Quinolones
All Antimicrobial's should be prescribed according to Trust antimicrobial policy or on the advice of a microbiologist. Restricted antimicrobials should be prescribed for the use or department specified unless on advice of the microbiologist. Please note some non formulary items maybe prescribed on strict advice of the microbiology team direction only.
Where antimicrobials are listed in the NICE/PHE Summary of antimicrobial prescribing guidance and this guidance is agreed locally, that those antibiotics are considered on formulary when prescribed in line with the guidance
Important safety information (for all quinolones)- also see drug safety update below for more details
Convulsions
With intravenous use or oral use or when used by inhalation:
The CSM has warned that quinolones may induce convulsions in patients with or without a history of convulsions; taking NSAIDs at the same time may also induce them.
Tendon damage
With intravenous use or oral use in adults/children, or when used by inhalation in adults:
Tendon damage (including rupture) has been reported rarely in patients receiving quinolones. Tendon rupture may occur within 48 hours of starting treatment; cases have also been reported several months after stopping a quinolone. Healthcare professionals are reminded that:
- quinolones are contra-indicated in patients with a history of tendon disorders related to quinolone use;
- patients over 60 years of age are more prone to tendon damage;
- the risk of tendon damage is increased by the concomitant use of corticosteroids;
- if tendinitis is suspected, the quinolone should be discontinued immediately.
Aortic aneurysm and dissection
With intravenous use or oral use in adults/children, or when used by inhalation in adults:
The MHRA advises that benefit-risk should be assessed and other therapeutic options considered before using fluoroquinolones in patients at risk of aortic aneurysm and dissection.
Patients (particularly the elderly and those at risk) and their carers should be informed about rare events of aortic aneurysm and dissection, and advised to seek immediate medical attention if sudden-onset severe abdominal, chest, or back pain develops.
Drug safety update
January 2024: Fluoroquinolone antibiotics: must now only be prescribed when other commonly recommended antibiotics are inappropriate
September 2023: Fluoroquinolone antibiotics: suicidal thoughts and behaviour
December 2020: Systemic and inhaled fluoroquinolones: small risk of heart valve regurgitation; consider other therapeutic options first in patients at risk
November 2018: Systemic and inhaled fluoroquinolones: small increased risk of aortic aneurysm and dissection; advice for prescribing in high-risk patients
Prescribing Notes
Drug interactions: as enzyme inhibitors, quinolones can cause several significant drug interactions including with theophylline. Concomitant use of theophylline and ciprofloxacin is not recommended. See BNF for details of drug interactions with quinolones.
Quinolones should be used with caution in individuals with G6PD deficiency.
Ciprofloxacin has good activity against Gram-negative bacteria including Pseudomonas and moderate activity against Gram-positives such as Streptococcus and Enterococcus. It has no anaerobic activity.
Bioavailability: Studies have demonstrated high bioavailability (60-80%) of orally administered ciprofloxacin tablets, with the time to peak concentration after an oral dose being 1-2 hours.
Administration route: oral ciprofloxacin is so well absorbed that a 500mg dose rapidly produces similar blood levels as a 400mg IV dose. It is also well tolerated and achieves excellent minimum inhibitory concentrations and has been shown to be effective in a wide range of infections. IV ciprofloxacin is restricted to situations where the oral route is NOT an option.
Levofloxacin has both Gram-negative and Gram-positive activity with greater activity against Pneumococcus than ciprofloxacin.
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- On Formulary Preferred
- On Formulary Second Line
- On Formulary Third Line
- Specialist Initiation
- Secondary Care Only
- Not Approved for Formulary