Erythromycin
NSC-55929
UNII63937KV33D
CAS number114-07-8
- Molecular FormulaC37H67NO13
- Average mass733.927 Da
-
эритромицин [Russian] [INN]إيريثروميسين [Arabic] [INN]红霉素 [Chinese] [INN]
IUPAC Name
Synthesis ReferenceTakehiro Amano, Masami Goi, Kazuto Sekiuchi, Tomomichi Yoshida, Masahiro Hasegawa, “Process for preparing erythromycin A oxime or a salt thereof.” U.S. Patent US5274085, issued October, 1966.
Product Ingredients
| INGREDIENT | UNII | CAS | INCHI KEY |
|---|---|---|---|
| Erythromycin estolate | XRJ2P631HP | 3521-62-8 | AWMFUEJKWXESNL-JZBHMOKNSA-N |
| Erythromycin ethylsuccinate | 1014KSJ86F | 1264-62-6 | NSYZCCDSJNWWJL-YXOIYICCSA-N |
| Erythromycin gluceptate | 2AY21R0U64 | 23067-13-2 | ZXBDZLHAHGPXIG-VTXLJDRKSA-N |
| Erythromycin lactobionate | 33H58I7GLQ | 3847-29-8 | NNRXCKZMQLFUPL-WBMZRJHASA-N |
| Erythromycin phosphate | I8T8KU14X7 | 4501-00-2 | VUEMAFLGEMYXIH-YZPBMOCRSA-N |
| Erythromycin stearate | LXW024X05M | 643-22-1 | YAVZHCFFUATPRK-YZPBMOCRSA-N |
| Erythromycin sulfate | KVW9N83AME | 7184-72-7 | XTSSJGRRFMNXGO-YZPBMOCRSA-N |
| Erythromycin thiocyanate | Y7A95YRI88 | 7704-67-8 | WVRRTEYLDPNZHR-YZPBMOCRSA-N |
Erythromycin is an antibiotic which belongs to the group of macrolide antibiotics. The pharmaceutically distributed product consists of three components: Erythromycin A, B, and C where Erythromycin A represents the main component. Naturally this antibiotic is synthesized by the grampositive bacteria Streptomyces erythreus (Saccharopolyspora erythrea).
In 1949 Erythromycin was found for the first time in a soil sample in the Philippine region Iloilo. A research team, led by J. M. McGuire, was able to isolate Erythromycin which was part of the soil sample. Under the brand name Ilosone the product was launched commercially in 1952. They named the brand after the region where the antibiotic was found. Analogically the first product name was Ilotycin. Furthermore, in 1953 the U.S. patent was granted. Since 1957 the structure of Erythromycin is known and in 1965 the X-ray structure analysis gave awareness of the absolute configuration. In 1981, almost 30 years after the detection of Erythromycin, Robert B. Woodward, the Nobel prize laureate of chemistry in 1965, and his coworkers posthumously reported the first synthesis of Erythromycin A
The structural characteristic of macrolides, to which Erythromycin affiliates, is a macrocyclic lactone ring of fourteen, fifteen or sixteen members. In case of Erythromycin the lactone ring consists of 14-members. Substituents on the mainchain are cladinose on C-3 and desosamine on C-5. Erythromycin is not a single compound but represents an alloy of structural very similar components. The main constituents are Erythromycin A, B and C. As shown in Table 1 and Figure 1 they only differ in two rests on the lactone ring or on the cladinose each case. In addition to the variants already mentioned, further variants, like Erythromycin D and E are known. They are pre- and post-stages in the biosynthesis and often do not have antibiotic effects
Chemical and Pharmacokinetic Properties Formula: C37H67NO13 CAS-Number: 114-07-8 Molar Mass: 733.93g/mol Half Hife 1.5 hours pkA: 8,6 – 8,8 Melting Point: 411K (hydrat) 463-466K (anhydrous)
Erythromycin is an antibiotic used for the treatment of a number of bacterial infections.[1] This includes respiratory tract infections, skin infections, chlamydia infections, pelvic inflammatory disease, and syphilis.[1] It may also be used during pregnancy to prevent Group B streptococcal infection in the newborn,[1] as well as to improve delayed stomach emptying.[3] It can be given intravenously and by mouth.[1] An eye ointment is routinely recommended after delivery to prevent eye infections in the newborn.[4]
Common side effects include abdominal cramps, vomiting, and diarrhea.[1] More serious side effects may include Clostridium difficile colitis, liver problems, prolonged QT, and allergic reactions.[1] It is generally safe in those who are allergic to penicillin.[1] Erythromycin also appears to be safe to use during pregnancy.[2] While generally regarded as safe during breastfeeding, its use by the mother during the first two weeks of life may increase the risk of pyloric stenosis in the baby.[5][6] This risk also applies if taken directly by the baby during this age.[7] It is in the macrolide family of antibiotics and works by decreasing bacterial protein production.[1]
Erythromycin was first isolated in 1952 from the bacteria Saccharopolyspora erythraea.[1][8] It is on the World Health Organization’s List of Essential Medicines, the safest and most effective medicines needed in a health system.[9] The World Health Organization classifies it as critically important for human medicine.[10] It is available as a generic medication.[5] In 2017, it was the 215th most commonly prescribed medication in the United States, with more than two million prescriptions.[11][12]
Table 4.2.1 Therapeutic indications for the macrolide antibiotics.
