Azythromycin
AZITHROMYCIN IS AN AZALIDE ANTIBIOTIC, A SUBCIASS OF THE MACROLIDES. IT RETAINS THE SPECTRUM OF ACTIVITY OF ERYTHROMYCIN AGAINST GRAM-POSITIVE AND GRAM-NEGATIVE PATHOGENS AND HAS INCREASED ACTIVITY AGAINST MANY GRAM-NEGATIVE AND ATYPICAL MICRO-ORGANISMS. IT HAS GREATER ACID-STABILITY THAN ERYTHROMYCIN AND ITS GASTROINTESTINAL TOLERANCE IS BETTER THAN THAT OF ERYTHROMYCIN. IT ACTS BY INTERFERING WITH MICROBIAL PROTEIN SYNTHESIS BY BINDING TO THE 50-S RIBOSOMAL SUBUNIT.
Dose :
UNCOMPLICATED GENITAL INFECTIONS :- 1 GM AS A SINGLE DOSE. GONORRHOEA, OTITIS MEDIA, RESPIRATORY-TRACT AND SKIN INFECTIONS :-500 MG AS A SINGLE DOSE DAILY FOR 3 DAYS FOLLOWED BY 250 MG ONCE DAILY ON 4 DAYS. PROPHYLAXIS OF DISSEMINATED MAC INFECTIONS :- 1.2 GM MAY BE GIVEN ONCE WEEKLY. CHILDREN :- 10 MG/KG AS A SINGLE DOSE ON THE FIRST DAY FOLLOWED BY 5 MG/KG ON DAYS 2 THROUGH 5. AZITHROMYCIN MAY ALSO BE GIVEN INITIALLY BY I.V. INFUSION (500 MG) AS A SINGLE DAILY DOSE FOR PNEUMONIA AND PELVIC INFLAMMATORY DISEASE.
Monograph
AZITHROMYCIN
DESCRIPTION:
AZITHRAL (azithromycin tablets, azithromycin capsules and azithromycin for
oral suspension) contain the active ingredient azithromycin, an azalide, a
subclass of macrolide antibiotics, for oral administration. Azithromycin has the
chemical name (2R,3S,4R,5R,8R,10R,11R,12S,13S,14R)-13-((2,6-did eoxy-3-C-methyl-
3-O-methyl-alpha-L-ribo- hexopyranosyl)oxy)-2-ethyl-3,4,10-trihydroxy-
3,5,6,8,10,12,14-heptamethyl-11-((3,4,6-trideoxy- 3-(dimethylamino)-beta-D-Xylo-
hexopyranosyl)oxy)-1-oxa-6-azacyclopentadecan- 15-one. Azithromycin is derived
from erythromycin; however, it differs chemically from erythromycin in that a
methyl-substituted nitrogen atom is incorporated into the lactone ring. Its
molecular formula is C38 H72N2O12, and its molecular weight is 749.00.
Azithromycin, as the dihydrate, is a white crystalline powder with a molecular
formula of C38H72N2O12.2H2O and a molecular weight of 785.0.
ACTIONS/CLINICAL PHARMACOLOGY:
ADULT PHARMACOKINETICS: Following oral administration, azithromycin is rapidly
absorbed and widely distributed throughout the body. Rapid distribution of
azithromycin into tissues and high concentration within cells result in
significantly higher azithromycin concentrations in tissues than in plasma or
serum.
The pharmacokinetic parameters of azithromycin capsules in plasma after a
loading dose of 500 mg (2-250 mg capsules) on day one followed by 250 mg (1-250
mg capsule) q.d. on days two through five in healthy young adults (age 18-40
years old) are portrayed in the following chart:
Pharmacokinetic Parameters
(Mean) Total n=12
DAY 1 DAY 5
Cmax (mcgm/mL) 0.41 0.24
Tmax (h) 2.5 3.2
AUC0-24 (mcgm.h/mL) 2.6 2.1
Cmin (mcgm/mL) 0.05 0.05
Urinary Excret. (% dose) 4.5 6.5
In this study, there was no significant difference in the disposition of
azithromycin between male and female subjects. Plasma concentrations of
azithromycin following single 500 mg oral and i.v. doses declined in a
polyphasic pattern resulting in an average terminal half-life of 68 hours. With
a regimen of 500 mg on Day 1 and 250 mg/day on Days 2-5, Cmin and Cmax remained
essentially unchanged from Day 2 through Day 5 of therapy. However, without a
loading dose, azithromycin Cmin levels required 5 to 7 days to reach steady-
state.
In an open, randomized, two-way crossover study, pharmacokinetic parameters
(AUC0-72 , Cmax, Tmax) determined from 36 fasted healthy male volunteers who
received two 250-mg commercial capsules and two 250-mg tablets were:
CAPSULE TABLET 90% Cl
---------------------------------------------------------------------------------
AUC0-72 (mcgm.h/mL) 4.1 (1.2) 4.3 (1.2) (99-113%)
Cmax (mcgm/mL) 0.5 (0.2) 0.5 (0.2) (96-121%)
Tmax (hours) 2.1 (0.8) 2.2 (0.9)
When azithromycin capsules were administered with food to 11 adult healthy male
subjects, the rate of absorption (Cmax) of azithromycin from the capsule
formulation was reduced by 52% and the extent of absorption (AUC) by 43%.
In an open label, randomized, two-way crossover study in 12 healthy subjects to
assess the effect of a high fat standard meal on the serum concentrations of
azithromycin resulting from the oral administration of two 250-mg film-coated
tablets, it was shown that FOOD INCREASED Cmax BY 23% WHILE THERE WAS NO CHANGE
IN AUC.
When azithromycin suspension was administered with food to 28 adult healthy male
subjects, the rate of absorption (Cmax) was increased by 56% while the extent of
absorption (AUC) was unchanged.
The AUC of azithromycin was unaffected by co- administration of an antacid
containing aluminum and magnesium hydroxide with AZITHRAL capsules
(azithromycin); however, the Cmax was reduced by 24%. Administration of
cimetidine (800mg) two hours prior to azithromycin had no effect on azithromycin
absorption.
When studied in healthy elderly subjects from age 65 to 85 years, the
pharmacokinetic parameters of azithromycin in elderly men were similar to those
in young adults; however, in elderly women, although higher peak concentrations
(increased by 30 to 50%) were observed, no significant accumulation occurred.
The high values in adults for apparent steady- state volume of distribution
(31.1 L/kg) and plasma clearance (630 mL/min) suggest that the prolonged half-
life is due to extensive uptake and subsequent release of drug from tissues.
The serum protein binding of azithromycin is variable in the concentration range
of approximating human exposure, decreasing from 51% at 0.02 mcgm/mL to 7% at 2
mcgm/mL.
Biliary excretion of azithromycin, predominantly as unchanged drug, is a major
route of elimination. Over the course of a week, approximately 6% of the
administered dose appears as unchanged drug in urine.
There are no pharmacokinetic data available from studies in hepatically- or
renally-impaired individuals.
The effect of azithromycin on the plasma levels or pharmacokinetics of
theophylline administered in multiple doses adequate to reach therapeutic
steady-state plasma levels is not known. (See PRECAUTIONS.)
