Erythromycin

Class: Erythromycins
VA Class: AM200
CAS Number: 114-07-8
Brands: E.E.S., ERYC, EryPed, Ery-Tab, Erythrocin, Eryzole, PCE, Pediazole

Introduction

Antibacterial; macrolide antibiotic produced by Saccharopolyspora erythraeus.^{263 268 f}

Uses for Erythromycin

Acute Otitis Media (AOM)

Treatment of AOM in children caused by susceptible Haemophilus influenzae.²⁶⁴ The fixed-combination preparation containing erythromycin ethylsuccinate and sulfisoxazole acetyl must be used;²⁶⁴ erythromycin is not effective when used alone for treatment of H. influenzae infections.^{264 c}

The fixed-combination preparation containing erythromycin ethylsuccinate and sulfisoxazole acetyl is an alternative (not a preferred agent) for treatment of AOM.^{311 483} The drug is recommended as an alternative in patients with type I penicillin hypersensitivity.³¹¹ May not be effective for treatment of AOM that fails to respond to amoxicillin since a high incidence of S. pneumoniae resistant to the fixed-combination drug has been reported.⁴⁸³

Pharyngitis and Tonsillitis

Treatment of pharyngitis and tonsillitis caused by S. pyogenes (group A β-hemolytic streptococci).^{242 262 263 268 311 392 441 472 f} Generally effective in eradicating S. pyogenes from the nasopharynx, but efficacy in prevention of subsequent rheumatic fever has not been established to date.^a

CDC, AAP, IDSA, AHA, and others recommend oral penicillin V or IM penicillin G benzathine as treatments of choice;^{243 311 392 441 472} oral cephalosporins and oral macrolides considered alternatives.^{311 392 441 472} Amoxicillin sometimes used instead of penicillin V, especially for young children.⁴⁴¹

Erythromycin usually the preferred alternative for treatment of streptococcal pharyngitis in patients hypersensitive to penicillin.^{243 311 392 441} Although S. pyogenes resistant to erythromycin and other macrolides have been reported and may be prevalent in some areas of the world (e.g., Japan, Finland), the incidence of these resistant S. pyogenes in the US has been relatively low to date.^{311 392 441 446}

Respiratory Tract Infections

Treatment of respiratory tract infections caused by susceptible S. pneumoniae.^{263 268 f 268 269 270 f}

Treatment of respiratory tract infections caused by Mycoplasma pneumoniae or C. pneumoniae.^{263 268 f 268 a c f}

Erythromycin usually not effective when used alone for treatment of respiratory tract infections caused by H. influenzae.^{242 262 269 c f}

Skin and Skin StructureInfections

Treatment of mild to moderate skin and skin structure infections caused by S. pyogenes or Staphylococcus aureus.^{263 268 f 268 a b c f} Consider that erythromycin-resistant Staphylococci may develop during treatment.^{263 268 f a b c f}

Treatment of erythrasma caused by Corynbacterium minutissimum.^{263 268 f 268 b c f}

Acne

Treatment of acne†.⁴⁵⁹

Amebiasis

Has been used for treatment of intestinal amebiasis caused by Entamoeba histolytica.^{242 262 263 268 f} Erythromycin generally not recommended for treatment of amebiasis; regimen of choice for intestinal amebiasis is metronidazole or tinidazole followed by a luminal amebicide such as iodoquinol or paromomycin.^{259 311}

Anthrax

Alternative for treatment of anthrax†.^{218 227 472}

Multiple-drug parenteral regimens recommended for treatment of inhalational anthrax that occurs as the result of exposure to B. anthracis spores in the context of biologic warfare or bioterrorism.^{216 347} Initiate treatment with IV ciprofloxacin or doxycycline and 1 or 2 other anti-infective agents predicted to be effective (e.g., chloramphenicol, clindamycin, rifampin, vancomycin, clarithromycin, imipenem, penicillin, ampicillin);^{216 347} if meningitis is established or suspected, use IV ciprofloxacin (rather than doxycycline) and chloramphenicol, rifampin, or penicillin.²¹⁶

Bartonella Infections

Has been used in conjunction with IM or IV ceftriaxone for treatment of bacteremia caused by Bartonella quintana† (formerly Rochalimaea quintana).⁴⁶⁰

Optimum regimens for treatment of infections caused by B. quintana or for treatment of cat scratch disease or other B. henselae infections have not been identified.^{460 462 463}

USPHS/IDSA suggests that long-term suppression with erythromycin or doxycycline be considered to prevent recurrence of Bartonella infection in HIV-infected patients†.⁴²⁰

Campylobacter Infections

Treatment of symptomatic enteric infections caused by Campylobacter jejuni†. Recommended by CDC,²⁷² IDSA,²⁷¹ and AAP³¹¹ as a treatment of choice.

