Erythromycin tolerances

Buspirone generally is well tolerated and does not cause sedation. Most common side effects include dizziness, nausea, and headaches. Drugs that inhibit CYP3A4 (e.g., verapamil, diltiazem, itraconazole, fluvoxamine, nefa-zodone, and erythromycin) can increase buspirone levels. Likewise, enzyme inducers such as rifampin can reduce buspirone levels significantly. Bupirone may increase blood pressure when coadministered with an monoamine oxidase inhibitor (MAOI). 

During lactation, azithromycin and doxycycline are first-line choices for chlamydia38 (Table 44—5). Both are deemed compatible with breast-feeding by the AAP and generally are more effective and better tolerated than erythromycin or amoxicillin.14,38... 

Although tetracycline, doxycycline, and minocycline are the most commonly prescribed oral antibiotics for acne, erythromycin and clindamycin are appropriate second-line agents for use when patients cannot tolerate or have developed resistance to tetracycline or its derivatives.3 See Table 62-3 for antibiotic dosing guidelines. 

Erythromycin has efficacy similar to tetracycline, but it induces higher rates of bacterial resistance. Resistance may be reduced by combination therapy with benzoyl peroxide. Erythromycin can be used for patients who require systemic antibiotics but cannot tolerate tetracyclines, or those who acquire bacterial resistance to tetracyclines. The usual dose is 1 g/day with meals to minimize GI intolerance. 

Trimethoprim-sulfamethoxazole (or trimethoprim alone) is a second-line oral agent that may be used for patients who do not tolerate tetracyclines and erythromycin or in cases of resistance to these antibiotics. The adult dose is usually 800 mg sulfamethoxazole and 160 mg trimethoprim twice daily. 

Treatment of uncomplicated urethral, endocervical, or rectal Chlamydia trachomaticinfections- As an alternative regimen to doxycycline or tetracycline (or if erythromycin is not tolerated), sulfisoxazole 500 mg 4 times/day for 10 days or equivalent sulfonamide course. 

Zafirlukast and montelukast are well tolerated. Zafirlukast increases plasma concentrations of warfarin and decreases the concentrations of theophylline and erythromycin. In rare cases, treatment of patients with CysLT receptor antagonists is associated with the development of Churg-Strauss syndrome, a condition marked by acute vasculitis, eosinophilia, and a worsening of pulmonary symptoms. Because these symptoms often appear when patients are given the leukotriene receptor antagonists when they are being weaned from oral corticosteroid therapy, it is not clear whether they are related to the action of the antagonists or are due to a sudden reduction in corticosteroid therapy. 

The advantages of clarithromycin compared with erythromycin are lower incidence of gastrointestinal intolerance and less frequent dosing. Except for the specific organisms noted above, the two drugs are otherwise therapeutically very similar, and the choice of one over the other usually turns out to be cost and tolerability. 

Azithromycin is rapidly absorbed and well tolerated orally. It should be administered 1 hour before or 2 hours after meals. Aluminum and magnesium antacids do not alter bioavailability but delay absorption and reduce peak serum concentrations. Because it has a 15-member (not 14-member) lactone ring, azithromycin does not inactivate cytochrome P450 enzymes and therefore is free of the drug interactions that occur with erythromycin and clarithromycin. 

To decrease the likelihood of irritation, application should be limited to a low concentration (2.5%) once daily for the first week of therapy and increased in frequency and strength if the preparation is well tolerated. Fixed-combination formulations of 5% benzoyl peroxide with 3% erythromycin base (Benzamycin) or 1% clindamycin (BenzaClin) appear to be more effective than individual agents alone. 

Macrolide antibiotics such as erythromycin directly stimulate motilin receptors on gastrointestinal smooth muscle and promote the onset of a migrating motor complex. Intravenous erythromycin (3 mg/kg) is beneficial in some patients with gastroparesis however, tolerance rapidly develops. It may be used in patients with acute upper gastrointestinal hemorrhage to promote gastric emptying of blood before endoscopy. 

Macrolides Erythromycin useful in diabetic gastroparesis but tolerance develops... 

Campylobacter species are most commonly responsible for outbreaks of bacterial gastroenteritis in developed countries. The majority of die gastrointestinal Campylobacter infections do not require antibiotic treatment and are selflimiting. Where treatment is required, erythromycin is usually recommended. However, fluoroquinolones are often also used pending laboratory results, because they can cover additional bacterial pathogens and are better tolerated than erythromycin. 

Epigastric distress This side effect is common and can lead to poor patient compliance for erythromycin. The new macrolides seem to be better tolerated by the patient gastrointestinal problems are their most common side effects. 

Tetracyclines are recommended as first-line treatment. When tetracyclines are not tolerated or contraindicated, erythromycin is an alternative. However erythromycin has problems with resistance and gastrointestinal adverse effects. If compliance is a problem, either doxycycline or lymecycline may be prescribed (can be taken once daily with food). Minocycline is second-line treatment (e.g. if oral antibiotic has failed). 

Doxycycline is commonly used for moderate to severe acne vulgaris. It is more effective and produces less resistance than tetracycline. The initial dose is 100 or 200 mg daily, followed by 50 mg daily as a maintenance dose after improvement is seen. Doxycycline maybe given with food, but it is more effective when taken 30 minutes before meals. / Minocycline is also commonly used for moderate to severe acne vulgaris. It is more effective than tetracycline. It is dosed similar to doxycycline (100 mg/day or 50 mg twice daily) and on an indefinite basis in selected patients. Minocycline has the most reported adverse effects of the tetracyclines, some of which may be serious. Trimethoprim-sulfamethoxazole (or trimethoprim alone) is a second-line oral agent that may be used for patients who do not tolerate tetracyclines and erythromycin or in cases of resistance to these antibiotics. The adult dose is usually 800 mg sulfamethoxazole and 160 mg trimethoprim twice daily. Clindamycin use is limited by diarrhea and the risk of pseudomembranous colitis. 

Erythromycin is bacteriostatic for many gram-positive organisms, such as S. aureus and S. pneumoniae. Erythromycin may have some bacteriostatic activity against Haemophilus and Neisseria, but it is not a drug of choice for these organisms. Resistant strains of S. aureus may be encountered. Because of its low incidence of adverse reactions, erythromycin is extremely well tolerated, particularly by children. It is used primarily as adjimctive therapy at bedtime. 

Space medication and food 2h apart if patient can tolerate if GI complaints, take erythromycin with small snack... 

Combined desloratadine 7.5 mg/day plus erythromycin 500 mg qds in 24 healthy volunteers was well tolerated and had no chnically important electrocardiographic effects (61). Although co-administration of erythromycin slightly increased plasma concentrations of desloratadine, this change did not correlate with prolongation of the QT interval, and there was no toxicity. 

The gastrointestinal adverse effects are the most common untoward effects of the macrolides (Table 2). Nausea and vomiting associated with abdominal pain and occasionally diarrhea can be minor and transitory or, in a small percentage of patients, become severe enough to result in premature withdrawal. The rate of these adverse effects varies among the different antibiotics. In general, newer macrolides, such as azithromycin, clarithromycin, or roxithromycin, are better tolerated and cause fewer adverse effects than erythromycin. 

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