The interaction of azithromycin with normal human serum was examined in relation to serum protein binding, MIC, and kinetics of killing of bacteria. While the binding of azithromycin to serum proteins is low (8.5% at a concentration of 0.01 mM in 95% serum), the presence of 40% serum during the MIC test decreased MICs by 26-fold for serum-resistant Escherichia coli and 15-fold for Staphylococcus aureus. Erythromycin had a similar but lesser effect, while roxithromycin was less active against S. aureus in the presence of serum. The rate of killing of E. coli and S. aureus by azithromycin was increased in the presence of serum. The enhancement of antibiotic activity by serum was pH independent, and heat inactivation and preabsorption with homologous bacteria failed to inhibit enhancement by serum. The macromolecular incorporation of [3H]thymidine by E. coli continuously exposed to 2 μg of azithromycin per ml (0.25 x the MIC) and 40% serum was decreased by 80% at pH 7.8 and by 48% at pH 7.2, while azithromycin alone failed to inhibit incorporation. Inhibition of nucleic acid biosynthesis at pH 7.2 in the presence of serum was also detected with sub-MICs of erythromycin, norfloxacin, and gentamicin but not roxithromycin. A diffusible serum factor was shown to interact with azithromycin to inhibit the growth of E. coli in an agar diffusion assay to detect antibiotic-serum synergy.