General

eh-rith-roe-MYE-sin

erythromycin base

• Apo-Erythro-EC [Canada]

• E-Mycin

• Erybid [Canada]

• Eryc

• Ery-Tab

• Erythromid [Canada]

• Novo-rythro [Canada]

• PCE

erythromycin ethylsuccinate

• Apo-Erythro-ES [Canada]

• E.E.S

• EryPed

erythromycin lactobionate

• Erythrocin

erythromycin stearate

• Erythrocin

• Novo-rythro [Canada]

erythromycin (topical)

• Akne-Mycin

• Erygel

• Sans-Acne [Canada]

Pregnancy Category
Category B

Ther. class.
anti-infectives

Pharm. class.
macrolides

†See Ophthalmic Medications for ophthalmic use

Indications

• IV, PO: Infections caused by susceptible organisms including:

» Upper and lower respiratory tract infections

» Otitis media (with sulfonamides)

» Skin and skin structure infections

» Pertussis

» Diphtheria

» Erythrasma

» Intestinal amebiasis

» Pelvic inflammatory disease

» Nongonococcal urethritis

» Syphilis

» Legionnaires' disease

» Rheumatic fever

• Useful when penicillin is the most appropriate drug but cannot be used because of hypersensitivity, including

» Streptococcal infections

» Treatment of syphilis or gonorrhea

• Topical: Treatment of acne

Action

Suppresses protein synthesis at the level of the 50S bacterial ribosome

Therapeutic Effect(s):
Bacteriostatic action against susceptible bacteria

Spectrum:

• Active against many gram-positive cocci, including

» Streptococci

» Staphylococci

• Gram-positive bacilli, including

» Clostridium

» Corynebacterium

• Several gram-negative pathogens, notably

» Neisseria

» Legionella pneumophila

• Mycoplasma and Chlamydia are also usually susceptible

Pharmacokinetics

Absorption: Variable absorption from the duodenum after oral administration (dependent on salt form). Absorption of enteric-coated products is delayed. Minimal absorption may follow topical or ophthalmic use

Distribution: Widely distributed. Minimal CNS penetration. Crosses placenta; enters breast milk

Protein Binding: 70–80%

Metabolism and Excretion: Partially metabolized by the liver, excreted mainly unchanged in the bile; small amounts excreted unchanged in the urine

Half-life: Neonates: 2.1 hr; Adults: 1.4–2 hr

TIME/ACTION PROFILE (blood levels)

ROUTE	ONSET	PEAK	DURATION
PO	1 hr	1–4 hr	6–12 hr
IV	rapid	end of infusion	6–12 hr

Contraindication/Precautions

Contraindicated in:

• Hypersensitivity

• Concurrent pimozide

• Known alcohol intolerance (most topicals)

• Tartrazine sensitivity (some products contain tartrazine—FDC yellow dye #5)

• Products containing benzyl alcohol should be avoided in neonates

Use Cautiously in:

• Liver/renal disease

• OB: May be used in pregnancy to treat chlamydial infections or syphilis

• Geri: ↑ risk of ototoxicity if parenteral dose >4 g/day, ↑ risk of QTc prolongation

Adverse Reactions/Side Effects

CNS: seizures (rare).

EENT: ototoxicity.

CV: QT C PROLONGATION (MAY RESULT IN TORSADES DE POINTES) , VENTRICULAR ARRHYTHMIAS, .

GI: nausea, vomiting, abdominal pain, cramping, diarrhea, drug-induced hepatitis, infantile hypertrophic pyloric stenosis, drug-induced pancreatitis (rare).

Derm: rashes.

Local: phlebitis at IV site.

Misc: allergic reactions, superinfection.

*CAPITALS indicates life-threatening.
*italic indicates most frequent.

Interactions

Drug-Drug

• Concurrent use with pimozide ↑ risk of serious arrhythmias (concurrent use contraindicated); similar effects may occur with diltiazem , verapamil , ketoconazole , itraconazole , nefazodone , and protease inhibitors ; avoid concurrent use

• Concurrent use with verapamil ↑ risk of hypotension, bradycardia, and lactic acidosis

• ↑ blood levels and effects of silfenafil , tadalafil and vardenafil ; use lower doses

• Concurrent rifabutin or rifampin may ↓ effect of erythromycin and ↑ risk of adverse GI reactions

• ↑ levels and risk of toxicity from alfentanil , alprazolam , buspirone , clozapine , bromocriptine , theophylline , carbamazepine , cyclosporine , cilostazol diazepam disopyramide , ergot alkaloids , felodipine , warfarin , methylprednisolone , midazolam , quinidine , rifabutin , tacrolimus , triazolam , or vinblastine

• Concurrent HMG-CoA reductase inhibitors ↑ risk of myopathy/rhabdomyolysis

• May ↑ serum digoxin levels in a few patients

• Theophylline may ↓ blood levels

• Beneficial effects may be ↓ by clindamycin or lincomycin

Route/Dosage

• 250 mg of erythromycin base or stearate = 400 mg of erythromycin ethylsuccinate

Most Infections

• PO (Adults): Base, stearate—250 mg q 6 hr, or 333 mg q 8 hr, or 500 mg q 12 hr. Ethylsuccinate—400 mg q 6 hr or 800 mg q 12 hr.

• PO (Children >1 mo): Base and ethylsuccinate—30–50 mg/kg/day divided q 6–8 hr (maximum 2 g/day as base or 3.2 g/day as ethylsuccinate). Stearate—30–50 mg/kg/day divided q 6 hr (maximum 2 g/day).

• PO (Neonates): Ethylsuccinate—20–50 mg/kg/day divided q 6–12 hr.

• IV (Adults): 250–500 mg (up to 1 g) q 6 hr.

• IV (Children > 1 mo): 15–50 mg/kg/day divided q 6 hr, maximum 4 g/day.

Acne

• Topical (Adults and Children >12 yr): 2% ointment, gel, or solution bid.

Availability

Erythromycin Base

• Enteric-coated tablets: 250 mg, 333 mg

• Tablets with polymer-coated particles: 333 mg, 500 mg

• Film-coated tablets: 500 mg

• Delayed-release capsules: 250 mg

Erythromycin Ethylsuccinate

• Chewable tablets (fruit flavor): 200 mg

• Tablets: 400 mg

• Oral suspension (fruit flavor, cherry): 200 mg/5 mL

• Oral suspension (orange, banana flavors): 400 mg/5 mL

• Drops (fruit flavor): 100 mg/2.5 mL

Erythromycin Lactobionate

• Powder for injection: 500 mg, 1 g

Erythromycin Stearate

• Film-coated tablets: 250 mg

Topical Preparations

• Ointment: 2%

• Gel: 2%

• Solution: 2%

• In combination with: sulfisoxazole (generic only) and benzoyl peroxide (Benzamycin). See combination drugs

Assessment

• Assess for infection (vital signs; appearance of wound, sputum, urine, and stool; WBC) at beginning of and during therapy

• Obtain specimens for culture and sensitivity before initiating therapy. First dose may be given before receiving results

Lab Test Considerations

• Monitor liver function tests periodically on patients receiving high-dose, long-term therapy

» May cause ↑ serum bilirubin, AST, ALT, and alkaline phosphatase concentrations

» May cause false ↑ of urinary catecholamines

Potential Nursing Diagnoses

• Risk for infection (Indications)(Side Effects)

• Noncompliance (Patient/Family Teaching)

Implementation

• Do not confuse erythromycin with azithromycin.

• PO: Administer around the clock. Erythromycin film-coated tablets (base and stearate) are absorbed better on an empty stomach, at least 1 hr before or 2 hr after meals; may be taken with food if GI irritation occurs. Enteric-coated erythromycin (base) may be taken without regard to meals. Erythromycin ethylsuccinate is best absorbed when taken with meals. Take each dose with a full glass of water

» Use calibrated measuring device for liquid preparations. Shake well before using

» Chewable tablets should be crushed or chewed and not swallowed whole

» Do not crush or chew delayed-release capsules or tablets; swallow whole.Erythromycin base delayed-release capsules may be opened and sprinkled on applesauce, jelly, or ice cream immediately before ingestion. Entire contents of the capsule should be taken

IV Adminstration:

• IV:
Add 10 mL of sterile water for injection without preservatives to 250- or 500-mg vials and 20 mL to 1-g vial. Solution is stable for 7 days after reconstitution if refrigerated

• Intermittent Infusion:

Diluent: Dilute in 0.9% NaCl or D5W.
Concentration: 1–5 mg/mL

• Rate:
Administer slowly over 20–60 min to avoid phlebitis. Assess for pain along vein; slow rate if pain occurs; apply ice and notify health care professional if unable to relieve pain

