Erythromycin Ethylsuccinate

What is Erythromycin Ethylsuccinate and how is it used?

Erythromycin Ethylsuccinate is a prescription medicine used to treat the symptoms of many different types of infections caused by bacteria. Erythromycin Ethylsuccinate may be used alone or with other medications.

Erythromycin Ethylsuccinate belongs to a class of drugs called Macrolides.

What are the possible side effects of Erythromycin Ethylsuccinate?

Erythromycin Ethylsuccinate may cause serious side effects including:

• hives,
• difficulty breathing,
• swelling in your face or throat,
• fever,
• sore throat,v
• burning eyes,
• skin pain,
• red or purple skin rash with blistering and peeling,
• severe stomach pain,
• diarrhea that is watery or bloody (even months after your last dose),
• headache with chest pain and severe dizziness,
• fainting,
• fast or pounding heartbeats,
• seizure,
• hearing problems,
• severe pain in your upper stomach spreading to your back,
• nausea,
• vomiting,
• loss of appetite,
• stomach pain (upper right side),
• tiredness,
• easy bruising or bleeding,
• dark urine,
• clay-colored stools, and
• yellowing of the skin or eyes (jaundice)

For a baby:

• vomiting, and
• irritable with feeding

Get medical help right away, if you have any of the symptoms listed above.

The most common side effects of Erythromycin Ethylsuccinate include:

• severe stomach pain,
• diarrhea that is watery or bloody (even months after your last dose),
• liver problems, and
• abnormal liver function tests

Tell the doctor if you have any side effect that bothers you or that does not go away.

These are not all the possible side effects of Erythromycin Ethylsuccinate. For more information, ask your doctor or pharmacist.

To reduce the development of drug-resistant bacteria and maintain the effectiveness (erythromycin ethylsuccinate) of E.E.S. (erythromycin ethylsuccinate) and other antibacterial drugs, E.E.S. (erythromycin ethylsuccinate) should be used only to treat or prevent infections that are proven or strongly suspected to be caused by bacteria.

DESCRIPTION

Erythromycin is produced by a strain of Saccharopolyspora erythraea (formerly Streptomyces erythraeus) and belongs to the macrolide group of antibiotics. It is basic and readily forms salts with acids. The base, the stearate salt, and the esters are poorly soluble in water. Erythromycin ethylsuccinate is an ester of erythromycin suitable for oral administration. Erythromycin ethylsuccinate is known chemically as erythromycin 2'-(ethylsuccinate). The molecular formula is C₄₃H₇₅NO₁₆ and the molecular weight is 862.06. The structural formula is:

E.E.S. (erythromycin ethylsuccinate) Granules are intended for reconstitution with water. Each 5-mL teaspoonful of reconstituted cherry-flavored suspension contains erythromycin ethylsuccinate equivalent to 200 mg of erythromycin.

The pleasant tasting, fruit-flavored liquids are supplied ready for oral administration.

E.E.S. 200 Liquid (erythromycin ethylsuccinate) : Each 5-mL teaspoonful of fruit-flavored suspension contains erythromycin ethylsuccinate equivalent to 200 mg of erythromycin.

E.E.S. (erythromycin ethylsuccinate) 400 Liquid: Each 5-mL teaspoonful of orange-flavored suspension contains erythromycin ethylsuccinate equivalent to 400 mg of erythromycin.

Granules and ready-made suspensions are intended primarily for pediatric use but can also be used in adults.

E.E.S. (erythromycin ethylsuccinate) 400® Filmtab® Tablets: Each tablet contains erythromycin ethylsuccinate equivalent to 400 mg of erythromycin.

The Filmtab® tablets are intended primarily for adults or older children.

Inactive Ingredients

E.E.S. 200 Liquid (erythromycin ethylsuccinate) : FD&C Red No. 40, methylparaben, polysorbate 60, propylparaben, sodium citrate, sucrose, water, xanthan gum and natural and artificial flavors.

