Babesiosis is a tick-borne infection caused by intraerythrocytic Babesia parasites and may result in severe hemolytic anemia and systemic complications. Coinfection with other Ixodes-borne pathogens may further complicate diagnosis and management. We report a 45-year-old immunocompetent man working as a landscaper in Connecticut who presented with syncope following two weeks of fever, fatigue, diaphoresis, arthralgias, jaundice, and dark urine. Laboratory evaluation revealed profound hemolytic anemia with a hemoglobin of 6.8 g/dL, elevated lactate dehydrogenase (LDH), undetectable haptoglobin, reticulocytosis, and stage 1 acute kidney injury. Peripheral blood smear demonstrated characteristic Maltese cross formations, with approximately 0.6% parasitemia, and polymerase chain reaction (PCR) testing confirmed Babesia microti and Borrelia burgdorferi coinfection. Direct antiglobulin testing for immunoglobulin G (IgG) was negative. The patient required intensive care monitoring and transfusion and improved following treatment with atovaquone, azithromycin, and doxycycline. Subsequent outpatient evaluation identified asymptomatic Strongyloides stercoralis infection, which was treated with ivermectin. This finding was clinically significant because warm autoimmune hemolytic anemia is a recognized complication of babesiosis and may require corticosteroid therapy, which can precipitate potentially life-threatening Strongyloides hyperinfection in patients with occult infection. This case highlights that severe babesiosis may occur despite low-level parasitemia and emphasizes the importance of recognizing coinfections and obtaining a detailed occupational and environmental exposure history, particularly when future immunosuppressive therapy may be considered.

Donovanosis is a chronic granulomatous sexually transmitted infection that may clinically mimic malignancy. We report a 64-year-old man with well-controlled HIV infection presenting with a chronic infiltrated vegetative scrotal ulcer showing progressive enlargement, exophytic growth, and hemorrhagic ulceration. Despite prolonged antimicrobial therapy with azithromycin and doxycycline, followed by adjunctive acyclovir because of suspected chronic herpes simplex coinfection, the lesion continued to progress, raising concern for squamous cell carcinoma. Initial histopathological and microbiological investigations, including cytology for Donovan bodies, were inconclusive. Repeat biopsy demonstrated pseudoepitheliomatous hyperplasia with a dense plasma cell-rich inflammatory infiltrate without cytological atypia, while periodic acid-Schiff staining identified intracellular Donovan bodies, confirming donovanosis. Doxycycline was reintroduced and maintained until complete healing after four months. This case highlights the diagnostic challenges of pseudotumoral donovanosis in patients living with HIV.

Macrolides are widely prescribed antibiotics with a well-established risk of QT prolongation, but their broader cardiotoxic profile has not been systematically compared across countries using large-scale real-world data. The aim of this study is to characterize the spectrum, drug-specific signal patterns, and clinical outcomes of macrolide-associated cardiac adverse events (cAEs) through a cross-national comparison using two independent national pharmacovigilance databases. We performed a comprehensive disproportionality analysis of macrolide-associated cardiac adverse events (cAEs) using the FDA Adverse Event Reporting System (FAERS) and the Japanese Adverse Drug Event Report database (JADER) from 2016 Q1 through 2025 Q4. We used Reporting Odds Ratio (ROR), Proportional Reporting Ratio (PRR), Bayesian Confidence Propagation Neural Network (BCPNN), and Empirical Bayesian Geometric Mean (EBGM) for signal detection. Time-to-onset (TTO) was characterized using cumulative incidence curves and non-parametric Wilcoxon rank-sum tests across individual macrolides, clinical outcomes, and event types. Among 42,605 macrolide-related reports in FAERS and 4613 in JADER, cAEs accounted for 1415 (3.32%) and 128 (2.77%) reports, respectively. Azithromycin predominated in FAERS (72.3%) and clarithromycin in JADER (66.4%). Erythromycin showed the highest FAERS ROR for long QT syndrome (81.82, 95% CI 45.09-148.46), followed by azithromycin (34.71, 95% CI 25.15-47.91) and clarithromycin (18.11, 95% CI 8.61-38.08); azithromycin and clarithromycin signals were independently confirmed in JADER (ROR 24.42 and 13.17, respectively). Azithromycin was uniquely associated with heart-failure-related signals (acute right ventricular failure ROR 52.48, 95% CI 19.37-142.19), whereas clarithromycin showed the strongest ischemic heart disease signals (myocardial ischemia ROR 6.55, 95% CI 2.94-14.60; JADER coronary artery spasm ROR 10.37, 95% CI 4.25-25.33). Overall mortality among cAE cases was 10.2% in FAERS and 10.4% in JADER, with QT/torsade de pointes (TdP)-related case-fatality rates of 12.5% for clarithromycin and 10.3% for azithromycin. Most cardiac events occurred within the first 2 weeks of therapy (median time to onset, 1 day). Macrolide-associated cardiotoxicity extends beyond QT prolongation/TdP to heart failure and ischemic heart disease, with drug-specific and cross-national differences in signal pattern. As disproportionality signals, these findings are hypothesis-generating rather than causal, but support targeted cardiac monitoring in high-risk patients, particularly during the first 2 weeks of macrolide therapy.