Selected tissue (or fluid) concentration and tissue (or fluid) to plasma/serum
concentration ratios are shown in the following table:
AZITHROMYCIN CONCENTRATIONS FOLLOWING TWO-250 mg (500 mg) CAPSULES IN
ADULTS
----------------------------------------------------------------------------------------------------------------------------------------------------------
TISSUE OR FLUID
TISSUE TIME AFTER CONCENTRATION
OR FLUID DOSE (h) (mcgm/g or mcgm/mL)(1)
----------------------------------------------------------------------------------------------------------------------------------------------------------
SKIN 72-96 0.4
LUNG 72-96 4.0
SPUTUM* 2-4 1.0
SPUTUM** 10-12 2.9
TONSIL*/* 9-18 4.5
TONSIL*/* 180 0.9
CERVIX**/* 19 2.8
----------------------------------------------------------------------------------------------------------------------------------------------------------
CORRESPONDING
PLASMA OR TISSUE (FLUID)
TISSUE SERUM PLASMA
OR FLUID LEVEL (mcgm/mL) (SERUM) RATIO(1)
----------------------------------------------------------------------------------------------------------------------------------------------------------
SKIN 0. 012 35
LUNG 0. 012 >100
SPUTUM* 0. 64 2
SPUTUM** 0. 1 30
TONSIL*/* 0. 03 >100
TONSIL*/* 0. 006 >100
CERVIX**/* 0. 04 70
----------------------------------------------------------------------------------------------------------------------------------------------------------
(1) High tissue concentrations should not be interpreted to be
quantitatively related to clinical efficacy. The antimicrobial
activity of azithromycin is pH related. Azithromycin is concentrated
in cell lysosomes which have a low intraorganelle pH, at which the
drug's activity is reduced. However, the extensive distribution of
drug to tissues may be relevant to clinical activity.
* Sample was obtained 2-4 hours after the first dose.
** Sample was obtained 10-12 hours after the first dose.
*/* Dosing regimen of 2 doses of 250 mg each, separated by 12 hours.
**/* Sample was obtained 19 hours after a single 500 mg dose.
The extensive tissue distribution was confirmed by examination of additional
tissues and fluids (bone, ejaculum, prostate, ovary, uterus, salpinx, stomach,
liver, and gallbladder). As there are no data from adequate and well- controlled
studies of azithromycin treatment of infections in these additional body sites,
the clinical significance of these tissue concentration data is unknown.
Following a regimen of 500 mg on the first day and 250 mg daily for 4 days, only
very low concentrations were noted in cerebrospinal fluid (less than 0.01
mcgm/mL) in the presence of non- inflamed meninges.
PEDIATRIC PHARMACOKINETICS:
In two clinical studies, azithromycin for oral suspension was dosed at 10 mg/kg
on day 1, followed by 5 mg/kg on days 2 through 5 to two groups of children
(aged 1-5 years and 5-15 years, respectively). The mean pharmacokinetic
parameters at Day 5 were Cmax=0.216 mcgm/mL, Tmax=1.9 hours, and AUC0-24 =1.822
mcgm.hr/mL for the 1- to 5-year-old group and were Cmax=0.383 mcgm/mL, Tmax=2.4
hours, and AUC0-24 =3.109 mcgm.hr/mL for the 5- to 15-year-old group.
There are no pharmacokinetic data on azithromycin suspension when administered
at a dose of 12 mg/kg/day IN THE PRESENCE OR ABSENCE OF FOOD. (For the pediatric
pharyngitis/tonsillitis dose, see DOSAGE AND ADMINISTRATION.)
MICROBIOLOGY: Azithromycin acts by binding to the 50S ribosomal subunit of
susceptible microorganisms and, thus, interfering with microbial protein
synthesis. Nucleic acid synthesis is not affected.
Azithromycin concentrates in phagocytes and fibroblasts as demonstrated by In
Vitro incubation techniques. Using such methodology, the ratio of intracellular
to extracellular concentration was >30 after one hour incubation. In Vivo
studies suggest that concentration in phagocytes may contribute to drug
distribution to inflamed tissues.
Azithromycin has been shown to be active against most strains of the following
microorganisms, both In Vitro and in clinical infections as described in the
INDICATIONS AND USAGE section.
AEROBIC GRAM-POSITIVE MICROORGANISMS
Staphylococcus Aureus
Streptococcus Agalactiae
Streptococcus Pneumoniae
Streptococcus Pyogenes
NOTE: Azithromycin demonstrates cross-resistance with erythromycin-resistant
gram-positive strains. Most strains of Enterococcus Faecalis and methicillin-
resistant staphylococci are resistant to azithromycin.
AEROBIC GRAM-NEGATIVE MICROORGANISMS
Haemophilus Ducreyi
Haemophilus Influenzae
Moraxella Catarrhalis
Neisseria Gonorrhoeae
"OTHER" MICROORGANISMS
Chlamydia Pneumoniae
Chlamydia Trachomatis
Mycoplasma Pneumoniae
Beta-lactamase production should have no effect on azithromycin activity.
The following In Vitro data are available, BUT THEIR CLINICAL SIGNIFICANCE IS
UNKNOWN.
Azithromycin exhibits In Vitro minimum inhibitory concentrations (MIC's) of 0.5
mcgm/mL or less against most (>/=90%) strains of streptococci and MIC's of 2.0
mcgm/mL or less against most (>/=90%) strains of other listed microorganisms.
However, the safety and effectiveness of azithromycin in treating clinical
infections due to these microorganisms have not been established in adequate and
well-controlled trials.
AEROBIC GRAM-POSITIVE MICROORGANISMS
Streptococci (Groups C, F, G)
Viridans group streptococci
ANAEROBIC MICROORGANISMS
Peptostreptococcus species
Prevotella Bivia
AEROBIC GRAM-NEGATIVE MICROORGANISMS
Bordetella Pertussis
Legionella Pneumophila
"OTHER" MICROORGANISMS
Ureaplasma Urealyticum
SUSCEPTIBILITY TESTS
Azithromycin can be solubilized for In Vitro susceptibility testing using
dilution techniques by dissolving in a minimum amount of 95% ethanol and
diluting to the working stock concentration with broth. Further dilutions may be
made in water.
DILUTION TECHNIQUES:
Quantitative methods are used to determine antimicrobial minimum inhibitory
concentrations (MIC's). These MIC's provide estimates of the susceptibility of
bacteria to antimicrobial compounds. The MIC's should be determined using a
standardized procedure. Standardized procedures are based on a dilution method
(REF. 1) (broth or agar) or equivalent with standardized inoculum concentrations
and standardized concentrations of azithromycin powder. The MIC values should be
interpreted according to the following criteria:
For testing aerobic microorganisms other than Haemophilus species, Neisseria
Gonorrhoeae, and streptococci:
MIC (MCGM/ML) INTERPRETATION
=2 Susceptible (S)
4 Intermediate (I)
>/=8 Resistant (R)
For testing Haemophilus species:(a)
MIC (MCGM/ML) INTERPRETATION
=4 Susceptible (S)
(a) These interpretive standards are applicable only to broth microdilution
susceptibility testing with Haemophilus species using Haemophilus Test
Medium. (REF. 1)
The current absence of data on resistant strains precludes defining any
categories other than "Susceptible." Strains yielding MIC results suggestive of
a "nonsusceptible" category should be submitted to a reference laboratory for
further testing.