E.E.S. (erythromycin ethylsuccinate) 400 Liquid: D&C Yellow No. 10, FD&C Yellow No. 6, methylparaben, polysorbate 60, propylparaben, sodium citrate, sucrose, water, xanthan gum and natural and artificial flavors.

E.E.S. (erythromycin ethylsuccinate) Granules: Citric acid, FD&C Red No. 3, magnesium aluminum silicate, sodium carboxymethylcellulose, sodium citrate, sucrose and artificial flavor.

E.E.S. (erythromycin ethylsuccinate) 400 Filmtab Tablets: Cellulosic polymers, confectioner's sugar (contains corn starch), corn starch, D&C Red No. 30, D&C Yellow No. 10, FD&C Red No. 40, magnesium stearate, polacrilin potassium, polyethylene glycol, propylene glycol, sodium citrate, sorbic acid, and titanium dioxide.

INDICATIONS

To reduce the development of drug-resistant bacteria and maintain the effectiveness (erythromycin ethylsuccinate) of E.E.S. (erythromycin ethylsuccinate) and other antibacterial drugs, E.E.S. (erythromycin ethylsuccinate) should be used only to treat or prevent infections that are proven or strongly suspected to be caused by susceptible bacteria. When culture and susceptibility information are available, they should be considered in selecting or modifying antibacterial therapy. In the absence of such data, local epidemiology and susceptibility patterns may contribute to the empiric selection of therapy.

E.E.S. (erythromycin ethylsuccinate) is indicated in the treatment of infections caused by susceptible strains of the designated organisms in the diseases listed below

Upper respiratory tract infections of mild to moderate degree caused by Streptococcus pyogenes, Streptococcus pneumoniae, or Haemophilus influenzae (when used concomitantly with adequate doses of sulfonamides, since many strains of H. influenzae are not susceptible to the erythromycin concentrations ordinarily achieved). (See appropriate sulfonamide labeling for prescribing information.)

Lower-respiratory tract infections of mild to moderate severity caused by Streptococcus pneumoniae or Streptococcus pyogenes.

Listeriosis caused by Listeria monocytogenes.

Pertussis (whooping cough) caused by Bordetella pertussis. Erythromycin is effective in eliminating the organism from the nasopharynx of infected individuals rendering them noninfectious. Some clinical studies suggest that erythromycin may be helpful in the prophylaxis of pertussis in exposed susceptible individuals.

Respiratory tract infections due to Mycoplasma pneumoniae.

Skin and skin structure infections of mild to moderate severity caused by Streptococcus pyogenes or Staphylococcus aureus (resistant staphylococci may emerge during treatment).

Diphtheria: Infections due to Corynebacterium diphtheriae , as an adjunct to antitoxin, to prevent establishment of carriers and to eradicate the organism in carriers.

Erythrasma: In the treatment of infections due to Corynebacterium minutissimum.

Intestinal amebiasis caused by Entamoeba histolytica (oral erythromycins only). Extraenteric amebiasis requires treatment with other agents.

Acute pelvic inflammatory disease caused by Neisseria gonorrhoeae: As an alternative drug in treatment of acute pelvic inflammatory disease caused by N. gonorrhoeae in female patients with a history of sensitivity to penicillin. Patients should have a serologic test for syphilis before receiving erythromycin as treatment of gonorrhea and a follow-up serologic test for syphilis after 3 months.

Syphilis caused by Treponema pallidum: Erythromycin is an alternate choice of treatment for primary syphilis in patients allergic to the penicillins. In treatment of primary syphilis, spinal fluid examinations should be done before treatment and as part of follow-up after therapy.

Erythromycins are indicated for the treatment of the following infections caused by Chlamydia trachomatis: conjunctivitis of the newborn, pneumonia of infancy, and urogenital infections during pregnancy. When tetracyclines are contraindicated or not tolerated, erythromycin is indicated for the treatment of uncomplicated urethral, endocervical, or rectal infections in adults due to Chlamydia trachomatis.