Antimicrobial resistance (AMR) in Salmonella enterica from aquatic animals represents an emerging food safety and public health concern, yet the global distribution patterns and trends remain insufficiently understood. Here, we performed a global genomic survey of Salmonella from aquatic animals using 2911 genomes collected from 67 countries across six continents between 1974 and 2025. These genomes represented 194 serovars and 364 sequence types. Notably, the dataset exhibited unbalanced geographical sampling, with Asian isolates accounting for 69.98% of all strains, which may limit the generalizability of our global trends. Globally, resistance to WHO-recommended clinically important antimicrobials showed substantial variation among antibiotic classes, with resistance rates for azithromycin (2.10%), cefepime (2.89%), cefotaxime (2.71%), ceftazidime (2.71%), and ceftriaxone (0.62%). Geographical differences were observed, with isolates from Asia exhibiting higher resistance levels, particularly for ciprofloxacin (13.50%) and doxycycline (18.02%). AMR temporal trends differed across geographical regions. A total of 111 acquired ARGs and 10 resistance-associated chromosomal mutations were identified, accompanied by changes in the distribution of resistance determinants. Collectively, this study provides a global genomic perspective on priority AMR in Salmonella from aquatic animals and highlights the importance of integrating aquaculture, environmental, and public health surveillance to monitor and mitigate AMR risks within the One Health framework.

Latency antibiotic therapy is an established component of expectant management after preterm prelabour rupture of membranes (PPROMs). Pooled randomised evidence from 22 trials involving 6872 women and infants shows that antibiotics prolong pregnancy, reduce chorioamnionitis (risk ratio 0.66) and reduce neonatal infection (risk ratio 0.67), without a significant reduction in perinatal mortality. The evidence supporting the therapeutic principle is stronger than the evidence defining how the therapy should be configured. This narrative review examines the three decisions an obstetrician makes at the bedside, namely, which agent, at which dose and route, and for how long, and the comparative evidence behind each. Contemporary practice descends from two protocols: the ampicillin-erythromycin regimen of the NICHD Maternal-Fetal Medicine Units Network trial and the erythromycin arm of ORACLE I. Neither was designed to identify an optimal regimen. Substitution of azithromycin for erythromycin rests predominantly on observational cohorts together with one small open-label randomised comparison that pre-specified no non-inferiority margin and is therefore pragmatic and guideline-permitted rather than confirmed by an adequately powered randomised trial. No randomised dose comparison using clinical endpoints has been performed in PPROM, although randomised pharmacokinetic data exist for azithromycin. The seven-day course derives from a trial protocol rather than from a duration-ranging study, and the two randomised duration comparisons published since 2023 point in opposite directions. Guideline agreement reflects shared historical ancestry rather than independent confirmation of optimality. Adequately powered pragmatic trials, stratified by gestational age, remain the principal unmet need.

