The efficacy of azithromycin in the treatment of influenza A infection: A systematic review [version 1; peer review: awaiting peer review]

Background The WHO recommendation against the use of macrolides reflects the little low-quality evidence about the effect of azithromycin (AZ) on influenza A infection. Considering recent reports about AZ use despite the WHO's unfavorable recommendations, we aimed to test the evidence for the usage of AZ in the treatment of influenza A infection. Methods Various online databases were searched till August 2023 and thorough text and evidence evaluation resulted in selecting 7 studies. Results The selected reports included randomized control trials (two), cohort (three), case/control (one) studies, and one case report. Pooling of the results was unattainable due to the variability among studies in patient criteria, study outcomes, and study designs. Based on the limited reports with insufficient evidence, a recommendation for the use of AZ in the treatment regimen was not possible despite the associated reduction in inflammatory cytokines by AZ administration and the absence of significant adverse effects or mortality in hospital-admitted or ICU patients. While these findings support the current guidelines for the treatment of influenza A infection, the evidence behind these guidelines and treatment characteristics were illustrated. Conclusion AZ shows a potential symptom improvement and pro-inflammatory laboratory indices in influenza A patients. Another positive aspect is the absence of complications associated with AZ administration to critically ill patients and acceptable prognosis. However, it is crucial to have more quality research on this matter that focuses on the indication of the use of AZ, and the timing of initiation, dosage, and duration of treatment while monitoring adverse events.