Azithromycin Nursing Considerations

Last updated on January 27th, 2024 at 09:17 am

Azithromycin Nursing Implications

Azithromycin Nursing Pharmacology

Azithromycin is a prescription drug used to treat various types of bacterial infections. It belongs to the class of medications known as macrolide antibiotics, which work by inhibiting bacterial growth.

It is frequently used to treat infections of the lungs, throat, sinuses, ears, skin, urinary tract, cervix, and genitals.

Colds, flu, and other viral infections will not respond to antibiotics such as azithromycin. Nurses and other healthcare professionals should take note that giving antibiotics to patients when they are not necessary increases the possibility of growing an infection that is resistant to treatment later on.

Indications of Azithromycin

Azithromycin should only be used for the following reasons:

  • To treat or reduce the risk of developing infections caused by pathogenic bacteria.
  •  To avoid the possibility of antimicrobial resistance.
  • To keep azithromycin’s efficacy.

Azithromycin is prescribed for the management of acute infections caused by susceptible pathogens of the microorganisms identified in the conditions below. Dosages, length of therapy, and relevant factors for different patient populations may differ between these infections.

  1. Adults
    • Acute bacterial sinusitis. Haemophilus influenzae, Moraxella catarrhalis, or Streptococcus pneumoniae are the bacteria that may cause this type of sinusitis.
    • Community-acquired pneumonia. This may be caused by the following microorganisms: Chlamydophilia pneumoniae, Haemophilus influenzae, Mycoplasma pneumoniae, or Streptococcus pneumoniae.
    • Pharyngitis or tonsilitis. This may be due to Streptococcus pyogenes.
    • Uncomplicated skin and skin structure infections. This is usually secondary to Staphylococcus aureus, Streptococcus pyogenes, or Streptococcus agalactiae.
    • Inflammation of urethra and cervix. This is commonly due to Chlamydia trachomatis or Neisseria gonorrhoeae.
    • Genital ulcer in men. This can be caused by Haemophilus ducreyi.
  1. Children/ Pediatrics
    • Acute otitis media. This type of ear infection is commonly caused by Haemophilus influenzae, Branhamella catarrhalis, or Streptococcus pneumoniae.
    • Community-acquired pneumonia. Oral therapy is recommended for patients with  this type of pneumonia that can be caused by Chlamydophilia pneumoniae, Haemophilus influenzae, Mycoplasma pneumoniae, or Streptococcus pneumoniae.
    • Pharyngitis and tonsilitis. Azithromycin can be prescribed and administered if the patient’s first-line treatment is not suitable.

Actions of Azithromycin

Bacteria require an actual protein synthesis process, which is allowed by ribosomal proteins, to replicate. Azithromycin binds to the bacterial 50S ribosomal subunit’s 23S rRNA.

It inhibits protein synthesis in bacteria by blocking the transpeptidation/translocation step as well as the assembly of the 50S ribosomal subunit.

As a result, various bacterial infections are controlled. The high affinity of macrolides for bacterial ribosomes, including azithromycin, is constant with their broad-spectrum antibacterial activity.

Azithromycin is highly stable at low pH, providing it with a longer serum half-life and higher tissue concentrations than other antibiotics.

Pharmacokinetics of Azithromycin

Macrolides inhibit the proliferation of bacteria by blocking the binding and transformation, which is used to treat bacterial infections. Azithromycin has increased immunomodulatory properties and has been used for this purpose in severe respiratory inflammatory diseases.

  • Absorption. Following oral administration, azithromycin has a bioavailability of 37%. Food does not affect absorption. The absorption of macrolides in the intestine is mainly mediated by P-glycoprotein (ABCB1) efflux transporters, which are encoded by the ABCB1 gene.
  • Volume distribution. Azithromycin is widely disseminated in tissues after oral administration, with an evident consistent bioavailability of 31.1 L/kg Label. Azithromycin concentrations in tissues were found to be significantly higher than in plasma or serum. The lung, tonsils, and prostate are among the organs with the highest rate of azithromycin uptake. This medication is centered in macrophages and polymorphonucleocytes, enabling it to be effective against Chlamydia trachomatis. Furthermore, in vitro incubation techniques reveal that azithromycin is consolidated in phagocytes and fibroblasts. In vivo studies show that phagocyte composition may add value to azithromycin distribution to affected tissues.
  • Metabolism. Azithromycin is eliminated by the liver.
  • Elimination. A major route of elimination for azithromycin is biliary excretion. Over a one-week duration, an estimated 6% of the administered drug is found in the urine in an active form.
  • Half-life. Terminal elimination half-life is 68 hours.