For testing Streptococci including S. Pneumoniae: (b)
MIC (MCGM/ML) INTERPRETATION
=0.5 Susceptible (S)
1 Intermediate (I)
>/=2 Resistant (R)
(b) These interpretive standards are applicable only to broth microdilution
susceptibility tests using cation-adjusted Mueller-Hinton broth with 2-5%
lysed horse blood.
No interpretive criteria have been established for testing Neisseria
Gonorrhoeae. This species is not usually tested.
A report of "Susceptible" indicates that the pathogen is likely to respond to
monotherapy with azithromycin. A report of "Intermediate" indicates that the
result should be considered equivocal, and, if the microorganism is not fully
susceptible to alternative, clinically feasible drugs, the test should be
repeated. This category implies possible clinical applicability in body sites
where the drug is physiologically concentrated or in situations where high
dosage of drug can be used. This category also provides a buffer zone which
prevents small uncontrolled technical factors from causing major discrepancies
in interpretation. A report of "Resistant" indicates that achievable drug
concentrations are unlikely to be inhibitory; other therapy should be selected.
Standardized susceptibility test procedures require the use of laboratory
control microorganisms to control the technical aspects of the laboratory
procedures. Standard azithromycin powder should provide the following MIC
values:
MICROORGANISM MIC (MCGM/ML)
Haemophilus Influenzae ATCC 49247(a) 1.0-4.0
Staphylococcus Aureus ATCC 29213 0.5-2.0
Streptococcus Pneumoniae ATCC 49619(b) 0.06-0.25
(a) This quality control range is applicable only to H. Influenzae ATCC 49247
tested by a broth microdilution procedure using Haemophilus Test Medium
(HTM). (REF. 1)
(b) This quality control range is applicable to only S. Pneumoniae ATCC 49619
tested by a broth microdilution procedure using cation-adjusted
Mueller-Hinton broth with 2-5% lysed horse blood.
No interpretive criteria have been established for testing Neisseria
Gonorrhoeae. This species is not usually tested.
DIFFUSION TECHNIQUES:
Quantitative methods that require measurement of zone diameters also provide
reproducible estimates of the susceptibility of bacteria to antimicrobial
compounds. One such standardized procedure (REF. 2) requires the use of
standardized inoculum concentrations. This procedure uses paper disks
impregnated with 15-mcgm azithromycin to test the susceptibility of
microorganisms to azithromycin.
Reports from the laboratory providing results of the standard single-disk
susceptibility test with a 15-mcgm azithromycin disk should be interpreted
according to the following criteria:
For testing aerobic microorganisms (including streptococci)(a) except
Haemophilus species and Neisseria Gonorrhoeae:
ZONE DIAMETER (MM) INTERPRETATION
>/=18 Susceptible (S)
14-17 Intermediate (I)
=13 Resistant (R)
(a)These zone diameter standards for streptococci apply only to tests
performed using Mueller-Hinton agar supplemented with 5% sheep blood and
incubated in 5% CO2.
For testing Haemophilus species:(b)
ZONE DIAMETER (MM) INTERPRETATION
>/=12 Susceptible (S)
(b)These zone diameter standards apply only to tests with Haemophilus species
using Haemophilus Test Medium (HTM). (REF. 2)
The current absence of data on resistant strains precludes defining any
categories other than "Susceptible." Strains yielding zone diameter results
suggestive of a "nonsusceptible" category should be submitted to a reference
laboratory for further testing.
No interpretive criteria have been established for testing Neisseria
Gonorrhoeae. This species is not usually tested.
Interpretation should be as stated above for results using dilution techniques.
Interpretation involves correlation of the diameter obtained in the disk test
with the MIC for azithromycin.
As with standardized dilution techniques, diffusion methods require the use of
laboratory control microorganisms that are used to control the technical aspects
of the laboratory procedures. For the diffusion technique, the 15-mcgm
azithromycin disk should provide the following zone diameters in these
laboratory test quality control strains:
Zone
MICROORGANISM DIAMETER (MM)
Haemophilus Influenzae ATCC 49247a 13-21
Staphylococcus Aureus ATCC 25923 21-26
Streptococcus Pneumoniae ATCC 49619b 19-25
(a) These quality control limits apply only to tests conducted with H.
Influenzae ATCC 49247 using Haemophilus Test Medium (HTM). (REF. 2)
(b) These quality control limits apply only to tests conducted with S.
Pneumoniae ATCC 49619 using Mueller-Hinton agar supplemented with 5%
sheep blood incubated in 5% CO2.
INDICATIONS AND USAGE:
AZITHRAL (azithromycin) is indicated for the treatment of patients with mild
to moderate infections (pneumonia: see WARNINGS) caused by susceptible strains
of the designated microorganisms in the specific conditions listed below. AS
RECOMMENDED DOSAGES, DURATIONS OF THERAPY, AND APPLICABLE PATIENT POPULATIONS
VARY AMONG THESE INFECTIONS, PLEASE SEE DOSAGE AND ADMINISTRATION for specific
dosing recommendations .
ADULTS:
ACUTE BACTERIAL EXACERBATIONS OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE due to
Haemophilus Influenzae, Moraxella Catarrhalis, or Streptococcus Pneumoniae.
COMMUNITY-ACQUIRED PNEUMONIA due to Chlamydia Pneumoniae, Haemophilus
Influenzae, Mycoplasma Pneumoniae, or Streptococcus Pneumoniae in patients
appropriate for oral therapy.
NOTE: AZITHROMYCIN SHOULD NOT BE USED IN PATIENTS WITH PNEUMONIA WHO ARE JUDGED
TO BE INAPPROPRIATE FOR ORAL THERAPY BECAUSE OF MODERATE TO SEVERE ILLNESS OR
RISK FACTORS SUCH AS ANY OF THE FOLLOWING:
PATIENTS WITH CYSTIC FIBROSIS,
PATIENTS WITH NOSOCOMIALLY ACQUIRED INFECTIONS,
PATIENTS WITH KNOWN OR SUSPECTED BACTEREMIA,
PATIENTS REQUIRING HOSPITALIZATION,
ELDERLY OR DEBILITATED PATIENTS, OR
PATIENTS WITH SIGNIFICANT UNDERLYING HEALTH PROBLEMS THAT MAY COMPROMISE THEIR
ABILITY TO RESPOND TO THEIR ILLNESS (INCLUDING IMMUNODEFICIENCY OR FUNCTIONAL
ASPLENIA).
PHARYNGITIS/TONSILLITIS caused by Streptococcus Pyogenes as an alternative to
first-line therapy in individuals who cannot use first-line therapy.
NOTE: Penicillin by the intramuscular route is the usual drug of choice in the
treatment of Streptococcus Pyogenes infection and the prophylaxis of rheumatic
fever. AZITHRAL is often effective in the eradication of susceptible strains
of Streptococcus Pyogenes from the nasopharynx. Because some strains are
resistant to AZITHRAL, susceptibility tests should be performed when
patients are treated with AZITHRAL. Data establishing efficacy of
azithromycin in subsequent prevention of rheumatic fever are not available.
