The FDA has issued an alert: Zithromax is associated with an increased risk of cardiac arrhythmia. Because of this I have shifted away from this therapy. I have found that IV Clindamycin, despite early concerns that it causes C. difficile colitis, is a highly effective drug and that it use had been effective for some patients with neuroborreliosis particularly in combination with Flagyl. Recently, several patients have had significant cognitive clearing with use of the combination. Clindamycin is highly active against Borrelia burgdorferi and has good penetration through the blood brain barrier.
Oral Zithromax as long been a cornerstone of anti-babesiosis therapy. Other macrolides, in particular Biaxin may be substituted with a good response. Alternatively, clindamycin or Bactrim may also be used. These drugs have been used to prevent resistance of Babesia to Mepron but also have mild anti-parasitic effects independently.
Bartonella: Levaquin/Cipro -- largely promoted for the treatment of bartonellosis may not be a good idea. The fluoroquinolones are associated with tendon /muscle/joint pain with the risk of tendon rupture. In a recent patient, the agents caused knee swelling and pain, not tendon pain which resolved with cessation of therapy. More importantly however: Bartonella species may develop resistance to these antibiotics fairly quickly. Overall, rifampin is a better choice. A big caveat here as well : rifampin should never be used as monotherapy. Bacteria develop quick resistance to rifampin when it is used as a sole agent . Traditionally, rifampin has been combined with Zithromax. Alternatives to Zithromax include doxycycline and others. I have consistently found minocycline to be anti-Bartonella, while doxycycline lacks this property. Biaxin/Zithromax do in fact have some (weak) anti-Bartonella properties although Bactrim remains a better drug for Bartonella.