Levofloxacin is a quinolone antibiotic available for oral, intravenous, or ophthalmic administration. It is the optically active L-isomer of ofloxacin. Plasma concentrations are similar after intravenous or oral administration and these routes can be considered interchangeable. Unlike ciprofloxacin, levofloxacin does not interact significantly with theophylline. Levofloxacin is FDA-approved for the treatment of bacterial conjunctivitis, community-acquired pneumonia (including cases caused by multi-drug-resistant strains of S. pneumoniae), nosocomial pneumonia, skin and skin structure infections, complicated urinary tract infections (UTIs), acute pyelonephritis, chronic bacterial prostatitis, inhalation anthrax (post-exposure), and plague. Levofloxacin is also FDA-approved for sinusitis, chronic bronchitis, and uncomplicated UTIs; however, due to the potential for serious adverse events, quinolones should only be used for these infection types when alternative treatment options cannot be used. Disabling and potentially irreversible serious adverse reactions associated with quinolones include tendinitis, tendon rupture, peripheral neuropathy, and central nervous system effects. Other significant adverse reactions include potential QT prolongation and myasthenia gravis exacerbation.
General Administration Information
For storage information, see the specific product information within the How Supplied section.
Tuberculosis patients*
-Directly observed therapy (DOT) is recommended for all children as well as adolescents and adults living with HIV.
Route-Specific Administration
Oral Administration
-If a dose is missed, take it as soon as possible anytime up to 8 hours before the next scheduled dose. If less than 8 hours remain before the next dose, wait until the next scheduled dose.
Oral Solid Formulations
-Tablets: Take with or without food; however, administer at least 2 hours before or 2 hours after any antacid, multivitamin, or other medication that contains divalent or trivalent cations.
Oral Liquid Formulations
-Administer 1 hour before or 2 hours after eating and at least 2 hours before or 2 hours after any antacid, multivitamin, or other medication that contains divalent or trivalent cations.
-Extemporaneous oral suspension: Shake well before administering. Measure dosage with calibrated measuring device.
Extemporaneous Compounding-Oral
NOTE: The extemporaneous preparation of levofloxacin is not FDA-approved.
Extemporaneous preparation of 50 mg/mL levofloxacin oral suspension
-Using a mortar and pestle, grind 6 x 500 mg levofloxacin tablets to a fine powder.
-Mix 30 mL of Ora-Plus with 30 mL of Strawberry Syrup, NF and stir vigorously.
-Add approximately 15 mL of the Ora-Plus and Strawberry Syrup, NF mixture to the powder, triturate well, and transfer the contents to an amber plastic bottle.
-Rinse the mortar with about 15 mL of the mixture and transfer the contents to the amber plastic bottle.
-Repeat with enough syrup mixture to bring the final volume to 60 mL.
-Label the bottle with 'Shake well before use'.
-Storage: The oral suspension is stable for at least 57 days when stored at room temperature or refrigerated.
Injectable Administration
-Visually inspect parenteral products for particulate matter and discoloration prior to administration whenever solution and container permit.
Intravenous Administration
Vials
Dilution
-Withdraw appropriate dose from vial (25 mg/mL) and dilute with a compatible intravenous solution to a concentration of 5 mg/mL.
--250 mg dose: Withdraw 10 mL and dilute with 40 mL.
-500 mg dose: Withdraw 20 mL and dilute with 80 mL.
-750 mg dose: Withdraw 30 mL and dilute with 120 mL.
-Compatible diluents include 0.9% Sodium Chloride Injection, 5% Dextrose Injection, 5% Dextrose and 0.9% Sodium Chloride Injection, 5% Dextrose in Lactated Ringers Injection, Plasma-Lyte 56/5% Dextrose Injection, 5% Dextrose and 0.45% Sodium Chloride and 0.15% Potassium Chloride Injection, and Sodium Lactate Injection (M/6).
-If more than 1 dose is to be prepared from a single vial, withdraw the full contents of the vial at once using a single-entry procedure; prepare and store the additional dose(s) for subsequent use.
-Storage: Vials are for single-dose only; discard any ununsed portion. The diluted solution may be stored for up to 72 hours when kept at or below 25 degrees C (77 degrees F) or for 14 days when stored under refrigeration at 5 degrees C (41 degrees F) in plastic containers. Solutions may be frozen for up to 6 months (-20 degrees C or -4 degrees F) in glass bottles or plastic containers. Thaw frozen solutions at room temperature (25 degrees C or 77 degrees F) or in the refrigerator (8 degrees C or 46 degrees F). Do not force thaw by microwave or water bath immersion. Do not refreeze after initial thawing.
Premixed IV Solution
-No dilution is necessary.
-Do not use flexible containers in series connections.
Intermittent IV infusion
-Infusion time varies by dose.
--250 or 500 mg dose: Infuse over 60 minutes.
-750 mg dose: Infuse over 90 minutes.
-Avoid shorter infusions or bolus injections because of the risk of hypotension.
Ophthalmic Administration
-Apply topically to the eye taking care to avoid contamination. For ophthalmic use only. Do not inject subconjunctivally or introduce directly into the anterior chamber of the eye.
-Instruct patient on proper instillation of ophthalmic solution.
-Do not touch the tip of the dropper to the eye, fingertips, or other surface.
The most frequently reported gastrointestinal adverse reactions during clinical trials of systemic levofloxacin in adult patients include nausea (7%), vomiting (2%), diarrhea (5%), constipation (3%), abdominal pain (2%), and dyspepsia (2%). Other adverse reactions occurring in 0.1% to 1% of patients include gastritis, stomatitis, pancreatitis, esophagitis, gastroenteritis, and glossitis. Ageusia and dysgeusia were noted in postmarketing reports. Diarrhea, dyspepsia, and nausea have all been reported in 1% to 2% of patients receiving levofloxacin ophthalmic drops. Taste disturbance has been reported in 8% to 10% of patients receiving the ophthalmic drops.
Quinolones, including levofloxacin, cause arthropathy and osteochondrosis in juvenile animals of several species. Evidence supporting sustained injury to developing joints in humans is lacking at this time; however, the possibility of rare occurrences has not been excluded. One retrospective study compared the rate of tendon or joint disorders in more than 7,000 children younger than 19 years old who received ciprofloxacin, ofloxacin, or levofloxacin with more than 20,000 children who received azithromycin. The incidence of potential tendon or joint disorders was found to be approximately 2% in both the quinolone and azithromycin groups, and verified disorders were reported in less than 1% in both groups. The authors state that this incidence is likely to reflect the background incidence of these disorders in children. Another published report evaluated the safety data collected from 2,523 children and adolescents who participated in 1 of 3 efficacy trials and were randomized to receive levofloxacin or non-quinolone antibiotics. Two of the trials were open-label and 1 was evaluator-blinded only. In addition, a subset of these children participated in a 1-year surveillance trial (n = 2,233). The safety analysis focused on 4 musculoskeletal disorders: arthralgia, arthritis, tendinopathy, and gait abnormality. The authors reported an odds ratio and 95% confidence interval of 2.2 (0.95 to 5.2) at 1 month and 1.9 (1.1 to 3.5) at 1 year after receiving levofloxacin for experiencing at least 1 of the 4 musculoskeletal disorders as reported by the patient or parent or evaluated by an investigator. The safety of levofloxacin for a treatment duration of more than 14 days in pediatric patients has not been studied. Clinical studies have shown an increased incidence of musculoskeletal adverse reactions in pediatric patients treated up to 14 days as compared to controls. Long-term safety data in pediatric populations is limited. Arthralgia has been specifically reported with systemic levofloxacin in 0.1% to 1% of patients in general.
Edema (1%), injection site reaction (1%), and phlebitis (0.1% to 1%) have been reported during clinical trials of systemic levofloxacin in adult patients. Multi-organ failure has been noted in postmarketing reports.
Allergic reactions to systemic levofloxacin have been reported in 0.1% to 1% of adult patients in clinical trials. Serious and sometimes fatal events, some due to hypersensitivity and some due to uncertain etiology, have been reported in patients receiving quinolones, including levofloxacin. Some reactions have been accompanied by cardiovascular collapse, low blood pressure, anaphylactoid reactions, anaphylactic shock, seizure, loss of consciousness, tingling, angioedema (tongue, throat, or facial edema/swelling or laryngeal edema), airway obstruction (bronchospasm, shortness of breath, acute respiratory distress), dyspnea (1%), urticaria, itching, and other serious skin reactions. Clinical manifestations may include fever, rash (unspecified), severe dermatologic reactions (e.g., toxic epidermal necrolysis, Stevens-Johnson syndrome), allergic pneumonitis, erythema multiforme, rhabdomyolysis, arthralgia, serum sickness, vasculitis, interstitial nephritis, acute renal impairment or renal failure (unspecified) (0.1% to 1%), and thrombotic thrombocytopenic purpura (TTP). Overall, rash has been reported in 2% of adult patients in clinical trials, pruritus has been reported in 1%, and urticaria has been reported in 0.1% to 1%. Postmarketing reports include anaphylactic/anaphylactoid reactions, anaphylactic shock, angioneurotic edema, serum sickness, Stevens-Johnson syndrome, toxic epidermal necrolysis, erythema multiforme, acute generalized exanthematous pustulosis (AGEP), and leukocytoclastic vasculitis. Discontinue levofloxacin immediately at the first appearance of a skin rash or any other sign of hypersensitivity. Fever has been reported in 1% to 3% of patients using levofloxacin ophthalmic drops.
There have been postmarketing reports of severe hepatotoxicity (including acute hepatitis, jaundice, and fatal events) in patients treated with systemic levofloxacin. Severe hepatotoxicity generally occurred within 14 days of initiation of therapy and most cases occurred within 6 days. Most cases of severe hepatotoxicity were not associated with hypersensitivity. The majority of fatal hepatotoxicity reports occurred in patients 65 years of age or older. Hepatobiliary disorders reported in 0.1% to 1% of adult patients in clinical trials include abnormal hepatic function, elevated hepatic enzymes, and increased alkaline phosphatase. Discontinue levofloxacin immediately if the patient develops signs and symptoms of hepatitis or hepatic disease. Other reports of hepatitis, jaundice, acute hepatic necrosis, or hepatic failure may be due to hypersensitivity or other uncertain etiology in patients taking quinolones.
Systemic quinolones, such as levofloxacin, have been associated with disabling and potentially irreversible serious adverse reactions that include central nervous system effects (neurotoxicity) and psychiatric events. Quinolones may cause convulsions (seizures), increased intracranial pressure (including pseudotumor cerebri), dizziness or lightheadedness, and tremors. Psychiatric adverse events associated with quinolones include toxic psychosis, hallucinations, paranoia, depression, self-injurious behavior such as suicidal ideation or acts, delirium, disorientation, confusion, disturbances in attention, anxiety, agitation, restlessness, nervousness, insomnia, nightmares, and memory impairment. Central nervous system and psychiatric adverse reactions that have been reported in adult patients receiving levofloxacin include dizziness (3%), headache (6%), severe headache (0.2% to 0.3%), and insomnia (4%). Adverse reactions reported in 0.1% to 1% of patients include convulsions or seizures, tremor, anxiety, confusion, hallucinations, depression, nightmares, sleep disorder, anorexia, agitation, abnormal dreaming, vertigo, hypertonia, hyperkinesis, abnormal gait, somnolence, and syncope. Anosmia, parosmia, isolated reports of encephalopathy, abnormal electroencephalogram (EEG), dysphonia, and psychosis have been noted in postmarketing reports. Neurological or psychiatric reactions can occur within hours to weeks after starting these agents in patients of any age, with or without pre-existing risk factors. Discontinue levofloxacin immediately if a patient reports any central nervous system side effects or psychiatric adverse reactions. Headache has been reported with the use of levofloxacin ophthalmic drops in 1% to 3% of patients.
Some quinolones, including systemic levofloxacin, have been associated with QT prolongation and torsade de pointes. During postmarketing surveillance with levofloxacin, rare cases of torsade de pointes have been reported. Other cardiac adverse reactions reported in 0.1% to 1% of adult patients in clinical trials include cardiac arrest, palpitations, ventricular tachycardia, and ventricular arrhythmia. Chest pain (unspecified) has been reported in 1% of patients during clinical trials. Peripheral vasodilation and tachycardia have been noted in postmarketing reports. Additionally, systemic quinolones are associated with an increased risk of aortic aneurysm and aortic dissection. Epidemiologic studies report an increased rate of aortic dissection within 2 months after quinolone use. Discontinue systemic quinolone treatment immediately if a patient reports side effects suggestive of aortic aneurysm or dissection.
Systemic quinolones, such as levofloxacin, have been associated with disabling and potentially irreversible serious adverse reactions that include peripheral neuropathy. Systemic quinolones have been associated with cases of sensory or sensorimotor axonal polyneuropathy affecting small and/or large axons. This has resulted in reports of paresthesias (0.1% to 1%), hypoesthesia, dysesthesia, and weakness. Symptoms of quinolone-induced neuropathy include pain, burning, tingling, numbness, and/or weakness in the arms and legs, or other alterations of sensation such as light touch, temperature, position sense, and vibratory sensation. These reactions can occur within hours to weeks after starting these agents in patients of any age, with or without pre-existing risk factors. Immediately discontinue use in patients experiencing symptoms of peripheral neuropathy. Myalgia and musculoskeletal pain have been reported in 0.1% to 1% of adult patients during levofloxacin clinical trials. Increased muscle enzymes and muscle injury, including rupture have been noted in postmarketing reports. In addition, serious postmarketing reports of myasthenia gravis exacerbations, including deaths and the requirement for ventilatory support, have been associated with quinolone use.
Microbial overgrowth and superinfection can occur with antibiotic use. C. difficile-associated diarrhea (CDAD) or pseudomembranous colitis (0.1% to 1%) has been reported with levofloxacin. If pseudomembranous colitis is suspected or confirmed, ongoing antibacterial therapy not directed against C. difficile may need to be discontinued. Institute appropriate fluid and electrolyte management, protein supplementation, C. difficile-directed antibacterial therapy, and surgical evaluation as clinically appropriate.
Systemic quinolones, such as levofloxacin, have been associated with disabling and potentially irreversible serious adverse reactions such as tendinopathy, including tendinitis and tendon rupture requiring surgical repair or resulting in prolonged disability. These reactions can occur within hours to weeks after starting these agents in patients of any age, with or without pre-existing risk factors. Discontinue quinolones at the first sign of tendon inflammation or tendon pain as these are symptoms that may precede rupture of the tendon. Ruptures have occurred unilaterally and bilaterally, and have mainly involved the Achilles tendon; however, ruptures in the shoulder joint, hand, biceps, thumb, and other tendon sites have been reported. The risk of tendon rupture is further increased in those over age 60, those receiving concomitant steroid therapy, and in kidney, heart, and lung transplant recipients. Other reasons for tendon ruptures include physical activity or exercise, kidney failure, and prior tendon problems.
Moderate to severe photosensitivity reactions have been observed in patients exposed to direct sunlight while receiving a systemic quinolone. Although phototoxicity has occurred only rarely during levofloxacin therapy, advise patients to avoid excessive sunlight (UV) exposure. Discontinue levofloxacin therapy if photosensitivity occurs.
Blood glucose disturbances, including hyperglycemia and hypoglycemia, were reported in 0.1% to 1% of adult patients in clinical trials with levofloxacin. A fatality due to hypoglycemia was reported in an elderly type 2 diabetic patient who was receiving levofloxacin. Because hypoglycemia, sometimes resulting in coma, occurs more frequently in elderly patients or patients with diabetes mellitus who are receiving an oral hypoglycemic agent or insulin concomitantly with levofloxacin, carefully monitor blood glucose concentrations in these patients. Discontinue levofloxacin if a hypoglycemic reaction occurs and initiate appropriate therapy immediately. Hyperkalemia has also been reported in 0.1% to 1% of adult patients in clinical trials with levofloxacin.
