When you have a patient who requests a Z-pack for what is almost certainly an acute viral respiratory infection, you probably respond internally or externally (possibly both) that antibiotics do not treat viruses. But could there be some effect on their symptoms, or the viral infection itself, that is not part of the common discussion when it comes to such things? We know that azithromycin is an antibiotic, but it turns out that azithromycin actually has some activity in the viral arena. This absolutely shocked me. The question is, does it matter? 

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We Discuss:

• In vitro studies show azithromycin reduces rhinovirus replication and release. 
• Another in vitro study on respiratory cells from lung transplant patients found azithromycin reduces rhinovirus-associated cellular inflammation.
• Kids with coronavirus (the pre-COVID, old-school coronavirus)  had reduced viral load with azithromycin. 
• In enterovirus-infected mice, azithromycin improved survival. 
• Patients infected with influenza a who were given azithromycin had reduced interleukins 6, 8, 17, tumor necrosis factor, and CRP, indicating anti-inflammatory properties in flu patients.
• This study, however, did not show improved clinical outcomes with azithromycin.
• Another study using a similar methodology did not see any change in inflammatory markers but had a slight improvement in sore throat and fever resolution in the azithromycin group. 
• A 2009 paper found that azithromycin did not improve disease course in hospitalized infants with a respiratory synovial virus. There has been signal of clarithromycin decreasing hospitalization in patients with severe RSV, but the preponderance of data are fairly consistent that there is no benefit in hospital stay, length of illness, or oxygen utilization.