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 Zambia HIV National Guidelines
 


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 Guide Editors
 Editor In Chief
    Joel E. Gallant, MD, MPH

Pharmacology Editor
    Paul Pham, PharmD, BCPS

Zambia Guideline Team
   Peter Mwaba MMed PhD FRCP
   Alywn Mwinga MMed
   Isaac Zulu MMed MPH
   Velepie Mtonga MMed
   Albert Mwango MBChB
   Jabbin Mulwanda MMed FCS
 

 

 

Drugs>Antimicrobial Agents>
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Erythromycin

Paul A. Pham Pharm.D. and John G. Bartlett M.D.
10-14-2010

Zambia Specific Information

  • Available formulation in Zambia: Capsule or tablet: 250 mg (as stearate or ethyl succinate). Powder for injection: 500 mg (as lactobionate) in vial. Powder for oral liquid: 125 mg/ 5 ml (as stearate or ethyl succinate).
  • Can be considered for treatment of cholera, but strains with reduced susceptibility have been reported.
  • High rates of GI distress and multiple interactions with drug metabolized by cytochrome P450.
  • Avoid co-administration with PIs due to increased risk for QTc prolongation.
  • Treatment of infection by susceptible bacteria; as alternative therapy in penicillin-allergic patients.
  • Syphilis: erythromycin 500 mg q6h x 7 days (if given with benzathine PCN 2.4MU) Treat for 14 days (if not given with benzathine PCN).
  • Chancroid: erythromycin 500 mg q6h x 7 days
  • LGV: erythromycin 500 mg q6h x 14 days
Zambia Information Author: Paul A. Pham Pharm.D.

INDICATIONS

FDA

  • Preoperative bowel preparation (with neomycin)
  • Syphilis caused byTreponema pallidum(in patients allergic to the penicillins, but azithromycin preferred)
  • Acute exacerbations of chronic bronchitis and sinusitis
  • Acute otitis media and pharyngitis
  • Diphtheria infections due to Corynebacterium diphtheriae, as an adjunct to antitoxin
  • Intestinal amebiasis caused by Entamoeba histolytica
  • Conjunctivitis in the newborn caused by Chlamydia trachomatis
  • Legionnaires disease
  • Pertussis
  • Rheumatic fever prophylaxis,also upper respiratory tract infections caused by Streptococcus pyogenes,Streptococcus pneumoniae,Haemophilus influenzae (when used concomitantly with adequate sulfonamide dosage), Lower respiratory tract infections caused by Streptococcus pyogenesor pneumoniae,listeriosis, skin and soft tissue infections,respiratory tract infections caused by Mycoplasma pneumoniae), erythrasma, acute inflammatory pelvic disease, uncomplicated urethral, endocervical, or rectal infections caused by Chlamydia trachomatis

FORMS

brand 
name
 
generic 
Mfg 
brand 
forms
 
cost* 
PCE DispertabErythromycin~AbbottPO
tab, EC
333mg
$2.30
      PO
tab, EC
500mg
$3.33
      PO
cap
250mg
$0.16
ErycErythromycinAbbott PO
cap, EC
250mg
$0.28
ErypedErythromycin~Abbott

      PO
susp
200mg/16 oz
$1.31
      PO
susp
400mg/16 oz
$2.43 
Erythrocin LactobionateErythromycinHospiraIV
vial
500mg
$141.10 per vial
     

Erythromycin stearateErythromycin~Abbott, Nycomed USPO
tab
250mg
$0.16
      PO
tab
500mg
$0.29
      Ophthalmic
ointment
5 mg/g
$1.53 per gram

*Prices represent cost per unit specified and are representative of "Average Wholesale Price" (AWP). AWP Prices were obtained and gathered by Lakshmi Vasist Pharm D using the Red Book, manufacturer's information, and the McKesson database.

^Dosage is indicated in mg unless otherwise noted.

USUAL ADULT DOSING

  • Erythromycin base 250-500 mg PO q6-8h
  • Erythromycin estolate 250-500 mg PO q6h
  • Erythromycin ethylsuccinate 400-800 mg PO q6h or 0.5-1Gm IV q6h
  • Bowel prep: 1 gm PO 1pm, 2pm and 11pm prior to surgery (plus neomycin).

RENAL DOSING

DOSING FOR GLOMERULAR FILTRATION OF 50-80

Usual dose.

DOSING FOR GLOMERULAR FILTRATION OF 10-50

Usual dose.

