A one-year study on the occurrence and fate of macrolide antibiotics and their metabolites, synthesis byproducts, and transformation products (TPs) was performed in the wastewater treatment plant of the city of Zagreb (Croatia). The target compounds were found in all analyzed influent and effluent samples with the total concentrations of azithromycin-, clarithromycin-, and erythromycin-related compounds reaching up to 25, 12, and 0.25 μg/L, respectively. The most prominent individual constituents were the parent macrolides azithromycin and clarithromycin. However, a substantial contribution of their derivatives, formed by deglycolysation and microbial phosphorylation, was also detected. In addition, widespread presence of several linearized nontarget TPs was confirmed for the first time in real wastewater samples by suspect screening analysis. Complex characterization of macrolide-derived compounds enabled decoupling of industrial and therapeutic sources from the in situ transformations. Due to the high inputs and incomplete removal and/or formation of several TPs during the conventional wastewater treatment, the average mass load of azithromycin-related compounds in secondary effluents exceeded 3.0 g/day/1000 inhabitants. This is the first study to reveal the importance of metabolites, byproducts, and TPs for the overall mass balance of macrolide antibiotics in urban wastewater systems.