Medical uses
Erythromycin can be used to treat bacteria responsible for causing infections of the skin and upper respiratory tract, including Streptococcus, Staphylococcus, Haemophilus and Corynebacterium genera. The following represents MIC susceptibility data for a few medically significant bacteria:[13]
- Haemophilus influenzae: 0.015 to 256 μg/ml
- Staphylococcus aureus: 0.023 to 1024 μg/ml
- Streptococcus pyogenes: 0.004 to 256 μg/ml
- Corynebacterium minutissimum: 0.015 to 64 μg/ml
It may be useful in treating gastroparesis due to this promotility effect. It has been shown to improve feeding intolerances in those who are critically ill.[14] Intravenous erythromycin may also be used in endoscopy to help clear stomach contents.
Available forms
Enteric-coated erythromycin capsule from Abbott Labs
Erythromycin is available in enteric-coated tablets, slow-release capsules, oral suspensions, ophthalmic solutions, ointments, gels, enteric-coated capsules, non enteric-coated tablets, non enteric-coated capsules, and injections. The following erythromycin combinations are available for oral dosage:[15]
- erythromycin base (capsules, tablets)
- erythromycin estolate (capsules, oral suspension, tablets), contraindicated during pregnancy[16]
- erythromycin ethylsuccinate (oral suspension, tablets)
- erythromycin stearate (oral suspension, tablets)
For injection, the available combinations are:[15]
- erythromycin gluceptate
- erythromycin lactobionate
For ophthalmic use:
- erythromycin base (ointment)
Adverse effects
Gastrointestinal disturbances, such as diarrhea, nausea, abdominal pain, and vomiting, are very common because erythromycin is a motilin agonist.[17] Because of this, erythromycin tends not to be prescribed as a first-line drug.
More serious side effects include arrhythmia with prolonged QT intervals, including torsades de pointes, and reversible deafness. Allergic reactions range from urticaria to anaphylaxis. Cholestasis, Stevens–Johnson syndrome, and toxic epidermal necrolysis are some other rare side effects that may occur.
Studies have shown evidence both for and against the association of pyloric stenosis and exposure to erythromycin prenatally and postnatally.[18] Exposure to erythromycin (especially long courses at antimicrobial doses, and also through breastfeeding) has been linked to an increased probability of pyloric stenosis in young infants.[19][20] Erythromycin used for feeding intolerance in young infants has not been associated with hypertrophic pyloric stenosis.[19]
Erythromycin estolate has been associated with reversible hepatotoxicity in pregnant women in the form of elevated serum glutamic-oxaloacetic transaminase and is not recommended during pregnancy. Some evidence suggests similar hepatotoxicity in other populations.[21]
It can also affect the central nervous system, causing psychotic reactions, nightmares, and night sweats.[22]
Interactions
Erythromycin is metabolized by enzymes of the cytochrome P450 system, in particular, by isozymes of the CYP3A superfamily.[23] The activity of the CYP3A enzymes can be induced or inhibited by certain drugs (e.g., dexamethasone), which can cause it to affect the metabolism of many different drugs, including erythromycin. If other CYP3A substrates — drugs that are broken down by CYP3A — such as simvastatin (Zocor), lovastatin (Mevacor), or atorvastatin (Lipitor)—are taken concomitantly with erythromycin, levels of the substrates increase, often causing adverse effects. A noted drug interaction involves erythromycin and simvastatin, resulting in increased simvastatin levels and the potential for rhabdomyolysis. Another group of CYP3A4 substrates are drugs used for migraine such as ergotamine and dihydroergotamine; their adverse effects may be more pronounced if erythromycin is associated.[22] Earlier case reports on sudden death prompted a study on a large cohort that confirmed a link between erythromycin, ventricular tachycardia, and sudden cardiac death in patients also taking drugs that prolong the metabolism of erythromycin (like verapamil or diltiazem) by interfering with CYP3A4.[24] Hence, erythromycin should not be administered to people using these drugs, or drugs that also prolong the QT interval. Other examples include terfenadine (Seldane, Seldane-D), astemizole (Hismanal), cisapride (Propulsid, withdrawn in many countries for prolonging the QT time) and pimozide (Orap). Theophylline, which is used mostly in asthma, is also contraindicated.