Rapid intravenous injection of levofloxacin may result in hypotension. Hypotension can be prevented by administering levofloxacin injection slowly over 60 to 90 minutes.
Crystalluria and cylindruria have been reported with quinolones, including systemic levofloxacin. Adequate hydration should be maintained to prevent the formation of highly concentrated urine in patients receiving levofloxacin.
Hematologic abnormalities have been reported with levofloxacin use and may be associated with hypersensitivity reactions. These hematologic adverse reactions include anemia (0.1% to 1%), including aplastic anemia and hemolytic anemia; thrombocytopenia (0.1% to 1%), including thrombotic thrombocytopenic purpura (TTP); leukopenia; agranulocytosis; pancytopenia; and/or other hematologic abnormalities. Granulocytopenia has been reported in 0.1% to 1% of patients in clinical trials. Pancytopenia, aplastic anemia, leukopenia, hemolytic anemia, eosinophilia, and prolonged bleeding time (prolonged prothrombin time and prolonged international normalized ratio (INR)) have all been noted in postmarketing reports.
Prolonged use of antimicrobials may lead to overgrowth of non-susceptible pathogens or superinfection. Moniliasis (candidiasis) has been reported in 1% of adult patients during clinical trials of systemic levofloxacin, including genital moniliasis (0.1% to 1%). Vaginitis has also been reported in 1% of adult patients during trials.
Epistaxis has been reported in 0.1% to 1% of adult patients during clinical trials of systemic levofloxacin. Pharyngitis (1% to 3%) has been reported with levofloxacin ophthalmic products.
Ophthalmologic adverse reactions have been associated with the use of ophthalmic levofloxacin as well as with systemic formulations. The most frequently reported adverse reactions associated with use of ophthalmic levofloxacin, which were reported in approximately 1% to 3% of patients, included transient visual impairment, foreign body sensation, transient ocular irritation (primarily burning), ocular pain or discomfort, and photophobia. Other reported reactions occurring in less than 1% of patients included allergic reactions, lid edema, ocular pruritus, and xerophthalmia. In clinical trials using multiple-dose systemic therapy, ophthalmologic abnormalities, including cataracts and multiple punctate lenticular opacities, have been reported in patients being treated with other quinolones. The relationship of levofloxacin to these adverse reactions has not been established. Other ophthalmic adverse reactions noted in postmarketing reports with systemic levofloxacin include uveitis, vision disturbance (including diplopia), reduced visual acuity, blurred vision, and scotoma (scotomata).
Tinnitus and hypoacusis have been noted in postmarketing reports with the use of systemic levofloxacin.
Levofloxacin is contraindicated in patients with known quinolone hypersensitivity. Serious and occasionally fatal hypersensitivity and/or anaphylactic reactions have occurred even after the first dose of the drug. Some reactions were accompanied by cardiovascular collapse, loss of consciousness, tingling, pharyngeal or facial edema, dyspnea, urticaria, and pruritus. Discontinue levofloxacin immediately at the first appearance of a skin rash or any other sign of hypersensitivity. Serious anaphylactic reactions require immediate emergency treatment with epinephrine. Administer oxygen, intravenous steroids, and airway management, including intubation, as indicated.
Systemic quinolones have been associated with disabling and potentially irreversible serious adverse reactions such as tendinopathy, including tendinitis and tendon rupture requiring surgical repair or resulting in prolonged disability. These reactions can occur within hours to weeks after starting these agents in patients of any age, with or without pre-existing risk factors. Because of this risk for serious and potentially permanent side effects, quinolones should only be used for the treatment of uncomplicated urinary tract infection, acute bacterial exacerbation of chronic bronchitis, or acute bacterial sinusitis in cases where alternative treatment options cannot be used. Discontinue quinolones at the first sign of tendon inflammation or tendon pain as these are symptoms that may precede rupture of the tendon. Avoid quinolone use in patients with a history of tendon disorders or tendon rupture. Tendon rupture typically involves the Achilles tendon; however, ruptures of the hand, shoulder, biceps, thumb, and other tendons have also been reported. Tendinitis and tendon rupture can occur bilaterally. Rupture can occur during therapy or up to a few months after therapy has been stopped. The risk of tendon rupture is increased in older adults over 60 years of age, those receiving concomitant corticosteroid therapy, and in organ transplant recipients (including kidney, heart, and lung transplants). Other reasons for tendon ruptures include physical activity or exercise, kidney failure, or tendon problems in the past. If patients experience tendon inflammation or pain, they should rest and refrain from exercise until the diagnosis of tendonitis or tendon rupture has been confidently excluded.
Systemic quinolones have been associated with disabling and potentially irreversible serious neurotoxicity, including central nervous system effects, peripheral neuropathy, or psychiatric event. These reactions can occur within hours to weeks after starting these agents in patients of any age, with or without pre-existing risk factors. Because of this risk for serious and potentially permanent side effects, use quinolones for the treatment of uncomplicated urinary tract infection, acute bacterial exacerbation of chronic bronchitis, or acute bacterial sinusitis only in cases where alternative treatment options cannot be used. Avoid quinolone use in patients who have previously experienced peripheral neuropathy. Additionally, use quinolones with caution in patients with a known or suspected CNS disorder (e.g., severe cerebrovascular disease or arteriosclerosis, seizure disorder) or in the presence of other risk factors (e.g., certain drug therapy, renal dysfunction) that may predispose to seizures or lower seizure threshold. Attempted or completed suicide has been reported, especially in patients with a history of depression, or an underlying risk factor for depression. Discontinue quinolone therapy at the first signs or symptoms of neuropathy (e.g., pain, burning, tingling, numbness, and/or weakness, or other alterations in sensations such as light touch, pain, temperature, position sense, and vibratory sensation, and/or motor strength), central nervous system adverse events (seizures or convulsions, increased intracranial pressure (including pseudotumor cerebri), dizziness, or tremors), or psychiatric adverse events (toxic psychosis, hallucinations, paranoia, depression, suicidal thoughts or acts, confusion, delirium, disorientation, disturbances in attention, anxiety, agitation, nervousness, insomnia, nightmares, or memory impairment).
Avoid use of systemic quinolones, such as levofloxacin, in patients with a history of myasthenia gravis. Systemic quinolones may exacerbate the signs of myasthenia gravis and lead to life threatening weakness of the respiratory muscles. Serious postmarketing events, including deaths and the requirement for ventilatory support, have been associated with quinolone use in patients with myasthenia gravis. Because of this risk for serious and potentially permanent side effects, quinolones should only be used for the treatment of uncomplicated urinary tract infection, acute bacterial exacerbation of chronic bronchitis, or acute bacterial sinusitis in cases where alternative treatment options cannot be used.
Levofloxacin should be used cautiously in patients with cardiac arrhythmias or other cardiac disease that predisposes to cardiac arrhythmias. Fluoroquinolones have the potential to cause QT prolongation and possibly torsade de pointes (TdP) by blocking human cardiac potassium (K+) channel currents. The potency of this blockade varies among the quinolones. Levofloxacin blocks human cardiac K+ channels at potencies greater than that of ciprofloxacin and ofloxacin but less than that of moxifloxacin. Based on cardiac studies, clinical trials, and postmarketing evaluations, the overall risk for TdP appears to be similar between levofloxacin and moxifloxacin. During postmarketing surveillance, rare cases of TdP have been spontaneously reported in patients receiving quinolones, including levofloxacin. The unmonitored use of quinolones in patients with a stable ischemic heart and preserved left ventricular function is likely safe and the risk of QT prolongation and TdP is low. However, avoid the unmonitored use of quinolones in patients with known QT prolongation, patients with ongoing proarrhythmic conditions that may increase the risk of developing TdP (e.g., uncorrected hypokalemia or hypomagnesemia, significant bradycardia, congestive heart failure, acute myocardial ischemia, and atrial fibrillation), or patients receiving medications known to prolong the QT interval. Use levofloxacin with caution in patients with conditions that may increase the risk of QT prolongation including congenital long QT syndrome, bradycardia, AV block, heart failure, stress-related cardiomyopathy, myocardial infarction, stroke, hypomagnesemia, hypokalemia, hypocalcemia, or in patients receiving medications known to prolong the QT interval or cause electrolyte imbalances. Females, people 65 years and older, patients with sleep deprivation, pheochromocytoma, sickle cell disease, hypothyroidism, hyperparathyroidism, hypothermia, systemic inflammation (e.g., human immunodeficiency virus (HIV) infection, fever, and some autoimmune diseases including rheumatoid arthritis, systemic lupus erythematosus (SLE), and celiac disease) and patients undergoing apheresis procedures (e.g., plasmapheresis [plasma exchange], cytapheresis) may also be at increased risk for QT prolongation. Silent mutations and genetic polymorphisms in potassium channels may further increase the risk of QT prolongation in patients taking quinolones. If a quinolone is desired in patients with risk factors for QT prolongation, the use of ciprofloxacin is preferable, with ECG monitoring at initiation of therapy. If other quinolones are used, ECG and/or Holter monitoring during therapy is recommended.
Clearance of levofloxacin is substantially reduced and plasma elimination half-life is substantially prolonged in patients with renal impairment, as evidenced by a creatinine clearance (CrCl) less than 50 mL/minute. Dosage adjustment of levofloxacin is required in such patients, including patients with renal failure or receiving dialysis, to avoid accumulation.
Systemic levofloxacin should be used with caution in patients with dehydration. Although levofloxacin is more soluble than other quinolones, adequate hydration should be maintained to ensure the formation of a dilute urine, thereby preventing crystalluria.
Use levofloxacin with caution in patients at risk for or with pre-existing hepatic disease. Cases of severe hepatotoxicity, including acute hepatitis and fatalities, have been reported in patients receiving systemic levofloxacin. Hepatotoxicity generally occurred within 14 days of initiating therapy with most cases occurring within 6 days. Most cases were not associated with hypersensitivity. The majority of fatal cases were reported in patients 65 years of age and older. Discontinue levofloxacin immediately if the patient develops signs and symptoms of hepatitis (e.g., jaundice, right upper abdominal pain, fatigue, nausea, vomiting, dark colored urine, light colored stools).
Blood glucose disturbances, including symptomatic hyperglycemia and hypoglycemia, have been reported in patients receiving systemic levofloxacin. Hypoglycemia, sometimes resulting in coma, occurs more frequently in elderly patients or patients with diabetes mellitus who are receiving an oral hypoglycemic agent or insulin concomitantly with levofloxacin; carefully monitor blood glucose concentrations in these patients. Educate patients on the symptoms of hypoglycemia and how to treat if they experience hypoglycemia. Discontinue levofloxacin if a hypoglycemic reaction occurs and initiate appropriate therapy immediately. Patients with diabetes may also be at an increased risk of developing detachment of the retina.
Moderate to severe phototoxicity reactions have been observed in patients exposed to direct sunlight while receiving a systemic fluoroquinolone, such as levofloxacin. Although phototoxicity has occurred only rarely during levofloxacin therapy, patients should avoid excessive sunlight (UV) exposure. Therapy should be discontinued if phototoxicity occurs.
Consider pseudomembranous colitis in patients presenting with diarrhea after antibacterial use. Careful medical history is necessary as pseudomembranous colitis has been reported to occur over 2 months after the administration of antibacterial agents. Almost all antibacterial agents, including levofloxacin, have been associated with pseudomembranous colitis or C. difficile-associated diarrhea (CDAD) which may range in severity from mild to life-threatening. Treatment with antibacterial agents alters the normal flora of the colon leading to overgrowth of C. difficile.
Reserve systemic quinolones for use only when there are no alternative antibacterial treatments available in patients at risk for aortic dissection, including those with a history of aneurysm of the aorta or other blood vessels, peripheral atherosclerotic vascular diseases, hypertension, certain genetic conditions such as Marfan syndrome and Ehlers-Danlos syndrome, and elderly patients. Epidemiologic studies report an increased rate of aortic dissection within 2 months after quinolone use, particularly in elderly patients.
Older adults may be at a higher risk of adverse events related to systemic quinolones. Geriatric patients are more likely to have decreased renal function and care should be taken in dose selection; it may be useful to monitor renal function. Cases of fatal hepatotoxicity, not related to hypersensitivity reactions, have occurred in older adults (65 years and older) taking levofloxacin. Older adults are also at increased risk of developing tendon disorders while receiving quinolones; concomitant use of corticosteroids further increases these risks. Elderly patients may also be more susceptible to drug-associated effects on the QT interval and aortic dissection.
Caution is warranted with the systemic use of quinolones such as levofloxacin in neonates, infants, children, and adolescents. Systemic quinolones cause arthropathy in juvenile animals of several species. Evidence supporting sustained injury to developing joints in humans is lacking at this time; however, the possibility of rare occurrences has not been excluded. Topical ocular administration to the eye is approved for Quixin solution for children as young as 1 year of age and for Iquix for children as young as 6 years of age; there is no evidence that the ophthalmic administration of levofloxacin has any effect on weight bearing joints. One retrospective study compared the rate of tendon or joint disorders in more than 7,000 children less than 19 years old who received ciprofloxacin, ofloxacin, or levofloxacin with more than 20,000 children who received azithromycin. The incidence of potential tendon or joint disorders was found to be approximately 2% in both the quinolone and azithromycin groups, and verified disorders were reported in less than 1% in both groups. The authors state that this incidence is likely to reflect the background incidence of these disorders in pediatric patients. Another published report evaluated the safety data collected from 2,523 children and adolescents who participated in 1 of 3 efficacy trials and were randomized to receive levofloxacin or nonquinolone antibiotics. Two of the trials were open-label and 1 was evaluator-blinded only. In addition, a subset of these children participated in a 1-year surveillance trial (n = 2,233). The safety analysis focused on 4 musculoskeletal disorders: arthralgia, arthritis, tendinopathy, and gait abnormality. The authors reported an odds ratio and 95% confidence interval of 2.2 (0.95 to 5.2) at 1 month and 1.9 (1.1 to 3.5) at 1 year for experiencing at least 1 of the 4 musculoskeletal disorders as reported by the patient or parent or evaluated by an investigator. Due to concerns of increasing bacterial resistance, the possibility of rare joint injury, and other possible serious adverse reactions (i.e., CNS effects, peripheral neuropathy), the American Academy of Pediatrics Committee on Infectious Diseases recommends reserving the use of systemic quinolones for infections caused by multidrug-resistant pathogens for which there is no safe and effective alternative, for the treatment of infections when parenteral therapy is not feasible and no other effective oral agent is available, and for the treatment of infections as an alternative to standard therapy because of concerns for antimicrobial resistance, toxicity, or characteristics of tissue penetration.
Whenever clinical judgment dictates, examine patients receiving ophthalmic levofloxacin with the aid of magnification, such as slit lamp biomicroscopy, and, where appropriate, fluorescein staining. Advise patients not to wear contact lenses if they have signs and symptoms of bacterial conjunctivitis.
Systemic levofloxacin can cause dizziness and light-headedness; therefore, patients should know how they react to the drug before driving or operating machinery or engaging in an activity requiring mental alertness or coordination.
Administration of levofloxacin may result in laboratory test interference. False positive urine screening results for opiates have been reported in patients using some quinolones. These false positives are more likely to occur with levofloxacin and ofloxacin when used clinically because they produce urinary concentrations sufficient to interfere with commercially available immunoassay kits. Confirmation of positive opiate screens by more specific methods may be necessary. Antimicrobials are also known to suppress H. pylori; thus, ingestion of these agents within 4 weeks of performing diagnostic tests for H. pylori may lead to false negative results. At a minimum, instruct the patient to avoid the use of levofloxacin in the 4 weeks prior to the test.
Published studies regarding adverse pregnancy outcomes with quinolone use during pregnancy have reported conflicting outcomes. Most systematic reviews and meta-analyses of observational studies have indicated no significant increases in rates of major malformations and adverse pregnancy outcomes for quinolone exposure during pregnancy. Some studies have demonstrated an increased risk of miscarriage or major malformations; however, some of these studies had significant methodological limitations, which could have led to a higher risk. The manufacturer states that data on levofloxacin administration during pregnancy have not identified any drug-associated risk of major birth defects, miscarriage or adverse maternal or fetal outcomes. Because of the minimal systemic absorption of levofloxacin after topical ophthalmic administration, there is expected to be minimal risk of maternal and fetal toxicity when administered during pregnancy.