• Continuous Infusion:
May also be administered as an infusion in a dilution of 1 g/L of 0.9% NaCl, D5W, or LR over 4 hr

Erythromycin Lactobionate

• Y-Site Compatibility:

» acyclovir

» alfentanil

» amikacin

» aminophylline

» amiodarone

» anidulafungin

» atracurium

» atropine

» azathioprine

» benztropine

» bivalirudin

» bumetanide

» buprenorphine

» butorphanol

» calcium chloride

» calcium gluconate

» carboplatin

» caspofungin

» cefotaxime

» ceftriaxone

» cefuroxime

» chlorpromazine

» cimetidine

» cisplatin

» cyanocobalamin

» cyclophosphamide

» cyclosporine

» cytarabine

» dactinomycin

» daptomycin

» dexmedetomidine

» digoxin

» diltiazem

» diphenhydramine

» dobutamine

» docetaxel

» dopamine

» doxacurium

» doxapram

» doxorubicin

» enalaprilat

» ephedrine

» epinephrine

» epirubicin

» epoetin alfa

» eftifibatide

» ertapenem

» esmolol

» etoposide

» etoposide phosphate

» famotidine

» fenoldopam

» fentanyl

» fluconazole

» fludarabine

» fluorouracil

» folic acid

» foscarnet

» gemcitabine

» gentamicin

» glycopyrrolate

» granisetron

» hydrocortisone

» hydromorphone

» idarubicin

» ifosfamide

» imipenem/cilastatin

» insulin

» isoproterenol

» labetalol

» levofloxacin

» lidocaine

» lorazepam

» mannitol

» mechlorethamine

» meperidine

» methotrexate

» methoxamine

» methyldopa

» methylprednisolone

» metoclopramide

» metronidazole

» miconazole

» midazolam

» milrinone

» mitoxantrone

» morphine

» multivitamins

» nafcillin

» nalbuphine

» naloxone

» nesiritide

» nicardipine

» nitroglycerin

» norepinephrine

» octreotide

» ondansetron

» oxaliplatin

» oxytocin

» paclitaxel

» palonosetron

» papaverine

» pentamidine

» pentazocine

» perphenazine

» phentolamine

» phenylephrine

» phytonadione

» piperacillin/tazobactam

» procainamide

» prochlorperazine

» promethazine

» propranolol

» protamine

» pyridoxine

» ranitidine

» sodium acetate

» sodium bicarbonate

» streptokinase

» succinylcholine

» sufentanil

» tacrolimus

» teniposide

» theophylline

» thiamine

» thiotepa

» tigecycline

» tirofiban

» tobramycin

» tolazoline

» trimethaphan

» urokinase

» vancomycin

» vasopressin

» vecuronium

» verapamil

» vincristine

» vinorelbine

» vitamin B complex with C

» voriconazole

» zidovudine

• Y-Site Incompatibility:

» amphotericin B colloidal

» amphotericin B liposome

» ascorbic acid

» aztreonam

» cefazolin

» cefepime

» cefotetan

» cefoxitin

» ceftizoxime

» chloramphenicol

» dantrolene

» dexamethasone

» diazepam

» diazoxide

» doxycycline

» furosemide

» ganciclovir

» indomethacin

» ketorolac

» metaraminol

» nitroprusside

» penicillin G

» pentobarbital

» phenobarbital

» phenytoin

» ticarcillin/clavulanate

» trimethoprim/sulfamethoxazole

• Topical: Cleanse area before application. Wear gloves during application

Patient/Family Teaching

• Instruct patient to take medication around the clock and to finish the drug completely as directed, even if feeling better. Take missed doses as soon as remembered, with remaining doses evenly spaced throughout day. Advise patient that sharing of this medication may be dangerous

• May cause nausea, vomiting, diarrhea, or stomach cramps; notify health care professional if these effects persist or if severe abdominal pain, yellow discoloration of the skin or eyes, darkened urine, pale stools, or unusual tiredness develops. May cause infantile hypertrophic pyloric stenosis in infants; notify health care professional if vomiting and irritability occur

• Advise patient to report signs of superinfection (black, furry overgrowth on the tongue; vaginal itching or discharge; loose or foul-smelling stools)

• Instruct patient to notify health care professional if symptoms do not improve

Evaluation/Desired Outcomes

• Resolution of the signs and symptoms of infection. Length of time for complete resolution depends on the organism and site of infection

• Improvement of acne lesions

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