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Levofloxacin

Oral
Intravenous
Ophthalmic
Class
Antibiotics
Subclass
Fluoroquinolones
Substance name
levoFLOXacin
Brand names
Levaquin®
Common formulations
Tablet
Dosage and administration
Adults patients
Treatment
Acute bacterial prostatitis
•
500 mg PO daily for 4-6 weeks
Acute bacterial rhinosinusitis
•
500 mg PO daily for 10 - 14 days
Chronic bacterial prostatitis
•
500 mg PO daily for 28 days
Community-acquired pneumonia
•
500 mg PO daily for 7-14 days
Dosing specific for community acquired pneumonia due to MSSA, S. pneumoniae (including multi-drug-resistant isolates [MDRSP]), H. influenzae, H. parainfluenzae, K. pneumoniae, M. catarrhalis, Chlamydophila pneumoniae, Legionella pneumoniae, or Mycoplasma pneumoniae.
Alternative
•
750 mg PO daily for 5 days
Dosing for community acquired pneumonia due to Due to S. pneumoniae (excluding multi-drug-resistant isolates), H. influenzae, H. parainfluenzae, or Chlamydophila pneumoniae.
Community-acquired pneumonia • Caused by Legionella pneumophila
•
750 mg PO daily for at least 5 days, and up to 7-10 days
COPD • Acute exacerbation
•
500 mg PO daily for 7 days
Hospital-acquired pneumonia
•
750 mg PO daily for 7-14 days
Nosocomial pneumonia
•
750 mg PO daily for 7 - 14 days
Plague
•
500 mg PO daily for 10-14 days
SSTIs • Complicated
•
750 mg PO daily for 7-14 days
SSTIs • Uncomplicated
•
500 mg PO daily for 7-10 days
UTIs • Pyelonephritis or complicated UTI
•
750 mg PO daily for 5 days
This regimen is indicated for cUTI due to E. coli, K. pneumoniae, P. mirabilis and AP due to E. coli, including cases with concurrent bacteremia.
UTIs • Uncomplicated cystitis
•
250 mg PO daily for 3 days
Acute epididymitis • Off-label
•
500 mg PO daily for 10 days
Anthrax • Cutaneous, no aerosol exposure • Off-label
•
750 mg PO daily for 7-14 days
Cervicitis • Caused by C. trachomatis • Off-label
•
500 mg PO daily for 7 days
Diabetic foot infection • Off-label
•
750 mg PO daily
Dosing if P-aeruginosa is suspected.
H. pylori infection • Off-label
•
500 mg PO daily
Reserve use for levofloxacin susceptible isolates or if the population resistance rate is < 15%. Administered in combination with amoxicillin 750 mg TID, plus a double-dose PPI BID.
Intra-abdominal infections • Off-label
•
750 mg PO daily 1 day after gallbladder removal or until clinical resolution in patients managed nonoperatively
Applicable for mild to moderate, community acquired infection in patients without risk factors for resistance or treatment failure. The addition of anaerobic therapy (eg, metronidazole) is recommended if biliary-enteric anastomosis is present.
Osteomyelitis • Off-label
•
750 mg PO daily
Pelvic inflammatory disease • Off-label
•
500 mg PO daily for 14 days
Prosthetic joint infection • Off-label
•
750 mg PO daily
Treatment for gram-negative bacilli.
Alternative
•
500-750 mg PO daily minimum of 3 months
Administered in combination with rifampin.
S. maltophilia infection • Off-label
•
750 mg PO daily
Prevention
Anthrax • Inhalational, post-exposure prophylaxis
•
500 mg PO daily for 60 days
Chemotherapy-induced neutropenia • Off-label
•
500 mg PO daily
Dose applicable to antibacterial prophylaxis in high-risk patients anticipated to have an ANC ≤ 100 cells/mm3 for > 7 days.
Other off-label uses
•
Treatment of acute diverticulitis (uncomplicated, outpatient, symptoms persisting or worsening after 48-72 hours)
•
Treatment of odontogenic infection
•
Treatment of tuberculosis
•
Treatment of urethritis in males with C. trachomatis infection
Indications for use
Labeled indications
Adults
•
Treatment of acute bacterial prostatitis
•
Treatment of acute bacterial rhinosinusitis
•
Treatment of acute pyelonephritis
•
Treatment of chronic bacterial prostatitis
•
Treatment of COPD (acute exacerbation)
•
Treatment of community-acquired pneumonia
•
Treatment of community-acquired pneumonia (caused by Legionella pneumophila)
•
Treatment of hospital-acquired pneumonia
•
Treatment of nosocomial pneumonia
•
Treatment of plague
•
Treatment of SSTIs (complicated)
•
Treatment of SSTIs (uncomplicated)
•
Treatment of UTIs (pyelonephritis or complicated UTI)
•
Treatment of UTIs (uncomplicated cystitis)
•
Prevention of anthrax (inhalational, post-exposure prophylaxis)
Off-label indications
Adults
•
Treatment of H. pylori infection
•
Treatment of S. maltophilia infection
•
Treatment of acute bacterial prostatitis
•
Treatment of acute diverticulitis (uncomplicated, outpatient, symptoms persisting or worsening after 48-72 hours)
•
Treatment of acute epididymitis
•
Treatment of anthrax (cutaneous, no aerosol exposure)
•
Treatment of cervicitis (caused by C. trachomatis)
•
Treatment of diabetic foot infection
•
Treatment of intra-abdominal infections
•
Treatment of odontogenic infection
•
Treatment of osteomyelitis
•
Treatment of pelvic inflammatory disease
•
Treatment of prosthetic joint infection
•
Treatment of tuberculosis
•
Treatment of urethritis in males with C. trachomatis infection
•
Prevention of chemotherapy-induced neutropenia
Safety risks
Boxed warnings
Exacerbation of myasthenia gravis
Tendon rupture, tendinitis, peripheral neuropathy, myasthenia gravis
•
Use extreme caution in all patients, especially older patients usually over 60 years of age, in patients taking corticosteroid drugs, and in patients with kidney, heart or lung transplants.