Levofloxacin is present in human breast milk after systemic administration. There is no information regarding the effects of levofloxacin on milk production or the breast-fed infant. Because of the potential risks of serious adverse reactions in breast-fed infants, breast-feeding is not recommended during treatment with levofloxacin and for an additional 2 days (5 half-lives) after the last dose. A lactating woman may consider pumping and discarding breast milk during treatment with levofloxacin and for an additional 2 days after the last dose. During an incident resulting in exposure to anthrax, the risk-benefit assessment of continuing breast-feeding while the mother is receiving levofloxacin may be acceptable; consider the developmental and health benefits of breast-feeding along with the mother's clinical need for levofloxacin and any potential adverse effects on the breast-fed child from levofloxacin or the underlying maternal condition. In a single case report, the peak levofloxacin breast milk concentration in a woman receiving 500 mg IV was 8.2 mcg/mL at 5 hours after the dose. The estimated maximum daily dose of levofloxacin through breast-feeding that an infant fed exclusively with breast milk (approximately 900 mL/day) would receive is 5 mg (approximately 1% of the maternal daily dose). Ciprofloxacin, sulfamethoxazole; trimethoprim, ceftazidime, ceftriaxone, cefepime, and piperacillin; tazobactam may be potential systemic alternatives to consider during breast-feeding. However, site of infection, patient factors, local susceptibility patterns, and specific microbial susceptibility should be assessed before choosing an alternative agent. Ophthalmic use of levofloxacin would result in minimal absorption. To minimize the amount of drug that reaches the systemic circulation and breast milk, apply pressure over the tear duct by the corner of the eye for 1 minute after ophthalmic administration.
Per the manufacturer, this drug has been shown to be active against most strains of the following microorganisms either in vitro and/or in clinical infections: Acinetobacter baumannii, Acinetobacter lwoffii, Bordetella pertussis, Chlamydophila pneumoniae, Citrobacter freundii, Citrobacter koseri, Clostridium perfringens, Enterobacter cloacae, Enterobacter sakazakii, Enterococcus faecalis, Escherichia coli, Haemophilus influenzae (beta-lactamase negative), Haemophilus influenzae (beta-lactamase positive), Haemophilus parainfluenzae, Klebsiella aerogenes, Klebsiella oxytoca, Klebsiella pneumoniae, Legionella pneumophila, Moraxella catarrhalis, Morganella morganii, Mycoplasma pneumoniae, Pantoea agglomerans, Proteus mirabilis, Proteus vulgaris, Providencia rettgeri, Providencia stuartii, Pseudomonas aeruginosa, Pseudomonas fluorescens, Serratia marcescens, Staphylococcus aureus (MSSA), Staphylococcus epidermidis, Staphylococcus haemolyticus, Staphylococcus saprophyticus, Streptococcus agalactiae (group B streptococci), Streptococcus milleri, Streptococcus pneumoniae, Streptococcus pyogenes (group A beta-hemolytic streptococci), Streptococcus sp., Viridans streptococci
NOTE: The safety and effectiveness in treating clinical infections due to organisms with in vitro data only have not been established in adequate and well-controlled clinical trials.
This drug may also have activity against the following microorganisms: Bacillus anthracis, Campylobacter jejuni, Campylobacter sp., Chlamydia trachomatis, Helicobacter pylori, Mycobacterium avium, Mycobacterium tuberculosis, Salmonella enterica serotype Typhi , Salmonella sp., Shigella dysenteriae, Shigella sp., Yersinia pestis
NOTE: Some organisms may not have been adequately studied during clinical trials; therefore, exclusion from this list does not necessarily negate the drug's activity against the organism.
For the treatment of acute bacterial sinusitis:
Oral dosage:
Adults: 500 mg PO once daily for 5 to 10 days as alternative therapy in patients with beta-lactam allergy or risks for resistance, those requiring hospitalization, or patients who failed initial therapy. The FDA-approved dose is 500 mg PO every 24 hours for 10 to 14 days or 750 mg PO every 24 hours for 5 days. Due to the risk for serious and potentially permanent side effects associated with quinolone antibiotics, levofloxacin should only be used in cases where alternative treatment options cannot be used.
Infants*, Children*, and Adolescents*: 10 to 20 mg/kg/day PO divided every 12 to 24 hours (Max: 500 mg/day) for 10 to 14 days as alternative therapy in patients with beta-lactam allergy or risks for resistance, those requiring hospitalization, or patients who failed initial therapy. Due to the risk for serious and potentially permanent adverse reactions associated with quinolone antibiotics, levofloxacin should only be used in cases where alternative treatment options cannot be used.
Intravenous dosage:
Adults: 500 mg IV once daily for 5 to 10 days as alternative therapy in patients with beta-lactam allergy or risks for resistance, those requiring hospitalization, or patients who failed initial therapy. The FDA-approved dose is 500 mg IV every 24 hours for 10 to 14 days or 750 mg IV every 24 hours for 5 days. Due to the risk for serious and potentially permanent side effects associated with quinolone antibiotics, levofloxacin should only be used in cases where alternative treatment options cannot be used.
Infants*, Children*, and Adolescents*: 10 to 20 mg/kg/day IV divided every 12 to 24 hours (Max: 500 mg/day) for 10 to 14 days as alternative therapy in patients with beta-lactam allergy or risks for resistance, those requiring hospitalization, or patients who failed initial therapy. Due to the risk for serious and potentially permanent adverse reactions associated with quinolone antibiotics, levofloxacin should only be used in cases where alternative treatment options cannot be used.
For the treatment of urinary tract infection (UTI), including cystitis, pyelonephritis, catheter-associated urinary tract infection, and infections with difficult-to-treat resistance*:
-for the treatment of acute uncomplicated cystitis:
Oral dosage:
Adults: 250 mg PO every 24 hours for 3 days. Due to the risk for serious and potentially permanent side effects associated with fluoroquinolone antibiotics, levofloxacin should only be used in cases where alternative treatment options cannot be used.
Intravenous dosage:
Adults: 250 mg IV every 24 hours for 3 days. Due to the risk for serious and potentially permanent side effects associated with fluoroquinolone antibiotics, levofloxacin should only be used in cases where alternative treatment options cannot be used.
-for the treatment of acute uncomplicated cystitis due to infections with difficult-to-treat resistance:
Oral dosage:
Adults: 750 mg PO every 24 hours for 3 days. Due to the risk for serious and potentially permanent side effects associated with fluoroquinolone antibiotics, levofloxacin should only be used in cases where alternative treatment options cannot be used.
Intravenous dosage:
Adults: 750 mg IV every 24 hours for 3 days. Due to the risk for serious and potentially permanent side effects associated with fluoroquinolone antibiotics, levofloxacin should only be used in cases where alternative treatment options cannot be used.
-for the treatment of complicated UTI, including acute pyelonephritis:
Oral dosage:
Adults: 750 mg PO every 24 hours for 5 days or 250 mg PO every 24 hours for 10 days.
Intravenous dosage:
Adults: 750 mg IV every 24 hours for 5 days or 250 mg IV every 24 hours for 10 days.
-for the treatment of catheter-associated UTI:
Oral dosage:
Adults: 750 mg PO every 24 hours for 5 days.
Intravenous dosage:
Adults: 750 mg IV every 24 hours for 5 days.
-for the treatment of complicated UTI, including acute pyelonephritis due to infections with difficult-to-treat resistance:
Oral dosage:
Adults: 750 mg PO every 24 hours for 5 days.
Intravenous dosage:
Adults: 750 mg IV every 24 hours for 5 days.
For the treatment of acute bacterial exacerbations of chronic obstructive pulmonary disease (COPD)*, including chronic bronchitis or emphysema*:
Oral dosage:
Adults: 500 mg PO every 24 hours for 5 to 7 days. Due to the risk for serious and potentially permanent side effects associated with fluoroquinolone antibiotics, levofloxacin should only be used in cases where alternative treatment options cannot be used.
Intravenous dosage:
Adults: 500 mg IV every 24 hours for 5 to 7 days. Due to the risk for serious and potentially permanent side effects associated with fluoroquinolone antibiotics, levofloxacin should only be used in cases where alternative treatment options cannot be used.
For the treatment of community-acquired pneumonia (CAP) and nosocomial pneumonia:
-for the treatment of community-acquired pneumonia (CAP), including infections due to resistant gram-negative organisms:
Oral dosage:
Adults: 750 mg PO every 24 hours for at least 5 days. Alternatively, 500 mg PO every 24 hours for 7 to 14 days. Guidelines recommend levofloxacin as monotherapy for outpatients with comorbidities or hospitalized patients with nonsevere pneumonia and as part of combination therapy for hospitalized patients with severe pneumonia. Guide treatment duration by clinical stability.
Adolescents*: 8 to 10 mg/kg/dose (Max: 750 mg/dose) PO every 24 hours for 5 to 10 days. Guidelines recommend levofloxacin as an alternative empiric therapy for hospitalized patients with presumed bacterial or atypical pneumonia, as preferred oral step-down therapy for patients with penicillin-resistant S. pneumoniae, and as alternative oral step-down therapy for patients with penicillin-susceptible S. pneumoniae, M. pneumoniae, or C. trachomatis, or C. pneumoniae. For persons living with HIV, levofloxacin is recommended as monotherapy for outpatients or hospitalized patients with nonsevere pneumonia or as part of combination therapy for hospitalized patients with severe pneumonia.
Children 5 to 12 years*: 8 to 10 mg/kg/dose (Max: 750 mg/dose) PO every 24 hours for 10 days. Guidelines recommend levofloxacin as an alternative empiric therapy for hospitalized patients with presumed bacterial or atypical pneumonia, as preferred oral step-down therapy for patients with penicillin-resistant S. pneumoniae, and as alternative oral step-down therapy for patients with penicillin-susceptible S. pneumoniae, M. pneumoniae, or C. trachomatis, or C. pneumoniae.
Infants and Children 6 months to 4 years*: 8 to 10 mg/kg/dose PO every 12 hours for 10 days. Guidelines recommend levofloxacin as an alternative empiric therapy for hospitalized patients with presumed bacterial or atypical pneumonia, as preferred oral step-down therapy for patients with penicillin-resistant S. pneumoniae, and as alternative oral step-down therapy for patients with penicillin-susceptible S. pneumoniae, M. pneumoniae, or C. trachomatis, or C. pneumoniae.
Intravenous dosage:
Adults: 750 mg IV every 24 hours for at least 5 days. Alternatively, 500 mg IV every 24 hours for 7 to 14 days. Guidelines recommend levofloxacin as monotherapy for hospitalized patients with nonsevere pneumonia or as part of combination therapy for hospitalized patients with severe pneumonia. Guide treatment duration by clinical stability.
Adolescents*: 8 to 10 mg/kg/dose (Max: 750 mg/dose) IV every 24 hours for 5 to 10 days. Guidelines recommend levofloxacin as an alternative empiric therapy for hospitalized patients with presumed bacterial or atypical pneumonia and as an alternative for patients with penicillin-resistant S. pneumoniae, H. influenzae, M. pneumoniae, C. trachomatis, or C. pneumoniae. For persons living with HIV, levofloxacin is recommended as monotherapy for hospitalized patients with nonsevere pneumonia or as part of combination therapy for hospitalized patients with severe pneumonia.
Children 5 to 12 years*: 8 to 10 mg/kg/dose (Max: 750 mg/dose) IV every 24 hours for 10 days. Guidelines recommend levofloxacin as an alternative empiric therapy for hospitalized patients with presumed bacterial or atypical pneumonia and as an alternative for patients with penicillin-resistant S. pneumoniae, H. influenzae, M. pneumoniae, C. trachomatis, or C. pneumoniae.
Infants and Children 6 months to 4 years*: 8 to 10 mg/kg/dose IV every 12 hours for 10 days. Guidelines recommend levofloxacin as an alternative empiric therapy for hospitalized patients with presumed bacterial or atypical pneumonia and as an alternative for patients with penicillin-resistant S. pneumoniae, H. influenzae, M. pneumoniae, C. trachomatis, or C. pneumoniae.
-for the treatment of nosocomial pneumonia, including infections due to resistant gram-negative organisms:
Oral dosage:
Adults: 750 mg PO every 24 hours for 7 days as a singular agent or as part of combination therapy. The FDA-approved duration is 7 to 14 days.
Intravenous dosage:
Adults: 750 mg IV every 24 hours for 7 days as a singular agent or as part of combination therapy. The FDA-approved duration is 7 to 14 days.
For the treatment of skin and skin structure infections, including impetigo, cellulitis, skin abscesses, furunculosis, pyoderma, animal bite wounds, diabetic foot ulcer, and surgical incision site infections:
-for the treatment of unspecified uncomplicated skin and skin structure infections:
Oral dosage:
Adults: 500 mg PO every 24 hours for 7 to 10 days.
Intravenous dosage:
Adults: 500 mg IV every 24 hours for 7 to 10 days.
-for the treatment of unspecified complicated skin and skin structure infections, including infections due to resistant gram-negative organisms:
Oral dosage:
Adults: 750 mg PO every 24 hours for 7 to 14 days.
Intravenous dosage:
Adults: 750 mg IV every 24 hours for 7 to 14 days.
-for the treatment of animal bite wounds:
Oral dosage:
Adults: 750 mg PO every 24 hours plus an anaerobic agent. In setting of a cat or dog bite, preemptive early antimicrobial therapy for 3 to 5 days is recommended for patients who are immunocompromised, asplenic, have advanced liver disease, have edema of the bite area, have moderate to severe injuries, particularly of the hand or face, or have penetrating injuries to the periosteum or joint capsule.
Intravenous dosage:
Adults: 750 mg IV every 24 hours plus an anaerobic agent. In setting of a cat or dog bite, preemptive early antimicrobial therapy for 3 to 5 days is recommended for patients who are immunocompromised, asplenic, have advanced liver disease, have edema of the bite area, have moderate to severe injuries, particularly of the hand or face, or have penetrating injuries to the periosteum or joint capsule.
-for the treatment of diabetic foot ulcer:
Oral dosage:
Adults: 750 mg PO every 24 hours for 7 to 14 days for mild infections in patients allergic or intolerant to beta-lactams or with recent antibiotic exposure or for moderate or severe infections in patients with risk factors for resistant gram-negative infections. Consider adding clindamycin for moderate or severe infections. Continue treatment for up to 28 days if infection is improving but is extensive and resolving slower than expected or if patient has severe peripheral artery disease.
Intravenous dosage:
Adults: 750 mg IV every 24 hours for 7 to 14 days for mild infections in patients allergic or intolerant to beta-lactams or with recent antibiotic exposure or for moderate or severe infections in patients with risk factors for resistant gram-negative infections. Consider adding clindamycin for moderate or severe infections. Continue treatment for up to 28 days if infection is improving but is extensive and resolving slower than expected or if patient has severe peripheral artery disease.
-for the treatment of surgical incision site infections:
Oral dosage:
Adults: 750 mg PO every 24 hours plus metronidazole for incisional surgical site infections of the axilla or perineum.
Intravenous dosage:
Adults: 750 mg IV every 24 hours plus metronidazole for incisional surgical site infections of the intestinal or genitourinary tract or axilla or perineum.
For the treatment of drug-susceptible tuberculosis infection* as part of combination therapy:
Oral dosage:
Adults: 500 to 1,000 mg PO once daily or 5 days/week. Daily dosing is defined as 5- or 7 days/week. Levofloxacin is generally recommended as second-line therapy; duration is dependent on the site of involvement.
Infants, Children, and Adolescents: 15 to 20 mg/kg/dose (Max: 1,000 mg/dose) PO once daily or 5 days/week. Daily dosing is defined as 5- or 7 days/week. Levofloxacin is generally recommended as second-line therapy; duration is dependent on the site of involvement.