Side Effects of Azithromycin

Azithromycin may have unwanted side effects. Inform the doctor if some of the following symptoms are severe or persistent:

In some cases, side effects are serious and may require immediate medical attention. Stop taking azithromycin and call for emergency help the soonest time if any of these symptoms are present:

  • Irregular heartbeat
  • Dizziness
  • Rashes
  • Blisters or peeling
  • Hives
  • Itchiness
  • Difficulty breathing
  • Wheezing
  • Swollen face, throat, tongue, lips, eyes, upper or lower extremities.
  • Hoarseness of voice
  • Yellow-colored skin and sclera
  • Fatigue
  • Bleeding and unusual bruising
  • Upper right side abdominal pain
  • Flu-like symptoms
  • Dark-colored urine
  • Muscle weakness
  • Severe stomach pain
  • Blood in stool
  • Clay-colored stool
  • Swollen lymph nodes
  • Serious skin condition (skin pain, red or purple colored skin rash).

Adverse Reactions of Azithromycin

  • General: Urticaria, angioedema, asthenia, fatigue, malaise
  • Cardiovascular: Irregular heartbeat, low blood pressure, prolonged QT interval, ventricular tachycardia, chest discomfort, or pain.
  • Gastrointestinal: Severe loss of appetite, constipation, indigestion, flatulence, vomiting, diarrhea, pancreatitis, oral candidiasis, pyloric stenosis, tongue discoloration, changes in the color of stool, bloody stool
  • Genitourinary: Acute renal failure, vaginitis, interstitial nephritis, dark-colored urine, testicular disorder, metrorrhagia.
  • Hematology: Thrombocytopenia, Decreased lymphocyte, hematocrit, hemoglobin, or neutrophil count, increased eosinophil count, increased platelets, hematocrit, lymphocytes, basophils, monocytes, or neutrophils.
  • Hepatobiliary: Abnormal liver function, hepatitis, jaundice, hepatic failure/fatal hepatic failure, fulminant hepatitis, liver failure, death of liver tissue.
  • Nervous: Dizziness, convulsion, headache, agitation, unusual nervousness, syncope, somnolence, hypesthesia, paresthesia, dysgeusia, hyperactivity.
  • Psychiatric: Aggressiveness and anxiety.
  • Skin: Pruritus, toxic epidermal necrosis, Steven-Johnson Syndrome, photosensitivity, fungal dermatitis, sweating, vesiculobullous rash, maculopapular rash.
  • Respiratory: Pneumonia, pharyngitis, rhinitis, respiratory disorder, epistaxis, bronchospasm, cough, pleural effusion, asthma, bronchitis
  • Senses: Hearing problems including hearing loss, and tinnitus. Smell and taste loss.
  • Musculoskeletal: Osteoarthritis, myalgia, back pain, neck pain, joint pain
  • Metabolic: Hypokalemia, hypomagnesemia, decreased blood bicarbonate, anorexia, abnormal sodium, increased blood alkaline phosphatase, bicarbonate, or chloride

Drug Interactions with Azithromycin

Azithromycin may have an interaction with other medications that a person is taking. It is important to inform the attending physician about the medication, supplements, and vitamins the patients are taking.

  • Antiretroviral medication. Some HIV medications co-administered at steady-state with a single administration of azithromycin resulted in higher azithromycin serum concentrations. Although azithromycin dose adjustment is not recommended when used in conjunction with antiretroviral drugs, close supervision for known azithromycin adverse reactions, such as liver enzyme abnormalities and poor hearing, is advised.
  • Anticoagulants. Although the prothrombin time was not directly affected in the dedicated drug interaction study with azithromycin and blood thinners, spontaneous postmarketing reports have suggested that concomitant administration of azithromycin may enhance the effects of the oral anticoagulants such as anticoagulants. Prothrombin times should be closely monitored in patients taking azithromycin and oral anticoagulants at the same time.
  • Live bacterial vaccines. Azithromycin may impair the effectiveness of live bacterial vaccines, such as the typhoid vaccine.

