Antimicrobials
Levofloxacin

Levofloxacin

High
Excellent
See below under General Info

Dosing

General Information

Hospital Formulary Status Yes (PO solid, parenteral inj)

In-Hospital Cost will be updated

PharmaCare Formulary Status No

Special Authority None

PharmaCare Coverage None

Outpatient Cost 250mg PO - $3.42-4.86/tab 500mg PO - $3.88-4.28/tab 750mg PO - $5.23-8.64/tab 5mg/ml soln - $0.51-0.55/ml

  • Lower respiratory infection (CAP, HAP)
  • Intraabdominal infection

Monitor QTc in patients with increased risk

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
  • Other QTc prolonging agents
  • Divalent cations - decreased absorption
  • NSAIDs - increase seizure risk
  • Warfarin - increased INR

Antimicrobial class: Fluoroquinolone

Pregnancy category: C

Average serum half life: 7.0 hr

Urine penetration: Therapeutic

Lung penetration: Therapeutic

Biliary penetration: Therapeutic