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Protein Binding: 7 51%.

Metabolism and Excretion: Mostly excreted unchanged in bile; 4.5% excreted

azithromycin (aye-zith-roe-mye-sin)

unchanged in urine.

Half-life: 11 14 hr after single dose; 2 4 days after several doses; 59 hr after ex-

Zithromax, Zmax
Classification
Therapeutic: agents for atypical mycobacterium, anti-infectives
Pharmacologic: macrolides
Pregnancy Category B

tended release suspension.

TIME/ACTION PROFILE (serum)

Indications

ROUTE

ONSET

PEAK

DURATION

PO
IV

rapid
rapid

2.53.2 hr
end of infusion

24 hr
24 hr

Contraindications/Precautions
Contraindicated in: Hypersensitivity to azithromycin, erythromycin, or other ma-

Treatment of the following infections due to susceptible organisms: Upper respiratory tract infections, including streptococcal pharyngitis, acute bacterial exacerbations of chronic bronchitis and tonsillitis, Lower respiratory tract infections, including bronchitis and pneumonia, Acute otitis media, Skin and skin structure infections,
Nongonococcal urethritis, cervicitis, gonorrhea, and chancroid. Prevention of disseminated Mycobacterium avium complex (MAC) infection in patients with advanced HIV infection. Extended-release suspension (ZMax) Acute bacterial sinusitis and community-acquired pneumonia in adults. Unlabeled Use: Prevention of
bacterial endocarditis. Treatment of cystic fibrosis lung disease. Treatment and postexposure prophylaxis of pertussis in infants.

crolide anti-infectives; History of cholestatic jaundice or hepatic dysfunction with

prior use of azithromycin.; QT interval prolongation, hypokalemia, hypomagnesemia, or bradycardia.; Concurrent use of quinidine, procainamide, dofetilide, amiodarone, or sotalol.
Use Cautiously in: Severe liver impairment (dose adjustment may be required);
Severe renal impairment (CCr 10 mL/min); Myasthenia gravis (may worsen symptoms); Geri: May haveqrisk of QT interval prolongation; OB, Lactation: Safety not
established;.

Action

Adverse Reactions/Side Effects

Inhibits protein synthesis at the level of the 50S bacterial ribosome. Therapeutic CNS: dizziness, seizures, drowsiness, fatigue, headache. CV: TORSADES DE POINTES,
Effects: Bacteriostatic action against susceptible bacteria. Spectrum: Active chest pain, hypotension, palpitations, QT interval prolongation. GI: HEPATOTOXICITY,
against the following gram-positive aerobic bacteria: Staphylococcus aureus, Strep- PSEUDOMEMBRANOUS COLITIS, abdominal pain, diarrhea, nausea, cholestatic jaundice,
tococcus pneumoniae, S. pyogenes (group A strep). Active against these gram-neg- qliver enzymes, dyspepsia, flatulence, melena, oral candidiasis, pyloric stenosis.
ative aerobic bacteria: Haemophilus influenzae, Moraxella catarrhalis, Neisseria GU: nephritis, vaginitis. Hemat: anemia, leukopenia, thrombocytopenia. Derm:
gonorrhoeae. Also active against: Bordetella pertussis, Mycoplasma, Legionella, STEVENS-JOHNSON SYNDROME, TOXIC EPIDERMAL NECROLYSIS, photosensitivity, rash.
Chlamydia pneumoniae, Ureaplasma urealyticum, Borrelia burgdorferi, M. av- EENT: ototoxicity. F and E: hyperkalemia. Misc: ANGIOEDEMA.
ium. Not active against methicillin-resistant S. aureus.

Pharmacokinetics
Absorption: Rapidly absorbed (40%) after oral administration. IV administration
results in complete bioavailability.
Distribution: Widely distributed to body tissues and fluids. Intracellular and tissue
levels exceed those in serum; low CSF levels.
Canadian drug name.

Genetic Implication.

Interactions
Drug-Drug: Quinidine, procainamide, dofetilide, sotalol, and amiodarone

mayqrisk of QT interval prolongation; concurrent use should be avoided. Aluminum- and magnesium-containing antacidsppeak levels. Nelfinavirqlevels
(monitor carefully); azithromycin alsopnelfinavir levels. Efavirenzqlevels. Mayq
the effects and risk of toxicity of warfarin and zidovudine. Other macrolide anti-

CAPITALS indicate life-threatening, underlines indicate most frequent.

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infectives have been known toqlevels and effects of digoxin, theophylline, ergotamine, dihydroergotamine, triazolam, carbamazepine, cyclosporine, tacrolimus, and phenytoin; careful monitoring of concurrent use is recommended.