Erythromycin and doxycycline can have a synergistic effect when combined and kill bacteria (E. coli) with a higher potency than the sum of the two drugs together. This synergistic relationship is only temporary. After approximately 72 hours, the relationship shifts to become antagonistic, whereby a 50/50 combination of the two drugs kills less bacteria than if the two drugs were administered separately.[25]
It may alter the effectiveness of combined oral contraceptive pills because of its effect on the gut flora. A review found that when erythromycin was given with certain oral contraceptives, there was an increase in the maximum serum concentrations and AUC of estradiol and dienogest.[26][27]
Erythromycin is an inhibitor of the cytochrome P450 system, which means it can have a rapid effect on levels of other drugs metabolised by this system, e.g., warfarin.
Pharmacology
Mechanism of action
Erythromycin displays bacteriostatic activity or inhibits growth of bacteria, especially at higher concentrations.[28] By binding to the 50s subunit of the bacterial rRNA complex, protein synthesis and subsequent structure and function processes critical for life or replication are inhibited.[28] Erythromycin interferes with aminoacyl translocation, preventing the transfer of the tRNA bound at the A site of the rRNA complex to the P site of the rRNA complex. Without this translocation, the A site remains occupied, thus the addition of an incoming tRNA and its attached amino acid to the nascent polypeptide chain is inhibited. This interferes with the production of functionally useful proteins, which is the basis of this antimicrobial action.
Erythromycin increases gut motility by binding to Motillin, thus it is a Motillin receptor agonist in addition to its antimicrobial properties.
Pharmacokinetics
Erythromycin is easily inactivated by gastric acid; therefore, all orally administered formulations are given as either enteric-coated or more-stable salts or esters, such as erythromycin ethylsuccinate. Erythromycin is very rapidly absorbed, and diffuses into most tissues and phagocytes. Due to the high concentration in phagocytes, erythromycin is actively transported to the site of infection, where, during active phagocytosis, large concentrations of erythromycin are released.
Metabolism
Most of erythromycin is metabolised by demethylation in the liver by the hepatic enzyme CYP3A4. Its main elimination route is in the bile with little renal excretion, 2%-15% unchanged drug. Erythromycin’s elimination half-life ranges between 1.5 and 2.0 hours and is between 5 and 6 hours in patients with end-stage renal disease. Erythromycin levels peak in the serum 4 hours after dosing; ethylsuccinate peaks 0.5-2.5 hours after dosing, but can be delayed if digested with food.[29]
Erythromycin crosses the placenta and enters breast milk. The American Association of Pediatrics determined erythromycin is safe to take while breastfeeding.[30] Absorption in pregnant patients has been shown to be variable, frequently resulting in levels lower than in nonpregnant patients.[29]
Chemistry
Composition
Standard-grade erythromycin is primarily composed of four related compounds known as erythromycins A, B, C, and D. Each of these compounds can be present in varying amounts and can differ by lot. Erythromycin A has been found to have the most antibacterial activity, followed by erythromycin B. Erythromycins C and D are about half as active as erythromycin A.[13][31] Some of these related compounds have been purified and can be studied and researched individually.