Nursing Considerations for Azithromycin

  • Inform the patient that all medications, along with prescription and non-prescription medications, vitamins, and herbal supplements, must be disclosed to their healthcare provider. Azithromycin and other medications can interact and cause side effects. It may affect how other medications work, and other treatments may have an effect on how azithromycin works.
  • Instruct the patient to inform their doctor or pharmacist about their medical history, particularly if they have liver disease, kidney disease, or specific muscle disease, before using this medication (myasthenia gravis). Azithromycin has been linked to a heart rhythm disorder (QT prolongation). QT prolongation can potentially cause (seldomly fatal) fast/irregular heartbeat and other symptoms (such as serious dizziness, and fainting) that require immediate medical attention. The risk of QT prolongation is continued to increase if the patient has certain medical conditions or is taking other medications that can cause QT prolongation.
  • Management or monitoring precautions should be observed for patients over the age of 60: the elderly may be more highly prone to QT prolongation. Keep an eye on the patient for signs of concomitant bradycardia, electrolyte imbalance, or underlying cardiac arrhythmia.
  • Low potassium and magnesium levels in the blood may also raise the chance of QT prolongation. This possibility may increase if the patient takes specific medications or has conditions such as excessive sweating, diarrhea, or vomiting. Advise the patient to consult the doctor about how to use azithromycin safely.
  • Observe for signs of high plasma potassium levels (hyperkalemia), such as bradycardia, tiredness, lack of strength, numbness, and tingling. Notify the doctor immediately because severe cases can result in fatal arrhythmias and paralysis.
  • Monitor and report nephritic symptoms such as blood in the urine, reduced urine output, and excess weight due to fluid retention.
  • Record the intake and output of the patient accurately to monitor water retention
  • Azithromycin may impair the effectiveness of live bacterial vaccines (such as typhoid vaccine). Inform the patient that they must inform their health care provider that they are taking azithromycin before receiving any immunizations or vaccinations.
  • Inform the patient that if they are scheduled for surgery, they must inform their doctor or dentist about all of the products they use (including prescription drugs, nonprescription drugs, and herbal products). This drug’s side effects, particularly QT prolongation, may be more severe in older people.
  • Long-term or repeated use of this medication may result in oral thrush or a new yeast infection. Instruct the patient to call their doctor if they notice any white patches in their mouth, a change in vaginal discharge, or any other new symptoms.
  • Azithromycin can be taken before or after meals, however, to avoid stomach upset, it is better to take azithromycin with food.
  • To assist the patient in remembering, suggest that they take this medication at the same time(s) every day.
  • Inform the patient that Antacids containing aluminum or magnesium should not be taken two hours before or after taking azithromycin because they can reduce its effectiveness.
  • Instruct the patient that If they notice any signs of an allergic reaction (rash or difficulty breathing), stop taking azithromycin immediately and call for emergency medical attention.
  • Monitor for new seizures or additional seizure activity, particularly at the start of drug treatment. Record the number, length of time, and intensity of seizures and immediately notify the doctor.
  • It may take a few days for infection symptoms to subside. Instruct the patient to always complete the course as instructed.
  • Remind the patient to take exactly as directed and complete the course as directed by the doctor, even after they already feel. Passing doses or failing to complete the remedy can reduce treatment effectiveness and initiate resistance development.
  • Instruct the patient that if they notice any symptoms of liver disease, which include a yellow discoloration of the skin or sclera, upper right abdominal pain, rash, clay-colored stools, severe nausea, and vomiting, they should consult the doctor right away.
  • Keep an eye out for symptoms of pseudomembranous colitis, such as diarrhea, stomach pain, fever, pus or mucus in the stool, and other severe or prolonged GI issues (nausea, vomiting, heartburn). Notify the doctor right away any of these symptoms are present.
  • Tell the patient not to take azithromycin if they are allergic to other macrolides. Also, stop azithromycin if they have previously taken it and it caused liver damage.