Intravenous dosage:
Adults: 500 to 1,000 mg IV once daily or 5 days/week. Daily dosing is defined as 5- or 7 days/week. Levofloxacin is generally recommended as second-line therapy; duration is dependent on the site of involvement.
Infants, Children, and Adolescents: 15 to 20 mg/kg/dose (Max: 1,000 mg/dose) IV once daily or 5 days/week. Daily dosing is defined as 5- or 7 days/week. Levofloxacin is generally recommended as second-line therapy; duration is dependent on the site of involvement.
For the treatment of Mycobacterium avium complex infection* (MAC) in HIV-infected patients:
Oral dosage:
Adults: 500 mg PO once daily plus clarithromycin or azithromycin and ethambutol. May consider addition of levofloxacin as a third or fourth drug (or rifabutin, amikacin, streptomycin, or moxifloxacin) for patients with high mycobacterial loads (more than 2 log CFU/mL of blood) or in the absence of effective antiretroviral therapy. Duration of treatment depends on clinical response but should continue for at least 12 months.
Adolescents: 500 mg PO once daily plus clarithromycin or azithromycin and ethambutol. May consider addition of levofloxacin as a third or fourth drug (or rifabutin, amikacin, streptomycin, or moxifloxacin) for patients with high mycobacterial loads (more than 2 log CFU/mL of blood) or in the absence of effective antiretroviral therapy. Duration of treatment depends on clinical response but should continue for at least 12 months.
Children: 500 mg PO once daily in children who are old enough to receive adult dosing plus clarithromycin or azithromycin and ethambutol. Doses of 15 to 20 mg/kg/day PO divided every 12 hours have been used in children (weighing less than 50 kg) for other indications. May consider addition of levofloxacin if rifabutin cannot be administered for severe disease or if a fourth drug is needed for patients with more severe symptoms or disseminated disease. Duration of treatment depends on clinical response but should continue for at least 12 months.
For the treatment of drug-resistant tuberculosis infection* as part of combination therapy:
Oral dosage:
Adults: 750 to 1,500 mg PO once daily.
Infants, Children, and Adolescents: 15 to 20 mg/kg/dose PO once daily. A pharmacokinetic study found that doses from 18 mg/kg/day PO for younger children, up to 40 mg/kg/day PO for older children may be required to achieve adult-equivalent exposures.
Intravenous dosage:
Adults: 750 to 1,500 mg IV once daily.
Infants, Children, and Adolescents: 15 to 20 mg/kg/dose IV once daily. A pharmacokinetic study found that doses from 18 mg/kg/day IV for younger children, up to 40 mg/kg/day IV for older children may be required to achieve adult-equivalent exposures.
For the treatment of chlamydia infection*:
Oral dosage:
Adults: 500 mg PO every 24 hours for 7 days as an alternative.
Children and Adolescents weighing 45 kg or more: 500 mg PO every 24 hours for 7 days an alternative.
For drug-resistant tuberculosis prophylaxis*:
Oral dosage:
Adults weighing more than 45 kg: 1,000 mg PO once daily for 6 months.
Adults weighing 45 kg or less: 750 mg PO once daily for 6 months.
Adolescents 15 to 17 years weighing more than 45 kg: 1,000 mg PO once daily for 6 months.
Children and Adolescents 35 to 45 kg: 750 mg PO once daily for 6 months.
Children weighing 24 to 34 kg: 500 to 750 mg PO once daily for 6 months.
Children weighing 16 to 23 kg: 300 to 400 mg PO once daily for 6 months.
Infants and Children weighing 10 to 15 kg: 200 to 300 mg PO once daily for 6 months.
Infants weighing 5 to 9 kg: 150 mg PO once daily for 6 months.
For the treatment of chronic bacterial prostatitis or epididymitis*:
-for the treatment of chronic bacterial prostatitis:
Oral dosage:
Adults: 500 mg PO once daily for 28 days.
Intravenous dosage:
Adults: 500 mg IV once daily for 28 days.
-for the treatment of epididymitis*:
Oral dosage:
Adults: 500 mg PO once daily for 10 days for enteric organisms; add ceftriaxone IM if likely due gonorrhea, chlamydia, or enteric organisms.
Children weighing 45 kg or more and Adolescents: 500 mg PO once daily for 10 days for enteric organisms; add ceftriaxone IM if likely due gonorrhea, chlamydia, or enteric organisms.
For the treatment of pelvic inflammatory disease (PID)*:
Oral dosage:
Adults: Due to resistance, guidelines no longer recommend the use of quinolones. However, if allergy precludes the use of parenteral cephalosporin therapy, levofloxacin 500 mg PO daily plus metronidazole for 14 days may be considered if the community prevalence and individual risk for gonorrhea are low. Diagnostic testing for gonorrhea must be performed before starting therapy.
Adolescents: Due to resistance, guidelines no longer recommend the use of quinolones. However, if allergy precludes the use of parenteral cephalosporin therapy, levofloxacin 500 mg PO daily plus metronidazole for 14 days may be considered if the community prevalence and individual risk for gonorrhea are low. Diagnostic testing for gonorrhea must be performed before starting therapy.
For Helicobacter pylori (H. pylori) eradication*:
-for Helicobacter pylori (H. pylori) eradication* as part of initial triple therapy:
Oral dosage:
Adults: 500 mg PO once daily in combination with amoxicillin and a proton pump inhibitor (PPI) for 10 to 14 days.
-for Helicobacter pylori (H. pylori) eradication* as part of salvage triple therapy:
Oral dosage:
Adults: 500 mg PO once daily in combination with amoxicillin and a proton pump inhibitor (PPI) for 14 days.
-for Helicobacter pylori (H. pylori) eradication* as part of sequential therapy after initial amoxicillin and proton pump inhibitor (PPI) therapy:
Oral dosage:
Adults: 500 mg PO once daily in combination with a nitroimidazole and a proton pump inhibitor (PPI) for 5 to 7 days after initial 5 to 7-day therapy with amoxicillin and a PPI.
-for Helicobacter pylori (H. pylori) eradication* as part of quadruple therapy:
Oral dosage:
Adults: 250 mg PO once daily in combination with nitazoxanide, doxycycline, and a proton pump inhibitor (PPI) for 7 to 10 days.
-for Helicobacter pylori (H. pylori) eradication* as part of an alternative bismuth-containing quadruple therapy:
Oral dosage:
Adults: 500 mg PO once daily in combination with bismuth subsalicylate, a proton pump inhibitor (PPI), and amoxicillin, clarithromycin, metronidazole, or tetracycline for 10 to 14 days.
For the treatment infectious diarrhea* and gastroenteritis*, including campylobacteriosis*, salmonellosis*, shigellosis*, and traveler's diarrhea*:
-for the treatment of campylobacteriosis* in persons living with HIV:
Oral dosage:
Adults: 750 mg PO every 24 hours for 7 to 10 days as an alternative; add an aminoglycoside and treat for at least 14 days if concurrent bacteremia. Treat for 2 to 6 weeks for recurrent infections.
Adolescents: 750 mg PO every 24 hours for 7 to 10 days as an alternative; add an aminoglycoside and treat for at least 14 days if concurrent bacteremia. Treat for 2 to 6 weeks for recurrent infections.
Intravenous dosage:
Adults: 750 mg IV every 24 hours for 7 to 10 days as an alternative; add an aminoglycoside and treat for at least 14 days if concurrent bacteremia. Treat for 2 to 6 weeks for recurrent infections.
Adolescents: 750 mg IV every 24 hours for 7 to 10 days as an alternative; add an aminoglycoside and treat for at least 14 days if concurrent bacteremia. Treat for 2 to 6 weeks for recurrent infections.
-for the treatment of salmonellosis* in persons without HIV:
Oral dosage:
Adults: 750 mg PO once daily for 48 to 72 hours or until the patient becomes afebrile. Routine use is not recommended; reserve for patients at high risk for invasive infection.
-for the treatment of salmonellosis* in persons living with HIV:
Oral dosage:
Adults: 750 mg PO every 24 hours for 7 to 14 days as an alternative; treat for at least 14 days if concurrent bacteremia in persons with a CD4 count more than 200 cells/mm3. Treat for 2 to 6 weeks in persons with a CD4 count less than 200 cells/mm3. Follow with long-term suppressive therapy if persistent bacteremia or recurrent gastroenteritis with a CD4 count less than 200 cells/mm3 and severe diarrhea.
Adolescents: 750 mg PO every 24 hours for 7 to 14 days as an alternative; treat for at least 14 days if concurrent bacteremia in persons with a CD4 count more than 200 cells/mm3. Treat for 2 to 6 weeks in persons with a CD4 count less than 200 cells/mm3. Follow with long-term suppressive therapy if persistent bacteremia or recurrent gastroenteritis with a CD4 count less than 200 cells/mm3 and severe diarrhea.
Intravenous dosage:
Adults: 750 mg IV every 24 hours for 7 to 14 days as an alternative; treat for at least 14 days if concurrent bacteremia in persons with a CD4 count more than 200 cells/mm3. Treat for 2 to 6 weeks in persons with a CD4 count less than 200 cells/mm3. Follow with long-term suppressive therapy if persistent bacteremia or recurrent gastroenteritis with a CD4 count less than 200 cells/mm3 and severe diarrhea.
Adolescents: 750 mg IV every 24 hours for 7 to 14 days as an alternative; treat for at least 14 days if concurrent bacteremia in persons with a CD4 count more than 200 cells/mm3. Treat for 2 to 6 weeks in persons with a CD4 count less than 200 cells/mm3. Follow with long-term suppressive therapy if persistent bacteremia or recurrent gastroenteritis with a CD4 count less than 200 cells/mm3 and severe diarrhea.
-for the treatment of shigellosis* in persons living with HIV:
Oral dosage:
Adults: 750 mg PO every 24 hours for 7 to 10 days as an alternative; treat for at least 14 days if concurrent bacteremia. Treat for up to 6 weeks for recurrent infections.
Adolescents: 750 mg PO every 24 hours for 7 to 10 days as an alternative; treat for at least 14 days if concurrent bacteremia. Treat for up to 6 weeks for recurrent infections.
Intravenous dosage:
Adults: 750 mg IV every 24 hours for 7 to 10 days as an alternative; treat for at least 14 days if concurrent bacteremia. Treat for up to 6 weeks for recurrent infections.
Adolescents: 750 mg IV every 24 hours for 7 to 10 days as an alternative; treat for at least 14 days if concurrent bacteremia. Treat for up to 6 weeks for recurrent infections.
-for the treatment of traveler's diarrhea*:
Oral dosage:
Adults: 500 mg PO as a single dose or 500 mg PO once daily for 3 days; if symptoms are not resolved after single dose, continue treatment for up to 3 days. Antibiotic treatment is not recommended for mild cases, may be considered for moderate cases, and should be used for severe cases.
For the treatment of bacterial conjunctivitis:
Ophthalmic dosage:
Adults: 1 to 2 drops in affected eye(s) every 2 hours while awake, up to 8 times per day on days 1 and 2. On days 3 through 7, 1 to 2 drops every 4 hours while awake, up to 4 times per day.
Children and Adolescents: 1 to 2 drops in affected eye(s) every 2 hours while awake, up to 8 times per day on days 1 and 2. On days 3 through 7, 1 to 2 drops every 4 hours while awake, up to 4 times per day.
For the treatment of anthrax:
-for the treatment of cutaneous anthrax without aerosol exposure or signs and symptoms of meningitis*:
Oral dosage:
Adults: 750 mg PO every 24 hours for 7 to 10 days or until clinical criteria for stability are met.
Children and Adolescents weighing 50 kg or more: 750 mg PO every 24 hours for 7 to 10 days or until clinical criteria for stability are met.
Infants, Children, and Adolescents weighing less than 50 kg: 8 mg/kg/dose (Max: 250 mg/dose) PO every 12 hours for 7 to 10 days or until clinical criteria for stability are met.
Neonates 32 weeks gestation and older and 7 days and older: 10 mg/kg/dose PO every 8 hours for 7 to 10 days or until clinical criteria for stability are met.
Neonates 32 weeks gestation and older and 0 to 6 days: 10 mg/kg/dose PO every 12 hours for 7 to 10 days or until clinical criteria for stability are met.
-for the treatment of cutaneous anthrax with aerosol exposure and without signs and symptoms of meningitis:
Oral dosage:
Adults: 750 mg PO every 24 hours for 7 to 10 days or until clinical criteria for stability are met and then transition to a postexposure prophylaxis regimen to complete a 42- to 60-day total treatment course depending on vaccine status and immunocompetence. The FDA-approved dosage is 500 mg PO every 24 hours for 60 days.
Children and Adolescents weighing 50 kg or more: 750 mg PO every 24 hours for 7 to 10 days or until clinical criteria for stability are met and then transition to a postexposure prophylaxis regimen to complete a 60-day total treatment course. The FDA-approved dosage is 500 mg PO every 24 hours for 60 days.
Infants, Children, and Adolescents 6 months to 17 years weighing less than 50 kg: 8 mg/kg/dose (Max: 250 mg/dose) PO every 12 hours for 7 to 10 days or until clinical criteria for stability are met and then transition to a postexposure prophylaxis regimen to complete a 60-day total treatment course.
Infants 1 to 5 months*: 8 mg/kg/dose PO every 12 hours for 7 to 10 days or until clinical criteria for stability are met and then transition to a postexposure prophylaxis regimen to complete a 60-day total treatment course.
Neonates 32 weeks gestation and older and 7 days and older*: 10 mg/kg/dose PO every 8 hours for 7 to 10 days or until clinical criteria for stability are met and then transition to a postexposure prophylaxis regimen to complete a 60-day total treatment course.
Neonates 32 weeks gestation and older and 0 to 6 days*: 10 mg/kg/dose PO every 12 hours for 7 to 10 days or until clinical criteria for stability are met and then transition to a postexposure prophylaxis regimen to complete a 60-day total treatment course.
Intravenous dosage:
Adults: 750 mg IV every 24 hours for 7 to 10 days or until clinical criteria for stability; may consider step-down to oral therapy. Transition to a postexposure prophylaxis regimen to complete a 42- to 60-day total treatment course depending on vaccine status and immunocompetence. The FDA-approved dosage is 500 mg IV every 24 hours for 60 days.
Children and Adolescents weighing 50 kg or more: 750 mg IV every 24 hours for 7 to 10 days or until clinical criteria for stability are met; may consider step-down to oral therapy. Transition to a postexposure prophylaxis regimen to complete a 60-day total treatment course. The FDA-approved dosage is 500 mg IV every 24 hours for 60 days.
Infants, Children, and Adolescents 6 months to 17 years weighing less than 50 kg: 8 mg/kg/dose (Max: 250 mg/dose) IV every 12 hours for 7 to 10 days or until clinical criteria for stability are met; may consider step-down to oral therapy. Transition to a postexposure prophylaxis regimen to complete a 60-day total treatment course.
Infants 1 to 5 months*: 8 mg/kg/dose IV every 12 hours for 7 to 10 days or until clinical criteria for stability are met; may consider step-down to oral therapy. Transition to a postexposure prophylaxis regimen to complete a 60-day total treatment course.
Neonates 32 weeks gestation and older and 7 days and older*: 10 mg/kg/dose IV every 8 hours for 7 to 10 days or until clinical criteria for stability are met; may consider step-down to oral therapy. Transition to a postexposure prophylaxis regimen to complete a 60-day total treatment course.
Neonates 32 weeks gestation and older and 0 to 6 days*: 10 mg/kg/dose IV every 12 hours for 7 to 10 days or until clinical criteria for stability are met; may consider step-down to oral therapy. Transition to a postexposure prophylaxis regimen to complete a 60-day total treatment course.
-for the treatment of systemic anthrax without aerosol exposure, including those with signs and symptoms of meningitis, as part of combination therapy*:
Intravenous dosage:
Adults: 500 mg IV every 12 hours for at least 14 days; may consider step-down to oral therapy.
