Can Azithromycin Be Taken With Probiotics?
Yes, azithromycin can and should be taken with probiotics in most patients, as probiotics are safe and effective when used alongside antibiotics in immunocompetent individuals and may help prevent antibiotic-associated complications. 1
Safety and Compatibility
Probiotics are safe to use concurrently with antibiotics including azithromycin in patients who are not immunocompromised or severely debilitated. 1
There are no documented drug interactions between azithromycin and probiotics that would contraindicate their simultaneous use. 2, 3
The only timing consideration is that azithromycin should not be taken simultaneously with aluminum- or magnesium-containing antacids, as these reduce azithromycin absorption—but this does not apply to probiotics. 4
Evidence Supporting Combined Use
Prevention of Antibiotic-Associated Diarrhea
A pediatric study demonstrated that co-administration of probiotics (live Clostridium butyricum plus Bifidobacterium infantis) with intravenous azithromycin resulted in zero cases of antibiotic-associated diarrhea (AAD) in 55 children with Mycoplasma pneumoniae pneumonia. 3
The probiotic combination restored bacterial diversity, improved intestinal mucosal barrier function (D-lactate, endotoxin, diamine oxidase levels), and attenuated systemic inflammation (IL-10). 3
Restoration of Gut Microbiota
Research in rats showed that Lactobacillus acidophilus helped restore intestinal microfloral balance after azithromycin-induced dysbiosis. 2
Azithromycin administration reduced total 16S rRNA gene counts and eliminated non-pathogenic E. coli and Bacteroides species, but probiotic use restored these populations. 2
Bifidobacterium levels significantly increased with probiotic supplementation after azithromycin treatment (P < 0.05). 2
Clinical Recommendations
When to Use Probiotics with Azithromycin
Consider prophylactic probiotics for inpatients receiving antibiotics during high-risk periods, such as during outbreaks or in settings with elevated C. difficile infection rates. 1
Probiotics may be particularly beneficial when azithromycin is used for longer durations or in patients at higher risk for antibiotic-associated complications. 3
Contraindications for Probiotics
Do not administer probiotics to immunocompromised patients due to rare but serious risk of bacteremia or fungemia. 1
Avoid probiotics in patients at risk of bacteremia or fungemia regardless of immune status. 1
Practical Timing
Probiotics can be started on the same day as azithromycin or within the first few days of treatment. 3
In the pediatric MPP study, probiotics were initiated on day 3 of azithromycin therapy with excellent results. 3
Continue probiotics throughout the duration of antibiotic therapy and potentially for several days afterward to maximize microbiome restoration. 2, 3
Additional Considerations
Gastrointestinal Side Effects
Both azithromycin and probiotics can cause mild gastrointestinal symptoms, though probiotics generally reduce rather than increase GI complications. 4, 3
Azithromycin causes GI side effects in approximately 3-4% of patients, which are generally less common than with erythromycin. 4, 5
Specific Probiotic Strains
Evidence supports specific strains including Lactobacillus acidophilus, Bifidobacterium infantis, Clostridium butyricum, and multi-strain lactobacilli preparations. 2, 3, 1
Saccharomyces boulardii has demonstrated efficacy when combined with other antibiotics (vancomycin) for C. difficile prevention, though specific data with azithromycin is limited. 1