When tetracyclines are contraindicated or not tolerated, erythromycin is indicated for the treatment of nongonococcal urethritis caused by Ureaplasma urealyticum.

Legionnaires' Disease caused by Legionella pneumophila. Although no controlled clinical efficacy studies have been conducted, in vitro and limited preliminary clinical data suggest that erythromycin may be effective in treating Legionnaires' Disease.

Prophylaxis

Prevention of Initial Attacks of Rheumatic Fever

Penicillin is considered by the American Heart Association to be the drug of choice in the prevention of initial attacks of rheumatic fever (treatment of Streptococcus pyogenes infections of the upper respiratory tract, e.g., tonsillitis or pharyngitis). Erythromycin is indicated for the treatment of penicillin-allergic patients.³ The therapeutic dose should be administered for 10 days.

Prevention of Recurrent Attacks of Rheumatic Fever

Penicillin or sulfonamides are considered by the American Heart Association to be the drugs of choice in the prevention of recurrent attacks of rheumatic fever. In patients who are allergic to penicillin and sulfonamides, oral erythromycin is recommended by the American Heart Association in the long-term prophylaxis of streptococcal pharyngitis (for the prevention of recurrent attacks of rheumatic fever).³

DOSAGE AND ADMINISTRATION

Erythromycin ethylsuccinate suspensions and Filmtab tablets may be administered without regard to meals.

Children

Age, weight, and severity of the infection are important factors in determining the proper dosage. In mild to moderate infections the usual dosage of erythromycin ethylsuccinate for children is 30 to 50 mg/kg/day in equally divided doses every 6 hours. For more severe infections this dosage may be doubled. If twice-a-day dosage is desired, one-half of the total daily dose may be given every 12 hours. Doses may also be given three times daily by administering one-third of the total daily dose every 8 hours.

The following dosage schedule is suggested for mild to moderate infections:

Body Weight	Total Daily Dose
Under 10 lbs	30-50 mg/kg/day 15-25 mg/kg/q 12 h
10 to 15 lbs	200 mg
16 to 25 lbs	400 mg
26 to 50 lbs	800 mg
51 to 100 lbs	1200 mg
over 100 lbs	1600 mg

Adults

400 mg erythromycin ethylsuccinate every 6 hours is the usual dose. Dosage may be increased up to 4 g per day according to the severity of the infection. If twice-a-day dosage is desired, one-half of the total daily dose may be given every 12 hours. Doses may also be given three times daily by administering one-third of the total daily dose every 8 hours.

For adult dosage calculation, use a ratio of 400 mg of erythromycin activity as the ethylsuccinate to 250 mg of erythromycin activity as the stearate, base or estolate.

In the treatment of streptococcal infections, a therapeutic dosage of erythromycin ethylsuccinate should be administered for at least 10 days. In continuous prophylaxis against recurrences of streptococcal infections in persons with a history of rheumatic heart disease, the usual dosage is 400 mg twice a day.

For Treatment of Urethritis Due to C. trachomatis or U. urealyticum

800 mg three times a day for 7 days.

For Treatment of Primary Syphilis

Adults: 48 to 64 g given in divided doses over a period of 10 to 15 days.

For Intestinal Amebiasis

Adults

400 mg four times daily for 10 to 14 days.

Children

30 to 50 mg/kg/day in divided doses for 10 to 14 days.

For Use in Pertussis

Although optimal dosage and duration have not been established, doses of erythromycin utilized in reported clinical studies were 40 to 50 mg/kg/day, given in divided doses for 5 to 14 days.

For Treatment of Legionnaires' Disease

Although optimal doses have not been established, doses utilized in reported clinical data were those recommended above (1.6 to 4 g daily in divided doses.)

HOW SUPPLIED

E.E.S. 200 LIQUID (erythromycin ethylsuccinate oral suspension, USP) is supplied in 1 pint bottles (NDC 0074-6306-16) and in 100-mL bottles (NDC 0074-6306-13).