Chancroid

Treatment of chancroid† (genital ulcers caused by H. ducreyi).^{228 248 472}

CDC and others recommend azithromycin, ceftriaxone, ciprofloxacin or erythromycin as drugs of choice for treatment of chancroid.^{228 248 472} HIV-infected patients and uncircumcised patients may not respond to treatment as well as those who are HIV-negative or circumcised.^{228 248 472} Some experts prefer the 7-day erythromycin regimen instead of single-dose azithromycin or ceftriaxone regimens in HIV-infected individuals.²²⁸

Chlamydial Infections

Alternative for treatment of uncomplicated urethral, endocervical, or rectal infections caused by Chlamydia trachomatis when tetracyclines and azithromycin are contraindicated or not tolerated.^{228 248 f} Erythromycin is less effective than either azithromycin or doxycycline and GI effects associated with the drug may discourage patient compliance with the regimen;²²⁸ CDC recommends that the first dose be taken under supervision.²²⁸

A drug of choice for treatment of urogenital chlamydial infections in pregnant women and in young children.²²⁸

Alternative for presumptive treatment of coexisting chlamydial infections in patients receiving treatment for gonorrhea.^{228 311} Preferred drugs are azithromycin or doxycycline;²²⁸ erythromycin may be preferred in young children.³¹¹

Treatment of urethritis caused by Ureaplasma urealyticum.^f

Treatment of chlamydial pneumonia in infants.^{f 248}

Treatment of initial episodes and recurrences of chlamydial conjunctivitis in neonates.^{228 248 311 f}

Alternative to doxycycline for treatment of lymphogranuloma venereum† caused by invasive serotypes of C. trachomatis (serovars L1, L2, L3).^{228 248 311} Erythromycin may be the preferred regimen for pregnant and lactating women.²²⁸

Alternative for treatment of psittacosis when tetracyclines are contraindicated (e.g., in pregnant women, children younger than 9 years of age).^{311 451}

Diphtheria

Adjunct to diphtheria antitoxin for treatment of diphtheria caused by Corynebacterium diphtheria.^{261 263 268 311 454 455 474 c f} Diphtheria antitoxin is the most important aspect of treatment of respiratory diphtheria.^{261 311 454 455} Anti-infectives may eliminate C. diphtheriae from infected sites, prevent spread of the organism and further toxin production, and prevent or terminate the diphtheria carrier state, but appear to be of no value in neutralizing diphtheria toxin and should not be considered a substitute for antitoxin therapy.^{311 454 455}

Because diphtheria infection often does not confer immunity, active immunization with a diphtheria toxoid preparation should be initiated or completed during convalescence.^{311 455}

Prevention of diphtheria in close contacts of patients with diphtheria.^{261 263 311 455} Prophylaxis is indicated in all household or other close contacts of individuals with suspected or proven diphtheria, regardless of vaccination status; prophylaxis should be initiated promptly and should not be delayed pending culture results.^{311 454 455} An age-appropriate diphtheria toxoid preparation also may be necessary depending on immunization status.^{261 311}

Elimination of diphtheria carrier state in individuals known to carry toxigenic strains of C. diphtheriae.^{261 311 454 455}

Granuloma Inguinale (Donovanosis)

Alternative for treatment of granuloma inguinale† (donovanosis) caused by Calymmatobacterium granulomatis.^{228 450}

CDC recommends doxycycline or co-trimoxazole as drugs of choice; ciprofloxacin, erythromycin, and azithromycin are alternatives.²²⁸ Erythromycin may be preferred in pregnant and lactating women.²²⁸

Legionnaires’ Disease

Treatment of Legionnaires’ disease caused by Legionella pneumophila; used with or without rifampin.^{242 262 263 268 270 311 452 453 472 c f}

