Black Health
Macrolide antibiotic Community-acquired pneumonia Atypical pneumonia Chlamydia Gonorrhea (with ceftriaxone) Strep pharyngitis (PCN-allergic)

Azithromycin (Zithromax, Zmax, Z-Pak) and Black patients

Brand names: Zithromax, Zmax, Z-Pak

Last reviewed: Sources checked:

What Azithromycin does

Azithromycin is a macrolide antibiotic with broad coverage including atypical respiratory pathogens (Mycoplasma, Chlamydophila, Legionella) and common STIs. The 'Z-Pak' 5-day course is widely prescribed. It is frequently overused for viral illnesses.

What the evidence says for Black patients

Two race-relevant concerns:

  • QT prolongation and cardiovascular death. A 2012 NEJM analysis (Ray et al., 2012;366:1881–90, PMID 22591294) found a small but real increase in cardiovascular death with azithromycin in the 5-day treatment window, particularly in patients with baseline CV risk. Black patients with higher baseline hypertension and heart disease prevalence should be considered for this risk. The absolute increase is small (~47 excess deaths per million courses).
  • Gonorrhea treatment. 2020 CDC guidelines moved to ceftriaxone monotherapy for uncomplicated gonorrhea rather than ceftriaxone + azithromycin, because N. gonorrhoeae azithromycin resistance is rising. Black patients with STIs disproportionately access care in under-resourced settings and may receive outdated regimens; ask whether the current CDC regimen is being used.

Common alternatives

Doxycycline (atypical pneumonia, chlamydia, CA-MRSA skin infection). Amoxicillin/clavulanate (respiratory). Ceftriaxone alone (gonorrhea per 2020 CDC).

Side effects

  • Diarrhea, GI upset
  • QT prolongation — avoid with other QT-prolonging drugs, long QT, low K/Mg
  • Hepatitis (rare)
  • Pyloric stenosis in infants (rare)
  • C. difficile

Factors that affect adherence

5-day course with a loading dose on day 1 is the standard Z-Pak. Generic is inexpensive. Take with or without food.

Questions to ask your doctor

Bring this list to your next appointment.

  • Is this actually bacterial, or could it be viral? Do I need an antibiotic?
  • Do I have any QT prolongation risk or other drugs that could interact?
  • For gonorrhea: is the current CDC regimen being used?

References

  1. Ray WA, Murray KT, Hall K, et al. Azithromycin and the risk of cardiovascular death. NEJM. 2012;366:1881–1890. PMID 22591294.
  2. Centers for Disease Control and Prevention. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR. 2021;70:1–187.
  3. U.S. Food and Drug Administration. FDA Drug Safety Communication: Azithromycin (Zithromax or Zmax) and the risk of potentially fatal heart rhythms. 2013-03-12. https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-azithromycin-zithromax-or-zmax-and-risk-potentially-fatal-heart

Medical disclaimer

This page is patient education, not prescribing guidance. It summarizes the published evidence about how this medication has been studied in Black patients — it is not a substitute for the judgment of your personal clinician. Never start, stop, or change a prescription based on something you read here. If you have questions about your medication, call your prescriber or pharmacist. For emergencies, call 911.

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