DOSING FOR GLOMERULAR FILTRATION OF <10 ML/MIN

Usual dose.

DOSING IN HEMODIALYSIS

Usual regimen.

DOSING IN PERITONEAL DIALYSIS

Usual regimen.

DOSING IN HEMOFILTRATION

No data. Usual dose likely.

ADVERSE DRUG REACTIONS

COMMON

  • GI intolerance (oral-dose related), diarrhea
  • Phlebitis with IV administration
OCCASIONAL

  • Stomatitis
  • Cholestatic hepatitis (1:1000 especially with estolate salt formulation-reversible)
  • Generalized rash
  • Prolonged QTc (especially with high dose IV)
  • LFTs elevation
  • Rash
  • Reversible ototoxicity (especially with high dose IV)
RARE

  • C. difficilecolitis
  • Torsades de pointes (especially in women)
  • Hypothermia
  • Exacerbation of symptoms of myasthenia gravis and new onset of symptoms of myasthenic syndrome have been reported.

DRUG INTERACTIONS

Substrate of CYP3A4 and potent inhibitor CYP3A4 and CYP1A2.

Drug-to-Drug Interactions

Drug-to-Drug Interaction

DrugEffect of InteractionRecommendations/Comments
DRV/r Erythromycin AUC may be increased. Risk of QTc prolongation may be increased. Avoid co-administration.
FPV Erythromycin AUC may be increased. Risk of QTc prolongation may be increased. Avoid co-administration.
IDV Erythromycin AUC may be increased. Risk of QTc prolongation may be increased. Avoid co-administration.
LPV/r Erythromycin AUC may be increased. Risk of QTc prolongation may be increased. Avoid co-administration.
NFV Erythromycin AUC may be increased. Risk of QTc prolongation may be increased. Avoid co-administration.
RTV Erythromycin AUC may be increased. Risk of QTc prolongation may be increased. Avoid co-administration.
SQV Erythromycin AUC may be increased. Risk of QTc prolongation may be increased. Avoid co-administration.
NVP Erythromycin serum levels may be decreased. Consider azithromycin.
EFV Erythromycin serum levels may be decreased. Consider azithromycin.
Alprazolam Alprazolam serum levels may be increased. Consider lorazepam, oxazepam, or temazepam.
Amiodarone Amiodarone serum levels may be increased. Avoid co-administration. May increase risk of QTc prolongation. ,
Amitriptyline Risk of QTc prolongation may be increased. Avoid co-administration.
Amoxapine Risk of QTc prolongation may be increased. Avoid co-administration.
Astemizole Risk of QTc prolongation increased. Contraindicated .
Atazanavir (ATV)Erythromycin AUC may be increased. Risk of QTc prolongation may be increased. Avoid co-administration.
Bretylium Risk of QTc prolongation may be increased. Avoid co-administration.
Budesonide Budesonide serum levels may be increased. Monitor.
Carbamazepine Carbamazepine serum levels may be increased.Erythromycin serum levels may be decreased.Avoid co-administration or monitor serum level.
Cisapride Risk of QTc prolongation increased. Contraindicated.
Cyclosporine Cyclosporine serum levels may be increased. Monitor.
Desipramine Risk of QTc prolongation may be increased. Avoid co-administration.
Diazepam Diazepam serum levels may be increased. Consider lorazepam, oxazepam, or temazepam.
Digoxin Digoxin serum levels may be increased. Monitor.
Diltiazem Diltiazem serum levels may be increased. Erythromycin serum levels may be increased.May increase risk of sudden cardiac death. Avoid co-administration.Consider azithromycin.
Disopyramide Risk of QTc prolongation may be increased. Avoid co-administration.
Dofetilide Dofetilide serum levels may be increased. Risk of QTc prolongation may be increased. Avoid co-administration.
Doxepin Risk of QTc prolongation may be increased. Avoid co-administration.
Ergot alkaloids Risk of ergotism increased. Avoid co-administration.
Fentanyl Fentanyl serum levels may be increased. Consider morphine.
Fluticasone Systemic exposure of fluticasone may be increased. Consider beclomethasone inhaler
Ibutilide Risk of QTc prolongation may be increased. Avoid co-administration.
Imipramine Risk of QTc prolongation may be increased. Avoid co-administration.
Irinotecan Irinotecan serum levels may be increased. Avoid co-administration.
Itraconazole Itraconazole serum levels may be increased. Erythromycin serum levels may be increased.May increase risk of sudden cardiac death. Avoid co-administration. Consider azithromycin.
Ketoconazole Ketoconazole serum levels may be increased. Erythromycin serum levels may be increased.May increase risk of sudden cardiac death. Avoid co-administration. Consider azithromycin.