Lyme Disease

Alternative for treatment of early Lyme disease†.^{214 310 311 394 395 397 399 472 473 476 477 478} IDSA, AAP, and others recommend doxycycline, amoxicillin, or cefuroxime as first-line agents; macrolides may be less effective.^{214 265 267 274 331 472 475}

Nongonococcal Urethritis

Treatment of nongonococcal urethritis (NGU).^{228 242 248 262 263}

CDC and others recommend azithromycin or doxycycline as drugs of choice for treatment of NGU;^{228 248} erythromycin (erythromycin base or ethylsuccinate) or fluoroquinolones (levofloxacin, ofloxacin) are alternatives.^{228 248} A regimen of erythromycin and metronidazole is recommended by CDC for treatment of recurrent and persistent urethritis in patients who were compliant with their initial regimen and have not been re-exposed.²²⁸

Pelvic Inflammatory Disease (PID)

IV erythromycin lactobionate followed by oral erythromycin has been used for treatment of PID) caused by N. gonorrhoeae,^{242 262 263 c f} but erythromycins are not included in current CDC recommendations for treatment of PID.²²⁸

Pertussis

Treatment of Bordetella pertussis infection (pertussis, whooping cough);^{268 253 261 311 455 457 472 f} a drug of choice.^{253 261 311 455 457 472}

Prevention of pertussis in contacts of patients with the disease;^{253 261 268 311 455 457 472 f} drug of choice.^{253 261 311 455 457 472}

CDC, AAP, and other clinicians recommend anti-infective prophylaxis for all household and other close contacts (e.g., those in childcare) of individuals with pertussis, regardless of age or vaccination status.^{261 311 455 456} Close contacts <7 years of age who are not fully immunized against pertussis also should receive the remaining required doses of a preparation containing pertussis vaccine (using minimal intervals between doses) and those who are fully immunized but have not received a vaccine dose within the last 3 years should receive a booster dose of a pertussis vaccine preparation.²⁶¹

Syphilis

Has been used as an alternative for treatment of primary syphilis in penicillin-allergic individuals.^{262 263 268 f}

Penicillin G is drug of choice for treatment of all stages of syphilis.^{228 248} Erythromycin is less effective than other possible penicillin alternatives²⁷⁵ and is not included in CDC recommendations for treatment of any form of syphilis in adults or adolescents (including primary, secondary, latent, or tertiary syphilis or neurosyphilis).²²⁸

Preoperative Intestinal Antisepsis

Adjunct to mechanical cleansing of the large intestine for intestinal antisepsis prior to elective colorectal surgery; used in conjunction with neomycin.^{237 262}

Prevention of Bacterial Endocarditis

Has been used as an alternative to penicillins for prevention of bacterial endocarditis in penicillin-allergic patients undergoing certain dental, oral, respiratory tract, or esophageal procedures who have cardiac conditions that put them at high or moderate risk.³⁰² AHA no longer recommends erythromycin for this use, but states that practitioners who have successfully used an erythromycin (i.e., erythromycin ethylsuccinate, erythromycin stearate) for prophylaxis in individual patients may choose to continue using these agents.⁴³⁶

Erythromycins are not appropriate for prevention of bacterial endocarditis in patients undergoing GI, biliary, or genitourinary tract procedures because causative organisms are likely to be erythromycin-resistant.⁴³⁶

Consult most recent AHA recommendations for specific information on which cardiac conditions are associated with high or moderate risk of endocarditis and which procedures require prophylaxis.⁴³⁶

Prevention of Rheumatic Fever Recurrence

Alternative to IM penicillin G benzathine, oral penicillin V potassium, and oral sulfadiazine for prevention of recurrence of rheumatic fever (secondary prophylaxis) in patients hypersensitive to penicillins and sulfonamides.^{311 392 c f}

Continuous prophylaxis recommended following treatment of documented rheumatic fever (even if manifested solely by Sydenham chorea) and in those with evidence of rheumatic heart disease.^{311 392}

Prevention of Perinatal Group B Streptococcal Disease

Alternative to penicillin G or ampicillin for prevention of perinatal group B streptococcal (GBS) disease† in penicillin-allergic pregnant women at risk for anaphylaxis with a β-lactam anti-infective.^{246 311 415}