Synthesis
Over the three decades after the discovery of erythromycin A and its activity as an antimicrobial, many attempts were made to synthesize it in the laboratory. The presence of 10 stereogenic carbons and several points of distinct substitution has made the total synthesis of erythromycin A a formidable task.[32] Complete syntheses of erythromycins’ related structures and precursors such as 6-deoxyerythronolide B have been accomplished, giving way to possible syntheses of different erythromycins and other macrolide antimicrobials.[33] Woodward successfully completed the synthesis of erythromycin A.[34][35][36]
History
In 1949 Abelardo B. Aguilar, a Filipino scientist, sent some soil samples to his employer Eli Lilly. Eli Lilly’s research team, led by J. M. McGuire, managed to isolate erythromycin from the metabolic products of a strain of Streptomyces erythreus (designation changed to Saccharopolyspora erythraea) found in the samples.[37]
Lilly filed for patent protection on the compound which was granted in 1953.[38] The product was launched commercially in 1952 under the brand name Ilosone (after the Philippine region of Iloilo where it was originally collected). Erythromycin was formerly also called Ilotycin.
The antibiotic clarithromycin was invented by scientists at the Japanese drug company Taisho Pharmaceutical in the 1970s as a result of their efforts to overcome the acid instability of erythromycin.
Scientists at Chugai Pharmaceuticals discovered an erythromycin-derived motilin agonist called mitemcinal that is believed to have strong prokinetic properties (similar to erythromycin) but lacking antibiotic properties. Erythromycin is commonly used off-label for gastric motility indications such as gastroparesis. If mitemcinal can be shown to be an effective prokinetic agent, it would represent a significant advance in the gastrointestinal field, as treatment with this drug would not carry the risk of unintentional selection for antibiotic-resistant bacteria.
Society and culture
Cost
It is available as a generic medication.[5]
In the United States in 2014 the price increased to seven dollars per tablet.[39]
The price of Erythromycin rose three times between 2010 and 2015, from 24 cents per tablet in 2010 to $8.96 in 2015.[40] In 2017, a Kaiser Health News study found that the per-unit cost of dozens of generics doubled or even tripled from 2015 to 2016, increasing spending by the Medicaid program. Due to price increases by drug manufacturers, Medicaid paid on average $2,685,330 more for Erythromycin in 2016 compared to 2015 (not including rebates).[41] By 2018, generic drug prices had climbed another 5% on average.[42]
Brand names
Brand names include Robimycin, E-Mycin, E.E.S. Granules, E.E.S.-200, E.E.S.-400, E.E.S.-400 Filmtab, Erymax, Ery-Tab, Eryc, Ranbaxy, Erypar, EryPed, Eryped 200, Eryped 400, Erythrocin Stearate Filmtab, Erythrocot, E-Base, Erythroped, Ilosone, MY-E, Pediamycin, Zineryt, Abboticin, Abboticin-ES, Erycin, PCE Dispertab, Stiemycine, Acnasol, and Tiloryth.
See also
Erythromycin/tretinoin, a combination of tretinoin and the antibiotic erythromycin
SYN
Synthesis
The total synthesis of the erythromycins (Figure 4.2.2) poses a supreme challenge and has attracted the attention of some of the world’s most eminent synthetic chemists, leading to many elegant examples of the total synthesis of complex natural products. The total synthesis of the erythronolide A aglycone (lacking the sugar units) was first reported by E. J. Corey (Nobel Prize in Chemistry in 1990) in a series of articles in the late 1970s (Scheme 4.2.2) (Corey et al., 1979 and references cited therein), and the total synthesis of erythromycin (known then as erythromycin A) by R. B. Woodward (Nobel Prize in Chemistry in 1965) in a series of articles in 1981, after his death (Scheme 4.2.3) (Woodward et al., 1981 and references cited therein). The Woodward synthesis is particularly elegant, as the dithiadecalin intermediate supplies both the C3-C8 and C9-C13 fragments (Scheme 4.2.3).
Figure 4.2.2 Erythromycins A and B and their aglycones, erythronolides A and B
Scheme 4.2.2 Corey’s total synthesis of erythronolide A (38 steps from the cyclohexadiene fragment; 0.04% overall yield)
Scheme 4.2.3 Woodward’s total synthesis of erythromycin (56 steps from 4-thianone; 0.01% overall yield)
Once again, erythromycin is such a complex antibiotic that its commercial production by total synthesis will never be feasible, and it is obtained from the submerged culture of free or immobilised Saccharopolyspora erythraea (El-Enshasy et al., 2008).