UNCOMPLICATED SKIN AND SKIN STRUCTURE INFECTIONS due to Staphylococcus Aureus,
Streptococcus Pyogenes, or Streptococcus Agalactiae. Abscesses usually require
surgical drainage.
URETHRITIS AND CERVICITIS due to Chlamydia Trachomatis or Neisseria Gonorrhoeae.
GENITAL ULCER DISEASE in men due to Haemophilus Ducreyi (chancroid). Due to the
small number of women included in clinical trials, the efficacy of azithromycin
in the treatment of chancroid in women has not been established.
AZITHRAL, at the recommended dose, should not be relied upon to treat
syphilis. Antimicrobial agents used in high doses for short periods of time to
treat non-gonococcal urethritis may mask or delay the symptoms of incubating
syphilis. All patients with sexually-transmitted urethritis or cervicitis should
have a serologic test for syphilis and appropriate cultures for gonorrhea
performed at the time of diagnosis. Appropriate antimicrobial therapy and
follow-up tests for these diseases should be initiated if infection is
confirmed.
Appropriate culture and susceptibility tests should be performed before
treatment to determine the causative organism and its susceptibility to
azithromycin. Therapy with AZITHRAL may be initiated before results of these
tests are known; once the results become available, antimicrobial therapy should
be adjusted accordingly.
CHILDREN: (See PEDIATRIC USE and CLINICAL STUDIES IN PEDIATRIC PATIENTS.)
ACUTE OTITIS MEDIA caused by Haemophilus Influenzae, Moraxella Catarrhalis, or
Streptococcus Pneumoniae. (For specific dosage recommendation, see DOSAGE AND
ADMINISTRATION.)
COMMUNITY-ACQUIRED PNEUMONIA due to Chlamydia Pneumoniae, Haemophilus
Influenzae, Mycoplasma Pneumoniae, or Streptococcus Pneumoniae in patients
appropriate for oral therapy. (For specific dosage recommendation, see DOSAGE
AND ADMINISTRATION.)
NOTE: AZITHROMYCIN SHOULD NOT BE USED IN PEDIATRIC PATIENTS WITH PNEUMONIA WHO
ARE JUDGED TO BE INAPPROPRIATE FOR ORAL THERAPY BECAUSE OF MODERATE TO SEVERE
ILLNESS OR RISK FACTORS SUCH AS ANY OF THE FOLLOWING:
PATIENTS WITH CYSTIC FIBROSIS,
PATIENTS WITH NOSOCOMIALLY ACQUIRED INFECTIONS,
PATIENTS WITH KNOWN OR SUSPECTED BACTEREMIA,
PATIENTS REQUIRING HOSPITALIZATION, OR
PATIENTS WITH SIGNIFICANT UNDERLYING HEALTH PROBLEMS THAT MAY COMPROMISE THEIR
ABILITY TO RESPOND TO THEIR ILLNESS (INCLUDING IMMUNODEFICIENCY OR FUNCTIONAL
ASPLENIA).
PHARYNGITIS/TONSILLITIS caused by Streptococcus Pyogenes as an alternative to
first-line therapy in individuals who cannot use first-line therapy. (For
specific dosage recommendation, see DOSAGE AND ADMINISTRATION.)
NOTE: Penicillin by the intramuscular route is the usual drug of choice in the
treatment of Streptococcus Pyogenes infection and the prophylaxis of rheumatic
fever. AZITHRAL is often effective in the eradication of susceptible strains
of Streptococcus Pyogenes from the nasopharynx. Because some strains are
resistant to AZITHRAL, susceptibility tests should be performed when
patients are treated with AZITHRAL. Data establishing efficacy of
azithromycin in subsequent prevention of rheumatic fever are not available.
Appropriate culture and susceptibility tests should be performed before
treatment to determine the causative organism and its susceptibility to
azithromycin. Therapy with AZITHRAL may be initiated before results of these
tests are known; once the results become available, antimicrobial therapy should
be adjusted accordingly.
CONTRAINDICATIONS:
AZITHRAL is contraindicated in patients with known hypersensitivity to
azithromycin, erythromycin, or any macrolide antibiotic.
WARNINGS:
Serious allergic reactions, including angioedema, anaphylaxis, and dermatologic
reactions including Stevens Johnson Syndrome and toxic epidermal necrolysis have
been reported rarely in patients on azithromycin therapy. Although rare,
fatalities have been reported. (See CONTRAINDICATIONS.) Despite initially
successful symptomatic treatment of the allergic symptoms, when symptomatic
therapy was discontinued, the allergic symptoms RECURRED SOON THEREAFTER IN SOME
PATIENTS WITHOUT FURTHER AZITHROMYCIN EXPOSURE. These patients required
prolonged periods of observation and symptomatic treatment. The relationship of
these episodes to the long tissue half-life of azithromycin and subsequent
prolonged exposure to antigen is unknown at present.
If an allergic reaction occurs, the drug should be discontinued and appropriate
therapy should be instituted. Physicians should be aware that reappearance of
the allergic symptoms may occur when symptomatic therapy is discontinued.
IN THE TREATMENT OF PNEUMONIA, AZITHROMYCIN HAS ONLY BEEN SHOWN TO BE SAFE AND
EFFECTIVE IN THE TREATMENT OF COMMUNITY-ACQUIRED PNEUMONIA DUE TO CHLAMYDIA
PNEUMONIAE, HAEMOPHILUS INFLUENZAE, MYCOPLASMA PNEUMONIAE, OR STREPTOCOCCUS
PNEUMONIAE IN PATIENTS APPROPRIATE FOR ORAL THERAPY. AZITHROMYCIN SHOULD NOT BE
USED IN PATIENTS WITH PNEUMONIA WHO ARE JUDGED TO BE INAPPROPRIATE FOR ORAL
THERAPY BECAUSE OF MODERATE TO SEVERE ILLNESS OR RISK FACTORS SUCH AS ANY OF THE
FOLLOWING: PATIENTS WITH CYSTIC FIBROSIS, PATIENTS WITH NOSOCOMIALLY ACQUIRED
INFECTIONS, PATIENTS WITH KNOWN OR SUSPECTED BACTEREMIA, PATIENTS REQUIRING
HOSPITALIZATION, ELDERLY OR DEBILITATED PATIENTS, OR PATIENTS WITH SIGNIFICANT
UNDERLYING HEALTH PROBLEMS THAT MAY COMPROMISE THEIR ABILITY TO RESPOND TO THEIR
ILLNESS (INCLUDING IMMUNODEFICIENCY OR FUNCTIONAL ASPLENIA).
PSEUDOMEMBRANOUS COLITIS HAS BEEN REPORTED WITH NEARLY ALL ANTIBACTERIAL AGENTS
AND MAY RANGE IN SEVERITY FROM MILD TO LIFE-THREATENING. THEREFORE, IT IS
IMPORTANT TO CONSIDER THIS DIAGNOSIS IN PATIENTS WHO PRESENT WITH DIARRHEA
SUBSEQUENT TO THE ADMINISTRATION OF ANTIBACTERIAL AGENTS.
Treatment with antibacterial agents alters the normal flora of the colon and may
permit overgrowth of clostridia. Studies indicate that a toxin produced by
Clostridium Difficile is a primary cause of "antibiotic-associated colitis."