Children and Adolescents weighing 50 kg or more: 750 mg IV every 24 hours for at least 14 days; may consider step-down to oral therapy.
Infants, Children, and Adolescents weighing less than 50 kg: 10 mg/kg/dose (Max: 250 mg/dose) IV every 12 hours for at least 14 days; may consider step-down to oral therapy.
Neonates 32 weeks gestation and older and 7 days and older: 10 mg/kg/dose IV every 8 hours for at least 14 days; may consider step-down to oral therapy.
Neonates 32 weeks gestation and older and 0 to 6 days: 10 mg/kg/dose IV every 12 hours for at least 14 days; may consider step-down to oral therapy.
Oral dosage:
Adults: 500 mg PO every 12 hours for at least 14 days; oral therapy is not recommended with signs and symptoms of meningitis.
Children and Adolescents weighing 50 kg or more: 750 mg PO every 24 hours for at least 14 days; oral therapy is not recommended with signs and symptoms of meningitis.
Infants, Children, and Adolescents weighing less than 50 kg: 10 mg/kg/dose (Max: 250 mg/dose) PO every 12 hours for at least 14 days; oral therapy is not recommended with signs and symptoms of meningitis.
Neonates 32 weeks gestation and older and 7 days and older: 10 mg/kg/dose PO every 8 hours for at least 14 days; oral therapy is not recommended with signs and symptoms of meningitis.
Neonates 32 weeks gestation and older and 0 to 6 days: 10 mg/kg/dose PO every 12 hours for at least 14 days; oral therapy is not recommended with signs and symptoms of meningitis.
-for the treatment of systemic anthrax with aerosol exposure, including those with signs and symptoms of meningitis, as part of combination therapy:
Intravenous dosage:
Adults: 500 mg IV every 12 hours for at least 14 days; may consider step-down to oral therapy. The FDA-approved dosage is 500 mg IV every 24 hours for 60 days.
Immunocompromised Adults: 500 mg IV every 12 hours for at least 14 days; may consider step-down to oral therapy. Transition to a postexposure prophylaxis regimen to complete a 60-day total treatment course from illness onset. The FDA-approved dosage is 500 mg IV every 24 hours for 60 days.
Children and Adolescents weighing 50 kg or more: 750 mg IV every 24 hours for at least 14 days; may consider step-down to oral therapy. The FDA-approved dosage is 500 mg IV every 24 hours for 60 days.
Immunocompromised Children and Adolescents weighing 50 kg or more: 750 mg IV every 24 hours for at least 14 days; may consider step-down to oral therapy. Transition to a postexposure prophylaxis regimen to complete a 60-day total treatment course from illness onset. The FDA-approved dosage is 500 mg IV every 24 hours for 60 days.
Infants, Children, and Adolescents 6 months to 17 years weighing less than 50 kg: 10 mg/kg/dose (Max: 250 mg/dose) IV every 12 hours for at least 14 days; may consider step-down to oral therapy. The FDA-approved dosage is 8 mg/kg/dose (Max: 250 mg/dose) IV every 12 hours for 60 days.
Immunocompromised Infants, Children, and Adolescents 6 months to 17 years weighing less than 50 kg: 10 mg/kg/dose (Max: 250 mg/dose) IV every 12 hours for at least 14 days; may consider step-down to oral therapy. Transition to a postexposure prophylaxis regimen to complete a 60-day total treatment course from illness onset. The FDA-approved dosage is 8 mg/kg/dose (Max: 250 mg/dose) IV every 12 hours for 60 days.
Infants 1 to 5 months*: 10 mg/kg/dose IV every 12 hours for at least 14 days; may consider step-down to oral therapy.
Immunocompromised Infants 1 to 5 months*: 10 mg/kg/dose IV every 12 hours for at least 14 days; may consider step-down to oral therapy. Transition to a postexposure prophylaxis regimen to complete a 60-day total treatment course from illness onset.
Neonates 32 weeks gestation and older and 7 days and older*: 10 mg/kg/dose IV every 8 hours for at least 14 days; may consider step-down to oral therapy. Transition to a postexposure prophylaxis regimen to complete a 60-day total treatment course from illness onset.
Neonates 32 weeks gestation and older and 0 to 6 days*: 10 mg/kg/dose IV every 12 hours for at least 14 days; may consider step-down to oral therapy. Transition to a postexposure prophylaxis regimen to complete a 60-day total treatment course from illness onset.
Oral dosage:
Adults: 500 mg PO every 12 hours for at least 14 days; oral therapy is not recommended with signs and symptoms of meningitis. The FDA-approved dosage is 500 mg PO every 24 hours for 60 days.
Immunocompromised Adults: 500 mg PO every 12 hours for at least 14 days. Transition to a postexposure prophylaxis regimen to complete a 60-day total treatment course from illness onset. Oral therapy is not recommended with signs and symptoms of meningitis. The FDA-approved dosage is 500 mg PO every 24 hours for 60 days.
Children and Adolescents weighing 50 kg or more: 750 mg PO every 24 hours for at least 14 days; oral therapy is not recommended with signs and symptoms of meningitis. The FDA-approved dosage is 500 mg PO every 24 hours for 60 days.
Immunocompromised Children and Adolescents weighing 50 kg or more: 750 mg PO every 24 hours for at least 14 days. Transition to a postexposure prophylaxis regimen to complete a 60-day total treatment course from illness onset. Oral therapy is not recommended with signs and symptoms of meningitis. The FDA-approved dosage is 500 mg PO every 24 hours for 60 days.
Infants, Children, and Adolescents 6 months to 17 years weighing less than 50 kg: 10 mg/kg/dose (Max: 250 mg/dose) PO every 12 hours for at least 14 days; oral therapy is not recommended with signs and symptoms of meningitis. The FDA-approved dosage is 8 mg/kg/dose (Max: 250 mg/dose) PO every 24 hours for 60 days.
Immunocompromised Infants, Children, and Adolescents 6 months to 17 years weighing less than 50 kg: 10 mg/kg/dose (Max: 250 mg/dose) PO every 12 hours for at least 14 days. Transition to a postexposure prophylaxis regimen to complete a 60-day total treatment course from illness onset. Oral therapy is not recommended with signs and symptoms of meningitis. The FDA-approved dosage is 8 mg/kg/dose (Max: 250 mg/dose) PO every 24 hours for 60 days.
Infants 1 to 5 months*: 10 mg/kg/dose PO every 12 hours for at least 14 days; oral therapy is not recommended with signs and symptoms of meningitis.
Immunocompromised Infants 1 to 5 months*: 10 mg/kg/dose PO every 12 hours for at least 14 days. Transition to a postexposure prophylaxis regimen to complete a 60-day total treatment course from illness onset. Oral therapy is not recommended with signs and symptoms of meningitis.
Neonates 32 weeks gestation and older and 7 days and older*: 10 mg/kg/dose PO every 8 hours for at least 14 days. Transition to a postexposure prophylaxis regimen to complete a 60-day total treatment course from illness onset. Oral therapy is not recommended with signs and symptoms of meningitis.
Neonates 32 weeks gestation and older and 0 to 6 days*: 10 mg/kg/dose PO every 12 hours for at least 14 days. Transition to a postexposure prophylaxis regimen to complete a 60-day total treatment course from illness onset. Oral therapy is not recommended with signs and symptoms of meningitis.
For the treatment of plague infection:
-for the treatment of bubonic or pharyngeal plague:
Oral dosage:
Adults: 750 mg PO every 24 hours for 10 to 14 days as first-line therapy. Monotherapy is recommended for stable patients with naturally occurring plague, although dual therapy can be considered for patients with large buboes. Use dual therapy with 2 distinct classes of antimicrobials for initial treatment of naturally occurring plague in pregnant patients and patients infected after intentional release of Y. pestis. The FDA-approved dosage is 500 mg to 750 mg PO every 24 hours.
Children and Adolescents weighing 50 kg or more: 500 to 750 mg PO every 24 hours for 10 to 14 days as first-line therapy. Monotherapy is recommended for stable patients with naturally occurring plague, although dual therapy can be considered for patients with large buboes. Use dual therapy with 2 distinct classes of antimicrobials for initial treatment in patients infected after intentional release of Y. pestis.
Children and Adolescents weighing less than 50 kg: 8 mg/kg/dose (Max: 250 mg/dose) PO every 12 hours for 10 to 14 days as first-line therapy. Monotherapy is recommended for stable patients with naturally occurring plague, although dual therapy can be considered for patients with large buboes. Use dual therapy with 2 distinct classes of antimicrobials for initial treatment in patients infected after intentional release of Y. pestis.
Infants 6 to 11 months: 8 mg/kg/dose PO every 12 hours for 10 to 14 days as first-line therapy. Monotherapy is recommended for stable patients with naturally occurring plague, although dual therapy can be considered for patients with large buboes. Use dual therapy with 2 distinct classes of antimicrobials for initial treatment in patients infected after intentional release of Y. pestis.
Infants 1 to 5 months*: 8 mg/kg/dose PO every 12 hours for 10 to 14 days as first-line therapy. Monotherapy is recommended for stable patients with naturally occurring plague, although dual therapy can be considered for patients with large buboes. Use dual therapy with 2 distinct classes of antimicrobials for initial treatment in patients infected after intentional release of Y. pestis.
Neonates*: 10 mg/kg/dose PO every 12 hours or 10 to 14 days as first-line therapy. Use dual therapy with 2 distinct classes of antimicrobials for initial treatment in patients infected after intentional release of Y. pestis.
Intravenous dosage:
Adults: 750 mg IV every 24 hours for 10 to 14 days as first-line therapy. Monotherapy is recommended for stable patients with naturally occurring plague, although dual therapy can be considered for patients with large buboes. Use dual therapy with 2 distinct classes of antimicrobials for initial treatment of naturally occurring plague in pregnant patients and patients infected after intentional release of Y. pestis. The FDA-approved dosage is 500 mg to 750 mg IV every 24 hours.
Children and Adolescents weighing 50 kg or more: 500 to 750 mg IV every 24 hours for 10 to 14 days as first-line therapy. Monotherapy is recommended for stable patients with naturally occurring plague, although dual therapy can be considered for patients with large buboes. Use dual therapy with 2 distinct classes of antimicrobials for initial treatment in patients infected after intentional release of Y. pestis.
Children and Adolescents weighing less than 50 kg: 8 mg/kg/dose (Max: 250 mg/dose) IV every 12 hours for 10 to 14 days as first-line therapy. Monotherapy is recommended for stable patients with naturally occurring plague, although dual therapy can be considered for patients with large buboes. Use dual therapy with 2 distinct classes of antimicrobials for initial treatment in patients infected after intentional release of Y. pestis.
Infants 6 to 11 months: 8 mg/kg/dose IV every 12 hours for 10 to 14 days as first-line therapy. Monotherapy is recommended for stable patients with naturally occurring plague, although dual therapy can be considered for patients with large buboes. Use dual therapy with 2 distinct classes of antimicrobials for initial treatment in patients infected after intentional release of Y. pestis.
Infants 1 to 5 months*: 8 mg/kg/dose IV every 12 hours for 10 to 14 days as first-line therapy. Monotherapy is recommended for stable patients with naturally occurring plague, although dual therapy can be considered for patients with large buboes. Use dual therapy with 2 distinct classes of antimicrobials for initial treatment in patients infected after intentional release of Y. pestis.
Neonates*: 10 mg/kg/dose IV every 12 hours for 10 to 14 days as first-line therapy. Use dual therapy with 2 distinct classes of antimicrobials for initial treatment in patients infected after intentional release of Y. pestis.
-for the treatment of pneumonic or septicemic plague:
Oral dosage:
Adults: 750 mg PO every 24 hours for 10 to 14 days as first-line therapy. Monotherapy can be considered for mild-to-moderate disease in patients with naturally occurring plague. Use dual therapy with 2 distinct classes of antimicrobials for initial treatment of naturally occurring plague in pregnant patients, patients with severe disease, and patients infected after intentional release of Y. pestis. The FDA-approved dosage is 500 mg to 750 mg PO every 24 hours.
Children and Adolescents weighing 50 kg or more: 500 to 750 mg PO every 24 hours for 10 to 14 days as first-line therapy. Monotherapy can be considered for mild-to-moderate disease in patients with naturally occurring plague. Use dual therapy with 2 distinct classes of antimicrobials for initial treatment in patients with severe disease and patients infected after intentional release of Y. pestis.
Children and Adolescents weighing less than 50 kg: 8 mg/kg/dose (Max: 250 mg/dose) PO every 12 hours for 10 to 14 days as first-line therapy. Monotherapy can be considered for mild-to-moderate disease in patients with naturally occurring plague. Use dual therapy with 2 distinct classes of antimicrobials for initial treatment in patients with severe disease and patients infected after intentional release of Y. pestis.
Infants 6 to 11 months: 8 mg/kg/dose PO every 12 hours for 10 to 14 days as first-line therapy. Monotherapy can be considered for mild-to-moderate disease in patients with naturally occurring plague. Use dual therapy with 2 distinct classes of antimicrobials for initial treatment in patients with severe disease and patients infected after intentional release of Y. pestis.
Infants 1 to 5 months*: 8 mg/kg/dose PO every 12 hours for 10 to 14 days as first-line therapy. Monotherapy can be considered for mild-to-moderate disease in patients with naturally occurring plague. Use dual therapy with 2 distinct classes of antimicrobials for initial treatment in patients with severe disease and patients infected after intentional release of Y. pestis.
Neonates*: 10 mg/kg/dose PO every 12 hours for 10 to 14 days as first-line therapy. Use dual therapy with 2 distinct classes of antimicrobials for initial treatment in patients with severe disease and patients infected after intentional release of Y. pestis.
Intravenous dosage:
Adults: 750 mg IV every 24 hours for 10 to 14 days as first-line therapy. Monotherapy can be considered for mild-to-moderate disease in patients with naturally occurring plague. Use dual therapy with 2 distinct classes of antimicrobials for initial treatment of naturally occurring plague in pregnant patients, patients with severe disease, and patients infected after intentional release of Y. pestis. The FDA-approved dosage is 500 mg to 750 mg IV every 24 hours.
Children and Adolescents weighing 50 kg or more: 500 to 750 mg IV every 24 hours for 10 to 14 days as first-line therapy. Monotherapy can be considered for mild-to-moderate disease in patients with naturally occurring plague. Use dual therapy with 2 distinct classes of antimicrobials for initial treatment in patients with severe disease and patients infected after intentional release of Y. pestis.
Children and Adolescents weighing less than 50 kg: 8 mg/kg/dose (Max: 250 mg/dose) IV every 12 hours for 10 to 14 days as first-line therapy. Monotherapy can be considered for mild-to-moderate disease in patients with naturally occurring plague. Use dual therapy with 2 distinct classes of antimicrobials for initial treatment in patients with severe disease and patients infected after intentional release of Y. pestis.
Infants 6 to 11 months: 8 mg/kg/dose IV every 12 hours for 10 to 14 days as first-line therapy. Monotherapy can be considered for mild-to-moderate disease in patients with naturally occurring plague. Use dual therapy with 2 distinct classes of antimicrobials for initial treatment in patients with severe disease and patients infected after intentional release of Y. pestis.
Infants 1 to 5 months*: 8 mg/kg/dose IV every 12 hours for 10 to 14 days as first-line therapy. Monotherapy can be considered for mild-to-moderate disease in patients with naturally occurring plague. Use dual therapy with 2 distinct classes of antimicrobials for initial treatment in patients with severe disease and patients infected after intentional release of Y. pestis.
Neonates*: 10 mg/kg/dose IV every 12 hours for 10 to 14 days as first-line therapy. Use dual therapy with 2 distinct classes of antimicrobials for initial treatment in patients with severe disease and patients infected after intentional release of Y. pestis.
