When you have a patient who requests a Z-pack for what is almost certainly an acute viral respiratory infection, you probably respond internally or externally (possibly both) that antibiotics do not treat viruses. But could there be some effect on their symptoms, or the viral infection itself, that is not part of the common discussion when it comes to such things? We know that azithromycin is an antibiotic, but it turns out that azithromycin actually has some activity in the viral arena. This absolutely shocked me. The question is, does it matter? 

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To wit…

In vitro studies show azithromycin reduces rhinovirus replication and release.  Another in vitro study on respiratory cells from lung transplant patients found azithromycin reduces rhinovirus-associated cellular inflammation. Kids with coronavirus (the pre-COVID, old-school coronavirus)  had reduced viral load with azithromycin.  In enterovirus-infected mice, azithromycin improved survival.  Patients infected with influenza a who were given azithromycin had reduced interleukins 6, 8, 17, tumor necrosis factor, and CRP, indicating anti-inflammatory properties in flu patients. This study, however, did not show improved clinical outcomes with azithromycin. Another study using a similar methodology did not see any change in inflammatory markers but had a slight improvement in sore throat and fever resolution in the azithromycin group.  A 2009 paper found that azithromycin did not improve disease course in hospitalized infants with a respiratory synovial virus. There has been signal of clarithromycin decreasing hospitalization in patients with severe RSV, but the preponderance of data are fairly consistent that there is no benefit in hospital stay, length of illness, or oxygen utilization.   Selective poison

Every medication is a selective poison and azithromycin poisons a lot of stuff: interleukin beta production, PGE2 synthesis, tumor necrosis factor, cytokine expression, it slows membrane trafficking towards lysosomes, and inhibits the fluid phase of endocytosis of macromolecules. Suffice it to say, there's a lot going on here. 

When we see these changes in inflammatory markers or in vitro decreased viral loads, it isn’t far-fetched. By extension, it frankly wouldn’t be far-fetched if this drug improved resolution and severity of illness in viral upper respiratory infections. When it comes to the flu, an illness with cytokine dysregulation, a medication such as azithromycin, with its immunomodulatory and anti-inflammatory effects, looks very tasty. 

Bottom line: It's pretty clear that something happens when a patients take this drug. It's even possible that they may even have a sense of feeling better. I can't refute that.  My assumption is that their cold or acute sinusitis improves despite their taking an antibiotic, but maybe there is something subtle afoot that is as yet unmeasured. Unfortunately, the data to date do not show observable clinical outcome benefits with azithromycin and viral infections.

Episode ID: 1000598226078

GUID: ce069b00-d563-4f8c-943e-236a0c1c8647

Release Date: 06/02/2023, 15:00:00