E.E.S. 400® LIQUID (erythromycin ethylsuccinate oral suspension, USP) is supplied in 1 pint bottles (NDC 0074-6373-16) and in 100-mL bottles (NDC 0074-6373-13).

Both liquid products require refrigeration to preserve taste until dispensed. Refrigeration by patient is not required if used within 14 days.

E.E.S. GRANULES (erythromycin ethylsuccinate for oral suspension, USP) is supplied in 100-mL (NDC 0074-6369-02) and 200-mL ( NDC 0074-6369-10) size bottles.

E.E.S. 400 Filmtab tablets (erythromycin ethylsuccinate tablets, USP) 400 mg, are supplied as pink tablets imprinted with the Abbott “A” logo, and two letter Abbo-Code designation, EE, in bottles of 100 (NDC 0074-5729-13), 500 (NDC 0074-5729-53) and 1000 (NDC 0074-5729-19) and in ABBO­PAC unit dose strip packages of 100 (NDC 0074-5729-11).

Recommended storage

Store tablets below 86°F (30°C).

Store granules, prior to mixing, below 86°F. After mixing, refrigerate and use within 10 days.

REFERENCES

3. Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease of the Council on Cardiovascular Disease in the Young, the American Heart Association: Prevention of Rheumatic Fever. Circulation. 78(4):1082-1086, October 1988.

Abbott Laboratories, North Chicago, IL 60064, U.S.A. FDA rev date: 12/10/2008

SIDE EFFECTS

The most frequent side effects of oral erythromycin preparations are gastrointestinal and are dose-related. They include nausea, vomiting, abdominal pain, diarrhea and anorexia. Symptoms of hepatitis, hepatic dysfunction and/or abnormal liver function test results may occur. (See WARNINGS.)

Onset of pseudomembranous colitis symptoms may occur during or after antibiotic treatment. (See WARNINGS.)

Erythromycin has been associated with QT prolongation and ventricular arrhythmias, including ventricular tachycardia and torsades de pointes.

Allergic reactions ranging from urticaria to anaphylaxis have occurred. Skin reactions ranging from mild eruptions to erythema multiforme, Stevens- (erythromycin ethylsuccinate) Johnson syndrome, and toxic epidermal necrolysis have been reported rarely.

There have been rare reports of pancreatitis and convulsions.

There have been isolated reports of reversi (erythromycin ethylsuccinate) ble hearing loss occurring chiefly in patients with renal insufficiency and in patients receiving high doses of erythromycin.

DRUG INTERACTIONS

Erythromycin use in patients who are receiving high doses of theophylline may be associated with an increase in serum theophylline levels (erythromycin ethylsuccinate) and potential theophylline toxicity. In case of theophylline toxicity and/or elevated serum theophylline levels, (erythromycin ethylsuccinate) the dose of theophylline should be reduced while the patient is receiving concomitant erythromycin therapy.

Hypotension, bradyarrhythmias, and lactic acidosis have been observed in patients receiving concurrent verapamil, belonging to the calcium channel blockers drug class.

Concomitant administration of erythromycin and digoxin has been reported to result in elevated digoxin serum levels. (erythromycin ethylsuccinate)

There have been reports of increased anticoagulant effects when erythromycin and oral anticoagulants were used concomitantly. Increased anticoagulation effects due to interactions of erythromycin with various oral anticoagulants may be more pronounced in the elderly.

Erythromycin is a substrate and inhibitor of the 3A isoform subfamily of the cytochrome p450 enzyme system (CYP3A). Coadministration of erythromycin and a drug primarily metabolized tions. Interactions with other drugs metabolized by the CYP3A isoform are also possible. The following CYP3A based drug interactions have been observed with erythromycin products in post-marketing experience:

Ergotamine/dihydroergotamine

Concurrent use of erythromycin and ergotamine or dihydroergotamine has been associated in some patients with acute ergot toxicity characterized by severe peripheral vasospasm and dysesthesia.