Intrapartum anti-infective prophylaxis to prevent early-onset neonatal GBS disease is administered to women identified as GBS carriers during routine prenatal GBS screening performed at 35–37 weeks during the current pregnancy and to women who have GBS bacteriuria during the current pregnancy, a previous infant with invasive GBS disease, unknown GBS status with delivery at <37 weeks gestation, amniotic membrane rupture for ≥18 hours, or intrapartum temperature of ≥38°C.^{246 415}

Penicillin G is the regimen of choice and ampicillin is the preferred alternative.^{246 415} Cefazolin can be used in penicillin-allergic women who do not have immediate-type penicillin hypersensitivity, but clindamycin or erythromycin should be used in penicillin-allergic women at high risk for anaphylaxis.⁴¹⁵

Consider that S. agalactiae (group B streptococci) with in vitro resistance to clindamycin and erythromycin has been reported with increasing frequency;⁴¹⁵ perform in vitro susceptibility tests of clinical isolates obtained during GBS prenatal screening.⁴¹⁵ GBS resistant to erythromycin often are resistant to clindamycin, although this may not be evident in results of in vitro testing.⁴¹⁵ If in vitro susceptibility testing is not possible, results are unknown, or isolates are found to be resistant to erythromycin or clindamycin, vancomycin is recommended for intrapartum prophylaxis in penicillin-allergic women at high risk for anaphylaxis with β-lactams.⁴¹⁵

Erythromycin Dosage and Administration

Administration

Administer orally as erythromycin base, stearate, ethylsuccinate, or estolate.^a Administer erythromycin lactobionate by IV infusion.^c

Oral route usually preferred and should replace parenteral route as soon as possible.^a

Oral Administration

Erthromycin delayed-release tablets (PCE Dispertab, Ery-Tab) may be given without regard to meals,^{262 b} but optimal absorption of PCE Dispertab occurs when the tablets are given in the fasting state (at least 30 minutes and, preferably, 2 hours before meals).^b Erythromycin film-coated tablets should be administered in the fasting state (at least 30 minutes and, preferably, 2 hours before or after meals).^{d e}

Erythromycin delayed-release capsules containing enteric-coated pellets of erythromycin (ERYC) may be swallowed intact or the entire contents of a capsule(s) may be sprinkled on a small amount of applesauce immediately prior to administration; subdividing the contents of a capsule is not recommended.^h The enteric-coated pellets contained in the capsules should not be chewed or crushed.^h If the capsule contents are administered by sprinkling on applesauce, the patient should drink some water after swallowing the applesauce to ensure that the pellets are swallowed.^h If the pellets are accidentally spilled, the dose preparation should be started over with a new capsule.^h

Erythromycin ethylsuccinate oral suspensions,^{268 f} chewable tablets,^f and film-coated tablets^{268 f} (E.E.S., EryPed) are given without regard to meals. Chewable tablets should not be swallowed whole.^f

Erythromycin stearate preferably should be administered in the fasting state or immediately before a meal.²⁶³

Fixed-combination preparation containing erythromycin ethylsuccinate and sulfisoxazole acetyl is given without regard to meals.²⁶⁴

Reconstitution

Reconstitute erythromycin ethylsuccinate powders for oral suspension with water according to manufacturers' directions.^{268 f}

IV Infusion

Administer erythromycin lactobionate by continuous or intermittent IV infusion.^c Do not administer by rapid or direct IV injection because of the local irritative effects of the drug.^c

Continuous IV infusion usually is preferred, but the drug may be administered by intermittent IV infusion every 6 hours.^c

Reconstitution

Reconstitute ADD-Vantage vials according to the manufacturer's instructions using 0.9% sodium chloride or 5% dextrose injection.^c The ADD-Vantage vials are for single use only.^c

Rate of Administration

For intermittent IV infusion; one-fourth of the total daily dose is administered over 20–60 minutes at intervals no longer than every 6 hours.^c

Dosage

Available as erythromycin base, estolate, ethylsuccinate, stearate, or lactobionate; dosage expressed in terms of erythromycin.^a Dosage of the fixed-combination preparation containing erythromycin ethylsuccinate and sulfisoxazole acetyl is expressed in terms of the erythromycin or sulfisoxazole content.²⁶⁴