Route/Dosage
Most Respiratory and Skin Infections
PO (Adults): 500 mg on 1st day, then 250 mg/day for 4 more days (total dose of 1.5
g); Acute bacterial sinusitis 500 mg once daily for 3 days or single 2-g dose of
extended-release suspension (Zmax).
PO (Children 6 mo): Pneumonia/Pertussis 10 mg/kg (not 500 m g/dose)
on 1st day, then 5 mg/kg (not 250 m g/dose) for 4 more days. Pharyngitis/tonsilitis 12 mg/kg once daily for 5 days (not 500 m g/dose); Acute bacterial sinusitis 10 mg/kg/day for three days.
PO (Neonates): Pertussis, treatment and post-exposure prophylaxis 10 mg/
kg/dose once daily for 5 days.

Otitis media

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Endocarditis Prophylaxis
PO (Adults): 500 mg 1 hr before procedure.
PO (Children): 15 mg/kg 1 hr before procedure.

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Nongonococcal Urethritis, Cervicitis, Chancroid, Chlamydia

PO (Adults): Single 1-g dose.
PO (Children): Chancroid: Single 20-mg/kg dose (not 1000 mg/dose). Urethritis or cervicitis: Single 10-mg/kg dose (not 1000 mg/dose).

Gonorrhea
PO (Adults): Single 2-g dose.

Prevention of Disseminated MAC Infection

PO (Adults): 1.2 g once weekly (alone or with rifabutin).
PO (Children): 5 mg/kg once daily (not 250 m g/dose) or 20 mg/kg (not 1200
mg/dose) once weekly (alone or with rifabutin).

Cystic Fibrosis
PO (Children 6 yrs, weight 25 kg to 40 kg): 250 mg q MWF. 40 kg: 500
mg q MWF.

PO (Children 6 mo): 30 mg/kg single dose (not 1500 mg/dose) or 10 mg/kg/

day as a single dose (not 500 m g/dose) for 3 days or 10 mg/kg as a single dose (not
500 m g/dose) on 1st day, then 5 mg/kg as a single dose (not 250 m g/dose) daily
for 4 more days.

NURSING IMPLICATIONS
Assessment

Acute bacterial exacerbations of chronic bronchitis

Obtain specimens for culture and sensitivity before initiating therapy. First dose

PO (Adults): 500 mg on 1st day, then 250 mg/day for 4 more days (total dose of 1.5
g) or 500 mg daily for 3 days.

Observe for signs and symptoms of anaphylaxis (rash, pruritus, laryn-

Community-Acquired Pneumonia
IV, PO (Adults): More severe 500 mg IV q 24 hr for at least 2 doses, then 500 mg
PO q 24 hr for a total of 7 10 days; less severe 500 mg PO, then 250 mg/day PO
for 4 more days or 2 g single dose as extended-release suspension (Zmax).
PO (Children 6 mo): 10 mg/kg on 1st day, then 5 mg/kg for 4 more days.

Pelvic Inflammatory Disease

IV, PO (Adults): 500 mg IV q 24 hr for 1 2 days, then 250 mg PO q 24 hr for a total
of 7 days.

Assess patient for infection (vital signs; appearance of wound, sputum, urine, and

stool; WBC) at beginning of and throughout therapy.

may be given before receiving results.

geal edema, wheezing). Notify health care professional immediately if

these occur.
Assess patient for skin rash frequently during therapy. Discontinue
azithromycin at first sign of rash; may be life-threatening. Stevens-Johnson syndrome or toxic epidermal necrolysis may develop. Treat symptomatically; may recur once treatment is stopped.
Lab Test Considerations: May causeqserum bilirubin, AST, ALT, LDH,
and alkaline phosphatase concentrations.
May causeqcreatine phosphokinase, potassium, prothrombin time, BUN, serum
creatinine, and blood glucose concentrations.
2015 F.A. Davis Company

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azithromycin
May occasionally causepWBC and platelet count.

Potential Nursing Diagnoses

Risk for infection (Indications) (Side Effects)
Noncompliance (Patient/Family Teaching)

Implementation

Zmax extended release oral suspension is not bioequivalent or interchangeable

with azithromycin oral suspension.

PO: Administer 1 hr before or 2 hr after meals.

For administration of single 1-g packet, thoroughly mix entire contents of packet

with 2 oz (60 mL) of water. Drink entire contents immediately; add an additional 2
oz of water, mix and drink to assure complete consumption of dose. Do not use
the single packet to administer doses other than 1000 mg of azithromycin. Pedi:
1-g packet is not for pediatric use.
For Zmax, shake suspension well and drink entire contents of bottle. Use within
12 hr of reconstitution. If patient vomits within 1 hr of administration, contact prescriber for instructions. Zmax may be taken without regard to antacids containing
magnesium or aluminum hydroxide.

IV Administration

pH: 6.4 6.6.