-for the treatment of plague meningitis*:
Oral dosage:
Adults: 750 mg PO every 24 hours in combination with chloramphenicol for 10 to 14 days. If chloramphenicol is not available, a nonfluoroquinolone first-line or alternative antimicrobial for treatment of septicemic plague can be substituted. For patients with secondary plague meningitis, add levofloxacin to the existing antimicrobial regimen and continue the entire regimen for an additional 10 days.
Children and Adolescents weighing 50 kg or more: 500 to 750 mg PO every 24 hours in combination with chloramphenicol for 10 to 14 days. If chloramphenicol is not available, a nonfluoroquinolone first-line or alternative antimicrobial for treatment of septicemic plague can be substituted. For patients with secondary plague meningitis, add levofloxacin to the existing antimicrobial regimen and continue the entire regimen for an additional 10 days.
Infants, Children, and Adolescents weighing less than 50 kg: 8 mg/kg/dose (Max: 250 mg/dose) PO every 12 hours in combination with chloramphenicol for 10 to 14 days. If chloramphenicol is not available or not desired due to potential toxicity in young children, a nonfluoroquinolone first-line or alternative antimicrobial for treatment of septicemic plague can be substituted. For patients with secondary plague meningitis, add levofloxacin to the existing antimicrobial regimen and continue the entire regimen for an additional 10 days.
Neonates: 10 mg/kg/dose PO every 12 hours in combination with chloramphenicol for 10 to 14 days. If chloramphenicol is not available or not desired due to potential toxicity in young children, a nonfluoroquinolone first-line or alternative antimicrobial for treatment of septicemic plague can be substituted. For patients with secondary plague meningitis, add levofloxacin to the existing antimicrobial regimen and continue the entire regimen for an additional 10 days.
Intravenous dosage:
Adults: 750 mg IV every 24 hours in combination with chloramphenicol for 10 to 14 days. If chloramphenicol is not available, a nonfluoroquinolone first-line or alternative antimicrobial for treatment of septicemic plague can be substituted. For patients with secondary plague meningitis, add levofloxacin to the existing antimicrobial regimen and continue the entire regimen for an additional 10 days.
Children and Adolescents weighing 50 kg or more: 500 to 750 mg IV every 24 hours in combination with chloramphenicol for 10 to 14 days. If chloramphenicol is not available, a nonfluoroquinolone first-line or alternative antimicrobial for treatment of septicemic plague can be substituted. For patients with secondary plague meningitis, add levofloxacin to the existing antimicrobial regimen and continue the entire regimen for an additional 10 days.
Infants, Children, and Adolescents weighing less than 50 kg: 8 mg/kg/dose (Max: 250 mg/dose) IV every 12 hours in combination with chloramphenicol for 10 to 14 days. If chloramphenicol is not available or not desired due to potential toxicity in young children, a nonfluoroquinolone first-line or alternative antimicrobial for treatment of septicemic plague can be substituted. For patients with secondary plague meningitis, add levofloxacin to the existing antimicrobial regimen and continue the entire regimen for an additional 10 days.
Neonates: 10 mg/kg/dose IV every 12 hours in combination with chloramphenicol for 10 to 14 days. If chloramphenicol is not available or not desired due to potential toxicity in young children, a nonfluoroquinolone first-line or alternative antimicrobial for treatment of septicemic plague can be substituted. For patients with secondary plague meningitis, add levofloxacin to the existing antimicrobial regimen and continue the entire regimen for an additional 10 days.
For postexposure anthrax prophylaxis:
-for postexposure anthrax prophylaxis after nonaerosol exposure (cutaneous or ingestion)*:
Oral dosage:
Adults: 500 mg PO every 24 hours for 7 days after exposure.
Children and Adolescents weighing 50 kg or more: 500 mg PO every 24 hours for 7 days after exposure.
Infants, Children, and Adolescents weighing less than 50 kg: 8 mg/kg/dose (Max: 250 mg/dose) PO every 12 hours for 7 days after exposure.
Neonates 32 weeks gestation and older and 7 days and older: 10 mg/kg/dose PO every 8 hours for 7 days after exposure.
Neonates 32 weeks gestation and older and 0 to 6 days: 10 mg/kg/dose PO every 12 hours for 7 days after exposure.
-for postexposure anthrax prophylaxis after aerosol exposure:
Oral dosage:
Adults 66 years and older: 500 mg PO every 24 hours for 60 days after exposure.
Adults 18 to 65 years: 500 mg PO every 24 hours for 60 days after exposure. For immunocompetent, nonpregnant persons who received the anthrax vaccine, may decrease duration to 42 days after first antibiotic dose or 2 weeks after the last vaccine dose, whichever occurs later.
Children and Adolescents weighing 50 kg or more: 500 mg PO every 24 hours for 60 days after exposure.
Infants, Children, and Adolescents 6 months to 17 years weighing less than 50 kg: 8 mg/kg/dose (Max: 250 mg/dose) PO every 12 hours for 60 days after exposure.
Infants 1 to 5 months*: 8 mg/kg/dose PO every 12 hours for 60 days after exposure.
Neonates 32 weeks gestation and older and 7 days and older*: 10 mg/kg/dose PO every 8 hours for 60 days after exposure.
Neonates 32 weeks gestation and older and 0 to 6 days*: 10 mg/kg/dose PO every 12 hours for 60 days after exposure.
Intravenous dosage:
Adults 66 years and older: 500 mg IV every 24 hours for 60 days after exposure.
Adults 18 to 65 years: 500 mg IV every 24 hours for 60 days after exposure. For immunocompetent, nonpregnant persons who received the anthrax vaccine, may decrease duration to 42 days after first antibiotic dose or 2 weeks after the last vaccine dose, whichever occurs later.
Children and Adolescents weighing 50 kg or more: 500 mg IV every 24 hours for 60 days after exposure.
Infants, Children, and Adolescents 6 months to 17 years weighing less than 50 kg: 8 mg/kg/dose (Max: 250 mg/dose) IV every 12 hours for 60 days after exposure.
Infants 1 to 5 months*: 8 mg/kg/dose IV every 12 hours for 60 days after exposure.
Neonates 32 weeks gestation and older and 7 days and older*: 10 mg/kg/dose IV every 8 hours for 60 days after exposure.
Neonates 32 weeks gestation and older and 0 to 6 days*: 10 mg/kg/dose IV every 12 hours for 60 days after exposure.
For surgical infection prophylaxis*:
Intravenous dosage:
Adults: 500 mg IV as a single preoperative dose for procedures involving lower urinary tract instrumentation or as an alternative option in beta-lactam allergic patients as part of combination therapy in gastrointestinal, transplantation, hysterectomy, urogynecology, and other urologic procedures. Doses should be administered within 120 minutes prior to the surgical incision. No redosing is recommended; the duration of prophylaxis should be less than 24 hours for most procedures.
Infants, Children, and Adolescents: 10 mg/kg/dose IV as a single dose (Max: 500 mg/dose) within 120 minutes prior to the surgical incision. No redosing is recommended. Quinolones are not considered drugs of first choice in pediatric populations due to the incidence of adverse reactions. Quinolones may be used as an alternative option in a number of surgical procedures including several gastrointestinal procedures, urologic procedures, and transplantations. Generally, they are used as part of combination therapy except for procedures involving lower urinary tract instrumentation.
For the empiric treatment of febrile neutropenia* as part of combination therapy:
Oral dosage:
Adults: 500 to 750 mg PO once daily. Levofloxacin is not routinely recommend due to the lack of well-published data to support this indication; however, levofloxacin plus amoxicillin; clavulanate may be considered for low-risk patients.
Intravenous dosage:
Adults: 500 to 750 mg IV once daily. Levofloxacin is not routinely recommend due to the lack of well-published data to support this indication; however, fluoroquinolones may be used as an add-on to IV therapy in certain high-risk patients.
For the treatment of sepsis*, including infections with difficult-to-treat resistance:
Intravenous dosage:
Adults: 750 mg IV every 24 hours. Start within 1 hour for septic shock or within 3 hours for possible sepsis without shock. Duration of therapy is not well-defined and dependent on patient- and infection-specific factors. Assess patient daily for deescalation of antimicrobial therapy based on pathogen identification and/or adequate clinical response.
For the treatment of intraabdominal infections*, including peritonitis*, appendicitis*, intraabdominal abscess*, biliary tract infections* (cholecystitis*, cholangitis*), complicated diverticulitis*, peritoneal dialysis-related peritonitis*, peritoneal dialysis catheter-related infection*:
-for the treatment of complicated community-acquired and healthcare-acquired intraabdominal infections* with adequate source control:
Oral dosage:
Adults: 500 to 750 mg PO every 24 hours as part of combination therapy for 3 to 7 days. Complicated infections include peritonitis and appendicitis complicated by rupture, intraabdominal abscess, and complicated diverticulitis .
Children and Adolescents weighing 50 kg or more: 500 mg PO every 24 hours as part of combination therapy for 3 to 7 days. Complicated infections include peritonitis and appendicitis complicated by rupture, and intraabdominal abscess.
Infants, Children, and Adolescents 6 months to 17 years weighing less than 50 kg: 8 to 10 mg/kg/dose (Max: 250 mg/dose) PO every 12 hours as part of combination therapy for 3 to 7 days. Complicated infections include peritonitis and appendicitis complicated by rupture, and intraabdominal abscess.
Intravenous dosage:
Adults: 500 to 750 mg IV every 24 hours as part of combination therapy for 3 to 7 days. Complicated infections include peritonitis and appendicitis complicated by rupture, and intraabdominal abscess.
Children and Adolescents weighing 50 kg or more: 500 mg IV every 24 hours as part of combination therapy for 3 to 7 days. Complicated infections include peritonitis and appendicitis complicated by rupture, and intraabdominal abscess.
Infants, Children, and Adolescents 6 months to 17 years weighing less than 50 kg: 8 to 10 mg/kg/dose (Max: 250 mg/dose) IV every 12 hours as part of combination therapy for 3 to 7 days. Complicated infections include peritonitis and appendicitis complicated by rupture, and intraabdominal abscess.
-for the treatment of complicated community-acquired and healthcare-acquired intraabdominal infections* with adequate source control due to resistant gram-negative organisms:
Oral dosage:
Adults: 750 mg PO every 24 hours as part of combination therapy for 3 to 7 days. Complicated infections include peritonitis and appendicitis complicated by rupture, and intraabdominal abscess.
Intravenous dosage:
Adults: 750 mg IV every 24 hours as part of combination therapy for 3 to 7 days. Complicated infections include peritonitis and appendicitis complicated by rupture, and intraabdominal abscess.
-for the treatment of uncomplicated intraabdominal infections*:
Oral dosage:
Adults: 500 to 750 mg PO once as part of combination therapy. Antibiotics should be discontinued within 24 hours. Uncomplicated infections include acute appendicitis without perforation, abscess, or local peritonitis; traumatic bowel perforations repaired within 12 hours; acute cholecystitis without perforation; and ischemic, non-perforated bowel.
Children and Adolescents weighing 50 kg or more: 500 mg PO once as part of combination therapy. Antibiotics should be discontinued within 24 hours. Uncomplicated infections include acute appendicitis without perforation, abscess, or local peritonitis; traumatic bowel perforations repaired within 12 hours; acute cholecystitis without perforation; and ischemic, non-perforated bowel.
Infants, Children, and Adolescents 6 months to 17 years weighing less than 50 kg: 8 to 10 mg/kg/dose (Max: 250 mg/dose) PO every 12 hours as part of combination therapy. Antibiotics should be discontinued within 24 hours. Uncomplicated infections include acute appendicitis without perforation, abscess, or local peritonitis; traumatic bowel perforations repaired within 12 hours; acute cholecystitis without perforation; and ischemic, non-perforated bowel.
Intravenous dosage:
Adults: 500 to 750 mg IV once as part of combination therapy. Antibiotics should be discontinued within 24 hours. Uncomplicated infections include acute appendicitis without perforation, abscess, or local peritonitis; traumatic bowel perforations repaired within 12 hours; acute cholecystitis without perforation; and ischemic, non-perforated bowel.
Children and Adolescents weighing 50 kg or more: 500 mg IV once as part of combination therapy. Antibiotics should be discontinued within 24 hours. Uncomplicated infections include acute appendicitis without perforation, abscess, or local peritonitis; traumatic bowel perforations repaired within 12 hours; acute cholecystitis without perforation; and ischemic, non-perforated bowel.
Infants, Children, and Adolescents 6 months to 17 years weighing less than 50 kg: 8 to 10 mg/kg/dose (Max: 250 mg/dose) IV every 12 hours as part of combination therapy. Antibiotics should be discontinued within 24 hours. Uncomplicated infections include acute appendicitis without perforation, abscess, or local peritonitis; traumatic bowel perforations repaired within 12 hours; acute cholecystitis without perforation; and ischemic, non-perforated bowel.
-for the treatment of peritoneal dialysis-related peritonitis*:
Oral dosage:
Adults: 250 mg PO every 24 hours for 21 to 28 days.
-for the treatment of peritoneal dialysis catheter-related infection*:
Oral dosage:
Adults: 250 mg PO every 24 hours for at least 14 to 21 days.
Infants, Children, and Adolescents: 10 mg/kg/dose PO every 48 hours (Max: 500 mg on day 1 then 250 mg) for at least 14 to 28 days.
For bacterial infection prophylaxis* in high-risk pediatric cancer patients:
NOTE: Consider prophylaxis in pediatric patients with AML or relapsed ALL receiving intensive chemotherapy expected to result in severe neutropenia (absolute neutrophil count (ANC) less than 500 cells/mm3) for at least 7 days. Routine prophylaxis is not recommended for patients receiving induction chemotherapy for newly diagnosed ALL, patients whose therapy is not expected to result in severe neutropenia for at least 7 days, or for patients undergoing HSCT.
Oral dosage:
Children and Adolescents 5 to 17 years: 10 mg/kg/dose PO every 24 hours (Max: 750 mg/day) continued through the period of severe neutropenia (ANC less than 500 cells/mm3).
Infants and Children 6 months to 4 years: 10 mg/kg/dose PO every 12 hours continued through the period of severe neutropenia (ANC less than 500 cells/mm3).
Intravenous dosage:
Children and Adolescents 5 to 17 years: 10 mg/kg/dose IV every 24 hours (Max: 750 mg/day) continued through the period of severe neutropenia (ANC less than 500 cells/mm3).
Infants and Children 6 months to 4 years: 10 mg/kg/dose IV every 12 hours continued through the period of severe neutropenia (ANC less than 500 cells/mm3).
For plague prophylaxis:
-for pre-exposure prophylaxis*:
Oral dosage:
Adults: 500 to 750 mg PO every 24 hours until 48 hours after the last perceived exposure as first-line therapy.
Pregnant patients: 750 mg PO every 24 hours until 48 hours after the last perceived exposure as first-line therapy.
Children and Adolescents weighing 50 kg or more: 500 to 750 mg PO every 24 hours until 48 hours after the last perceived exposure as first-line therapy.
Infants, Children, and Adolescents weighing less than 50 kg: 8 mg/kg/dose (Max: 250 mg/dose) PO every 12 hours until 48 hours after the last perceived exposure as first-line therapy.
-for postexposure prophylaxis:
Oral dosage:
Adults: 500 to 750 mg PO every 24 hours for 7 days as first-line therapy. The FDA-approved duration is 10 to 14 days.
Pregnant patients: 750 mg PO every 24 hours for 7 days as first-line therapy. The FDA-approved dosage is 500 mg PO every 24 hours for 10 to 14 days.
Children and Adolescents weighing 50 kg or more: 500 to 750 mg PO every 24 hours for 7 days as first-line therapy. The FDA-approved duration is 10 to 14 days.
Children and Adolescents weighing less than 50 kg: 8 mg/kg/dose (Max: 250 mg/dose) PO every 12 hours for 7 days as first-line therapy. The FDA-approved duration is 10 to 14 days.
Infants 6 to 11 months: 8 mg/kg/dose PO every 12 hours for 7 days as first-line therapy. The FDA-approved duration is 10 to 14 days.