Erythromycin ethylsuccinate has different absorption characteristics than other commercially available forms of oral erythromycin and higher doses of the ethylsuccinate may be needed to achieve therapeutic effects.^{268 f} For adults, 400 mg of erythromycin as the ethylsuccinate provides erythromycin activity similar to that provided by 250 mg of erythromycin as the base, estolate, or stearate.^{268 f}

Pediatric Patients

General Pediatric Dosage

Treatment of Infections

Oral

Erythromycin (base, estolate, ethylsuccinate, or stearate): 30–50 mg/kg daily in 2–4 equally divided doses.^{242 262 263 268 311 b d e f i}

Dosage may be doubled for severe infections.^{242 262 268 311 b d e f}

IV

Erythromycin (lactobionate): 15–20 mg/kg daily.^c Dosage up to 4 g daily may be used for severe infections.^c

Acute Otitis Media (AOM)

Oral

Children ≥2 months of age (fixed combination containing erythromycin ethylsuccinate and sulfisoxazole acetyl): 12.5 mg/kg (based on erythromycin content) every 6 hours or 17 mg/kg (based on erythromycin content) every 8 hours (up to 2 g daily).²⁶⁴ Alternatively, the following approximate dosages expressed in terms of volumes of the fixed-combination suspension can be used.²⁶⁴ (See Table 1 and Table 2.)

Pediazole Dosage (6-Hour Dosing) for AOM in Children ≥2 Months of Age

Weight (in kg)	Dose (repeated every 6 h for 10 days)
<8	Calculate dose by body weight
8–15.9	2.5 mL
16–23.9	5 mL
24–31.9	7.5 mL
>32	10 mL

Pediazole Dosage (8-Hour Dosing) for AOM in Children ≥2 Months of Age

Weight (in kg)	Dose (repeated every 8 h for 10 days)
<6	Calculate dose by body weight
6–11.9	2.5 mL
12–17.9	5 mL
18–23.9	7.5 mL
24–30	10 mL
>30	12.5 mL

Amebiasis

Entamoeba histolytica Infections

Oral

Erythromycin (base, estolate, ethylsuccinate, or stearate): 30–50 mg/kg daily in divided doses for 10–14 days.^{242 262 268 d e f}

Anthrax†

IV

Erythromycin (lactobionate): 20–40 mg/kg daily given in divided doses every 6 hours.²¹⁸

Must be used in multiple-drug regimens that initially include IV ciprofloxacin or IV doxycycline and 1 or 2 other anti-infectives predicted to be effective.^{216 347}

Duration of treatment is 60 days if anthrax occurred as the result of exposure to anthrax spores in the context of biologic warfare or bioterrorism.^{216 347}

Chlamydial Infections

Uncomplicated Urethral, Endocervical, or Rectal Infections in Children Weighing <45 kg

Oral

Erythromycin (base or ethylsuccinate): 50 mg/kg daily (maximum 2 g daily) given in 4 divided doses for 14 days.²²⁸

Uncomplicated Urethral, Endocervical, or Rectal Infections in Adolescents

Oral

Erythromycin (base or stearate): 500 mg 4 times daily for 7 days.^{228 242 248 262 311 d e} Alternatively, 666 mg every 8 hours for 7 days.^{242 262}

Erythromycin (ethylsuccinate): 800 mg 4 times daily for 7 days.²²⁸

Presumptive Treatment of Chlamydial Infections in Children Weighing <45 kg with Gonorrhea

Oral

Erythromycin (base or ethylsuccinate): 50 mg/kg daily (maximum 2 g daily) given in 4 divided doses for 7 days.^{228 311}

Presumptive Treatment of Chlamydial Infections in Adolescents with Gonorrhea

Oral

Erythromycin (base): 500 mg 4 times daily for 7 days.²²⁸

Erythromycin (ethylsuccinate): 800 mg 4 times daily for 7 days.²²⁸

Treatment of Pneumonia Caused by C. trachomatis

Oral

Erythromycin (base, ethylsuccinate, or stearate): 50 mg/kg daily given in 4 divided doses for ≥14 days.^{228 248 262 263 311} Follow-up is recommended and a second course of therapy may be necessary.^{228 311}

Treatment of Ophthalmia Neonatorum Caused by C. trachomatis

Oral

Erythromycin (base, ethylsuccinate, or stearate): 50 mg/kg daily given in 4 divided doses for 14 days.^{228 248 263 311} Follow-up is recommended and a second course of therapy may be necessary.^{228 311}