Contraindications
Hypersensitivity to levofloxacin or any member of the quinolone class of antimicrobial agents, or any of the product components
Warnings and precautions
Antimicrobial resistance
•
Use caution Prescribing levofloxacin in the absence of a proven or strongly suspected bacterial infection or a prophylactic indication is unlikely to provide benefit to the patient and increases the risk of the development of drug-resistant bacteria.
C. difficile infection
•
Use caution in all patients who present with diarrhea following antibacterial use.
Cardiac arrhythmias
•
Use caution in patients with cardiac disease that predisposes to cardiac arrhythmias.
Exacerbation of dehydration
•
Use extreme caution in patients with diarrhea and dehydration.
Exacerbation of seizure
•
Use caution in patients with a known or suspected CNS disorder.
Hypoglycemia
•
Use caution in diabetic patients receiving concomitant treatment with an oral hypoglycemic agent (for example, glyburide) or with insulin.
Photosensitivity of skin
•
Use caution, as levofloxacin increases the risk of such adverse event.
Prolonged QT interval
•
Use caution in patients with known prolongation, those with hypokalemia, and with other drugs that prolong the QT interval.
Reactivation of peripheral neuropathy
•
Use extreme caution in patients with history of peripheral neuropathy.
Suicidal ideation, hallucinations, psychosis, depression
•
Maintain a high level of suspicion for psychiatric adverse reactions.
Specific populations
Renal impairment
eGFR > 50 mL/min/1.73 m²
•
Use acceptable. No dose adjustment required.
eGFR 20-50 mL/min/1.73 m²
•
Start at dose of 250-500 mg. Maximal dose of then 125-250 mg. Do not exceed frequency of q12-24h.
eGFR 10-20 mL/min/1.73 m²
•
Start at dose of 250-500 mg. Maximal dose of then 125 mg. Do not exceed frequency of q24-48h.
eGFR < 10 mL/min/1.73 m²
•
Start at dose of 250-500 mg. Maximal dose of then 125 mg. Do not exceed frequency of q24-48h.
Renal replacement therapy
Continuous renal replacement
•
Reduce dose. Start at a dose of 500mg. Maximal dose of 250mg. Maximal frequency of daily.
Intermittent hemodialysis
•
Reduce dose. Dose as in eGFR < 10 mL/min/1.73 m². Start at a dose of 250-500 mg. Maximal dose of then 125 mg. Maximal frequency of q24-48h.
Peritoneal dialysis
•
Reduce dose. Dose as in eGFR < 10 mL/min/1.73 m². Start at a dose of 250-500 mg. Maximal dose of then 125 mg. Maximal frequency of q24-48h.
Hepatic impairment
Any severity
•
Use acceptable. No dose adjustment required.
Pregnancy and breastfeeding
Pregnancy
All trimesters
•
Use only if benefits outweigh potential risks. Evidence of fetal harm in animals.
Breastfeeding
Acceptable for use during breastfeeding.
Unknown amount excreted in breastmilk.
Unknown drug levels in breastfed infants.
Adverse reactions
Common 1-10%
•
Agitation, cardiac arrest, ↓ platelet count, edema, hyperkinesia, hypertonia, ↑ liver enzymes, ↑ serum potassium, pharyngitis, phlebitis, pseudomembranous colitis, renal failure, abdominal pain, anxiety, chest pain, constipation, diarrhea, dizziness, dysgeusia, dyspepsia, dyspnea, eye pain, fever, foreign body sensation in the eyes, generalized pruritus, hallucinations, headache, insomnia, itchy eyes, loss of appetite, musculoskeletal pain, nausea, nightmares, nosebleed, photophobia, seizure, skin rash, syncope, vertigo, visual disturbances, vomiting, VT, vaginitis, xerophthalmia
Uncommon < 1%
•
Acute kidney injury, acute pancreatitis, anemia, candidiasis, ↓ blood glucose, epistaxis, esophagitis, gastritis, gastroenteritis, glossitis, ↑ blood glucose, arthralgia, confusion, depression, myalgia, palpitations, paresthesia, stomatitis, tremor, urticaria
Unknown frequency
•
Acute liver failure, acute generalized exanthematous pustulosis, agranulocytosis, angioedema, aortic dissection, aplastic anemia, bronchospasm, Clostridioides difficile infection, coma, ↓ WBC count, delirium, dysphonia, encephalopathy, erythema multiforme, hemolytic anemia, hepatic necrosis, hepatitis, hypotension, ↑ ICP, ↑ blood eosinophil count, interstitial nephritis, jaundice, laryngeal edema, pancytopenia, peripheral neuropathy, peripheral vasodilation, photosensitivity of skin, pneumonitis, ↑QTc interval, ↑bleeding time, anosmia, asthenia, blurred vision, diplopia, dysesthesia, hypoesthesia, memory impairment, paranoid ideation, parosmia, restlessness, suicidal ideation, tinnitus, weakness, rhabdomyolysis, serum sickness, Stevens-Johnson syndrome, thrombotic thrombocytopenic purpura, tendinitis, torsade de pointes, toxic epidermal necrolysis, uveitis, vasculitis
Interactions
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