After the diagnosis of pseudomembranous colitis has been established,
therapeutic measures should be initiated. Mild cases of pseudomembranous colitis
usually respond to discontinuation of the drug alone. In moderate to severe
cases, consideration should be given to management with fluids and electrolytes,
protein supplementation, and treatment with an antibacterial drug clinically
effective against Clostridium Difficile colitis.
PRECAUTIONS:
GENERAL: Because azithromycin is principally eliminated via the liver, caution
should be exercised when azithromycin is administered to patients with impaired
hepatic function. Thera are no data regarding azithromycin usage in patients
with renal impairment; thus, caution should be exercised when prescribing
azithromycin in these patients.
The following adverse events have not been reported in clinical trials with
azithromycin, an azalide; however, they have been reported with macrolide
products: ventricular arrhythmias, including ventricular tachycardia and
Torsades De Pointes, in individuals with prolonged QT intervals.
There has been a spontaneous report from the post-marketing experience of a
patient with previous history of arrhythmias who experienced Torsades De Pointes
and subsequent myocardial infarction following a course of azithromycin therapy.
INFORMATION FOR PATIENTS:
Patients should be cautioned to take AZITHRAL capsules and AZITHRAL
suspension at least one hour prior to a meal or at least two hours after a meal.
These medications should not be taken with food.
AZITHRAL tablets can be taken with or without food.
Patients should also be cautioned not to take aluminum- and magnesium-containing
antacids and azithromycin simultaneously.
The patient should be directed to discontinue azithromycin immediately and
contact a physician if any signs of an allergic reaction occur.
DRUG INTERACTIONS: Aluminum- and magnesium- containing antacids reduce the peak
serum levels (rate) but not the AUC (extent) of azithromycin absorption.
Administration of cimetidine (800 mg) two hours prior to azithromycin had no
effect on azithromycin absorption.
Azithromycin did not affect the plasma levels or pharmacokinetics of
theophylline administered as a single intravenous dose. The effect of
azithromycin on the plasma levels or pharmacokinetics of theophylline
administered in multiple doses resulting in therapeutic steady- state levels of
theophylline is not known. However, concurrent use of macrolides and
theophylline has been associated with increases in the serum concentrations of
theophylline. Therefore, until further data are available, prudent medical
practice dictates careful monitoring of plasma theophylline levels in patients
receiving azithromycin and theophylline concomitantly.
Azithromycin did not affect the prothrombin time response to a single dose of
warfarin. However, prudent medical practice dictates careful monitoring of
prothrombin time in all patients treated with azithromycin and warfarin
concomitantly. Concurrent use of macrolides and warfarin in clinical practice
has been associated with increased anticoagulant effects.
The following drug interactions have not been reported in clinical trials with
azithromycin; however, no specific drug interaction studies have been performed
to evaluate potential drug- drug interaction. Nonetheless, they have been
observed with macrolide products. Until further data are developed regarding
drug interactions when azithromycin and these drugs are used concomitantly,
careful monitoring of patients is advised:
Digoxin--elevated digoxin levels.
Ergotamine or dihydroergotamine--acute ergot toxicity characterized by severe
peripheral vasospasm and dysesthesia.
Triazolam--decrease the clearance of triazolam and thus may increase the
pharmacologic effect of triazolam.
Drugs metabolized by the cytochrome P450 system- -elevations of serum
carbamazepine, terfenadine, cyclosporine, hexobarbital, and phenytoin levels.
LABORATORY TEST INTERACTIONS: There are no reported laboratory test
interactions.
CARCINOGENESIS, MUTAGENESIS, IMPAIRMENT OF FERTILITY: Long-term studies in
animals have not been performed to evaluate carcinogenic potential. Azithromycin
has shown no mutagenic potential in standard laboratory tests: mouse lymphoma
assay, human lymphocyte clastogenic assay, and mouse bone marrow clastogenic
assay. No evidence of impaired fertility due to azithromycin was found.
PREGNANCY: Teratogenic Effects. Pregnancy Category B: Reproduction studies have
been performed in rats and mice at doses up to moderately maternally toxic dose
levels (i.e., 200 mg/kg/day). These doses, based on a mg/M(squared) basis, are
estimated to be 4 and 2 times, respectively, the human daily dose of 500 mg. In
the animal studies, no evidence of harm to the fetus due to azithromycin was
found. There are, however, no adequate and well- controlled studies in pregnant
women. Because animal reproduction studies are not always predictive of human
response, azithromycin should be used during pregnancy only if clearly needed.
NURSING MOTHERS: It is not known whether azithromycin is excreted in human milk.
Because many drugs are excreted in human milk, caution should be exercised when
azithromycin is administered to a nursing woman.
PEDIATRIC USE: (See ACTIONS/CLINICAL PHARMACOLOGY, INDICATIONS AND USAGE, and
DOSAGE AND ADMINISTRATION.)
Acute Otitis Media (dosage regimen: 10 mg/kg on Day 1 followed by 5 mg/kg on
Days 2-5): Safety and effectiveness in the treatment of children with otitis
media under 6 months of age have not been established.
Community-acquired Pneumonia (dosage regimen: 10 mg/kg on Day 1 followed by 5
mg/kg on Days 2-5): Safety and effectiveness in the treatment of children with
community-acquired pneumonia under 6 months of age have not been established.
Safety and effectiveness for pneumonia due to Chlamydia Pneumoniae and
Mycoplasma Pneumoniae were documented in pediatric clinical trials. Safety and
effectiveness for pneumonia due to Haemophilus Influenzae and Streptococcus
Pneumoniae were not documented bacteriologically in the pediatric clinical trial
due to difficulty in obtaining specimens. Use of azithromycin for these two
microorganisms is supported, however, by evidence from adequate and well-
controlled studies in adults.
Pharyngitis/Tonsillitis (dosage regimen: 12 mg/kg on Days 1-5): Safety and
effectiveness in the treatment of children with pharyngitis/tonsillitis under 2
years of age have not been established.
STUDIES EVALUATING THE USE OF REPEATED COURSES OF THERAPY HAVE NOT BEEN
CONDUCTED. (SEE ACTIONS/CLINICAL PHARMACOLOGY AND ANIMAL TOXICOLOGY.)
GERIATRIC USE: Pharmacokinetic parameters in older volunteers (65-85 years old)
were similar to those in younger volunteers (18-40 years old) for the 5-day
therapeutic regimen. Dosage adjustment does not appear to be necessary for older
patients with normal renal and hepatic function receiving treatment with this
dosage regimen. (See ACTIONS/CLINICAL PHARMACOLOGY.)
DRUG INTERACTIONS:
Aluminum- and magnesium-containing antacids reduce the peak serum levels (rate)
but not the AUC (extent) of azithromycin absorption.
Administration of cimetidine (800 mg) two hours prior to azithromycin had no
effect on azithromycin absorption.
Azithromycin did not affect the plasma levels or pharmacokinetics of
theophylline administered as a single intravenous dose. The effect of
azithromycin on the plasma levels or pharmacokinetics of theophylline
administered in multiple doses resulting in therapeutic steady- state levels of
theophylline is not known. However, concurrent use of macrolides and
theophylline has been associated with increases in the serum concentrations of
theophylline. Therefore, until further data are available, prudent medical
practice dictates careful monitoring of plasma theophylline levels in patients
receiving azithromycin and theophylline concomitantly.
