Is azithromycin (Zithromax) safe to use during breastfeeding?

From the Guidelines

Azithromycin is generally considered safe to use during breastfeeding, with minimal risk to the nursing infant, as supported by recent guidelines 1.

Key Points to Consider

• The amount of azithromycin that passes into breast milk is small, resulting in minimal exposure to the baby 1.
• The American Academy of Pediatrics and other clinical guidelines suggest that azithromycin is compatible with breastfeeding 1.
• When prescribed, the typical adult dosage is 500 mg on the first day followed by 250 mg daily for 4 more days, though this may vary depending on the infection being treated.
• No special precautions are needed while breastfeeding, and you can continue nursing your baby as usual while taking this antibiotic.
• It's essential to note that an epidemiological study suggests a very low risk of hypertrophic pyloric stenosis in infants exposed to macrolides, including azithromycin, during the first 13 days of breastfeeding, but not after 2 weeks 1.

Monitoring and Precautions

• If you notice any unusual symptoms in your baby, such as diarrhea, vomiting, or rash, while taking azithromycin, contact your healthcare provider, though such reactions are rare.
• The safety profile of azithromycin during breastfeeding is due to its pharmacokinetic properties, which concentrate in tissues rather than serum, limiting the amount available to transfer into breast milk.
• Additionally, azithromycin is commonly prescribed for infants directly, further supporting its safety profile during breastfeeding.

Recommendation

Based on the most recent and highest quality study 1, azithromycin can be used during breastfeeding, and it is suggested for use in breastfeeding patients with hidradenitis suppurativa who require systemic antibiotics.

From the Research

Azithromycin and Breastfeeding

• Azithromycin is a macrolide antibiotic that has been studied in the context of breastfeeding to determine its safety for use during lactation 2.
• One case report found that azithromycin appears to demonstrate a time-dependent versus time-accumulation profile in breast milk, suggesting that the amount of azithromycin in breast milk may vary over time 2.
• A study on the safety of macrolides during lactation, which included azithromycin, found that the rate of adverse reactions in infants exposed to macrolides via breast milk was comparable to those exposed to amoxicillin via breast milk 3.
• The adverse reactions reported in infants exposed to macrolides, including azithromycin, were mild and included rash, diarrhea, loss of appetite, and somnolence 3.
• The study found no association between macrolide exposure during breastfeeding and pyloric stenosis, although larger prospective studies are needed to confirm this observation 3.

General Guidelines for Medication Use During Breastfeeding

• Most medications, including antibiotics like azithromycin, can be used safely during breastfeeding at the recommended dose, but there are exceptions that require caution 4, 5.
• The amount of medication that enters breast milk varies based on the maternal serum concentration and the pharmacologic properties of the medication 4.
• Prescribers should use current, accurate resources, such as LactMed, to determine the safety of medications during breastfeeding 4.
• When prescribing medications for a breastfeeding patient, those with the lowest risk to the infant should be selected, and dosing should be before the infant's longest sleep interval 4.