  • Rashes, raised patches of red or white skin (welts), burning/itching skin, swelling in the face, and difficulty breathing are all signs of angioedema. Inform the doctor right away if any of these symptoms are present.
  • Azithromycin can cause severe skin reactions. If the patient develops blistering, peeling, or loose skin, red skin lesions, severe acne or skin rash, sores or ulcers on the skin, or fever or chills while taking azithromycin, advise the patient to consult a doctor right away.
  • Keep an eye out for rashes or other skin issues like hives, acne, dermatitis, excessive sweating, and exfoliation. Notify the doctor right away because these skin reactions may indicate severe symptoms (Stevens-Johnson syndrome).
  • Keep an eye out for signs of leukopenia (fever, sore throat, infection), thrombocytopenia (bruising, nose bleeds, bleeding gums), or unordinary weakness and fatigue caused by anemia. Inform the doctor about these symptoms.
  • Advise the patient to try to limit sun exposure or tanning beds. When going outside, use a sunblock with an SPF of 30 or higher and wear protective clothing because azithromycin can cause sunburn.
  • Instruct the patient that before taking azithromycin, inform the doctor if they are pregnant or intend to become pregnant.
  • If the patient is currently breastfeeding or intends to breastfeed, tell them to consult their doctor beforehand. It has been reported that azithromycin passes into breast milk. The safest way to feed the baby while taking azithromycin should be discussed with their healthcare provider first.
  • For patients taking azithromycin Oral Suspension, instruct them to shake the bottle thoroughly before taking it. Also, to measure the correct amount of medication, use a dosing spoon, oral syringe, or measuring cup. After taking the full dose of medication, thoroughly rinse the measuring device with water.
  • Any medication that carries the potential of bleeding may react with azithromycin. Alcohol may promote the side effects of azithromycin, and grapefruit products may interact with azithromycin. Advise the patient to be on the lookout for any signs of bleeding, such as unusual bruising, bloody stool, and severe abdominal pain.
  • Call the emergency hotline if someone has overdosed and is experiencing severe symptoms such as passing out or difficulty breathing. Otherwise, contact a poison control center immediately.
  • If the patient forgets to take a dose, remind them to do so as soon as they remember. If the next dose is approaching, skip the missed dose. Have their next dose at the regularly scheduled time to catch up, do not double the dose.
  • Inform the patient that azithromycin should be stored at room temperature, and protected from sunlight and moisture. Keep out of the bathroom. Keep all medicines away from children and pets. Do not flush or pour medications down the drain unless advised to do so. When this product has expired or is no longer needed, properly dispose of it. Seek advice from their pharmacist or the waste disposal company in their area.
  • If the patient experiences persistent diarrhea, abdominal or stomach pain/cramping, or blood/mucus in their stool, they should seek medical attention immediately. If they have these symptoms, tell them not to take anti-diarrhea or opioid medications because they may aggravate the symptoms.
  • Take precautions in patients with the following conditions: azithromycin oral should not be used to manage pneumonia in people who have cystic fibrosis, an infection after being in a hospital, a blood infection, a weakened immune system (caused by diseases such as HIV/AIDS or cancer), or a compromised immune system.
  • Some medicines should not be taken at or near the time of eating food, or when eating specific types of food, because reactions may happen. Drinking alcohol or smoking tobacco while taking some medications may also result in interactions. Speak to a doctor regarding the use of azithromycin with food, alcohol, or tobacco.
  • When administered intravenously, azithromycin is given via a needle inserted into one of the veins. Since azithromycin is administered slowly, the needle will remain in place for approximately an hour.
  • The doctor may administer a few doses of azithromycin until the patient’s condition improves, and then switch to an oral medicine that works in the same way. If they have any concerns, they should consult with their doctor.
  • After receiving azithromycin, newborn babies may develop infantile hypertrophic pyloric stenosis, a condition that involves the narrow tube where food exits the stomach. Observe the baby for vomiting and irritability during feeding, and notify the doctor right away if any of these occur.

