Gastritis (PO and IV)
- mild and transient GI upset
- sx: anorexia, nausea, vomiting, and abdominal discomfort
Increase in liver enzymes (mainly with IV)
- mild elevations in hepatic transaminases
- similar risk to moxifloxacin and more risk than ciprofloxacin and clarithromycin of hospital admission for acute liver injury within 30 days of initiation
- liver failure is rare
CNS toxicity (mainly with IV)
- more common: mild and transient sx (headache, dizziness, change in mood or sleep)
- less common: delirium, hallucination, seizures, memory impairment, disorientation, agitation, and disturbances in attention
- seizures may be caused by theophylline accumulation or the ability of theophylline and NSAIDS to augment fluoroquinolone-mediated displacement of gamma-aminobutyric acid from its receptors
- can occur after a single dose
Peripheral neuropathy (mainly with IV)
- sx: pain, burning, tingling, numbness, weakness, or a change in sensation to light, touch, pain, temperature, or the sense of body position
- onset: rapid, often within a few days
- can occur at any time during treatment and last for months to years after discontinuation or be permanent
- higher risk for men and patients >60 years old
- risk can increase by ~3% with each day of exposure and persist for 180 days
- treatment: discontinue offending agent and provide symptomatic care
Secondary pseudotumor cerebri syndrome (mainly with IV)
- sx: headache, tinnitus, diplopia
- fluoroquinolone use within 15-30 days of benign intracranial hypertension diagnosis increases the risk
Myasthenia gravis exacerbations (mainly with IV)
- may exacerbate muscle weakness in individuals with myasthenia gravis
- caused by neuromuscular-blocking activity
- avoid in individuals with myasthenia gravis due to risk of death and respiratory failure requiring mechanical ventilation
QT interval prolongation (mainly with IV)
- caused by inhibition of cardiac KCHN2 potassium voltage-gated channels
- less risk than moxifloxacin and more risk than ciprofloxacin
- may lead to torsades de pointes
- avoid fluoroquinolone use for patients taking other QT-prolonging drugs and patients with long QT syndromes or other significant risk factors for arrhythmia
Aortic aneurysm and dissection (mainly with IV)
- associated with increased risk of aortic aneurysm within 60 days from initiation
- avoid fluoroquinolones in patients with known aortic aneurysms or risk factors such as Marfan syndrome, Ehlers Danlos syndrome, peripheral atherosclerotic vascular diseases, uncontrolled hypertension, and/or advanced age
Tendinopathy (mainly with IV)
- includes tendon rupture and achilles tendinopathy
- usually occurs early in treatment (~8 days after initiation)
- higher risk for patients >60 years old, nonobese, using oral glucocorticoids and with kidney, heart, or lung transplants
- advise patient to avoid exercise, contact their physician for evaluation, transition to non-fluoroquinolone antibiotic when appropriate and discontinue drug if any sign of tendinopathy develops (pain, swelling)
Arthropathy (mainly with IV)
- usually reversible
- involves cartilage erosions and noninflammatory effusions in weight-bearing joints
- children: 9-22%
Dysglycemia (mainly with IV)
- associated with hypoglycemia and hyperglycemia in diabetic and nondiabetic patients
- higher risk for older adults and patients with diabetes mellitus
- less risk than moxifloxacin
Retinal detachment (PO and IV)
- small risk within 10 days after initiation
- includes rhegmatogenous and exudative retinal detachment
Phototoxicity (PO and IV)
- low risk
- sunscreen containing UVA blockers may offer some protection
Hypersensitivity reactions (PO and IV)
- more common: delayed-onset maculopapular rash
- less common: immediate reactions (urticaria, pruritus, angioedema, wheezing and anaphylaxis), acute interstitial nephritis (associated with eosinophiluria but not crystalluria)
Persistent multisystem adverse effects (mainly with IV)
- involves musculoskeletal, neuropsychiatric and peripheral nervous system symptoms
- can last for ≥30 days after stopping drug
- higher risk for women and patients aged 30-59
- similar low risk between levofloxacin, ciprofloxacin and moxifloxacin
Other
- increased risk of aortic or mitral regurgitation