6 Non-Infectious Indications for Antibiotics

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Timothy P. Gauthier, PharmD, BCPS-AQ ID

Timothy P. Gauthier, PharmD, BCPS-AQ ID, graduated from Northeastern University's School of
Pharmacy in 2008 and then completed 2 years of post-graduate residency training. Since then he
has been engaged in clinical infectious diseases pharmacy and antimicrobial stewardship
teaching, practice and research. You can find him on social media @IDstewardship.

6 Non-Infectious Indications for Antibiotics

Published Online: Friday, November 6, 2015

Pharmacy school prepares us to join the workforce, but our dynamic and evolving profession demands that
we continue our education as lifelong learners.

In pursuit of filling knowledge gaps and extending our capacity to provide quality care for patients, we get
the opportunity to learn more about various disease states and the remedies employed to treat them.
During this time of learning through real-world experiences, it is inevitable that we will eventually encounter
various oddities and curiosities not discussed in school.

As an infectious diseases pharmacist specialist, I am a huge proponent of antimicrobial stewardship,

infection control, and limiting inappropriate antibiotic use in all settings. When it comes to determining
whether an antibiotic is appropriate, it would seem intuitive that if the indication is not an infection, then the
antibiotic is not indicated.

However, there are some non-infectious purposes for which antibiotics can be used.

Here are 6 non-infectious indications for antibiotics that you may not have learned about during pharmacy
school. As you read through them, note that potential toxicities and ecologic consequences of antimicrobial
use should always be considered prior to employing such therapy.

1. Minocycline for acute stroke.

Minocycline is a tetracycline antibiotic that has been found to have anti-inflammatory, anti-apoptotic, and
neuroprotective effects.1 Animal and human data suggest that minocycline may provide benefit for patients
with acute stroke while imposing little risk.

2. Azithromycin for treating cystic fibrosis lung disease or preventing COPD exacerbations.

In addition to antimicrobial effects, azithromycin has anti-inflammatory and immunomodulatory effects.

A 2015 review paper on azithromycin and cystic fibrosis concluded that available data support azithromycin
efficacy during the first year of administration, though the long-term benefits remain debated.2 In a review of
azithromycin for preventing chronic obstructive pulmonary disease (COPD) exacerbations, it was noted that
long-term use can reduce COPD exacerbations, but concerns over adverse effects have limited its use for
this indication.3

3. Doxycycline as a sclerosing agent for pleural effusion.

For more than 2 decades, tetracycline antibiotic doxycycline has been administered via the intrapleural
route in the management of malignant pleural effusion,4 and it continues to be used today for this purpose.

4. Cholroquine or hydroxychloroquine for lupus erythematosus or rheumatoid arthritis.

Both antimalarial agents hydroxychloroquine and chloroquine have immunomodulatory effects and been

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Publications

6 Non-Infectious Indications for Antibiotics

used for more than 7 decades in the management of systemic lupus erythematous and rheumatoid
arthritis.5 Hydroxychloroquine is generally preferred over chloroquine because it has fewer gastrointestinal
and ocular adverse effects.

5. Fluconazole or ketoconazole for boosting tacrolimus levels.

Both azole antifungal agents fluconazole and ketoconazole have been used to increase the concentrations
of the immunosuppressant agent tacrolimus.6,7 These increased tacrolimus concentrations result from
cytochrome P450 and p-glycoprotein drug-drug interactions.

6. Erythromycin or azithromycin for gastroparesis.

Erythromycin is a macrolide antibiotic, a motilin receptor agonist, and a potent prokinetic, which decreases
gastric emptying time.8 Azithromycin is also a macrolide antibiotic and has been studied in gastroparesis.9

Although most evidence focuses on erythromycin, interest persists regarding its replacement with
azithromycin, since it has fewer drug-drug interactions, fewer gastrointestinal effects, less impact on the
QTc interval, and a longer half-life.

The views expressed in this article are those of the author and do not necessarily reflect the position or
policy of the Department of Veterans Affairs or the United States government.

References:

1. Vedantam S, Moller AR. Minocycline: a novel stroke therapy. J Neurol Stroke. 2015; 2(6): 00073.

2. Principi N, Blasi F, Esposito S. Azithromycin use in patients with cystic fibrosis. Eur J Clin Microbial Infect
Dis. 2015; 34(6):1071-1079.

3. Taylor SP, Sellers E, Taylor BT. Azithromycin for the prevention of COPD exacerbations: the good, bad
and ugly. Am J Med. 2015; epub ahead of print.

4. Robinson LA, Fleming WH, Galbraith TA. Intrapleural doxycycline control of malignant pleural effusions.
Ann Thorac Surg. 1993; 55(5):1115-1121.

5. Rainsford KD, Parke AL, Clifford-Rashotte M, Kean WF. Therapy and pharmacologic properties of
hydroxychloroquine and chloroquine in the treatment of systemic lupus erythematous, rheumatoid arthritis
and related diseases. Inflammopharmacology. 2015; 23(5): 231-269.

6. Dhawan A, et al. Tacrolimus (FK506) malabsorption: management with fluconazole coadministration.

Translp Int. 1997; 10(4): 331-4.

7. Soltero L, Carbajal H, Rodriguez-Montalvo C, Valdes A. Coadministration of tacrolimus and ketoconazole

in renal transplant recipients: cost analysis and review of metabolic effects. Transplant Proc. 2003; 35(4):
1319-1321.

8. Enweluzo C, Aziz F. Gastroparesis: a review of current and emerging treatment options. Clin Exp
Gastroenterol. 2013; 6: 161-165.

9. Potter TG, Snider KR. Azithromycin for the treatment of gastroparesis. Ann pharmacother. 2013; 47(3):
411-415.
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