Azithromycin in COVID-19 Treatment

Evidence Against Azithromycin Use in COVID-19

The European Respiratory Society (ERS) provides a conditional recommendation against offering azithromycin to hospitalized patients with COVID-19 in the absence of bacterial infection, based on very low quality evidence 1
Multiple randomized trials demonstrate no difference in mortality (OR 1.02, 95% CI 0.69–1.49), length of hospital stay, clinical status, or disease deterioration when azithromycin is used for COVID-19 2, 3
The American College of Physicians (ACP) explicitly recommends against using azithromycin in combination with hydroxychloroquine for COVID-19 treatment or prophylaxis 4, 5
The RECOVERY trial results showed no benefit of azithromycin in COVID-19 patients 3

Widespread use of azithromycin during the pandemic raises significant antimicrobial resistance concerns 1
Azithromycin can cause QT prolongation, especially when combined with other medications, potentially leading to cardiac complications 6
Patients with hepatic or renal impairment may experience increased drug levels and associated risks 6
Electrolyte abnormalities, particularly hypokalemia and hypomagnesemia, can exacerbate QT prolongation risks when using azithromycin 6

Bacterial co-infection is reported infrequently in COVID-19 patients, with systematic reviews suggesting <10% of patients isolate a bacterial pathogen 1, 3
Antibiotics should be reserved only for patients with proven or strongly suspected bacterial co-infection 2, 3

For patients with confirmed COVID-19 without evidence of bacterial infection, do NOT prescribe azithromycin, and focus on supportive care and evidence-based COVID-19 treatments 1, 2, 3
For COVID-19 patients with suspected bacterial co-infection, obtain appropriate cultures when possible, consider targeted antibiotic therapy based on local resistance patterns, and discontinue antibiotics if bacterial infection is ruled out 1, 2, 3

Combining azithromycin with hydroxychloroquine increases risk of adverse events without clinical benefit 7