Background/Objectives: Antibiotic residues in aquatic environments reflect interacting physicochemical, climatic, and microbiological processes. This study characterized selected antibiotics in wastewater and surface water associated with the Danube River near Novi Sad, Serbia, and evaluated explainable stacked machine-learning models for concentration prediction. Methods: Thirty-six samples collected during summer and autumn 2024 were analyzed using SPE-HPLC-MS/MS. Artificial neural network, random forest, support vector machine, XGBoost, stacked linear, and stacked random forest (STACK-RF) models were developed using environmental/physicochemical variables or presumptive resistant bacterial taxa. Models were evaluated by fivefold cross-validation, complementary error metrics, Holm-adjusted Diebold-Mariano tests, XGBoost Gain, and SHAP analysis. Results: All target antibiotics were detected at least once. Azithromycin was most prevalent (75.0%), followed by sulfamethoxazole (58.3%), trimethoprim, and ciprofloxacin (52.8% each), while wastewater generally exhibited broader antibiotic profiles and higher concentrations than surface water. Standalone algorithms showed weak-to-moderate performance, whereas STACK-RF achieved the highest numerical accuracy for all environmental/physicochemical models (R[2] = 0.745-0.913) and the available microbial-taxa models (R[2] = 0.819-0.945), with consistently lower prediction errors. However, most pairwise differences were not significant after Holm correction. Influential environmental predictors were compound-specific and included COD, BOD5, pH, turbidity, electrical conductivity, water temperature, and relative humidity. Leading bacterial predictors included Klebsiella pneumoniae, Escherichia coli, Citrobacter freundii, and Aeromonas veronii. Conclusions: The results provide a proof-of-concept for machine-learning-assisted antibiotic prediction. Explainable STACK-RF modeling captured nonlinear, antibiotic-specific associations among residues, water-quality conditions, and microbial indicators. It may complement targeted chemical monitoring and support hypothesis generation, although larger, externally validated datasets are required before broader application.

Introduction: Severe periodontitis, corresponding to Stage III and Stage IV disease according to the 2018 World Workshop classification, represents a substantial global health burden. Systemic antibiotics have been investigated as adjuncts to mechanical periodontal therapy; however, their effectiveness and appropriate use in severe periodontitis remain uncertain. This umbrella review aimed to synthesize the available evidence on adjunctive systemic antibiotics in Stage III and Stage IV periodontitis and assess the methodological quality of the available systematic reviews. Methods: This umbrella review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A systematic search of MEDLINE, Embase, and other relevant databases was conducted from June 2018 to June 2026. Systematic reviews evaluating adjunctive systemic antibiotics in patients with Stage III or Stage IV periodontitis, classified according to the 2018 World Workshop, were eligible. Methodological quality was assessed using AMSTAR-2 and overlap among primary studies was evaluated using the Corrected Covered Area (CCA). Results: Two systematic reviews met the inclusion criteria: a network meta-analysis by Lin et al. and a systematic review by Jones and Hoyle focusing on azithromycin. The CCA was approximately 52.9%, indicating substantial overlap between the included reviews. Lin et al. reported moderate-certainty evidence that adjunctive amoxicillin plus metronidazole (AMX + MTZ) resulted in greater clinical attachment level gain and probing pocket depth reduction compared with mechanical debridement alone. Jones and Hoyle found insufficient evidence to support routine adjunctive azithromycin, owing to low certainty and heterogeneity among studies. Discussion and Conclusions: Adjunctive systemic antibiotics, particularly AMX + MTZ, may provide additional clinical benefits in severe periodontitis. However, the limited number of systematic reviews, substantial overlaps, and uncertainty surrounding some antibiotic protocols limit the strength of the evidence. Current findings support selective rather than routine antibiotic use, guided by individual patient and disease characteristics and antimicrobial stewardship. Future studies should emphasize long-term outcomes and consistently distinguish Stage III from Stage IV periodontitis.

Half a century after smallpox eradication, this feat has not been repeated, although there is hope for the Guinea worm. This article examines whether two uncommon genital ulcerative diseases, donovanosis and chancroid, should be targeted for eradication. Many think that their decline has been such that they might be heading towards spontaneous eradication, following more effective treatments, integration of sexually transmitted infection management in primary healthcare, enhanced condom use by sex workers and promotion of male circumcision. However, examples of syphilis and mpox suggest spontaneous eradication may be a fallacy.Donovanosis occurs sporadically in several countries, especially India. In other formerly endemic nations (eg, Papua New Guinea and the Papua region of Indonesia), the current epidemiological situation is unclear. Worldwide incidence might be a few hundred cases annually, perhaps a thousand. The availability of effective interventions, relatively easy clinical diagnosis, adequate laboratory tests and the absence of animal reservoirs suggest that eradication could be achieved through enhanced surveillance and a stronger contact tracing system with presumptive treatment of all sexual contacts, including sex workers.Chancroid's current annual caseload is unknown but likely in the hundreds of thousands of cases globally. Prior to eradication activities, a first phase should document its status in all previously endemic countries using molecular tests on patients presenting with genital ulcers in sentinel clinics. Additional research should investigate whether Haemophilus ducreyi in skin ulcers can cause genital infections. Chancroid is strongly associated with sex work: this is the tap that must be turned off. Where it remains endemic, sex workers' services should be supported to treat symptomatic cases, enhance condom use and deliver periodic presumptive treatment with azithromycin.Given their overlapping geographic distribution and the preponderant role of sex workers in transmission dynamics, an eradication programme could address both diseases simultaneously, with the same personnel.

