What alternative antibiotics are recommended for pneumonia in patients with an allergy to azithromycin (Zithromax)?

From the Guidelines

For pneumonia in patients with an azithromycin allergy, the most appropriate alternative antibiotics include doxycycline (100 mg twice daily for 5-7 days), fluoroquinolones like levofloxacin (750 mg once daily for 5 days) or moxifloxacin (400 mg once daily for 5-7 days), or amoxicillin-clavulanate (875/125 mg twice daily for 5-7 days) 1. When considering treatment options, it's essential to take into account the severity of pneumonia, whether it's community-acquired or hospital-acquired, and the patient's specific allergy profile.

• The choice of antibiotic should be based on the most recent and highest quality evidence available, which in this case is the 2019 guideline from the American Thoracic Society and Infectious Diseases Society of America 1.
• True allergies to azithromycin are rare, so it's worth confirming if the reaction was a true allergy or side effect.
• If the patient has a macrolide class allergy, it's crucial to avoid clarithromycin and erythromycin as well.
• Treatment should be adjusted based on culture results when available, and patients should complete the full course even if symptoms improve quickly. Some key points to consider when selecting an antibiotic include:
• The patient's medical history and comorbidities, such as chronic heart, lung, liver, or renal disease; diabetes mellitus; alcoholism; malignancy; or asplenia.
• The presence of risk factors for antibiotic-resistant pathogens.
• The severity of pneumonia, which can influence the choice between monotherapy and combination therapy.
• The potential for drug interactions and side effects, particularly with fluoroquinolones and macrolides.

From the FDA Drug Label

Levofloxacin has in vitro activity against Gram-negative and Gram-positive bacteria fections as described in Indications and Usage (1): Gram-PositiveBacteria Streptococcus pneumoniae (including multi-drug resistant isolates [MDRSP] ) Gram-Negative Bacteria Haemophilus influenzae Other Bacteria Chlamydophila pneumoniae Mycoplasma pneumoniae

Alternative antibiotics for pneumonia with an allergy to azithromycin may include levofloxacin, as it has in vitro activity against Streptococcus pneumoniae, Haemophilus influenzae, Chlamydophila pneumoniae, and Mycoplasma pneumoniae, which are common causes of pneumonia 2.

From the Research

Alternatives to Azithromycin for Pneumonia Treatment

In cases where a patient has an allergy to azithromycin, alternative antibiotics can be considered for the treatment of pneumonia. The choice of antibiotic depends on various factors, including the severity of the pneumonia, the patient's medical history, and the presence of any other health conditions.

Options for Community-Acquired Pneumonia

• Fluoroquinolones, such as levofloxacin or moxifloxacin, can be used as an alternative to azithromycin for the treatment of community-acquired pneumonia (CAP) 3, 4.
• A combination of a third-generation cephalosporin (e.g., ceftriaxone) and doxycycline can also be considered for the treatment of CAP, especially in patients with severe pneumonia or those who are at risk of developing complications 5, 6.
• Doxycycline can be used as a substitute for macrolides, such as azithromycin, in combination therapy with a beta-lactam antibiotic for the treatment of CAP 6.

Considerations for Antibiotic Selection

When selecting an antibiotic for the treatment of pneumonia in a patient with an allergy to azithromycin, it is essential to consider the following factors:

• The severity of the pneumonia and the patient's risk of developing complications
• The presence of any underlying health conditions, such as heart disease or kidney disease
• The patient's medical history, including any previous allergic reactions to antibiotics
• The potential for antibiotic resistance and the need for alternative treatment options 5, 7, 4