Triazolobenzodiazepines (such as triazolam and alprazolam) and related benzodiazepines

Erythromycin has been reported to decrease the clearance of triazolam and midazolam, and thus, may increase the pharmacologic effect of these benzodiazepines.

HMG-CoA Reductase Inhibitors

Erythromycin has been reported to increase concentrations of HMG-CoA reductase inhibitors (e.g., lovastatin and simvastatin). Rare reports of rhabdomyolysis have been reported in patients taking these drugs concomitantly.

Sildenafil (Viagra)

Erythromycin has been reported to increase the systemic exposure (AUC) of sildenafil. Reduction of sildenafil dosage should be considered. (See Viagra package insert.)

There have been spontaneous or published reports of CYP3A based interactions of erythromycin with cyclosporine, carbamazepine, tacrolimus, alfentanil, disopyramide, rifabutin, quinidine, methylprednisolone, cilostazol, vinblastine, and bromocriptine.

Concomitant administration of erythromycin with cisapride, pimozide, astemizole, or terfenadine is contraindicated. (See CONTRAINDICATIONS.)

In addition, there have been reports of interactions of erythromycin with drugs not thought to be metabolized by CYP3A, including hexobarbital, phenytoin, and valproate.

Erythromycin has been reported to significantly alter the metabolism of the nonsedating antihistamines terfenadine and astemizole when taken concomitantly. Rare cases of serious cardiovascular adverse events, including electrocardiographic QT/QT_c interval prolongation, cardiac arrest, torsades de pointes, and other ventricular arrhythmias have been observed. (See CONTRAINDICATIONS.) In addition, deaths have been reported rarely with concomitant administration of terfenadine and erythromycin.

There have been post-marketing reports of drug interactions when erythromycin is co-administered with cisapride, resulting in QT prolongation, cardiac arrhythmias, ventricular tachycardia, ventricular fibrillation, and torsades de pointes, most likely due to inhibition of hepatic metabolism of cisapride by erythromycin. Fatalities have been reported. (See CONTRAINDICATIONS.)

Drug/Laboratory Test Interactions

Erythromycin interferes with the fluorometric determination of urinary catecholamines.

WARNINGS

There have been reports of hepatic dysfunction, including increased liver enzymes, and hepatocellular and/or cholestatic hepatitis, with or without jaundice, occurring in patients receiving oral erythromycin products.

There have been reports suggesting that erythromycin does not reach the fetus in adequate concentration to prevent congenital syphilis. Infants born to women treated during pregnancy with oral erythromycin for early syphilis should be treated with an appropriate penicillin regimen.

Clostridium difficile associated diarrhea (CDAD) has been reported with use of nearly all antibacterial agents, including E.E.S. (erythromycin ethylsuccinate) , and may range in severity from mild diarrhea to fatal colitis. Treatment with antibacterial agents alters the normal flora of the colon leading to overgrowth of C. difficile.

C. difficile produces toxins A and B which contribute to the development of CDAD. Hypertoxin producing strains of C. difficile cause increased morbidity and mortality, as these infections can be refractory to antimicrobial therapy and may require colectomy. CDAD must be considered in all patients who present with diarrhea following antibiotic use. Careful medical history is necessa (erythromycin ethylsuccinate) ry since CDAD has been reported to occur over two months after the administration of antibacterial agents.

If CDAD is suspected or confirmed, ongoing antibiotic use not directed against C. difficile may need to be discontinued. Appropriate fluid and electrolyte management, protein supplementation, antibiotic treatment of C. difficile, and surgical evaluation should be instituted as clinically indicated.

Rhabdomyolysis with or without renal impairment has been reported in seriously ill patients receiving erythromycin concomitantly with lovastatin. Therefore, patients receiving concomitant lovastatin and erythromycin should be carefully monitored for creatine kinase (CK) and serum transaminase levels. (erythromycin ethylsuccinate) (See package insert for lovastatin.)

