Retrieved 1 June 2022. 

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