Macrolide Antibiotics

• Understand the uses of macrolide antibiotics and the main organisms they can treat.
• Various drug interactions and adverse effects must be noted before the administration of macrolide antibiotics.
• Educational information that nurses can provide to both the patient and family/caregiver in order for effective treatment to be maintained.

Macrolides are a class of antibiotics that are often given in severe or complicated bacterial infections.  Azithromycin, clarithromycin, and erythromycin are commonly used to treat infections such as pneumonia, pharyngitis, sinusitis, and tonsillitis.  They are also sometimes used in uncomplicated skin infections and otitis media in pediatric patients.

Uses of Macrolides

The following are specific uses of macrolide antibiotics:

• Erythromycin is a broad-spectrum antibiotic that works against gram-positive and gram-negative bacteria, including Mycobacterium, Treponema, Mycoplasma, and Chlamydia. Erythromycin is also effective against pneumococci and Group A streptococci. Erythromycin also works against Staphylococcus aureus, but sometimes resistant strains can appear.
• Erythromycin is a drug of choice in Mycoplasma pneumoniae infections as well as pneumonia caused by Legionella pneumonia.
• Erythromycin works well in patients allergic to penicillin and those that have infections produced by Group A beta-hemolytic streptococci or streptococcus pneumonia.
• Erythromycin is also useful in treating syphilis and gonorrhea in patients who cannot tolerate penicillin G or tetracyclines.
• Erythromycin may also be used to treat minor staphylococcal infections of the skin.
• Azithromycin is also a broad-spectrum antibiotic, active against gram-positive and gram-negative bacteria, including Mycobacterium, S. aureus, Haemophilus influenza, Moraxella catarrhalis, and Chlamydia. It is also effective against pneumococci and groups C, F, and G streptococci.
• Clarithromycin shows activity against gram-positive aerobes, such as Staphylococcus aureus, Streptococcus pneumonia, and Streptococcus pyogenes; gram-negative aerobes, such as H. influenzae and Moraxella catarrhalis; and other aerobes such as Mycoplasma pneumonia.
• Clarithromycin is used to treat Helicobacter pylori-induced duodenal ulcer disease and may be used in combination with a proton pump inhibitor.

Drug Interactions and Adverse Effects

Drug Interactions

The drug interactions that can occur with macrolide antibiotics are as follows:

• Theophylline, when given in high doses with erythromycin, azithromycin, and clarithromycin, can result in theophylline toxicity; therefore, one must be cautious about administering macrolide antibiotics to patients taking high doses of theophylline.
• Erythromycin can potentiate the anticoagulant effects and alter the metabolism of non-sedating antihistamines such as astemizole and terfenadine.
• Clarithromycin can increase the concentration of carbamazepine when both are given together.

Adverse Reactions

Macrolides are typically well tolerated but it is important to note the adverse reactions such as the following:

• Epigastric distress
• Nausea and vomiting
• Diarrhea, especially when given in large doses
• Rashes
• Fever
• Eosinophilia
• Erythromycin can cause hepatotoxicity
• Azithromycin can cause QTC interval prolongation

Nurse’s Role in Macrolide Administration

With macrolide therapy, it is important for the nurse to ensure that both the patient and family/caregiver(s) are mindful of the following:

• When giving a suspension dosage form of the macrolide antibiotic, check the concentration every time to avoid over or underdosing.
• For efficient absorption, give the oral dosage form with a full glass of water one hour before a meal or two hours after meal consumption. The coated tablets should be given with meals.
• Ask the patient to not drink fruit juice with macrolide therapy.
• Ask the patient to not swallow chewable erythromycin tablets but to chew them only.
• For a patient having trouble tolerating erythromycin, administer coated or encapsulated pellets that cause less gastrointestinal irritation.
• For intravenous infusions, prepare them as per the guidelines of the manufacturer. Dilute each 250 mg in at least 100 ml of normal saline solution and infuse over 1 hour.
• Do not give erythromycin lactobionate with other drugs.
• With erythromycin therapy, especially erythromycin lactobionate, keep a close watch on liver function tests as it can cause hepatotoxicity. They can cause increased levels of alkaline phosphatase, alanine aminotransferase, aspartate aminotransferase, and bilirubin.  Patients who develop hepatotoxicity from erythromycin estolate may react similarly to treatment with other erythromycin preparations.
• Erythromycin should not be given with other ototoxic drugs as it can potentiate toxicity.
• Azithromycin use should be avoided in patients with a history of arrhythmia as it can cause QTC interval prolongation.
• If adverse gastrointestinal symptoms occur, check the patient’s hydration status. If dehydration is present, it is important to monitor and replenish the lost fluid and electrolytes.

The Bottom Line

Macrolides are essential agents in preventing and treating serious bacterial infections and are typically well tolerated.  Before administration of the antibiotic, it is imperative to be certain that the organism is sensitive to the antibiotic by having a culture and sensitivity test performed in order to implement effective treatment. 

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