Azithromycin has rapidly been adopted as a repurposed drug for the treatment of COVID-19, despite the lack of high-quality evidence. In this review, we critically appraise the current pharmacological, preclinical and clinical data of azithromycin for treating COVID-19. Interest in azithromycin has been fuelled by favourable treatment outcomes in other viral pneumonias, a documented antiviral effect on SARS-CoV-2 in vitro and uncontrolled case series early in the pandemic. Its antiviral effects presumably result from interfering with receptor mediated binding, viral lysosomal escape, intracellular cell-signalling pathways and enhancing type I and III interferon expression. Its immunomodulatory effects may mitigate excessive inflammation and benefit tissue repair. Currently, in vivo reports on azithromycin in COVID-19 are conflicting and do not endorse its widespread use outside of clinical trials. They are, however, mostly retrospective and therefore inherently biased. The effect size of azithromycin may depend on when it is started. Also, extended follow-up is needed to assess benefits in the recovery phase. Safety data warrant monitoring of drug–drug interactions and subsequent cardiac adverse events, especially with hydroxychloroquine. More prospective data of large randomised controlled studies are expected and much-needed. Uniform reporting of results should be strongly encouraged to facilitate data pooling with the many ongoing initiatives.
- viral infection
- respiratory infection
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Collaborators Kurt Vandeurzen, MD; Lynn Decoster, MD; Jean-Benoît Martinot, MD; Pieter Goeminne, MD, PhD; Hong Nguyen, MD; Eef Vanderhelst, MD, PhD; Charles Pilette, MD, PhD; Ann-Catherine Soenen, MD; Nikolaas De Maeyer, MD; Aurelie Derweduwen, MD; Bernard Bouckaert, MD; Patrick Alexander, MD; Emmanuelle Papleux, MD; Rob Schildermans, MD.
Contributors Writing-original draft: IG. Writing-review and editing: PV, WJ and RV.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests IG has nothing to disclose. WJ reports grants from Research Fund Flanders (FWO), grants and personal fees from Astra Zeneca, grants and personal fees from Chiesi, and is cofounder of ArtiQ, outside the submitted work. PV has nothing to disclose. RV reports grants from Research Foundation Flanders, outside the submitted work. There was no specific funding for this manuscript. The manuscript, the abstract or the figures have never been published or presented.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement Data sharing not applicable as no datasets generated and/or analysed for this study.
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