Nursing Care Plan for Patients on Azithromycin

Possible Nursing Diagnoses

  1. Diarrhea related to the possible side effect of azithromycin
  2. Acute Pain (Headache) related to the possible side effect of azithromycin
  3. Nausea  related to the possible side effect of azithromycin
  4. Risk for Bleeding related to adverse effect of using azithromycin with anticoagulants
  5. Risk for Anaphylactic Reaction related to drug allergy to azithromycin
  6. Risk for Electrolyte Imbalance (Hypokalemia) secondary to adverse reaction of azithromycin

Nursing Assessment

Azithromycin Nursing InterventionsRationale
Assess the patient for signs and symptoms of bacterial infection.To confirm the indication for administering azithromycin.
Assess if the patient has hypokalemia, C.difficile infection, seizures, clotting disorders, myasthenia gravis, or torsades de pointesAzithromycin is generally contraindicated in patients with hypokalemia because one of the adverse effects of this drug is that it lowers the serum potassium level by increased urinary elimination of potassium. Patients with C.difficile infection, seizures, clotting disorders, myasthenia gravis, or torsades de pointes may receive azithromycin with caution.
Check the patient’s allergy status.Previous allergic reactions to azithromycin may render the patient unable to take them. Alternatives to azithromycin should therefore be considered in case of allergy.
Assess if the patient is pregnant or lactating.Azithromycin can be prescribed to a pregnant woman  as this drug is under pregnancy category B which means it does not impose known harm to humans. However, azithromycin must only be administered under the direction of the physician.
Perform a focused neurological assessment of the patient.Azithromycin may cause adverse CNS effects such as hearing loss and parasthesia.  
Assess the patient’s veins in preparation for administering azithromycin.To ensure that there is a good venous access before azithromycin is given.
Collect blood for a liver function check.Azithromycin may cause adverse effects on the liver if not dosed properly.

Nursing Planning and Intervention

Azithromycin Nursing InterventionsRationale
Administer intravenous azithromycin via a peripheral or central venous line. Azithromycin is also available in oral route which should be considered if the patient has no swallowing problems and as indicated by the physician.To ensure optimal absorption and therapeutic action by azithromycin, as well as reduce possible side effects.
Monitor venous access after administration. Ask the patient to report any pain or discomfort during and after administration of the drug.To check for any infiltration or phlebitis around the IV site.  
Educate the patient about the action, indication, common side effects, and adverse reactions to note when taking azithromycin.To inform the patient on the basics of azithromycin.
Monitor the patient’s input and output and commence stool chart.azithromycin may cause diarrhea. Early detection of diarrhea can help institute a bowel program and relieve them effectively.
Discourage alcohol intake when on azithromycin.Alcohol can increase the possible GI side effects of azithromycin, such as nausea and vomiting.
Inform the patient that azithromycin may cause nausea and vomiting and this should be reported to any healthcare professional once noticed.To inform the patient of the possible side effect of azithromycin on the gastrointestinal system, and to be able to administer antiemetics as soon as the patient reports the symptom.

Nursing Evaluation

Azithromycin Nursing InterventionsRationale
Ask the patient to repeat the information about azithromycin.To evaluate the effectiveness of health teaching on azithromycin.
Check for any signs of allergic reaction to azithromycin, such as shortness of breath, skin rash, or swelling.To ensure the patient’s safety after the initial dose of azithromycin and to be able to reverse anaphylaxis quickly.
Monitor the patient’s full blood count and liver function.To ensure that the azithromycin did not cause any anemia or thrombocytopenia, as well as damage to the liver function.  
Monitor the patient on anticoagulants for any signs of bleeding such as bruising.To check for any adverse effect of azithromycin which is the risk for bleeding when used with anticoagulants.

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.  Buy on Amazon

Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier.  Buy on Amazon

Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.  Buy on Amazon


Please follow your facility’s guidelines, policies, and procedures.

The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes.

This information is intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.

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Anna Curran. RN, BSN, PHN

Anna Curran. RN-BC, BSN, PHN, CMSRN I am a Critical Care ER nurse. I have been in this field for over 30 years. I also began teaching BSN and LVN students and found that by writing additional study guides helped their knowledge base, especially when it was time to take the NCLEX examinations.

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