Macrolide antibiotics are a class of antibiotics that includes azithromycin, erythromycin and clarithromycin. Tinnitus and hearing loss are uncommon reported side effects: most published cases cleared once the drug was stopped or the dose lowered, a few did not, and large studies disagree on how much, if at all, the risk rises.

Why it matters for tinnitus

Macrolides are prescribed widely, and some people take them for months: a 2018 Cochrane review found that all its trials of continuous or intermittent antibiotics to prevent COPD flare-ups used macrolides. The US label for azithromycin (Zithromax) lists hearing loss, deafness and tinnitus among post-marketing reports, while noting that such voluntary reports cannot reliably establish frequency or cause. Unlike the aminoglycosides described in ototoxic medications, the reported pattern is mostly reversible.

What the evidence says

  • Case reports. A 1986 report counted 30 to 40 earlier reports of reversible erythromycin ototoxicity and described persistent tinnitus after intravenous erythromycin. A 2000 case report described permanent hearing loss after low-dose azithromycin in an otherwise healthy woman; earlier azithromycin reports had followed prolonged high-dose treatment in people with AIDS and had resolved. A 2003 letter reported tinnitus attributed to clarithromycin.
  • Small erythromycin studies. In a prospective study of pneumonia, tinnitus or hearing loss confirmed by audiogram occurred in 5 of 30 people on erythromycin and none of 15 on other antibiotics, only at 4 g a day and with high blood levels; all cleared 6 to 14 days after stopping. A chart review of kidney transplant recipients found hearing loss in 11 of 34 intravenous courses (8 of 15 at 4 g a day, 3 of 19 at 2 g), all reversible.
  • Pharmacovigilance. In Italy's spontaneous reporting database (325,980 reports, 2001 to 2017), hearing loss was reported disproportionately often with azithromycin and clarithromycin. Reports like these flag a signal; they cannot give a rate.
  • Trials. In a randomised trial of 1,142 people with COPD, hearing decrements were more common on azithromycin 250 mg daily for a year than on placebo (25% vs 20%). The Cochrane review of 14 trials found azithromycin linked to significant hearing loss, in many cases reversible or partly reversible; stopping treatment because of tinnitus was not significantly more frequent than on placebo.
  • Cohort and case-control studies. In the population-based Rotterdam Study, ever using a macrolide was linked to 25% higher odds of having tinnitus among 4,286 people, more so above 14 defined daily doses, and use between visits to more than twice the risk of new tinnitus among 636; there was no general link with hearing loss. A US claims study of 5,989 people with sensorineural hearing loss found a higher rate after macrolide prescriptions, but a similar rise with amoxicillin and fluoroquinolones, and the authors attributed it to the infections being treated. A cohort of 493,774 US Medicaid adults found short-course azithromycin no riskier for hearing loss than amoxicillin.
  • Meta-analysis. A 2024 systematic review pooling 13 studies and 1,142,021 patients estimated 25% higher odds of hearing loss with macrolides, and 37% higher across its randomised trials.

What this means for you

  • If tinnitus, muffled hearing or dizziness starts during a macrolide course, tell the prescriber promptly rather than stopping the antibiotic on your own. In the published erythromycin series, symptoms cleared after the drug was stopped or the dose changed.
  • For long-term treatment, ask whether a baseline hearing test makes sense; the COPD trial enrolled only people without hearing impairment, and ototoxicity monitoring explains how drug-related change is tracked.
  • Sudden hearing loss over hours to 3 days needs same-day assessment. Severe vertigo or loss of balance that will not settle is an emergency: call your local emergency number or go to an emergency department.

How it connects