Part III: Guidelines for Selected Antimicrobial Use
3.15 Macrolides
Erythromycin, clarithromycin, and azithromycin are some common examples of macrolides for systemic use.
A number of health authorities have provided updates or warnings regarding the use of macrolides, especially azithromycin [300–304]
The following is a non-exhaustive list of possible serious side effects that have been suggested to be associated with macrolides:
A meta-analysis reported macrolide treatment is associated with an absolute risk increase of 118.1 additional sudden cardiac deaths or ventricular tachyarrhythmias, and 38.2 additional cardiovascular deaths per one million treatment courses. [309]
Macrolides should be avoided in patients with known QT interval prolongation or a history of ventricular arrhythmia; Caution should be exercised in patients with pre-existing cardiac conditions, e.g. coronary artery disease, severe cardiac insufficiency, conduction disturbances, or clinically relevant bradycardia. [301]
Carefully consider the benefits and risk before prescribing macrolides to patients taking drugs that can prolong QT interval. For example, co-administration of azithromycin with hydroxychloroquine in patients with rheumatoid arthritis has been associated with an increased risk of cardiovascular events and cardiovascular mortality. [302]
Consider screening electrocardiogram in high-risk patients, e.g. those with pre-existing cardiac conditions.
Drug-drug interactions
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