Diphtheria

Treatment of Diphtheria

Oral

Erythromycin: 40–50 mg/kg daily (maximum 2 g daily) for 14 days.^{261 311} Patients usually are no longer contagious 48 hours after initiation of anti-infective therapy.²⁶¹ Eradication of the organism should be confirmed by 2 consecutive negative cultures following completion of therapy.^{261 311}

Prevention of Diphtheria

Oral

Erythromycin: 40–50 mg/kg daily (maximum 2 g daily) for 7–10 days.^{261 311 455}

Elimination of Diphtheria Carrier State

Oral

Erythromycin: 40–50 mg/kg daily (maximum 2 g daily) for 7–10 days.^{311 455} Obtain follow-up cultures ≥2 weeks after completion of therapy; if cultures are positive, an additional 10-day course should be given and additional follow-up cultures obtained.^{311 455}

Lyme Disease†

Early Localized or Early Disseminated Lyme Disease†

Oral

Erythromycin: 12.5 mg/kg (up to 500 mg) 4 times daily for 14–21 days.²¹⁴ Alternatively, 30 mg/kg daily in 3 divided doses (or 250 mg 3 times daily) for 14–21 days.²⁷⁴

Nongonococcal Urethritis in Adolescents

Oral

Erythromycin (base): 500 mg 4 times daily for 7 days.²²⁸ Alternatively, 666 mg every 8 hours for ≥7 days.^{242 262} For recurrent and persistent urethritis, CDC recommends 500 mg 4 times daily for 7 days in conjunction with a single dose of oral metronidazole (2 g).²²⁸

Erythromycin (ethylsuccinate): 800 mg 4 times daily for 7 days.^{228 268 f} For recurrent and persistent urethritis, CDC recommends 800 mg 4 times daily for 7 days in conjunction with a single dose of oral metronidazole (2 g).²²⁸

Pertussis

Treatment or Prevention of Pertussis

Oral

Erthromycin (base or stearate): 40–50 mg/kg daily (maximum 2 g daily) in divided doses for 14 days.^{263 311 455}

Prevention of Bacterial Endocarditis†

Patients Undergoing Certain Dental, Oral, Respiratory Tract, or Esophageal Procedures†

Oral

Erythromycin (ethylsuccinate): 20 mg/kg 2 hours before the procedure and 10 mg/kg 6 hours later.³⁰²

Erythromycin (stearate): 20 mg/kg 2 hours before the procedure and 10 mg/kg 6 hours later.³⁰²

Adults

General Adult Dosage

Treatment of Infections

Oral

Erythromycin (base): 250 mg every 6 hours,^{262 d e} 333 mg every 8 hours,^{242 262 d} or 500 mg every 12 hours.^{242 262 d e} In severe infections, dosage may be increased up to 4 g daily; however, a twice-daily dosing schedule is not recommended when dosages exceeding 1 g daily are administered.^{242 262 e}

Erythromycin (estolate): 250 mg every 6 hours.ⁱ In severe infections, dosage may be increased up to 4 g daily.ⁱ

Erythromycin (ethylsuccinate): 400 mg every 6 hours.^{268 f} Dosage up to 4 g daily may be used for severe infections.^{268 f}

Erythromycin (stearate): 250 mg every 6 hours or 500 mg every 12 hours. In severe infections, dosage may be increased up to 4 g daily; however, a twice-daily dosing schedule is not recommended when dosage is >1 g daily.²⁶³

Pharyngitis and Tonsillitis

Oral

Erythromycin (base): 250 mg every 6 hours,^{262 d e} 333 mg every 8 hours,^{242 262 d} or 500 mg every 12 hours^{242 262 d e} for 10 days.

Amebiasis

Entamoeba histolytica Infections

Oral

Erythromycin (base or stearate): 250 mg every 6 hours,^{242 d e} 333 mg every 8 hours,^{242 263} or 500 mg every 12 hours^{242 263 d} for 10–14 days.

