From the Guidelines
Azithromycin is not recommended for routine use in patients post cardiac arrest, as it does not provide a significant benefit in reducing morbidity, mortality, or improving quality of life. The use of prophylactic antibiotics, including azithromycin, has been evaluated in the context of post-cardiac arrest care, and the current evidence suggests that it does not offer a significant advantage 1. According to the 2020 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science, meta-analyses of randomized trials and observational studies have shown no overall benefit in the use of prophylactic antibiotics during post–cardiac arrest care 1.
The primary focus of post-cardiac arrest care should be on:
- Targeted temperature management
- Hemodynamic stabilization
- Ventilatory support
- Treating the underlying cause of the arrest Antibiotics, including azithromycin, should only be considered if there is evidence of infection, such as aspiration pneumonia, or if the cardiac arrest was precipitated by an infectious process 1. When infection is suspected, empiric antibiotic therapy should be guided by the likely source, local resistance patterns, and patient factors. Azithromycin (typically 500mg IV or PO daily) may be considered as part of an antibiotic regimen for respiratory infections, but it is not a standard component of post-cardiac arrest protocols.
The rationale for withholding routine antibiotics is to prevent unnecessary antimicrobial exposure, which can lead to resistance, adverse effects, and Clostridioides difficile infections 1. Clinicians should perform thorough clinical assessments, including chest imaging and laboratory studies, to determine if infection is present before initiating antibiotic therapy in post-cardiac arrest patients. This approach prioritizes the patient's morbidity, mortality, and quality of life, while also minimizing the risks associated with unnecessary antibiotic use 1.
From the Research
Azithromycin Use Post Cardiac Arrest
- The role of azithromycin in patients post cardiac arrest is not well established, and its use may be associated with increased cardiovascular risk 2, 3, 4.
- A case report suggests that azithromycin may induce life-threatening arrhythmias, including ventricular tachycardia and ventricular fibrillation, which may require extracorporeal membrane oxygenation support 2.
- Meta-analyses and observational studies have yielded conflicting results regarding the association between azithromycin and cardiovascular events, with some studies suggesting an increased risk of cardiovascular death and others finding no significant association 5, 3, 4, 6.
- A study of patients with COVID-19 and preexisting cardiovascular disease found that azithromycin therapy was associated with an increased risk of acute heart failure and 30-day mortality 4.
- Another study found no significant difference in the risk of cardiovascular death between azithromycin and amoxicillin-clavulanate among US Veterans treated for respiratory or ear-nose-throat infections 6.
Key Findings
- Azithromycin may be associated with an increased risk of cardiovascular events, including arrhythmias and cardiac death, particularly in patients with preexisting cardiovascular disease 2, 3, 4.
- The evidence regarding the safety of azithromycin in patients post cardiac arrest is limited and conflicting, and further studies are needed to establish its role in this population.
- Clinicians should carefully consider the potential risks and benefits of azithromycin therapy in patients with cardiovascular disease or those who have experienced cardiac arrest 3, 4.