I admit I used to prescribe quinolones. But, my personal prescribing trend has definatively moved away from this pattern.

I used to like Levoquine as a drug of choice as it has nice broad coverage and was a once a day dosing. I was able to give it to my PCN alergic patients and overall had good results with it. (A bad cellulitis, diabetic foot infections),

I stopped. Not so much because I personally encountered many problems with my own patients.  But, rather because I keep reading of warnings and more warnings.

So, many may have known of the potetnial for tendon ruptures with this antibiotic class but last month in Mid August the FDA warned of the risk of nerve damage with this class of drugs with the possibility of the damage being permanent.

Neuropathy as a side effect was actually added to the drug label as early as 2004. Apparently, reports of this side effect continue to come in.

Also in August a study out of Taiwain revealed blood sugar swings amongst the diabetic population taking quinolones.

I do not recall the last time I wrote for a quinolone and now reserve them ONLY when absolutely needed.

I would suggest all take out" their "risk-reward" calculator the next time considering prescribing a quinolone. if you do decide to prescribe them, make sure to inform the patient of the possible side effects and to inform you ASAP if they are getting any of the symptoms or associated pathology.

 

  • Comments (7)
  • Never knew about the neuropathy side effect.  Will definately have to keep that in mind.  I've had a couple of cases where I had to put patients with OM on Cipro because they were uninsured and refused to go to the hospital.  In all cases it resolved the OM (we're talking digits only) and fortunately had no tendon ruptures.  Those patients were already neuropathic to begin with.  Good information to keep in mind though.

  • Rich - I am confused. Was your posting meant for this blog? Medical malpractice? What was the connection to quinolones?
  • In my experience, the real danger of a Medical Malpractice action is the Complaint to the State Board made by the plantiff's lawyer or the plantiff.

    Med Mal is adjudicated by a Court under the rules of Civil Law.  You have an objective Judge, rules of evidence, folks are put under Oath, and one has insurance coverage for it.

    Regarding the State Board, one would say they are under the rules of Administrative Law which is a dramatic short cut.  The Boards will work fast and aggressive.  Expect to be hammered.  Than that peer review is used against the doctor in the Civil Action.

    Slick.

     

    Richard Willner

     

  • There are anti-pseudomonal fluoroquinolones.  The problem is mopping up the atypicals which Cipro does nicely in addition to the gram positives as well very nicely.  But yes indeed, this must be weighed against hepatotoxicity, and then there is the collagen effects.

    Now, in teens, later teens that whom may have multiple allergic sensitivies to antibiotics, and whom have a history of being on many antibiotics, I have found that pediatricians will take the risk of putting them on a fluoroquinolone for say an upper respiratory infection.  That said, when one is having problems eradicating a forefoot infection, and the cultures come back positive for pseudomonas and gram positives, and they have multiple allergies to the ceph's, then Cipro may be the way to go... of course, it would be rare for them to get their liver dinged.

    WG

  • About 15 years ago I was using a lot of Levaquin, for many of the same reasons given by Jeffrey.  Today the only reason I use quinalones is for a Pseudomonas infection.  Interestingly enough, many hospitals here have gone to restricting the use of quinalones, and it has to be approved by I.D.

    I think you'll find in the literature that tendon rupture risk is directly related to age, not a high risk in the young, but markedly high in the aged.

    Best wishes,

    Daryl

  • Eric - you would be surprised how many patients come into my office with an ingrown toenail infection informing me they were put on Cipro by their internist.
    Cipro/Clinda is a popular combo that was in vogue during my training years for the diabetic population and I continue to see this combo utilized.
    In hospitals that I bring my patients too for the most part Podiatry can't admit or coadmit. Hence, I am regulated to consultant even on my own patients. ID docs here seem to be Infatuated with Levaquin.

    My uncle down in Florida was recently put on levoquin for a respiratory infection and ended up with bilateral Achilles' tendon ruptures.

    The medication is dangerous. Of course, medication should be geared towards the actual or suspected bugs.
    Doxy is my office based drug of choice when confirmed MRSA is present.
    The only issue I have with this antibiotic and often have it with a few others is the dosing.

    How is it possible that the "standard dose" is 100mg bid?????
    Shouldn't standard be based on weight? I ask this question at almost every drug lecture I attend, and never really get a good answer. Often times I am told "I wonder the same thing"....

    I happen to be a thin guy....so if I'm being put on doxy, I would get 100mg bid.
    Yet, if the linebacker of the giants comes in he gets the same dosage...?

    It doesn't make sense. Big guys get 100mg Tid for bad infections in my practice.
    Eric - since you appear to rx doxy do you ever find yourself adjusting dosages?
  • Quote:

    I admit I used to prescribe quinolones. But, my personal prescribing trend has definatively moved away from this pattern.

    I used to like Levoquine as a drug of choice as it has nice broad coverage and was a once a day dosing. I was able to give it to my PCN alergic patients and overall had good results with it. (A bad cellulitis, diabetic foot infections),

    I stopped. Not so much because I personally encountered many problems with my own patients.  But, rather because I keep reading of warnings and more warnings.

    So, many may have known of the potetnial for tendon ruptures with this antibiotic class but last month in Mid August the FDA warned of the risk of nerve damage with this class of drugs with the possibility of the damage being permanent.

    Neuropathy as a side effect was actually added to the drug label as early as 2004. Apparently, reports of this side effect continue to come in.

    Also in August a study out of Taiwain revealed blood sugar swings amongst the diabetic population taking quinolones.

    I do not recall the last time I wrote for a quinolone and now reserve them ONLY when absolutely needed.

    I would suggest all take out" their "risk-reward" calculator the next time considering prescribing a quinolone. if you do decide to prescribe them, make sure to inform the patient of the possible side effects and to inform you ASAP if they are getting any of the symptoms or associated pathology.

     

    Jeff,

    The issue is not whether or not to prescribe quinolones as part of routine care.  The question is really what bugs are yout trying to kill?

    We all know that the majority of cellulitic infectious processes are 90+% going to be either MSSA/MRSA or Strep Group B.  The IDSA recommends the use of doxycycline hyclate 100 mg bid as your starting antibiotic for these patients.  I am not too worried about broad spectum coverage until I get my sensitivities back.  My major concern in cSSI is killing Staph/Strep.

    I really don't care so much about the Gram negatives, unless it is a diabetic foot infection, and in which case, I admit the patient to the hospital, as most of the time, they have already progressed to a toxin producing infection that needs parenteral stabilization with IV.

    Eric