Azithromycin did not affect the prothrombin time response to a single dose of
warfarin. However, prudent medical practice dictates careful monitoring of
prothrombin time in all patients treated with azithromycin and warfarin
concomitantly. Concurrent use of macrolides and warfarin in clinical practice
has been associated with increased anticoagulant effects.
The following drug interactions have not been reported in clinical trials with
azithromycin; however, no specific drug interaction studies have been performed
to evaluate potential drug- drug interaction. Nonetheless, they have been
observed with macrolide products. Until further data are developed regarding
drug interactions when azithromycin and these drugs are used concomitantly,
careful monitoring of patients is advised:
Digoxin--elevated digoxin levels.
Ergotamine or dihydroergotamine--acute ergot toxicity characterized by severe
peripheral vasospasm and dysesthesia.
Triazolam--decrease the clearance of triazolam and thus may increase the
pharmacologic effect of triazolam.
Drugs metabolized by the cytochrome P450 system- -elevations of serum
carbamazepine, terfenadine, cyclosporine, hexobarbital, and phenytoin levels.
(See Also PRECAUTIONS section.)
ADVERSE REACTIONS:
In clinical trials, most of the reported side effects were mild to moderate in
severity and were reversible upon discontinuation of the drug. Approximately
0.7% of the patients (adults and children) from the multiple-dose clinical
trials discontinued AZITHRAL (azithromycin) therapy because of treatment-
related side effects. Most of the side effects leading to discontinuation were
related to the gastrointestinal tract, e.g., nausea, vomiting, diarrhea, or
abdominal pain. Potentially serious side effects of angioedema and cholestatic
jaundice were reported rarely.
CLINICAL:
ADULTS:
Multiple-dose Regimen: Overall, the most common side effects in adult patients
receiving a multiple-dose regimen of AZITHRAL were related to the
gastrointestinal system with diarrhea/loose stools (5%), nausea (3%), and
abdominal pain (3%) being the most frequently reported.
No other side effects occurred in patients on the multiple-dose regimen of
AZITHRAL with a frequency greater than 1%. Side effects that occurred with a
frequency of 1% or less included the following:
CARDIOVASCULAR: Palpitations, chest pain.
GASTROINTESTINAL: Dyspepsia, flatulence, vomiting, melena, and cholestatic
jaundice.
GENITOURINARY: Monilia, vaginitis, and nephritis.
NERVOUS SYSTEM: Dizziness, headache, vertigo, and somnolence.
GENERAL: Fatigue.
ALLERGIC: Rash, photosensitivity, and angioedema.
Single 1-Gram Dose Regimen: Overall, the most common side effects in patients
receiving a single-dose regimen of 1 gram of AZITHRAL were related to the
gastrointestinal system and were more frequently reported than in patients
receiving the multiple-dose regimen.
Side effects that occurred in patients on the single one-gram dosing regimen of
AZITHRAL with a frequency of 1% or greater included diarrhea/loose stools
(7%), nausea (5%), abdominal pain (5%), vomiting (2%), dyspepsia (1%), and
vaginitis (1%).
Single 2-Gram Dose Regimen: Overall, the most common side effects in patients
receiving a single 2-gram dose of AZITHRAL were related to the
gastrointestinal system. Side effects that occurred in patients in this study
with a frequency of 1% or greater included nausea (18%), diarrhea/loose stools
(14%), vomiting (7%), abdominal pain (7%), vaginitis (2%), dyspepsia (1%), and
dizziness (1%). The majority of these complaints were mild in nature.
CHILDREN:
Multiple-Dose Regimens: The types of side effects in children were comparable to
those seen in adults, with different incidence rates for the two dosage regimens
recommended in children.
Acute Otitis Media: For the recommended dosage regimen of 10 mg/kg on Day 1
followed by 5 mg/kg on Days 2-5, the most frequent side effects attributed to
treatment were diarrhea/loose stools (2%), abdominal pain (2%), vomiting (1%),
and nausea (1%).
Community-Acquired Pneumonia: For the recommended dosage regimen of 10 mg/kg on
Day 1 followed by 5mg/kg on Days 2-5, the most frequent side effects attributed
to treatment were diarrhea/loose stools (5.8%), abdominal pain, vomiting, and
nausea (1.9% each), and rash (1.6%).
Pharyngitis/tonsillitis: For the recommended dosage regimen of 12 mg/kg on Days
1-5, the most frequent side effects attributed to treatment were diarrhea/loose
stools (6%), vomiting (5%), abdominal pain (3%), nausea (2%), and headache (1%).
With either treatment regimen, no other side effects occurred in children
treated with AZITHRAL with a frequency greater than 1%. Side effects that
occurred with a frequency of 1% of less included the following:
CARDIOVASCULAR: Chest pain.
GASTROINTESTINAL: Dyspepsia, constipation, anorexia, flatulence, and gastritis.
NERVOUS SYSTEM: Headache (otitis media dosage), hyperkinesia, dizziness,
agitation, nervousness, insomnia.
GENERAL: Fever, fatigue, malaise.
ALLERGIC: Rash.
SKIN AND APPENDAGES: Pruritus, urticaria.
SPECIAL SENSES: Conjunctivitis.
POST-MARKETING EXPERIENCE:
Adverse events reported with azithromycin during the post-marketing period in
adult and/or pediatric patients for which a causal relationship may not be
established include:
ALLERGIC: Arthralgia, edema, urticaria.
CARDIOVASCULAR: Arrhythmias including ventricular tachycardia.
GASTROINTESTINAL: Anorexia, constipation, dyspepsia, flatulence,
vomiting/diarrhea rarely resulting in dehydration.
GENERAL: Asthenia, paresthesia.
GENITOURINARY: Interstitial nephritis and acute renal failure.
LIVER/BILIARY: Abnormal liver function including hepatitis and cholestatic
jaundice.
NERVOUS SYSTEM: Convulsions.
SKIN/APPENDAGES: Rarely serious skin reactions including erythema multiforme,
Stevens Johnson Syndrome, and toxic epidermal necrolysis.
SPECIAL SENSES: Hearing disturbances including hearing loss, deafness, and/or
tinnitus, rare reports of taste disturbances.
LABORATORY ABNORMALITIES:
ADULTS:
Significant abnormalities (irrespective of drug relationship) occurring during
the clinical trials were reported as follows: with an incidence of 1-2%,
elevated serum creatine phosphokinase, potassium, ALT (SGPT), GGT, and AST
(SGOT); with an incidence of less than 1%, leukopenia, neutropenia, decreased
platelet count, elevated serum alkaline phosphatase, bilirubin, BUN, creatinine,
blood glucose, LDH, and phosphate.
When follow-up was provided, changes in laboratory tests appeared to be
reversible.
In multiple-dose clinical trials involving more than 3000 patients, 3 patients
discontinued therapy because of treatment-related liver enzyme abnormalities and
1 because of a renal function abnormality.
CHILDREN:
Significant abnormalities (irrespective of drug relationship) occurring during
clinical trials were all reported at a frequency of less than 1%, but were
similar in type to the adult pattern.