PRECAUTIONS

General

Prescribing E.E.S. (erythromycin ethylsuccinate) in the absence of a proven or strongly suspected bacterial infection or a prophylactic indication is unlikely to provide benefit to the patient and increases the risk of the development of drug-resistant bacteria.

Since erythromycin is principally excreted by the liver, caution should be exercised when erythromycin is administered to patients with impaired hepatic function. (See CLINICAL PHARMACOLOGY and WARNINGS sections.)

Exacerbation of symptoms of myasthenia gravis and new onset of symptoms of myasthenic syndrome has been reported in patients receiving erythromycin therapy.

There have been reports of infantile hypertrophic pyloric stenosis (IHPS) occurring in infants following erythromycin therapy. In one cohort of 157 newborns who were given erythromycin for pertussis prophylaxis, seven neonates (5%) developed symptoms of non-bilious vomiting or irritability with feeding and were su (erythromycin ethylsuccinate) bsequently diagnosed as having IHPS requiring surgical pyloromyotomy. A possible dose-response effect was described with an absolute risk of IHPS of 5.1% for infants who took erythromycin for 8-14 days and 10% for infants who took erythromycin for 15-21 days. ⁴ Since erythromycin may be used in the treatment of conditions in infants which are associated with significant mortality or morbidity (such as pertussis or neonatal Chlamydia trachomatis infections), the benefit of erythromycin therapy needs to be weighed against the potential risk of developing IHPS. Parents should be informed to contact their physician if vomiting or irritability with feeding occurs.

Prolonged or repeated use of erythromycin may result in an overgrowth of nonsusceptible bacteria or fungi. If superinfection occurs, erythromycin should be discontinued and appropriate therapy instituted.

by CYP3A may be associated with elevations in drug concentrations that could increase or prolong both the therapeutic and adverse effects of the concomitant drug. Dosage adjustments may be considered, and when possible, serum concentrations of drugs primarily metabolized by CYP3A should be monitored closely in patients concurrently receiving erythromycin.

The following are examples of some clinically significant CYP3A based drug interac When indicated, incision and drainage or other surgical procedures should be performed in conjunction with antibiotic therapy.

Carcinogenesis, Mutagenesis, Impairment of Fertility

Long-term (2-year) oral studies in rats with erythromycin ethylsuccinate and erythromycin base did not provide evidence of tumorigenicity. Mutagenicity studies have not been conducted. There was no apparent effect on male or female fertility in rats fed erythromycin (base) at levels (erythromycin ethylsuccinate) up to 0.25% of diet.

Pregnancy

Teratogenic Effects

Pregnancy Category B

There is no evidence of teratogenicity or any other adverse effect on reproduction in female rats fed erythromycin base (up to 0.25% of diet) prior to and during mating, during gestation, and through weaning of two successive litters. There are, however, no adequate and well controlled studies in pregnant women. Because animal reproduction studies are not always predictive of human response, this drug should be used during pregnancy only if clearly needed.

Labor and Delivery

The effect of erythromycin on labor and delivery is unknown.

Nursing Mothers

Erythromycin is excreted in human milk. Caution should be exercised when erythromycin is administered to a nursing woman.

Pediatric Use

See INDICATIONS AND USAGE and DOSAGE AND ADMINISTRATION sections.

Geriatric Use

Elderly patients, particularly those with reduced renal or hepatic function, may be at increased risk for developing erythromycin-induced hearing loss. (See ADVERSE REACTIONS and DOSAGE AND ADMINISTRATION).

Elderly patients may be more susceptible to the development of torsades de pointes arrhythmias than younger patients. (See ADVERSE REACTIONS).

Elderly patients may experience increased effects of oral anticoagulant therapy while undergoing treatment with erythromycin. (See PRECAUTIONS - DRUG INTERACTIONS).