We have now seen a number of examples of how very complex semi-synthetic antibiotics can be prepared through the combination of fermentation (to give the complex natural product) and chemical modification, so you will no doubt already have spotted that both clarithromycin and roxithromycin are semi-synthetic macrolide antibiotics. Clarithromycin can be obtained in a five-step synthetic procedure, from erythromycin oxime (Brunet et al., 2007), while roxithromycin can also be prepared from this oxime (Massey et al., 1970) in a single step (Scheme 4.2.4) (Gouin d’Ambrieres et al., 1982). What is not so obvious is that azithromycin is also a semi-synthetic macrolide, having originally been produced by PLIVA Pharmaceuticals from erythromycin oxime via a sequence of reactions which included the well-known Beckmann rearrangement (Djoki
et al., 1986). For more on the synthesis of the erythromycins, see Paterson and Mansuri (1985).
Scheme 4.2.4 Preparation of the semi-synthetic macrolide antibiotic roxithromycin
CLIP
Erythromycin. Erythromycin (1) was discovered in 1952 during the investigation of soil samples from Iloilo, Philippines for antibiotic activity[18, 19] and its molecular structure was assigned in 1957.[20] The microorganism that produced erythromycin was isolated and characterised as Streptomyces erythreus, strain NRRL 2338.[18, 19] Over the years, strain improvements and genetic engineering has allowed the yield of erythromycin to be increased so that 8–10 g L1 can now be produced from a tryptic soy broth.[21–25] Erythromycin forms anhydro-erythromycin 6 and 6:9, 9:12 spiroketal 7 under the acidic conditions in the stomach (Scheme 1), which results in the loss of its antibacterial activity and induction of abdominal pain.[26, 27] Generation of by-products 6 and 7 occurs through an acid-catalysed intramolecular reaction of the C-6 hydroxyl group with the C-9 keto moiety. To avoid this by-product formation several different semi-synthetic derivatives of erythromycin have been prepared in which either of these two functionalities are modified. They led to the discovery of clarithromycin (2) by O-6 methylation of erythromycin (Figure 3). Removal of the C-9 ketone by the formation of an oxime followed by Beckmann rearrangement and reduction led to azithromycin (3), which belongs to a new class of macrolides called “azalides”. Alternatively, conversion of the C-9 ketone to an amine, followed by reaction with an aldehyde, gave dirithromycin (4). Yet another approach involved the transformation of clarithromycin to the conformationally restricted telithromycin
SYN
Chemical Synthesis
Erythromycin, (3R,4S,5S,6R,7R,9R,11R,12R,13S,14R)-4-[(2,6-dideoxy-3-Cmethyl-3-O-methyl-α-L-ribo-hexopyranosyl)-oxy]-14-ethyl-7,12,13-trihydroxy- 3,5,7,9,11,13-hexamethyl-6-[[3,4,6-trideoxy-3-(dimethylamino)-β-D-xylo-hexopyranosyl]oxy ]oxacyclotetradecan-2,10-dione (32.2.1), is more specifically called erythromycin A. It was first isolated in 1952 from the culture liquid of microorganisms of the type Streptomyces erytherus. Minor amounts of erythromycin B and C were also found in the culture fluid. Erythromycin B differs from A in that a hydrogen atom is located at position 12 in the place of a hydroxyl group, while erythromycin C differs from A in that the residue of a different carbohydrate, micarose (2-6-di-deoxy-3-C-methyl-L-ribohexose), is bound to the macrocycle in position 3 in the place of cladinose (4-methoxy-2,4-dimethyl-tetrahydropyran-3,6-diol).
Erythromycin A is produced only microbiologically using active strains of microorganisms of the type Saccharopolospora erythraea.
SYN
CLIP
The chemical synthesis of Erythromycin poses a huge challenge. The molecule contains ten stereogenic centers of which five are arranged consecutively. R. B. Woodward and his research team first succeeded in synthesizing Erythromycin A. The reaction sequence, however, is so complicated that the yield was only about 0,02 % and, thus, the synthesis is not utilizable comercially. This is the reason for the preferred use of the biosynthesis of Erythromycin via fermentation of Streptomyces erythreus. Other scientists and research teams dealt with the synthesis of Erythromycin as well and developed very similar approaches. Most methods for the Erythromycin synthesis are based on the construction of the aglycon from secoic acid via glycosylation. Indeed the process is also possible inversely: first, a glycosylation, then a lactonization occurs. The yield, however, is considerably less. While earlier scientist mainly dealt with the production of the different secoic acids, the lactonization process is the major problem today because there is no fully developed method for it yet. A lot of side reactions such as dimerization and polymerization appear, because a 14 membered ring is hard to enclose. Even if the chemical synthesis of Erythromycin has no importance for the comercial fabrication of the antibiotic, it is still important for the development and fabrication of its derivatives.