In multiple-dose clinical trials involving almost 3300 pediatric patients, no
patients discontinued therapy because of treatment-related laboratory
abnormalities
DOSAGE AND ADMINISTRATION:
(SEE INDICATIONS AND USAGE AND ACTIONS/CLINICAL PHARMACOLOGY.)
ADULTS:
The recommended dose of AZITHRAL for the treatment of mild to moderate acute
bacterial exacerbations of chronic obstructive pulmonary disease, community-
acquired pneumonia of mild severity, pharyngitis/tonsillitis (as second-line
therapy), and uncomplicated skin and skin structure infections due to the
indicated organisms is: 500 mg as a single dose on the first day followed by 250
mg once daily on days 2 through 5.
AZITHRAL CAPSULES SHOULD BE GIVEN AT LEAST 1 HOUR BEFORE OR 2 HOURS AFTER A
MEAL. AZITHRAL CAPSULES SHOULD NOT BE TAKEN WITH FOOD.
AZITHRAL tablets can be taken with or without food.
The recommended dose of AZITHRAL for the treatment of genital ulcer disease
due to Haemophilus Ducreyi (chancroid), non-gonococcal urethritis and cervicitis
due to C. Trachomatis is: a single 1 gram (1000 mg) dose of AZITHRAL.
The recommended dose of AZITHRAL for the treatment of urethritis and
cervicitis due to Neisseria Gonorrhoeae is a single 2 gram (2000 mg) dose of
AZITHRAL.
CHILDREN:
ACUTE OTITIS MEDIA AND COMMUNITY-ACQUIRED PNEUMONIA: The recommended dose of
AZITHRAL for oral suspension for the treatment of children with acute otitis
media and community-acquired pneumonia is 10 mg/kg as a single dose on the first
day (not to exceed 500 mg/day) followed by 5 mg/kg on days 2 through 5 (not to
exceed 250 mg/day). (See chart below.)
AZITHRAL FOR ORAL SUSPENSION SHOULD BE GIVEN AT LEAST 1 HOUR BEFORE OR 2
HOURS AFTER A MEAL.
AZITHRAL FOR ORAL SUSPENSION SHOULD NOT BE TAKEN WITH FOOD.
------------------------------------------------------------------------------------------------------------------------------------
PEDIATRIC DOSAGE GUIDELINES
FOR OTITIS MEDIA AND COMMUNITY-ACQUIRED PNEUMONIA
(AGE 6 MONTHS AND ABOVE, SEE PEDIATRIC USE.)
BASED ON BODY WEIGHT
-------------------------------------------------------------------------------------------------------------------------------------
OTITIS MEDIA AND COMMUNITY-ACQUIRED PNEUMONIA
-------------------------------------------------------------------------------------------------------------------------------------
DOSING CALCULATED ON 10 MG/KG ON DAY 1 DOSE,
FOLLOWED BY 5 MG/KG ON DAYS 2 TO 5.
Weight 100 mg/5mL 200 mg/5 mL Total mL per
Suspension Suspension Treatment
Kg lbs Day 1 Days 2-5 Day 1 Days 2-5 Course
-------------------------------------------------------------------------------------------------------------------------------------
10 22 5 mL 2.5 mL 15 mL
(1 tsp) (1/2 tsp)
20 44 5 mL 2.5 mL 15 mL
(1 tsp) (1/2 tsp)
30 66 7.5 mL 3.75 mL 22.5 mL
(1 1/2 tsp) (3/4 tsp)
40 88 10 mL 5 mL 30 mL
(2 tsp) (1 tsp)
------------------------------------------------------------------------------------------------------------------------------------
PHARYNGITIS/TONSILLITIS: The recommended dose for children with
pharyngitis/tonsillitis is 12 mg/kg once a day for 5 days (not to exceed 500
mg/day). (See chart below.)
AZITHRAL FOR ORAL SUSPENSION SHOULD BE GIVEN AT LEAST 1 HOUR BEFORE OR 2
HOURS AFTER A MEAL.
AZITHRAL FOR ORAL SUSPENSION SHOULD NOT BE TAKEN WITH FOOD.
PEDIATRIC DOSAGE GUIDELINES FOR
PHARYNGITIS/TONSILLITIS
(AGE 2 YEARS AND ABOVE, SEE PEDIATRIC USE.)
Based on Body Weight
-----------------------------------------------------------------------------------------------------------------------------------
PHARYNGITIS/TONSILLITIS
-----------------------------------------------------------------------------------------------------------------------------------
DOSING CALCULATED ON 12 MG/KG ONCE DAILY DAYS 1 TO 5.
200 mg/5 mL
Weight Suspension Total mL per
Kg lbs Day 1-5 Treatment Course
-----------------------------------------------------------------------------------------------------------------------------------
8 18 2.5 mL 12.5 mL
(1/2 tsp)
17 37 5 mL 25 mL
(1 tsp)
25 55 7.5 mL 37.5 mL
(1 1/2 tsp)
33 73 10 mL 50 mL
(2 tsp)
40 88 12.5 mL 62.5 mL
(2 1/2 tsp)
----------------------------------------------------------------------------------------------------------------------------------
Constituting instructions for AZITHRAL Oral Suspension, 300, 600, 900, 1200
mg bottles. The table below indicates the volume of water to be used for
constitution.
-------------------------------------------------------------------------------------------------------------------
Total volume
after Azithromycin
Amount of constitution concentration
water to (azithromycin after
BE ADDED CONTENT) CONSTITUTION
9 mL (300 mg) 15 mL (300 mg) 100 mg/5 mL
9 mL (600 mg) 15 mL (600 mg) 200 mg/5 mL
12 mL (900 mg) 22.5 mL (900 mg) 200 mg/5 mL
15 mL (1200 mg) 30 mL (1200 mg) 200 mg/5 mL
-------------------------------------------------------------------------------------------------------------------
Shake well before each use. Oversized bottle provides shake space. Keep tightly
closed.
After mixing, store at 5 deg to 30 deg C (41 deg to 86 deg F) and use within 10
days. Discard after full dosing is completed.
CLINICAL STUDIES:
CLINICAL STUDIES IN PEDIATRIC PATIENTS
(SEE INDICATIONS AND USAGE AND PEDIATRIC USE.)
From the perspective of evaluating pediatric clinical trials, Days 11-14 (6-9
days after completion of the five-day regimen) were considered on-therapy
evaluations because of the extended half-life of azithromycin. Day 11-14 data
are provided for clinical guidance. Day 30 evaluations were considered the
primary test of cure endpoint.
ACUTE OTITIS MEDIA
Efficacy Protocol 1
In a double-blind, controlled clinical study of acute otitis media performed in
the United States, azithromycin (10 mg/kg on Day 1 followed by 5 mg/kg on Days
2-5) was compared to an antimicrobial/beta-lactamase inhibitor. In this study,
very strict evaluability criteria were used to determine clinical response and
safety results were obtained. For the 553 patients who were evaluated for
clinical efficacy, the clinical success rate (i.e., cure plus improvement) at
the Day 11 visit was 88% for azithromycin and 88% for the control agent. For the
521 patients who were evaluated at the Day 30 visit, the clinical success rate
was 73% for azithromycin and 71% for the control agent.