E.E.S. (erythromycin ethylsuccinate) ® Granules contains 25.9 mg (1.1 mEq) of sodium per individual dose.

REFERENCES

4. Honein, M.A., et. al.: Infantile hypertrophic pyloric stenosis after pertussis prophylaxis with erythromycin: a case review and cohort study. The Lancet 1999;354 (9196):2101-5.

OVERDOSE

In case of overdosage, erythromycin should be discontinued. Overdosage should be handled with the prompt elimination of unabsorbed drug and all other appropriate measures should be instituted.

Erythromycin is not removed by peritoneal dialysis or hemodialysis.

CONTRAINDICATIONS

Erythromycin is contraindicated in patients with known hypersensitivity to this antibiotic. Erythromycin is contraindicated in patients taking terfenadine, astemizole, pimozide, or cisapride. (See PRECAUTIONS - DRUG INTERACTIONS.)

CLINICAL PHARMACOLOGY

Orally administered erythromycin ethylsuccinate suspensions and Filmtab tablets are readily and reliably absorbed. Comparable serum levels (erythromycin ethylsuccinate) of erythromycin are achieved in the fasting and nonfasting states.

Erythromycin diffuses readily into most body fluids. Only low concentrations are normally achieved in the spinal fluid, but passage of the drug across the blood-brain barrier increases in meningitis. In the presence of normal hepatic function, erythromycin is concentrated in the liver and excreted in the bile; the effect of hepatic dysfunction on excretion of erythromycin by the liver into the bile is not known. Less than 5 percent of the orally administered dose of erythromycin is excreted in active form in the urine.

Erythromycin crosses the placental barrier, but fetal plasma levels (erythromycin ethylsuccinate) are low. The drug is excreted in human milk.

Microbiology

Erythromycin acts by inhibition of protein synthesis by binding 50 S ribosomal subunits of susceptible organisms. It does not affect nucleic acid synthesis. Antagonism has been demonstrated in vitro between erythromycin and clindamycin, lincomycin, and chloramphenicol.

Many strains of Haemophilus influenzae are resistant to erythromycin alone but are susceptible to erythromycin and sulfonamides used concomitantly.

Staphylocci resistant to erythromycin may emerge during a course of therapy.

Erythromycin has been shown to be active against most strains of the following microorganisms, both in vitro and in clinical infections as described in the INDICATIONS AND USAGE section.

Gram-positive Organisms

Corynebacterium diphtheriae
Corynebacterium minutissimum
Listeria monocytogenes
Staphylococcus aureus(resistant organisms may emerge during treatment)
Streptococcus pneumoniae
Streptococcus pyogenes

Gram-negative Organisms

Bordetella pertussis
Legionella pneumophila
Neisseria gonorrhoeae

Other Microorganisms

Chlamydia trachomatis
Entamoeba histolytica
Mycoplasma pneumoniae
Treponema pallidum
Ureaplasma urealyticum

The following in vitro data are available, but their clinical significance is unknown.

Erythromycin exhibits in vitro minimal inhibitory concentrations (MIC's) of 0.5 μg/mL or less against most ( ≥ 90%) strains of the following microorganisms; however, the safety and effectiveness (erythromycin ethylsuccinate) of erythromycin in treating clinical infections due to these microorganisms have not been established in adequate and well controlled clinical trials.

Gram-positive Organisms

Viridans group streptococci

Gram-negative Organisms

Moraxella catarrhalis

Susceptibility Tests

Dilution Techniques

Quantitative methods are used to determine antimicrobial minimum inhibitory concentrations (MIC's). These MIC's provide estimates of the susceptibility of bacteria to antimicrobial compounds. The MIC's should be determined using a standardized procedure. Standardized procedures are based on a dilution method¹ (broth or agar) or equivalent with standardized inoculum concentrations and standardized concentrations of erythromycin powder. The MIC values should be interpreted according to the following criteria:

MIC (μg/mL)	Interpretation
≤ 0.5	Susceptible (S)
1-4	Intermediate (I)
≥ 8	Resistant (R)

A report of “Susceptible” indicates that the pathogen is likely to be inhibited if the antimicrobial compound in the blood reaches the concentrations usually achievable. A report of “Intermediate” indicates that the result should be considered equivocal, and, if the microorganism is not fully susceptible to alternative, clinically feasible drugs, the test should be repeated. This category implies possible clinical applicability in body sites where the drug is physiologically concentrated or in situations where high dosage of drug can be used. This category also provides a buffer zone which prevents small uncontrolled technical factors from causing major discrepancies in interpretation. A report of “Resistant” indicates that the pathogen is not likely to be inhibited if the antimicrobial compound in the blood reaches the concentrations usually achievable; other therapy should be selected.

Standardized susceptibility test procedures require the use of laboratory control microorganisms to control the technical aspects of the laboratory procedures. Standard erythromycin powder should provide the following MIC values:

Microorganism	MIC (μg/mL)
S. aureus ATCC 25923	0.12-0.5
E. faecalis ATCC 29212	1-4

Diffusion Techniques

Quantitative methods that require measurement of zone diameters (erythromycin ethylsuccinate) also provide reproducible estimates of the susceptibility of bacteria to antimicrobial compounds. One such standardized procedure² requires the use of standardized inoculum concentrations. This procedure uses paper disks impregnated with 15-μg erythromycin to test the susceptibility of microorganisms to erythromycin.

Reports from the laboratory providing results of the standard single-disk susceptibility test with a 15­ μg erythromycin disk should be interpreted according to the following criteria:

Zone Diameter (mm)	Interpretation
≥ 23	Susceptible (S)
14-22	Intermediate (I)
≤ 13	Resistant (R)

Interpretation should be as stated above for results using dilution techniques. Interpretation involves correlation of the diameter obtained in the disk test with the MIC for erythromycin.

As with standardized dilution techniques, diffusion methods require the use of laboratory control microorganisms that are used to control the technical aspects of the laboratory procedures. For the diffusion technique, the 15-μg erythromycin disk should provide the following zone diameters (erythromycin ethylsuccinate) in these laboratory test quality control strains:

Microorganism	Zone Diameter (mm)
S. aureus ATCC 25923	22-30

REFERENCES

1. National Committee for Clinical Laboratory Standards, Methods for Dilution Antimicrobial Susceptibility Tests for Bacteria that Grow Aerobically , Third Edition. Approved Standard NCCLS Document M7-A3, Vol. 13, No. 25. NCCLS, Villanova, PA, December 1993.

2. National Committee for Clinical Laboratory Standards, Performance Standards for Antimicrobial Disk Susceptibility Tests, Fifth Edition. Approved Standard NCCLS Document M2-A5, Vol. 13, No. 24. NCCLS, Villanova, PA, December 1993.

PATIENT INFORMATION

Patients should be counseled that antibacterial drugs including E.E.S. (erythromycin ethylsuccinate) should only be used to treat bacterial infections. They do not treat viral infections (e.g., the common cold). When E.E.S. (erythromycin ethylsuccinate) is prescribed to treat a bacterial infection, patients should be told that although it is common to feel better early in the course of therapy, the medication should be taken exactly as directed. Skipping doses or not completing the full course of therapy may (1) decrease the effectiveness (erythromycin ethylsuccinate) of the immediate treatment and (2) increase the likelihood that bacteria will develop resistance and will not be treatable by E.E.S. (erythromycin ethylsuccinate) or other antibacterial drugs in the future.

Diarrhea is a common problem caused by antibiotics which usually ends when the antibiotic is discontinued. Sometimes after starting treatment with antibiotics, patients can develop watery and bloody stools (with or without stomach cramps and fever) even as late as two or more months after having taken the last dose of the antibiotic. If this occurs, patients should contact their physician as soon as possible.