The implementation of HIV pre-exposure prophylaxis and doxycycline post-exposure prophylaxis may influence antimicrobial resistance in Neisseria gonorrhoeae among men who have sex with men (MSM). We examined trends in antimicrobial resistance among MSM, stratified by HIV and PrEP status, and assessed tetracycline resistance in relation to doxyPEP use. We included all MSM with an N. gonorrhoeae isolate at Melbourne Sexual Health Centre (MSHC) between 2015 and 2024. Resistance was defined using 2025 EUCAST breakpoints and epidemiological cutoff values. Trends were assessed using the Cochran-Armitage test, and tetracycline resistance was compared between doxyPEP users and non-users using the chi-square test. A total of 11,334 isolates from 6,611 MSM were included. Ceftriaxone resistance remained rare (3/11,334; 0.03%). The proportion of isolates with acquired azithromycin resistance mechanisms increased from 0.9% (8/940) in 2015 to 6.4% (102/1,584) in 2024 (Ptrend < 0.001), above the 5% level at which the WHO recommends that an antimicrobial no longer be used for empirical treatment. Ciprofloxacin resistance increased substantially, from 18.5% (170/920) to 55.2% (875/1,584) (Ptrend < 0.001), with significant trends in all three groups. Tetracycline resistance, assessable from 2019 onward, was consistently high (around 80%), with no significant trend. Among 1,020 isolates with known doxyPEP status, tetracycline resistance was significantly higher in doxyPEP users than in non-users (89.2% [107/120] vs 77.2% [695/900], P = 0.003). High-level tetracycline resistance (MIC > 8 mg/L) was also more common among doxyPEP users (54.2% vs 29.7%, P < 0.001). Ceftriaxone remains effective for empirical gonorrhea treatment among MSM in Melbourne. Rising the proportion of azithromycin non-wild-type raises concerns about its ongoing utility in dual therapy. Higher tetracycline resistance among doxyPEP users, particularly high-level tetracycline resistance, underscores the need to monitor for multidrug-resistant strains as doxyPEP use expands.IMPORTANCEAntimicrobial-resistant Neisseria gonorrhoeae is an urgent global health threat, and the expanding use of doxyPEP among MSM has raised concerns regarding its selective pressure on resistance. Linking a decade of individual-level clinical data to over 11,000 isolates from a major Australian sexual health clinic, we show that the proportion of azithromycin non-wild-type has risen to 6.4%, surpassing the 5% threshold at which the WHO recommends discontinuing an agent for empirical therapy. This finding raises concerns about the ongoing utility of dual ceftriaxone-azithromycin treatment. Furthermore, tetracycline resistance was significantly higher among doxyPEP users, with a disproportionate increase in high-level resistance (MIC >8 mg/L) that was associated with ciprofloxacin co-resistance. These findings provide timely real-world evidence to inform gonorrhea treatment guidelines and antimicrobial surveillance as doxyPEP implementation expands globally.

Due to Pseudomonas aeruginosa (P. aeruginosa)'s inherent resistance to many antibiotics and the increasing incidence of multidrug-resistant (MDR) organisms, P. aeruginosa infection has become a growing global threat to humanity. Azithromycin (AZM) does not have prominent antibacterial activity against P. aeruginosa at a clinically reasonable level because of the bacteria's outer membrane and efflux pump system; however, it does demonstrate other properties, including reduction of inflammation and suppression of P. aeruginosa virulence. With the promising potential of AZM as an anti-P. aeruginosa active compound, we proposed the application of a Trojan horse strategy to the synthesis of AZM derivatives. In this study, we designed and synthesized catechol-conjugated AZM derivatives and evaluated their anti-P. aeruginosa activity. One of the derivatives showed superior antibacterial activity to AZM, even against MDR P. aeruginosa clinical isolates.