In the safety analysis of the above study, the incidence of adverse events,
primarily gastrointestinal, in all patients treated was 9% with azithromycin and
31% with the control agent. The most common side effects were diarrhea/loose
stools (4% azithromycin vs. 20% control), vomiting (2% azithromycin vs. 7%
control), and abdominal pain (2% azithromycin vs. 5% control).
Efficacy Protocol 2
In a noncomparative clinical and microbiologic trial performed in the United
States, where significant rates of beta-lactamase producing organisms (35%) were
found, 131 patients were evaluable for clinical efficacy. The combined clinical
success rate (i.e., cure and improvement) at the Day 11 visit was 84% for
azithromycin. For the 122 patients who were evaluated at the Day 30 visit, the
clinical success rate was 70% for azithromycin.
Microbiologic determinations were made at the pre-treatment visit. Microbiology
was not reassessed at later visits. The following presumptive bacterial/clinical
cure outcomes (i.e., clinical success) were obtained from the evaluable group.
Bacteriologic Eradication:
Day 11 Day 30
Azithromycin Azithromycin
S. Pneumoniae 61/74 (82%) 40/56 (71%)
H. Influenzae 43/54 (80%) 30/47 (64%)
M. Catarrhalis 28/35 (80%) 19/26 (73%)
S. Pyogenes 11/11 (100%) 7/7
Overall 177/217 (82%) 97/137 (73%)
In the safety analysis of this study, the incidence of adverse events, primarily
gastrointestinal, in all patients treated was 9%. The most common side effect
was diarrhea (4%).
Efficacy Protocol 3
In another controlled comparative clinical and microbiologic study of otitis
media performed in the United States, azithromcyin was compared to an
antimicrobial/beta-lactamase inhibitor. This study utilized two of the same
investigators as Efficacy Protocol 2 (above), and these two investigators
enrolled 90% of the patients in Efficacy Protocol 3. For this reason, Efficacy
Protocol 3 was not considered to be an independent study. Significant rates of
beta- lactamase producing organisms (20%) were found. Ninety-two (92) patients
were evaluable for clinical and microbiologic efficacy. The combined clinical
success rate (i.e., cure and improvement) of those patients with a baseline
pathogen at the Day 11 visit was 88% for azithromycin vs. 100% for control; at
the Day 30 visit, the clinical success rate was 82% for azithromycin vs. 80% for
control.
Microbiologic determinations were made at the pre-treatment visit. Microbiology
was not reassessed at later visits. At the Day 11 and Day 30 visits, the
following presumptive bacterial/clinical cure outcomes (i.e., clinical success)
were obtained from the evaluable group:
Bacteriologic Eradication:
-----------------------------------------------------------------------------------------------------------------------
Day 11 Day 30
Azithromycin Control Azithromycin Control
S. Pneumoniae 25/29 (86%) 26/26 (100%) 22/28 (79%) 18/22 (82%)
H. Influenzae 9/11 (82%) 9/9 8/10 (80%) 6/8
M. Catarrhalis 7/7 5/5 5/5 2/3
S. Pyogenes 2/2 5/5 2/2 4/4
Overall 43/49 (88%) 45/45 (100%) 37/45 (82%) 30/37 (81%)
-------------------------------------------------------------------------------------------------------------------------
In the safety analysis of the above study, the incidence of adverse events,
primarily gastrointestinal, in all patients treated was 4% with azithromycin and
31% with the control agent. The most common side effect was diarrhea/loose
stools (2% azithromycin vs. 29% control.)
PHARYNGITIS/TONSILLITIS
In 3 double-blind controlled studies, conducted in the United States,
azithromycin (12 mg/kg once a day for 5 days) was compared to penicillin V (250
mg three times a day for 10 days) in the treatment of pharyngitis due to
documented Group A beta-hemolytic streptococci (GABHS or S. Pyogenes).
Azithromycin was clinically and microbiologically statistically superior to
penicillin at Day 14 and Day 30 with the following clinical success (i.e., cure
and improvement) and bacteriologic efficacy rates (for the combined evaluable
patient with documented GABHS):
Three U.S. Streptococcal Pharyngitis Studies
Azithromycin vs. Penicillin V
EFFICACY RESULTS
Day 14 Day 30
Bacteriologic Eradication:
Azithromycin 323/340 (95%) 255/330 (77%)
Penicillin V 242/332 (73%) 206/325 (63%)
Clinical Success (Cure plus improvement):
Azithromycin 336/343 (98%) 310/330 (94%)
Penicillin V 284/338 (84%) 241/325 (74%)
Approximately 1% of azithromycin-susceptible S. Pyogenes isolates were resistant
to azithromycin following therapy.
The incidence of adverse events, primarily gastrointestinal, in all patients
treated was 18% on azithromycin and 13% on penicillin. The most common side
effects were diarrhea/loose stools (6% azithromycin vs. 2% penicillin), vomiting
(6% azithromycin vs. 4% penicillin), and abdominal pain (3% azithromycin vs. 1%
penicillin).
ANIMAL TOXICOLOGY
Phospholipidosis (intracellular phospholipid accumulation) has been observed in
some tissues of mice, rats, and dogs given multiple doses of azithromycin. It
has been demonstrated in numerous organ systems (e.g., eye, dorsal root ganglia,
liver, gallbladder, kidney, spleen, and pancreas) in dogs treated with
azithromycin at doses which, expressed on a mg/kg basis, are only 2 times
greater than the recommended adult human dose and in rats at doses comparable to
the recommended adult human dose. This effect has been reversible after
cessation of azithromycin treatment. Phospholipidosis has been observed to a
similar extent in the tissues of neonatal rats and dogs given daily doses of
azithromycin ranging from 10 days to 30 days. Based on the pharmacokinetic data,
phospholipidosis has been seen in the rat (30 mg/kg dose) at observed Cmax value
of 1.3 mcgm/mL (6 times greater than the observed Cmax of 0.216 mcgm/mL at the
pediatric dose of 10 mg/kg). Similarly, it has been shown in the dog (10 mg/kg
dose) at observed Cmax value of 1.5 mcgm/mL (7 times greater than the observed
same Cmax and drug dose in the studied pediatric population). On mg/M(squared)
basis, 30 mg/kg dose in the rat (135 mg/M(squared)) and 10 mg/kg dose in the dog
(79 mg/M(squared)) are approximately 0.4 and 0.6 times, respectively, the
recommended dose in the pediatric patients with an average body weight of 25 kg.
This effect, similar to that seen in the adult animals, is reversible after
cessation of azithromycin treatment. The significance of these findings for
animals and for humans is unknown.
REFERENCES:
1. National Committee for Clinical Laboratory Standards. Methods for Dilution
Antimicrobial Susceptibility Tests for Bacteria that Grow Aerobically--Third
Edition. Approved Standard NCCLS Document M7-A3, Vol. 13, No. 25, NCCLS,
Villanova, PA, December 1993.
2. National Committee for Clinical Laboratory Standards. Performance Standards
for Antimicrobial Disk Susceptibility Tests--Fifth Edition. Approved Standard
NCCLS Document M2-A5, Vol. 13, No. 24, NCCLS, Villanova, PA, December 1993.