Can azithromycin (Zithromax) cause Stevens-Johnson Syndrome (SJS)?

From the Guidelines

Yes, azithromycin can cause Stevens-Johnson Syndrome (SJS), though it is a rare adverse reaction. SJS is a serious, potentially life-threatening skin reaction characterized by fever, skin pain, and widespread blistering of the skin and mucous membranes. While the risk of developing SJS from azithromycin is low compared to some other medications like certain anticonvulsants and sulfonamide antibiotics, it remains an important potential side effect to be aware of. If you're taking azithromycin and develop symptoms such as unexplained skin rash, especially if accompanied by fever, blistering, peeling skin, or mucosal involvement (mouth, eyes, genitals), you should seek immediate medical attention. Do not wait for symptoms to worsen as SJS can progress rapidly. The mechanism behind azithromycin-induced SJS involves an immune-mediated hypersensitivity reaction, where the drug or its metabolites trigger an abnormal immune response in susceptible individuals. If you've previously experienced any severe skin reaction to azithromycin or other macrolide antibiotics, inform your healthcare provider as you may need to avoid this class of medications in the future. According to the British Association of Dermatologists' guidelines for the management of Stevens-Johnson syndrome/toxic epidermal necrolysis in children and young people, 2018 1, implicated medications in children are anticonvulsants and antibiotics, and azithromycin is an antibiotic that can potentially cause SJS.

Some key points to consider when managing SJS/TEN include:

• Discontinuing any potential culprit drug causing SJS/TEN immediately 1
• Establishing peripheral venous access and commencing appropriate intravenous fluid resuscitation if clinically indicated 1
• Providing adequate analgesia to ensure comfort at rest, with the addition of supplementary opiates as required 1
• Using a patient-appropriate validated pain tool to assess pain in all conscious patients at least once daily 1
• Applying an ocular lubricant every 2 hours through the acute illness to prevent ocular surface damage 1
• Using a potent topical corticosteroid ointment once daily to the involved, but noneroded, surfaces 1

It's essential to note that while azithromycin can cause SJS, the risk is rare, and the benefits of the medication often outweigh the risks. However, if you're taking azithromycin and experience any symptoms of SJS, seek medical attention immediately. As stated in the guidelines for the management of SJS/TEN in adults 2016 1, routine drug hypersensitivity testing is not recommended following an episode of SJS/TEN, but seeking specialist advice on hypersensitivity testing may be necessary in certain cases.

In terms of morbidity, mortality, and quality of life, it's crucial to prioritize the patient's safety and well-being when prescribing azithromycin or any other medication that can potentially cause SJS. As mentioned in the study on the management of SJS/TEN in children and young people, 2018 1, any suspected medication should be withdrawn as soon as possible to decrease the risk of death. By being aware of the potential risks and taking prompt action, healthcare providers can help minimize the impact of SJS on patients' lives.

From the FDA Drug Label

WARNINGS SECTION Hypersensitivity Serious allergic reactions, including angioedema, anaphylaxis, and dermatologic reactions including Stevens Johnson Syndrome and toxic epidermal necrolysis have been reported rarely in patients on azithromycin therapy.

• Yes, azithromycin can cause Stevens Johnson Syndrome (SJS), a serious allergic reaction, as stated in the drug label 2.
• The drug label reports that these reactions have been rarely observed in patients on azithromycin therapy.
• If an allergic reaction occurs, the drug should be discontinued and appropriate therapy should be instituted.

From the Research

Azithromycin and Stevens-Johnson Syndrome

• Azithromycin has been reported to cause Stevens-Johnson syndrome (SJS) in several cases, as documented in studies 3, 4, 5, 6.
• SJS is a severe form of erythema multiforme, characterized by mucocutaneous lesions, and can result in severe morbidity and mortality 4.
• The association between azithromycin and SJS has been reported in both adults and children, with symptoms developing within a few days to weeks after exposure to the drug 3, 5.
• In some cases, azithromycin-induced SJS has presented with unusual complications, such as lip synechiae 4 or without skin manifestations 5.
• While azithromycin is not considered a common cause of SJS, these cases highlight the importance of recognizing the potential risk of this antibiotic 6.
• Other antibiotics, such as doxycycline, have also been reported to induce SJS, although this is rare 7.