Lovastatin Lovastatin serum levels may be increased. Consider pravastatin.
Methadone Methadone serum concentrations may be increased. Increased QTc prolongation.Monitor for increased sedation. Methadone dose reduction may be needed.
Methylprednisolone Methylprednisolone serum levels may be increased. Monitor.
Midazolam Midazolam serum levels may be increased. Consider lorazepam, oxazepam, or temazepam.
Nortriptyline Risk of QTc prolongation may be increased. Avoid co-administration.
Olanzapine Olanzapine serum levels may be increased. Monitor.
Phenobarbital Erythromycin serum levels may be decreased. Consider azithromycin.
Phenytoin Erythromycin serum levels may be decreased. Consider azithromycin.
Pimozide Risk of QTc prolongation increased. Contraindicated.
Posaconazole Posaconazole serum levels may be increased. Erythromycin serum levels may be increased.May increase risk of sudden cardiac death. Avoid co-administration. Consider azithromycin.Monitor posaconazole serum concentrations.
Prednisone Prednisone serum concentrations may be increase Monitor.
Procainamide Risk of QTc prolongation may be increased. Avoid co-administration.
Protriptyline Risk of QTc prolongation may be increased. Avoid co-administration.
Quinidine Quinidine serum levels may be increased. Risk of QTc prolongation may be increased. Avoid co-administration.
Rifabutin Rifabutin serum levels may be increased. Erythromycin serum levels may be decreased. Consider azithromycin.
Rifampin Rifampin AUC may be increased. Erythromycin AUC may be decreased. Avoid co-administration.Consider azithromycin
Rifapentine Erythromycin serum levels may be decreased. Consider azithromycin.
Sildenafil Sildenafil serum levels may be increased. Monitor. Sildenafil dose need to be decreased.
Simvastatin Simvastatin serum levels may be increased. Consider pravastatin.
Sirolimus Sirolimus serum levels may be significantly increased. Monitor.
Sotalol Risk of QTc prolongation may be increased. Avoid co-administration.
Tacrolimus Tacrolimus serum levels may be significantly increased. Monitor.
Tadalafil Tadalafil serum levels may be increased. Monitor. Tadalafil dose need to be decreased.
Terfenadine Risk of QTc prolongation increased. Contraindicated.
Theophylline Theophylline serum levels may be increased. Monitor serum level.
TPV/r Erythromycin AUC may be increased. Risk of QTc prolongation may be increased. Avoid co-administration.
Triazolam Triazolam serum levels may be increased. Consider lorazepam, oxazepam, or temazepam.
Trimipramine Risk of QTc prolongation may be increased. Avoid co-administration.
Troleandomycin May increase erythromycin serum concentrations and increase risk of sudden cardiac death. Avoid co-administration.
Vardenafil Vardenafil serum levels may be increased. Monitor. Vardenafil dose need to be decreased.
Verapamil Verapamil serum levels may be increased. Erythromycin serum levels may be increased.May increase risk of sudden cardiac death. Avoid co-administration.Consider azithromycin.
Voriconazole Voriconazole serum levels may be increased. Erythromycin serum levels may be increased.May increase risk of sudden cardiac death. Avoid co-administration.Consider azithromycin.Monitor voriconazole serum concentrations.
Warfarin Anticoagulation may be increased. Monitor INR.

SPECTRUM

Detailed Spectrum of Activity

RESISTANCE

  • Group A strep resistance increasing. Up to 35%of pharyngeal isolates in chlidren were resistant (Green et al. AAC 2004; 48: 473)
  • S. pneumoniae macrolide resistance ~26% but clinical significance unclear (especially with intermediate resistance); treatment failures not consistently reported.

PHARMACOLOGY

Pharmacology

COMMENTS

Oral and parenteral macrolide that often causes GI distress especially with oral administration. It has decreasing activity against S. pneumoniaeand it has multiple drug interactions with drug metabolized by cytochrome P450. Highest risk for QTc prolongation among antimicrobials (especially with high dose erythromycin). Therapeutically equivalent and better tolerated macrolides such asazithromycinand clarithromycin are preferred.

REFERENCES

REFERENCED WITHIN THIS GUIDE


 
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