Erythromycin (estolate): 250 mg 4 times daily for 10–14 days.ⁱ

Erythromycin (ethylsuccinate): 400 mg 4 times daily for 10–14 days.^{268 f}

Anthrax†

IV

Erythromycin (lactobionate): 15–20 mg/kg (up to 4 g) daily given in divided doses every 6 hours.²¹⁸

Must be used in multiple-drug regimens that initially include IV ciprofloxacin or IV doxycycline and 1 or 2 other anti-infectives predicted to be effective.^{216 347}

Duration of treatment is 60 days if anthrax occurred as the result of exposure to anthrax spores in the context of biologic warfare or bioterrorism.^{216 347}

Chancroid†

Oral

Erythromycin (base): 500 mg 3–4 times daily for 7 days.^{228 248}

Erythromycin (ethylsuccinate): 800 mg 4 times daily for 7 days.²⁴⁸

Chlamydial Infections

Uncomplicated Urethral, Endocervical, or Rectal Infections

Oral

Erythromycin (base or stearate): 500 mg 4 times daily for 7 days.^{228 248 242 262 263 d e} Alternatively, 666 mg every 8 hours for 7 days.^{242 262 263} If these regimens are not tolerated in pregnant women, a dosage of 500 mg every 12 hours, 333 mg every 8 hours, or 250 mg 4 times daily for at least 14 days.^{228 242 262 263}

Erythromycin (estolate): 500 mg 4 times daily for 7 daysⁱ

Erythromycin (ethylsuccinate): 800 mg 4 times daily for 7 days.^{228 248} If this regimen is not tolerated in pregnant women, a dosage of 400 mg 4 times daily for 14 days may be used.²²⁸

Presumptive Treatment of Chlamydial Infections in Adults with Gonorrhea

Oral

Erythromycin (base): 500 mg 4 times daily for 7 days.²²⁸

Erythromycin (ethylsuccinate): 800 mg 4 times daily for 7 days.²²⁸

Lymphogranuloma venereum†

Oral

Erythromycin (base): 500 mg 4 times daily for 21 days.^{228 248}

Erythromycin (ethylsuccinate): 800 mg 4 times daily for 21 days.²⁴⁸

Diphtheria

Treatment of Diphtheria

Oral

Erythromycin: 40–50 mg/kg daily (maximum 2 g daily) for 14 days.^{261 311} Patients usually are no longer contagious 48 hours after initiation of anti-infective therapy.²⁶¹ Eradication of the organism should be confirmed by 2 consecutive negative cultures following completion of therapy.^{261 311}

Prevention of Diphtheria

Oral

Erythromycin: 1 g daily for 7–10 days.^{261 455}

Elimination of Diphtheria Carrier State

Oral

Erythromycin: 1 g daily for 7–10 days.^{311 455} Obtain follow-up cultures ≥2 weeks after completion of therapy; if cultures are positive, an additional 10-day course should be given and additional follow-up cultures obtained.^{311 455}

Granuloma Inguinale (Donovanosis)†

Oral

Erythromycin (base): 500 mg 4 times daily for ≥3 weeks or until all lesions have healed completely;²²⁸ consider adding IV aminoglycoside (e.g., gentamicin) if improvement is not evident within the first few days of therapy and in HIV-infected patients.²²⁸

Relapse can occur 6–18 months after apparently effective treatment.²²⁸

Legionnaires' Disease

Oral

Erthromycin (base, ethylsuccinate, or stearate): 1–4 g daily in divided doses has been used alone or in conjunction with rifampin.^{242 311 262 263 268 311 452 453 d e f} Usual duration is 10–21 days.^{311 452 453}

IV

Erythromycin (lactobionate): 1–4 g daily in divided doses has been used alone or in conjunction with rifampin.^{311 452 453 c} After a response is obtained, rifampin can be discontinued and therapy changed to oral erythromycin.^{311 452 453} Usual duration is 10–21 days.^{311 452 453}

Early Localized or Early Disseminated Lyme Disease†

Oral

Erythromycin: 500 mg 4 times daily for 14–21 days.²¹⁴ Alternatively, 250 mg 4 time daily for 14–21 days.²⁷⁴

Nongonococcal Urethritis

Oral

Erythromycin (base or stearate): 500 mg 4 times daily for 7 days.^{228 248 263} Alternatively, 666 mg every 8 hours for ≥7 days.^{242 262 263} For recurrent and persistent urethritis, CDC recommends 500 mg 4 times daily for 7 days in conjunction with a single dose of oral metronidazole (2 g).²²⁸

Erythromycin (ethylsuccinate): 800 mg 4 times daily for 7 days.^{228 248 268 f}