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- ^ Woodward RB, Logusch E, Nambiar KP, Sakan K, Ward DE, Au-Yeung, Balaram P, Browne LJ, Card PJ, et al. (1981). “Asymmetric Total Synthesis of Erythromycin. 1. Synthesis of an Erythronolide A Seco Acid Derivative via Asymmetric Induction”. J. Am. Chem. Soc. 103 (11): 3210–3213. doi:10.1021/ja00401a049.
- ^ Woodward RB, Logusch E, Nambiar KP, Sakan K, Ward DE, Au-Yeung, Balaram P, Browne LJ, Card PJ, et al. (1981). “Asymmetric Total Synthesis of Erythromycin. 2. Synthesis of an Erythronolide A Lactone System”. J. Am. Chem. Soc. 103 (11): 3213–3215. doi:10.1021/ja00401a050.
- ^ Woodward RB, Logusch E, Nambiar KP, Sakan K, Ward DE, Au-Yeung, Balaram P, Browne LJ, Card PJ, et al. (1981). “Asymmetric Total Synthesis of Erythromycin. 3. Total Synthesis of Erythromycin”. J. Am. Chem. Soc. 103 (11): 3215–3217. doi:10.1021/ja00401a051.
- ^ Hibionada, F. Remembering the battle of Dr. Abelardo Aguilar: Cure for millions, deprived of millions. The News Today. Retrieved 22 September 2015
- ^ U.S. Patent 2,653,899
- ^ Stahl, Stephanie (September 26, 2014) Health: Generic Drugs Prices Increasing Archived 2016-04-09 at the Wayback Machine CBS Philadelphia. Retrieved March 24, 2016.
- ^ “Some Generic Drugs See Huge Price Increases”. www.medscape.com. Retrieved 29 June 2018.
- ^ “Climbing cost of decades-old drugs threatens to break Medicaid bank”. Philly.com. Retrieved 29 June 2018.
- ^ “Are Drugs Really Getting More Expensive? Yes”. The GoodRx Prescription Savings Blog. 27 February 2018. Retrieved 29 June2018.
External links
- “Erythromycin”. Drug Information Portal. U.S. National Library of Medicine.
- U.S. Patent 2,653,899
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| Clinical data | |
|---|---|
| Trade names | Eryc, Erythrocin, others[1] |
| AHFS/Drugs.com | Monograph |
| MedlinePlus | a682381 |
| License data |
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| Pregnancy category |
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| Routes of administration |
By mouth, intravenous (IV), intramuscular (IM), topical, eye drops |
| Drug class | Macrolide antibiotic |
| ATC code | |
| Legal status | |
| Legal status | |
| Pharmacokinetic data | |
| Bioavailability | Depends on the ester type between 30% – 65% |
| Protein binding | 90% |
| Metabolism | liver (under 5% excreted unchanged) |
| Elimination half-life | 1.5 hours |
| Excretion | bile |
| Identifiers | |
| CAS Number | |
| PubChem CID | |
| IUPHAR/BPS | |
| DrugBank | |
| ChemSpider | |
| UNII | |
| KEGG | |
| ChEBI | |
| ChEMBL | |
| PDB ligand | |
| CompTox Dashboard (EPA) | |
| ECHA InfoCard | 100.003.673  |
| Chemical and physical data | |
| Formula | C37H67NO13 |
| Molar mass | 733.937 g·mol−1 |
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//////////erythromycin, NSC-55929, NSC 55929, эритромицин , إيريثروميسين , 红霉素 , ANTIBACTERIAL, MACROLIDES, ANTIBIOTICS
#erythromycin, #NSC-55929, #NSC 55929, #эритромицин , #إيريثروميسين , #红霉素 , #ANTIBACTERIAL, #MACROLIDES, #ANTIBIOTICS