Salmonella Typhimurium (S. Typhimurium) is a leading cause of bacterial gastroenteritis worldwide, and its escalating antimicrobial resistance (AMR) poses a critical threat to global public health. Nevertheless, epidemiological and genomic data for this pathogen in Guizhou Province remain limited. We integrated phenotypic and genomic analyses of 103 clinical S. Typhimurium isolates, collected from nine cities between 2019 and 2023, to characterize their genetic backgrounds, resistance mechanisms, and evolutionary dynamics. The isolates exhibited persistently high resistance to conventional antibiotics. Multidrug resistance (MDR) was universal (100% during 2019-2021), with extensively drug-resistant (XDR) isolates emerged in 2020. Substantial resistance to first-line antibiotics was also observed, including ciprofloxacin (16.5%), ceftazidime (19.4%), cefotaxime (36.9%), and azithromycin (12.6%). Whole-genome sequencing (WGS) identified 61 antimicrobial resistance genes (ARGs) and six distinct point mutations. Efflux pump-associated genes were widely distributed, and ARGs conferring tetracyclines and sulfonamides were detected at high frequencies. Resistance genotypes correlated well with phenotypes for azithromycin, ceftazidime, ampicillin, chloramphenicol, trimethoprim-sulfamethoxazole, and tetracycline (Kappa: 0.48-0.74). Twenty plasmid replicons were detected, with IncF (24.3%), IncI1-I (15.5%), and IncHI2 (13.6%) being the most prevalent. Notably, ARGs associated with resistance to critically important antibiotics (such as qnr variants, bla CTX-M and bla CMY-2 , and mphA/mrx) were frequently predicted to locate on plasmid-associated contigs. Plasmid diversity expanded significantly over the five-year period, particularly in economically developed cities. Molecular typing identified ST19 and its subtypes, cgST121877 (30.1%) and cgST59516 (12.6%), as the dominant clones, suggesting pronounced regional clonal expansion. Furthermore, phylogenetic analysis revealed close genetic relatedness between Guizhou clinical isolates and human- and livestock-derived isolates from other Chinese provinces. These findings highlight the cross-regional and cross-species circulation of shared genomic lineages, suggesting complex ecological networks that may involve the food supply chain. Implementing an integrated "One Health" surveillance strategy is critical to track and limit the circulation of these resistant lineages and mitigate the associated public health threat.

The rise of multidrug-resistant (MDR) pathogens presents a major challenge to food safety, particularly in preservation approaches. Lactic acid bacteria (LAB) gain probiotic recognition by effectively controlling MDR pathogens using antimicrobial substances (AMSs) and bacteriocin-like inhibitory substances (BLISs). The study evaluated the probiotic properties and AMS production potential of five LAB strains: Lactiplantibacillus plantarum NBRC 3070 (LP), Lactobacillus acidophilus ATCC 4356 (LA), Lacticaseibacillus casei ATCC 393 (LC), Lacticaseibacillus rhamnosus GG ATCC 53103 (LGG), and Bifidobacterium animalis subsp. lactis ATCC 27673 (BAL). AMS was extracted from neutralized and concentrated cell-free supernatant and tested for antimicrobial activities against common foodborne pathogens using minimum inhibitory concentrations (MICs). All LAB strains showed antagonistic activity, with LP demonstrating the most substantial antagonism. Four strains are resistant to multiple antibiotics but remain susceptible to azithromycin and tetracycline, while LP is resistant to all tested antibiotics. LP and LC demonstrated the highest probiotic potential based on cell surface hydrophobicity and aggregation abilities. Optimal AMS activity (85.36%-91.29%) occurred between 24 and 36 h at 37°C or 28-48 h at 30°C. LGG exhibited the highest AMS activity with the lowest MIC against Salmonella enterica serovar Typhimurium. Enzyme sensitivity confirmed the peptide nature of BLIS produced by BLIS from LP, LA, LC, and LGG. In conclusion, LAB strains demonstrated significant probiotic traits and the ability to produce AMS, especially BLIS, from four strains, with LP and LC showing the most potential. These findings support their application as natural biopreservation against MDR pathogens; however, further validation in the food system is required.