Intermittent Infusion: Diluent: Reconstitute each 500-mg vial with 4.8 mL of

sterile water for injection to achieve a concentration of 100 mg/mL. Reconstituted

solution is stable for 24 hr at room temperature. Further dilute the 500-mg dose
in 250 mL or 500 mL of 0.9% NaCl, 0.45% NaCl, D5W, LR, D5/0.45% NaCl, or D5/
LR. Infusion is stable for 24 hr at room temperature or for 7 days if refrigerated.
Concentration: Final concentration of infusion is 1 2 mg/mL. Rate: Administer the 1-mg/mL solution over 3 hr or the 2-mg/mL solution over 1 hr. Do not
administer as a bolus.
Y-Site Compatibility: acyclovir, alemtuzumab, alfentanil, aminophylline, amphotericin B lipid complex, amphotericin B liposome, ampicillin/sulbactam, an Canadian drug name.

Genetic Implication.

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idulafungin, argatroban, atracurium, bivalirudin, bleomycin, bumetanide, buprenorphine, butorphanol, calcium chloride, calcium gluconate, carboplatin,
carmustine, cefazolin, cefepime, cefoperazone, cefotetan, cefoxitin, ceftaroline,
ceftazidime, cisatracurium, cisplatin, cyclophosphamide, cyclosporine, cytarabine, daptomycin, dedxamethasone, dexmedetomidine, dexrazoxane, digoxin,
diltiazem, diphenhydramine, dobutamine, docetaxel, dopamine, doripenem, doxacurium, doxycycline, droperidol, enalaprilat, ephedrine, epinephrine, eptifibatide, ertapenem, esmolol, etoposide, etoposide phosphate, fenoldopam, fluconazole, fluorouracil, foscarnet, fosphenytoin, ganciclovir, gemcitabine, granisetron,
haloperidol, heparin, hetastarch, hydrocortisone, hydromorphone, idarubicin,
ifosfamide, irinotecan, isoproterenol, leucovorin, levorphanol, lidocaine, linezolid, lorazepam, magnesium sulfate, mannitol, mechlorethamine, meperidine,
meropenem, mesna, methohexital, methotrexate, methylprednisolone, metoclopramide, metronidazole, milrinone, nalbuphine, naloxone, nesiritide, nitroglycerin, nitroprusside, octreotide, ondansetron, oxaliplatin, oxytocin, paclitaxel, palonosetron, pamidronate, pancuronium, pantoprazole, pemetrexed,
pentobarbital, phenobarbital, phenylephrine, potassium acetate, potassium chloride, potassium phosphates, procainamide, prochlorperazine, promethazine,
propranolol, ranitidine, remifentanil, rocuronium, sodium acetate, sodium bicarbonate, sodium phosphates, succinylcholine, sufentanil, tacrolimus, telavancin,
teniposide, thiotepa, tigecycline, tirofiban, trimethoprim/sulfamethoxazole, vancomycin, vasopressin, vecuronium, verapamil, vincristine, voriconazole, zidovudine, zoledronic acid.
Y-Site Incompatibility: amiodarone, amphotericin B colloidal, chlorpromazine, diazepam, doxorubicin, epirubicin, midazolam, mitoxantrone, mycophenolate, nicardipine, pentamidine, piperacillin-tazobactam, potassium chloride,
quinupristin/dalfopristin, thiopental.

Patient/Family Teaching

Instruct patients to take medication as directed and to finish the drug completely,

even if they are feeling better. Take missed doses as soon as possible unless almost
time for next dose; do not double doses. Advise patients that sharing of this medication may be dangerous.
Instruct patient not to take azithromycin with food or antacids.
May cause drowsiness and dizziness. Caution patient to avoid driving or other activities requiring alertness until response to medication is known.
Advise patient to use sunscreen and protective clothing to prevent photosensitivity
reactions.

CAPITALS indicate life-threatening, underlines indicate most frequent.

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Advise patient to report symptoms of chest pain, palpitations, yellowing

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of skin or eyes, or signs of superinfection (black, furry overgrowth on

the tongue; vaginal itching or discharge; loose or foul-smelling stools)
or rash.
Instruct patient to notify health care professional if fever and diarrhea
develop, especially if stool contains blood, pus, or mucus. Advise patient
not to treat diarrhea without advice of health care professional.
Advise patients being treated for nongonococcal urethritis or cervicitis that sexual
partners should also be treated.
Instruct parents, caregivers, or patient to notify health care professional if symptoms do not improve.
Pedi: Tell parents or caregivers that medication is generally well tolerated in children. Most common side effects in children are mild diarrhea and rash. Tell parents to notify health care practitioner if these occur.

Evaluation/Desired Outcomes

Resolution of the signs and symptoms of infection. Length of time for complete res-

olution depends on the organism and site of infection.

Why was this drug prescribed for your patient?

2015 F.A. Davis Company