Infants 1 to 5 months*: 8 mg/kg/dose PO every 12 hours for 7 days as first-line therapy.
Neonates*: 10 mg/kg/dose PO every 12 hours for 7 days as first-line therapy.
Intravenous dosage:
Adults: 500 to 750 mg IV every 24 hours for 7 days as first-line therapy. The FDA-approved duration is 10 to 14 days.
Pregnant patients: 750 mg IV every 24 hours for 7 days as first-line therapy. The FDA-approved dosage is 500 mg IV every 24 hours for 10 to 14 days.
Children and Adolescents weighing 50 kg or more: 500 to 750 mg IV every 24 hours for 7 days as first-line therapy. The FDA-approved duration is 10 to 14 days.
Children and Adolescents weighing less than 50 kg: 8 mg/kg/dose (Max: 250 mg/dose) IV every 12 hours for 7 days as first-line therapy. The FDA-approved duration is 10 to 14 days.
Infants 6 to 11 months: 8 mg/kg/dose IV every 12 hours for 7 days as first-line therapy. The FDA-approved duration is 10 to 14 days.
Infants 1 to 5 months*: 8 mg/kg/dose IV every 12 hours for 7 days as first-line therapy.
Neonates*: 10 mg/kg/dose IV every 12 hours for 7 days as first-line therapy.
For secondary salmonellosis prophylaxis* (i.e., long-term suppressive therapy*) in persons living with HIV:
Oral dosage:
Adults: 750 mg PO every 24 hours in persons with recurrent bacteremia or gastroenteritis with a CD4 count of less than 200 cells/mm3 and severe diarrhea as an alternative. Discontinuation may be considered after resolution of infection in persons with a response to antiretroviral therapy with sustained viral suppression and CD4 count more than 200 cells/mm3.
Adolescents: 750 mg PO every 24 hours in persons with recurrent bacteremia or gastroenteritis with a CD4 count of less than 200 cells/mm3 and severe diarrhea as an alternative. Discontinuation may be considered after resolution of infection in persons with a response to antiretroviral therapy with sustained viral suppression and CD4 count more than 200 cells/mm3.
For the treatment of invasive vibriosis*:
Oral dosage:
Adults: 500 mg PO every 24 hours for 7 to 14 days as an alternative.
Intravenous dosage:
Adults: 500 mg IV every 24 hours for 7 to 14 days as an alternative.
For the treatment of bone and joint infections*, including osteomyelitis*, infectious arthritis*, and infectious bursitis*:
-for the treatment of unspecified osteomyelitis*:
Intravenous dosage:
Adults: 500 to 750 mg IV once daily for 4 to 6 weeks; use in combination with rifampin for Staphylococcal infections.
Children and Adolescents 5 to 17 years: 8 to 10 mg/kg/dose (Max: 750 mg/dose) IV once daily. Treat for 2 to 4 days or until clinically improved, followed by oral step-down therapy for a total duration of 3 to 4 weeks for uncomplicated cases. A longer course (i.e., 4 to 6 weeks or longer) may be needed for severe or complicated infections.
Infants and Children 6 months to 4 years: 8 to 10 mg/kg/dose IV every 12 hours. Treat for 2 to 4 days or until clinically improved, followed by oral step-down therapy for a total duration of 3 to 4 weeks for uncomplicated cases. A longer course (i.e., 4 to 6 weeks or longer) may be needed for severe or complicated infections.
Oral dosage:
Adults: 500 to 750 mg PO once daily for 4 to 6 weeks; use in combination with rifampin for Staphylococcal infections.
Children and Adolescents 5 to 17 years: 8 to 10 mg/kg/dose (Max: 750 mg/dose) PO once daily. Treat for a total duration of 3 to 4 weeks (parenteral plus oral) for uncomplicated cases. A longer course (i.e., 4 to 6 weeks or longer) may be needed for severe or complicated infections.
Infants and Children 6 months to 4 years: 8 to 10 mg/kg/dose PO every 12 hours as step-down therapy after initial parenteral therapy. Treat for a total duration of 3 to 4 weeks (parenteral plus oral) for uncomplicated cases. A longer course (i.e., 4 to 6 weeks or longer) may be needed for severe or complicated infections.
-for the treatment of native vertebral osteomyelitis*:
Intravenous dosage:
Adults: 500 to 750 mg IV once daily for 6 weeks; add rifampin for Staphylococcal infections.
Oral dosage:
Adults: 500 to 750 mg PO once daily for 6 weeks; add rifampin for Staphylococcal infections.
-for the treatment of infectious arthritis*:
Intravenous dosage:
Adults: 750 mg IV once daily. Treat for 1 to 2 weeks or until clinically improved, followed by oral step-down therapy for 2 to 4 weeks.
Children and Adolescents 5 to 17 years: 8 to 10 mg/kg/dose (Max: 750 mg/dose) IV once daily. Treat for 2 to 4 days or until clinically improved, followed by oral step-down therapy for a total duration of 2 to 3 weeks for uncomplicated cases. A longer course (i.e., 4 to 6 weeks or longer) may be needed for septic hip arthritis or severe or complicated infections.
Infants and Children 6 months to 4 years: 8 to 10 mg/kg/dose IV every 12 hours. Treat for 2 to 4 days or until clinically improved, followed by oral step-down therapy for a total duration of 2 to 3 weeks for uncomplicated cases. A longer course (i.e., 4 to 6 weeks or longer) may be needed for septic hip arthritis or severe or complicated infections.
Oral dosage:
Adults: 750 mg PO once daily as step-down therapy after initial parenteral therapy. Treat for a total duration of 3 to 6 weeks (parenteral plus oral).
Children and Adolescents 5 to 17 years: 8 to 10 mg/kg/dose (Max: 750 mg/dose) PO once daily as step-down therapy after initial parenteral therapy. Treat for a total duration of 2 to 3 weeks (parenteral plus oral) for uncomplicated cases. A longer course (i.e., 4 to 6 weeks or longer) may be needed for septic hip arthritis or severe or complicated infections.
Infants and Children 6 months to 4 years: 8 to 10 mg/kg/dose PO every 12 hours as step-down therapy after initial parenteral therapy. Treat for a total duration of 2 to 3 weeks (parenteral plus oral) for uncomplicated cases. A longer course (i.e., 4 to 6 weeks or longer) may be needed for septic hip arthritis or severe or complicated infections.
-for the treatment of infectious bursitis*:
Intravenous dosage:
Adults: 750 mg IV once daily for 2 to 3 weeks. Generally, 2 weeks is appropriate for most patients; immunocompromised patients may require a longer duration.
Children and Adolescents 5 to 17 years: 8 to 10 mg/kg/dose (Max: 750 mg/dose) IV once daily for 2 to 3 weeks. Generally, 2 weeks is appropriate for most patients; immunocompromised patients may require a longer duration.
Children 1 to 4 years: 8 to 10 mg/kg/dose IV every 12 hours for 2 to 3 weeks. Generally, 2 weeks is appropriate for most patients; immunocompromised patients may require a longer duration.
Oral dosage:
Adults: 750 mg PO once daily for 2 to 3 weeks. Generally, 2 weeks is appropriate for most patients; immunocompromised patients may require a longer duration.
Children and Adolescents 5 to 17 years: 8 to 10 mg/kg/dose (Max: 750 mg/dose) PO once daily for 2 to 3 weeks. Generally, 2 weeks is appropriate for most patients; immunocompromised patients may require a longer duration.
Children 1 to 4 years: 8 to 10 mg/kg/dose PO every 12 hours for 2 to 3 weeks. Generally, 2 weeks is appropriate for most patients; immunocompromised patients may require a longer duration.
For the treatment of acute exacerbations of bronchiectasis*:
Oral dosage:
Adults: 500 mg PO every 24 hours for 14 days.
Intravenous dosage:
Adults: 500 mg IV every 24 hours for 14 days.
For the treatment of epiglottitis*:
Intravenous dosage:
Adults: 750 mg IV every 24 hours for 5 to 10 days.
Children and Adolescents weighing 50 kg or more: 500 mg IV every 24 hours for 5 to 10 days.
Infants, Children, and Adolescents 6 months to 17 years weighing less than 50 kg: 8 mg/kg/dose (Max: 250 mg/dose) IV every 12 hours for 5 to 10 days.
Maximum Dosage Limits:
-Adults
750 mg/day PO/IV; 1,250 mg/day PO/IV has been used off-label.
-Geriatric
750 mg/day PO/IV; 1,250 mg/day PO/IV has been used off-label.
-Adolescents
weight 50 kg or more: 500 mg/day PO/IV is FDA-approved; however, doses up to 20 mg/kg/day PO/IV (Usual Max: 1,000 mg/day) have been used off-label.
weight less than 50 kg: 16 mg/kg/day PO/IV (Max: 500 mg/day or 250 mg/dose) is FDA-approved; however, doses up to 20 mg/kg/day PO/IV (Usual Max: 1,000 mg/day) have been used off-label.
-Children
weight 50 kg or more: 500 mg/day PO/IV is FDA-approved; however, doses up to 20 mg/kg/day PO/IV (Max: 1,000 mg/day) have been used off-label.
weight less than 50 kg: 16 mg/kg/day PO/IV (Max: 500 mg/day or 250 mg/dose) is FDA-approved; however, doses up to 20 mg/kg/day PO/IV (Max: 1,000 mg/day) have been used off-label.
-Infants
6 to 11 months: 16 mg/kg/day PO/IV is FDA-approved; however, doses up to 20 mg/kg/day PO/IV have been used off-label.
1 to 5 months: Safety and efficacy have not been established; however, doses up to 20 mg/kg/day PO/IV have been used off-label.
-Neonates
Safety and efficacy have not been established.
Patients with Hepatic Impairment Dosing
No dosage adjustment needed.
Patients with Renal Impairment Dosing
Adult patients with a usual dose of 750 mg IV or PO every 24 hours (FDA-approved labeling)
CrCl 50 mL/minute or more: No dosage adjustment needed.
CrCl 20 to 49 mL/minute: 750 mg IV or PO every 48 hours.
CrCl 10 to 19 mL/minute: 750 mg IV or PO once, then 500 mg IV or PO every 48 hours.
Adult patients with a usual dose of 500 mg IV or PO every 24 hours (FDA-approved labeling)
CrCl 50 mL/minute or more: No dosage adjustment needed.
CrCl 20 to 49 mL/minute: 500 mg IV or PO once, then 250 mg IV or PO every 24 hours.
CrCl 10 to 19 mL/minute: 500 mg IV or PO once, then 250 mg IV or PO every 48 hours.
Adult patients with a usual dose of 250 mg IV or PO every 24 hours (FDA-approved labeling)
CrCl 20 mL/minute or more: No dosage adjustment needed.
CrCl 10 to 19 mL/minute: 250 mg IV or PO every 48 hours except when treating uncomplicated UTI, then no dosage adjustment needed.
Adult patients receiving therapy for tuberculosis*
CrCl 30 mL/minute or more: No dosage adjustment needed.
CrCl less than 30 mL/minute: 750 to 1,000 mg IV or PO 3 times weekly.
Pediatric patients*
NOTE: The following dose adjustments are based on a usual pediatric dose of 5 to 10 mg/kg/dose (Max: 750 mg/dose) IV or PO every 12 hours for children 5 years and younger and 5 to 10 mg/kg/dose (Max: 750 mg/dose) IV or PO every 24 hours for children older than 5 years.
GFR 30 mL/minute/1.73 m2 or more: No dosage adjustment necessary.
GFR 10 to 29 mL/minute/1.73 m2: 5 to 10 mg/kg/dose (Max: 750 mg/dose) IV or PO every 24 hours for all ages.
GFR less than 10 mL/minute/1.73 m2: 5 to 10 mg/kg/dose (Max: 750 mg/dose) IV or PO every 48 hours for all ages.
Pediatric patients receiving therapy for tuberculosis*
CrCl 30 mL/minute or more: No dosage adjustment needed.
CrCl less than 30 mL/minute: 15 to 20 mg/kg/dose (Max: 1,000 mg/dose) IV or PO 3 times weekly.
Intermittent hemodialysis
NOTE: Levofloxacin is not effectively removed during hemodialysis.
Adult patients with a usual dose of 750 mg IV or PO every 24 hours (FDA-approved labeling)
750 mg IV or PO once, then 500 mg IV or PO every 48 hours.
Adult patients with a usual dose of 500 mg IV or PO every 24 hours (FDA-approved labeling)
500 mg IV or PO once, then 250 mg IV or PO every 48 hours.
Adult patients with a usual dose of 250 mg IV or PO every 24 hours (FDA-approved labeling)
No information is available for dosage adjustment.
Adult patients receiving therapy for tuberculosis*
750 to 1,000 mg IV or PO 3 times weekly.
Pediatric patients*
5 to 10 mg/kg/dose (Max: 750 mg/dose) IV or PO every 48 hours.
Pediatric patients receiving therapy for tuberculosis*
15 to 20 mg/kg/dose (Max: 1,000 mg/dose) IV or PO 3 times weekly.
Peritoneal dialysis
NOTE: Levofloxacin is not effectively removed during peritoneal dialysis.
Adult patients with a usual dose of 750 mg IV or PO every 24 hours (FDA-approved labeling)
750 mg IV or PO once, then 500 mg IV or PO every 48 hours.
Adult patients with a usual dose of 500 mg IV or PO every 24 hours (FDA-approved labeling)
500 mg IV or PO once, then 250 mg IV or PO every 48 hours.
Adult patients with a usual dose of 250 mg IV or PO every 24 hours (FDA-approved labeling)
No information is available for dosage adjustment.
Pediatric patients*
5 to 10 mg/kg/dose (Max: 750 mg/dose) IV or PO every 48 hours.
Hybrid hemodialysis*
NOTE: Hybrid hemodialysis modalities include prolonged intermittent renal replacement therapy (PIRRT), sustained low-efficiency dialysis (SLED), slow extended daily dialysis/diafiltration (SLEDD-f), and extended daily dialysis (EDD). Dosing should take into consideration patient-specific factors (e.g., intrinsic renal function), the type of infection, the duration of renal replacement therapy, the ultrafiltration rate, the dialysis flow rate, and how often dialysis sessions occur.
Adult patients
PIRRT: Levofloxacin is not recommended as empiric monotherapy for serious gram-negative infections in patients receiving PIRRT due to suboptimal efficacy; however, when used in combination with another primary antibiotic for gram-negative infections, levofloxacin 750 mg IV once, then 750 mg IV post-PIRRT is recommended. For gram-positive infections, 750 mg IV once, then 500 mg IV post-PIRRT achieved about 90% probability of target attainment with an 8-hour PIRRT session. In an in silico trial using Monte Carlo simulation, levofloxacin dosing was studied using 4 different PIRRT setting simulations over 8 to 10 hours/day.
EDD: Administer levofloxacin after EDD. In a pharmacokinetic study of 5 critical care patients receiving an 8-hour EDD session, dialysis removed 20% to 30% of levofloxacin.
Continuous renal replacement therapy (CRRT)*
NOTE: Various CRRT modalities include continuous venovenous hemofiltration (CVVH), continuous venovenous hemodialysis (CVVHD), continuous venovenous hemodiafiltration (CVVHDF), continuous venovenous high-flux hemodialysis (CVVHFD), continuous arteriovenous hemofiltration (CAVH), continuous arteriovenous hemodialysis (CAVHD), and continuous arteriovenous hemodiafiltration (CAVHDF). Dosing should take into consideration patient-specific factors (e.g. intrinsic renal function), type of infection, the duration of renal replacement therapy, the effluent flow rate, and the replacement solution administered.
Adult patients
In general, 500 mg IV or PO every 48 hours or 500 or 750 mg IV or PO once, then 250 or 500 mg IV every 24 has been suggested for CRRT.
CVVH: 500 or 750 mg IV or PO once, then 250 mg IV or PO every 24 hours.