Ventilator-induced lung injury (VILI) is a significant complication of mechanical ventilation, contributing to morbidity and mortality in critically ill patients. Excessive mechanical stress triggers an inflammatory cascade, leading to lung damage, pulmonary oedema, and systemic complications. While macrolide antibiotics such as azithromycin (AZM) have demonstrated anti-inflammatory and epithelial barrier strengthening effects, their use is limited by concerns regarding antibiotic resistance. EP317, an azithromycin-derived compound with negligible antibacterial activity, was designed to retain the immunomodulatory and epithelial barrier enhancing effects of AZM while mitigating the risk of bacterial resistance. This study investigated the effects of AZM and EP317 in a rat model of VILI. Forty-eight rats were divided into six groups (N = 8 per group), receiving either placebo, AZM, or EP317 (5 mg/kg daily for seven days), with half of the animals subjected to mechanical ventilation with peak airway pressure at 35 cmH2O. Both compounds attenuated ventilation-induced pulmonary oedema, reflected in a smaller increase in lung wet/dry ratio, whereas ventilation-induced increases in total protein in bronchoalveolar lavage fluid (BALF) were not significantly reduced by either treatment. Cytokine profiling in plasma (L-Selectin, PAI-1, RANTES, MCP-3, IL-6, SCF, IL-17a, RAGE, MIP-3α, IL-13, G-CSF, IL-10, M-CSF, IFN-γ, GRO-KC and MMP9) revealed that both treatments attenuated inflammatory responses, while cytokine levels in BALF in ventilated animals were either unchanged or increased. Survival rates were improved in the treatment groups. Histological analysis indicated increased oedema in ventilated animals, likely due to the high-pressure ventilation, while drug-treated groups exhibited reduced oedema. Global gene expression profiling by RNA sequencing revealed robust upregulation of inflammatory and stress-response pathways in ventilated animals, with partial attenuation following AZM or EP317 pre-treatment. These findings suggest that EP317 and AZM offer protective effects against VILI. EP317 presents a promising alternative to conventional macrolide therapy by circumventing antibiotic resistance concerns.

Azithromycin is a frontline oral treatment for uncomplicated enteric fever in South Asia; however, emerging resistance in Salmonella enterica serovars Typhi and Paratyphi challenges its long-term efficacy. We conducted a PRISMA-compliant systematic review and meta-analysis, searching 6 databases to estimate the prevalence of azithromycin resistance in low-income and developing countries in South Asia. Accepted resistance classifications were based on interpretive criteria used by individual study authors, acknowledging that the Clinical and Laboratory Standards Institute breakpoints for S. Typhi were introduced in 2015 and that no official breakpoints exist for S. Paratyphi. From 1863 screened records, 74 studies comprising 30 085 isolates were analyzed using random-effects models. The pooled azithromycin resistance was 5% (95% CI: 4%-5%) for S. Typhi and 5% (95% CI: 0%-9%) for S. Paratyphi. When both serotypes were combined, the overall prevalence was 9% (95% CI: 3%-14%). Subgroup analysis revealed significant geographical heterogeneity: Pakistan and India reported the highest prevalence (8% and 7%, respectively), while Nepal and Bangladesh remained at 1%. Meta-regression did not detect a statistically significant temporal trend from 2005 to 2024. Although overall resistance remains relatively low, high prevalence in specific regions necessitates rigorous antimicrobial stewardship and enhanced surveillance to preserve azithromycin's clinical utility against enteric fever in South Asia.

Alveolar echinococcosis (AE) is a serious zoonotic parasitic disease caused by the larvae of Echinococcus multilocularis. Given the limitations of current medications, there is an urgent necessity for the development of novel pharmacological treatments for AE. Azithromycin, a macrolide antibiotic, exhibits both antibacterial and antiparasitic effects. This study aimed to investigate its effects on the viability of E. multilocularis protoscoleces (EmPSCs) and to elucidate the underlying mechanisms. Ultrastructural changes were examined using scanning and transmission electron microscopy. Glucose assays, reactive oxygen species (ROS) assays, mitochondrial membrane potential (MMP) assays, and Western blot were used to evaluate the in vitro effects of azithromycin on EmPSCs. Our results demonstrated that azithromycin treatment significantly decreased the viability of EmPSCs and caused pronounced ultrastructural damage. Mechanistically, it significantly downregulated glucose transporter 1 (GLUT1) and protein kinase B (AKT) signaling, elevated ROS levels (P < 0.001), and decreased MMP. Furthermore, Azithromycin treatment significantly elevated the expression of the DNA damage marker γ-H2AX (P < 0.001), while also increasing lipid peroxidation and Fe[2+] levels, depleting GSH content, and downregulating GPX4 and DHODH expression(P < 0.001). Collectively, azithromycin may exert multiple effects on EmPSCs in vitro, encompassing glucose metabolic disruption, oxidative stress, and ferroptosis.