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J Res Med Sci 2021,  26:101

Antibiotic resistance: A disregarded concern for misuse of azithromycin in COVID-19 treatment

1 Student Research Committee, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
2 Student Research Committee, Faculty of Medicine; Research Center for Evidence - Based Medicine; Emergency Medicine Research Team, Tabriz University of Medical Sciences, Tabriz, Iran

Date of Submission20-Sep-2020
Date of Decision28-Mar-2021
Date of Acceptance14-Apr-2021
Date of Web Publication18-Oct-2021

Correspondence Address:
Dr. Mohammad-Salar Hosseini
Research Center for Evidence-Based Medicine, Tabriz University of Medical Sciences, Golgasht Street, Postal Code 5166/15731, Tabriz, EA
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jrms.JRMS_1124_20

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How to cite this article:
Jahanshahlou F, Hosseini MS. Antibiotic resistance: A disregarded concern for misuse of azithromycin in COVID-19 treatment. J Res Med Sci 2021;26:101

How to cite this URL:
Jahanshahlou F, Hosseini MS. Antibiotic resistance: A disregarded concern for misuse of azithromycin in COVID-19 treatment. J Res Med Sci [serial online] 2021 [cited 2022 Oct 4];26:101. Available from: https://www.jmsjournal.net/text.asp?2021/26/1/101/328498

Dear Editor,

In late November 2019, a new viral infection began to spread from Wuhan, China, resulting in an outbreak that was later declared a pandemic on March 12, 2020. So far, over 125,000,000 confirmed cases and 2,700,000 deaths have resulted from the spread of coronavirus disease-2019 (COVID-19) infection. Concerns about the disease increase when we consider the fact that no definitive cure is currently available. Due to time constraints, many researchers and physicians have begun to use existing drugs that could rationally invade the underlying mechanisms of the disease, hoping to achieve positive results in stopping the progression of the disease or preventing the expected complications.[1] One of the proposed protocols was the use of azithromycin, mostly combined with hydroxychloroquine. At the beginning of the pandemic, azithromycin was thought to be a beneficial agent against COVID-19. However, at present, it is not recommended – either alone or in combination with hydroxychloroquine – since it has shown no antiviral effect, and no positive results have been observed on patients' mortality or the severity of the disease.[2]

The recommenders used to emphasize the fact that the usefulness and efficiency of macrolides have been previously proven in similar viral cases such as rhinovirus infection and influenza.[3] Furthermore, in addition to the antibacterial properties, macrolides have shown immunomodulatory effects, including anti-inflammatory outcomes. Macrolides' ability to suppress the infections lies in their ability to terminate the viral replication, block the internalization of the virus into the host cells, and modify the endosomal and lysosomal pH.[4]

A wide range of usage and fewer side effects, along with the possibility of rapid production, has turned azithromycin into a strategic antimicrobial agent. Despite all potential benefits, it should be noted that considering azithromycin as a treatment for COVID-19 infection can have its consequences. According to the World Health Organization, azithromycin is one of the “highest priority critically important antimicrobials,” which should be used prudently to prevent antimicrobial resistance.[5] Therefore, the excessive consumption of azithromycin – among the terrified community, who are looking for ways to prevent the infection, and the clinical wards treating the COVID-19 patients – may result in an undeniable crisis of resistance to this irreplaceable agent. This could also leave short-term complications if the resistance happens in vulnerable COVID-19 patients with immunodeficiency or underlying diseases, such as cancer and metabolic disorders. Hence, misuse and overuse of azithromycin have to be strongly avoided, and it should always be administered with caution in vulnerable patients [Figure 1].
Figure 1: Status of viral (SARS-CoV-2) and bacterial (e.g., Streptococcus pneumoniae) resistance. The blue color indicates susceptibility and the red color indicates resistance. At the beginning, azithromycin is prescribed in combination with some antiviral agents. Azithromycin-resistant bacteria appear and gradually grow in number. Eventually, azithromycin loses its place as an effective antibiotic. By the spread of the resistant bacteria, the infected patients with bacterial pneumonia are now more susceptible to other infections, including viral pneumonia, which results in fatal superinfections

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As a global state of emergency, any effort to achieve a reliable treatment or prevention is quite rational and valuable during the pandemics. However, it should be considered that a wrong move may result in an irreversible catastrophe, which can cause life-long trouble for human beings.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Madrid PB, Panchal RG, Warren TK, Shurtleff AC, Endsley AN, Green CE, et al. Evaluation of ebola virus inhibitors for drug repurposing. ACS Infect Dis 2015;1:317-26.  Back to cited text no. 1
Siemieniuk RA, Bartoszko JJ, Ge L, Zeraatkar D, Izcovich A, Kum E, et al. Drug treatments for COVID-19: Living systematic review and network meta-analysis. BMJ 2020;370:m2980.  Back to cited text no. 2
Lee N, Wong CK, Chan MCW, Yeung ESL, Tam WWS, Tsang OTY, et al. Anti-inflammatory effects of adjunctive macrolide treatment in adults hospitalized with influenza: A randomized controlled trial. Antiviral Res 2017;144:48-56.  Back to cited text no. 3
Ohe M, Shida H, Jodo S, Kusunoki Y, Seki M, Furuya K, et al. Macrolide treatment for COVID-19: Will this be the way forward? Biosci Trends 2020;14:159-60.  Back to cited text no. 4
World Health Organization. Highest Priority Critically Important Antimicrobials; 2019. Available from: https://www.who.int/foodsafety/cia/en/. [Last accessed on 2020 Sep 12].  Back to cited text no. 5


  [Figure 1]

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