CVVHD: 500 or 750 mg IV or PO once, then 250 or 500 mg IV or PO every 24 hours.
CVVHDF: 500 or 750 mg IV or PO once, then 250 to 750 mg IV or PO every 24 hours.
Pediatric patients
10 mg/kg/dose (Max: 750 mg/dose) IV or PO every 24 hours.
*non-FDA-approved indication
Acarbose: (Moderate) Monitor blood glucose carefully when systemic quinolones and antidiabetic agents, including alpha-glucosidase inhibitors, are coadministered. Discontinue the quinolone if a hypoglycemic reaction occurs and initiate appropriate therapy immediately. Disturbances of blood glucose, including hyperglycemia and hypoglycemia, have been reported in patients treated concomitantly with quinolones and an antidiabetic agent. Hypoglycemia, sometimes resulting in coma, can occur.
Acetaminophen; Ibuprofen: (Moderate) Use quinolones and nonsteroidal anti-inflammatory drugs (NSAIDs) concomitantly with caution due to potential increased risk of CNS stimulation and convulsive seizures. NSAIDs in combination with very high doses of quinolones have been shown to provoke convulsions in preclinical studies and postmarketing.
Adagrasib: (Major) Concomitant use of adagrasib and levofloxacin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Albuterol; Budesonide: (Moderate) Quinolones have been associated with an increased risk of tendon rupture requiring surgical repair or resulting in prolonged disability; this risk is further increased in those receiving concomitant corticosteroids. Discontinue quinolone therapy at the first sign of tendon inflammation or tendon pain, as these are symptoms that may precede rupture of the tendon.
Alfuzosin: (Moderate) Concomitant use of levofloxacin and alfuzosin may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Alogliptin: (Moderate) Monitor blood glucose during concomitant dipeptidyl peptidase-4 inhibitors and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Alogliptin; Metformin: (Moderate) Monitor blood glucose carefully when systemic quinolones and antidiabetic agents, including metformin, are coadministered. Discontinue the quinolone if a hypoglycemic reaction occurs and initiate appropriate therapy immediately. Disturbances of blood glucose, including hyperglycemia and hypoglycemia, have been reported in patients treated concomitantly with quinolones and an antidiabetic agent. Hypoglycemia, sometimes resulting in coma, can occur. (Moderate) Monitor blood glucose during concomitant dipeptidyl peptidase-4 inhibitors and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Alogliptin; Pioglitazone: (Moderate) Monitor blood glucose during concomitant dipeptidyl peptidase-4 inhibitors and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia. (Moderate) Monitor blood glucose during concomitant thiazolidinedione and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Alpha-glucosidase Inhibitors: (Moderate) Monitor blood glucose carefully when systemic quinolones and antidiabetic agents, including alpha-glucosidase inhibitors, are coadministered. Discontinue the quinolone if a hypoglycemic reaction occurs and initiate appropriate therapy immediately. Disturbances of blood glucose, including hyperglycemia and hypoglycemia, have been reported in patients treated concomitantly with quinolones and an antidiabetic agent. Hypoglycemia, sometimes resulting in coma, can occur.
Aluminum Hydroxide: (Moderate) Administer products that contain aluminum hydroxide at least 2 hours before or 2 hours after orally administered levofloxacin. Levofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Chelation of divalent cations with levofloxacin is less than with other quinolones. Examples of compounds that may interfere with quinolone bioavailability include antacids that contain aluminum hydroxide.
Aluminum Hydroxide; Magnesium Carbonate: (Moderate) Administer magnesium carbonate at least 2 hours before or 2 hours after orally administered levofloxacin. Levofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Chelation of divalent cations with levofloxacin is less than with other quinolones. (Moderate) Administer products that contain aluminum hydroxide at least 2 hours before or 2 hours after orally administered levofloxacin. Levofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Chelation of divalent cations with levofloxacin is less than with other quinolones. Examples of compounds that may interfere with quinolone bioavailability include antacids that contain aluminum hydroxide.
Aluminum Hydroxide; Magnesium Hydroxide: (Moderate) Administer magnesium hydroxide at least 2 hours before or 2 hours after orally administered levofloxacin. Levofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Chelation of divalent cations with levofloxacin is less than with other quinolones. (Moderate) Administer products that contain aluminum hydroxide at least 2 hours before or 2 hours after orally administered levofloxacin. Levofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Chelation of divalent cations with levofloxacin is less than with other quinolones. Examples of compounds that may interfere with quinolone bioavailability include antacids that contain aluminum hydroxide.
Aluminum Hydroxide; Magnesium Hydroxide; Simethicone: (Moderate) Administer magnesium hydroxide at least 2 hours before or 2 hours after orally administered levofloxacin. Levofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Chelation of divalent cations with levofloxacin is less than with other quinolones. (Moderate) Administer products that contain aluminum hydroxide at least 2 hours before or 2 hours after orally administered levofloxacin. Levofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Chelation of divalent cations with levofloxacin is less than with other quinolones. Examples of compounds that may interfere with quinolone bioavailability include antacids that contain aluminum hydroxide.
Aluminum Hydroxide; Magnesium Trisilicate: (Moderate) Administer products that contain aluminum hydroxide at least 2 hours before or 2 hours after orally administered levofloxacin. Levofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Chelation of divalent cations with levofloxacin is less than with other quinolones. Examples of compounds that may interfere with quinolone bioavailability include antacids that contain aluminum hydroxide. (Moderate) Administer products that contain magnesium trisilicate at least 2 hours before or 2 hours after orally administered levofloxacin. Levofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Chelation of divalent cations with levofloxacin is less than with other quinolones.
Amiodarone: (Major) Concomitant use of amiodarone and levofloxacin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary. Due to the extremely long half-life of amiodarone, a drug interaction is possible for days to weeks after drug discontinuation.
Amisulpride: (Major) Concomitant use of levofloxacin and amisulpride increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Amlodipine; Celecoxib: (Moderate) Use quinolones and nonsteroidal anti-inflammatory drugs (NSAIDs) concomitantly with caution due to potential increased risk of CNS stimulation and convulsive seizures. NSAIDs in combination with very high doses of quinolones have been shown to provoke convulsions in preclinical studies and postmarketing.
Amoxicillin; Clarithromycin; Omeprazole: (Major) Concomitant use of levofloxacin and clarithromycin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Anagrelide: (Major) Concomitant use of levofloxacin and anagrelide increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Apomorphine: (Moderate) Concomitant use of levofloxacin and apomorphine may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Aripiprazole: (Moderate) Levofloxacin should be used cautiously with other agents that may prolong the QT interval or increase the risk of torsade de pointes (TdP). Levofloxacin has been associated with a risk of QT prolongation and TdP. Although extremely rare, TdP has been reported during postmarketing surveillance of levofloxacin. QT prolongation has occurred during therapeutic use of aripiprazole and following overdose.
Arsenic Trioxide: (Major) Concomitant use of levofloxacin and arsenic trioxide increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Artemether; Lumefantrine: (Major) Concomitant use of levofloxacin and artemether increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary. (Major) Concomitant use of levofloxacin and lumefantrine increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Asenapine: (Major) Concomitant use of levofloxacin and asenapine increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Atomoxetine: (Moderate) Concomitant use of levofloxacin and atomoxetine may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Azithromycin: (Major) Concomitant use of azithromycin and levofloxacin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Bedaquiline: (Major) Concomitant use of levofloxacin and bedaquiline increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Betamethasone: (Moderate) Quinolones have been associated with an increased risk of tendon rupture requiring surgical repair or resulting in prolonged disability; this risk is further increased in those receiving concomitant corticosteroids. Discontinue quinolone therapy at the first sign of tendon inflammation or tendon pain, as these are symptoms that may precede rupture of the tendon.
Bexagliflozin: (Moderate) Monitor blood glucose during concomitant SGLT2 inhibitor and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Bismuth Subcitrate Potassium; Metronidazole; Tetracycline: (Moderate) Concomitant use of metronidazole and levofloxacin may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Bismuth Subsalicylate; Metronidazole; Tetracycline: (Moderate) Concomitant use of metronidazole and levofloxacin may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Budesonide: (Moderate) Quinolones have been associated with an increased risk of tendon rupture requiring surgical repair or resulting in prolonged disability; this risk is further increased in those receiving concomitant corticosteroids. Discontinue quinolone therapy at the first sign of tendon inflammation or tendon pain, as these are symptoms that may precede rupture of the tendon.
Budesonide; Formoterol: (Moderate) Quinolones have been associated with an increased risk of tendon rupture requiring surgical repair or resulting in prolonged disability; this risk is further increased in those receiving concomitant corticosteroids. Discontinue quinolone therapy at the first sign of tendon inflammation or tendon pain, as these are symptoms that may precede rupture of the tendon.
Budesonide; Glycopyrrolate; Formoterol: (Moderate) Quinolones have been associated with an increased risk of tendon rupture requiring surgical repair or resulting in prolonged disability; this risk is further increased in those receiving concomitant corticosteroids. Discontinue quinolone therapy at the first sign of tendon inflammation or tendon pain, as these are symptoms that may precede rupture of the tendon.
Bupivacaine; Meloxicam: (Moderate) Use quinolones and nonsteroidal anti-inflammatory drugs (NSAIDs) concomitantly with caution due to potential increased risk of CNS stimulation and convulsive seizures. NSAIDs in combination with very high doses of quinolones have been shown to provoke convulsions in preclinical studies and postmarketing.
Buprenorphine: (Major) Concomitant use of levofloxacin and buprenorphine increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Buprenorphine; Naloxone: (Major) Concomitant use of levofloxacin and buprenorphine increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Cabotegravir; Rilpivirine: (Moderate) Concomitant use of levofloxacin and rilpivirine may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP. The degree of QT prolongation associated with rilpivirine is not clinically significant when administered within the recommended dosage range; QT prolongation has been described at 3 times the maximum recommended dose.
Calcium Acetate: (Moderate) Administer oral products that contain calcium at least 2 hours before or 2 hours after orally administered levofloxacin. Levofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Chelation of divalent cations with levofloxacin is less than with other quinolones. Examples of compounds that may interfere with quinolone bioavailability include antacids and multivitamins that contain calcium.
Calcium Carbonate: (Moderate) Administer oral products that contain calcium at least 2 hours before or 2 hours after orally administered levofloxacin. Levofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Chelation of divalent cations with levofloxacin is less than with other quinolones. Examples of compounds that may interfere with quinolone bioavailability include antacids and multivitamins that contain calcium.
Calcium Carbonate; Famotidine; Magnesium Hydroxide: (Moderate) Administer oral products that contain calcium at least 2 hours before or 2 hours after orally administered levofloxacin. Levofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Chelation of divalent cations with levofloxacin is less than with other quinolones. Examples of compounds that may interfere with quinolone bioavailability include antacids and multivitamins that contain calcium.
Calcium Carbonate; Magnesium Hydroxide: (Moderate) Administer oral products that contain calcium at least 2 hours before or 2 hours after orally administered levofloxacin. Levofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Chelation of divalent cations with levofloxacin is less than with other quinolones. Examples of compounds that may interfere with quinolone bioavailability include antacids and multivitamins that contain calcium.
Calcium Carbonate; Magnesium Hydroxide; Simethicone: (Moderate) Administer oral products that contain calcium at least 2 hours before or 2 hours after orally administered levofloxacin. Levofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Chelation of divalent cations with levofloxacin is less than with other quinolones. Examples of compounds that may interfere with quinolone bioavailability include antacids and multivitamins that contain calcium.
Calcium Carbonate; Simethicone: (Moderate) Administer oral products that contain calcium at least 2 hours before or 2 hours after orally administered levofloxacin. Levofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Chelation of divalent cations with levofloxacin is less than with other quinolones. Examples of compounds that may interfere with quinolone bioavailability include antacids and multivitamins that contain calcium.
Calcium Chloride: (Moderate) Administer oral products that contain calcium at least 2 hours before or 2 hours after orally administered levofloxacin. Levofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Chelation of divalent cations with levofloxacin is less than with other quinolones. Examples of compounds that may interfere with quinolone bioavailability include antacids and multivitamins that contain calcium.
Calcium Gluconate: (Moderate) Administer oral products that contain calcium at least 2 hours before or 2 hours after orally administered levofloxacin. Levofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Chelation of divalent cations with levofloxacin is less than with other quinolones. Examples of compounds that may interfere with quinolone bioavailability include antacids and multivitamins that contain calcium.
Calcium: (Moderate) Administer oral products that contain calcium at least 2 hours before or 2 hours after orally administered levofloxacin. Levofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Chelation of divalent cations with levofloxacin is less than with other quinolones. Examples of compounds that may interfere with quinolone bioavailability include antacids and multivitamins that contain calcium.
Calcium; Vitamin D: (Moderate) Administer oral products that contain calcium at least 2 hours before or 2 hours after orally administered levofloxacin. Levofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Chelation of divalent cations with levofloxacin is less than with other quinolones. Examples of compounds that may interfere with quinolone bioavailability include antacids and multivitamins that contain calcium.
Canagliflozin: (Moderate) Monitor blood glucose during concomitant SGLT2 inhibitor and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Canagliflozin; Metformin: (Moderate) Monitor blood glucose carefully when systemic quinolones and antidiabetic agents, including metformin, are coadministered. Discontinue the quinolone if a hypoglycemic reaction occurs and initiate appropriate therapy immediately. Disturbances of blood glucose, including hyperglycemia and hypoglycemia, have been reported in patients treated concomitantly with quinolones and an antidiabetic agent. Hypoglycemia, sometimes resulting in coma, can occur. (Moderate) Monitor blood glucose during concomitant SGLT2 inhibitor and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Celecoxib: (Moderate) Use quinolones and nonsteroidal anti-inflammatory drugs (NSAIDs) concomitantly with caution due to potential increased risk of CNS stimulation and convulsive seizures. NSAIDs in combination with very high doses of quinolones have been shown to provoke convulsions in preclinical studies and postmarketing.
Celecoxib; Tramadol: (Moderate) Use quinolones and nonsteroidal anti-inflammatory drugs (NSAIDs) concomitantly with caution due to potential increased risk of CNS stimulation and convulsive seizures. NSAIDs in combination with very high doses of quinolones have been shown to provoke convulsions in preclinical studies and postmarketing.
Ceritinib: (Major) Concomitant use of levofloxacin and ceritinib increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Chloroquine: (Major) Concomitant use of levofloxacin and chloroquine increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Chlorpheniramine; Ibuprofen; Pseudoephedrine: (Moderate) Use quinolones and nonsteroidal anti-inflammatory drugs (NSAIDs) concomitantly with caution due to potential increased risk of CNS stimulation and convulsive seizures. NSAIDs in combination with very high doses of quinolones have been shown to provoke convulsions in preclinical studies and postmarketing.
Chlorpheniramine; Pseudoephedrine: (Major) Administer oral products that contain zinc at least 2 hours before or 2 hours after orally administered levofloxacin. Levofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Chelation of divalent cations with levofloxacin is less than with other quinolones. Examples of compounds that may interfere with quinolone bioavailability include multivitamins that contain zinc.
Chlorpromazine: (Major) Concomitant use of levofloxacin and chlorpromazine increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Chlorpropamide: (Moderate) Monitor blood glucose during concomitant sulfonylurea and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Choline Salicylate; Magnesium Salicylate: (Moderate) Administer magnesium salicylate at least 2 hours before or 2 hours after orally administered levofloxacin. Levofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Chelation of divalent cations with levofloxacin is less than with other quinolones.
Chromium: (Moderate) Administer oral products that contain calcium at least 2 hours before or 2 hours after orally administered levofloxacin. Levofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Chelation of divalent cations with levofloxacin is less than with other quinolones. Examples of compounds that may interfere with quinolone bioavailability include antacids and multivitamins that contain calcium.
Cisapride: (Contraindicated) Avoid concomitant use of levofloxacin and cisapride due to an increased risk for torsade de pointes (TdP) and QT/QTc prolongation.
Citalopram: (Major) