Antibiotic Therapy Associated Cardiotoxicity

  • Manisha Jha
  • Akram Khan
Keywords: Antibiotics, Cardiac Toxicity, Adverse Reactions


The improper and frequent use of antibiotics has been on a rise. Empirical use for unapproved indications leads to development of resistant pathogens. Many other adverse drug reactions are associated with the use of antibiotics. These may be due to the direct effect of these drugs or due to their interactions with other therapeutic agents. Cardiac toxicities like QT prolongation, aortic aneurysms and dissections are of high concern and may result in long-term health risks. To prevent these adverse reactions, antibiotics should be used as per the manufacturer’s and physician’s instructions. The use of interacting drugs should be avoided wherever possible. Polypharmacy practice should be done after considering all the patient’s health aspects. This review summarizes the cardiac toxicities of commonly prescribed antibiotics and their interactions with other drugs.


Download data is not yet available.

Author Biographies

Manisha Jha

MD (Pharmacology), Consultant Physician, Visiting Professor and Private Practitioner

Akram Khan

GNM, Shiva Nursing Home, Bhusawal, Maharashtra


Fleming-Dutra KE, Hersh AL, Shapiro DJ, Bartoces M, Enns EA, File TM Jr, et al. Prevalence of inappropriate antibiotic prescriptions among US ambulatory care visits, 2010–2011. JAMA 2016; 315: 1864–73.

Linder JA, Brown T, Lee JY, Chua K-P, Fischer MA. 1632. Non-Visit-Based and Non-Infection-Related Ambulatory Antibiotic Prescribing. Open Forum Infect Dis. 2018; 5 (Suppl 1): S43.

Heianza Y, Zheng Y, Ma W, Rimm EB, Albert CM, Hu FB, et al. Duration and life-stage of antibiotic use and risk of cardiovascular events in women. Eur Heart J. 2019; 40: 3838–3845.

Nachimuthu S, Assar MD, Schussler JM. Drug-induced QT interval prolongation: mechanisms and clinical management. Ther Adv Drug Saf. 2012; 3: 241-53.

Li X, Wang M, Liu G, Ma J, Li C. Association of macrolides with overall mortality and cardiac death among patients with various infections: a meta-analysis. Eur J Intern Med. 2016; 28:32–7.

Wong AYS, Chan EW, Anand S, Worsley AJ, Wong ICK. Managing cardiovascular risk of macrolides: systematic review and meta-analysis. Drug Saf. 2017; 40: 663–77.

Bin Abdulhak AA, Khan AR, Garbati MA, Qazi AH, Erwin P, Kisra S, et al. Azithromycin and risk of cardiovascular death: a meta-analytic review of observational studies. Am J Ther. 2015; 22: e122–e129.

Ray WA, Murray KT, Hall K, Arbogast PG, Stein CM. Azithromycin and the risk of cardiovascular death. N Engl J Med. 2012; 366: 1881–90.

Schembri S, Williamson PA, Short PM, Singanayagam A, Akram A, Taylor J, et al. Cardiovascular events after clarithromycin use in lower respiratory tract infections: analysis of two prospective cohort studies. BMJ 2013; 346: f1235.

Svanström H, Pasternak B, Hviid A. Use of clarithromycin and roxithromycin and risk of cardiac death: cohort study. BMJ 2014; 349: g4930.

Khosropour CM, Capizzi JD, Schafer SD, Kent JB, Dombrowski JC, Golden MR. Lack of association between azithromycin and death from cardiovascular causes. N Engl J Med. 2014; 370: 1961–2.

Chou HW, Wang JL, Chang CH, Lai CL, Lai MS, Chan KA. Risks of cardiac arrhythmia and mortality among patients using new-generation macrolides, fluoroquinolones, and β-lactam/β- lactamase inhibitors: a Taiwanese nationwide study. Clin Infect Dis. 2015; 60: 566–77.

Mortensen EM, Halm EA, Pugh MJ, Copeland LA, Metersky M, Fine MJ, et al. Association of azithromycin with mortality and cardiovascular events among older patients hospitalized with pneumonia. JAMA 2014; 311: 2199–208.

Winkel P, Hilden J, Hansen JF, Kastrup J, Kolmos HJ, Kjøller E, et al.; CLARICOR trial group. Clarithromycin for stable coronary heart disease increases all-cause and cardiovascular mortality and cerebrovascular morbidity over 10 years in the CLARICOR randomised, blinded clinical trial. Int J Cardiol. 2015; 182: 459–65.

Wong AY, Root A, Douglas IJ, Chui CS, Chan EW, Ghebremichael-Weldeselassie Y, et al. Cardiovascular outcomes associated with use of clarithromycin: population based study. BMJ 2016; 352: h6926.

Inghammar M, Nibell O, Pasternak B, Melbye M, Svanström H, Hviid A. Long term risk of cardiovascular death with use of clarithromycin and roxithromycin: a nationwide cohort study. Am J Epidemiol. 2018; 187: 777–85.

Gandhi S, Fleet JL, Bailey DG, McArthur E, Wald R, Rehman F, Garg AX. Calcium-channel blocker – clarithromycin drug interactions and acute kidney injury. JAMA 2013; 310: 2544-53.

Fralick M, Macdonald EM, Gomes T, Antoniou T, Hollands S, Mamdani MM, Juurlink DN; Canadian Drug Safety and Effectiveness Research Network. Co-trimoxazole and sudden death in patients receiving inhibitors of renin-angiotensin system: population based study. BMJ 2014; 349: g6196.

Jie Z, Xia H, Zhong SL, Feng Q, Li S, Liang S, et al. The gut microbiome in atherosclerotic cardiovascular disease. Nat Commun. 2017;8:845.

Kita E, Sawaki M, Mikasa K, Oku D, Hamada K, Maeda K, et al. Proliferation of erythromycin-stimulated mouse peritoneal macrophages in the absence of exogenous growth factors. Nat Immun. 1993; 12: 326–38.

Xu G, Fujita J, Negayama K, Yuube K, Hojo S, Yamaji Y, et al. Effect of macrolide antibiotics on macrophage functions. Microbiol Immunol. 1996; 40: 473–9.

Robbins CS, Hilgendorf I, Weber GF, Theurl I, Iwamoto Y, Figueiredo JL, et al. Local proliferation dominates lesional macrophage accumulation in atherosclerosis. Nat Med. 2013; 19: 1166–72.

Kappel B, De Angelis L, Nonnast A, Stoehr R, Menghini R, Marx N, Federici M. Oral antibiotics increase atherosclerosis independently of diet. Eur Heart J. 2017; 38 (Suppl 1): 138.

Wang Z, Klipfell E, Bennett BJ, Koeth R, Levison BS, Dugar B, et al. Gut flora metabolism of phosphatidylcholine promotes cardiovascular disease. Nature 2011;472:57–63.

Scott NA, Andrusaite A, Andersen P, Lawson M, Alcon-Giner C, Leclaire C, et al. Antibiotics induce sustained dysregulation of intestinal T cell immunity by perturbing macrophage homeostasis. Sci Transl Med. 2018; 10 (464): eaao4755.

DOI: 10.26440/IHRJ/0401.10384
Published: 2021-01-23
How to Cite
Manisha Jha, Akram Khan. Antibiotic Therapy Associated Cardiotoxicity. IHRJ [Internet]. 2021Jan.23 [cited 2021Mar.1];4(10):RV18-RV21. Available from: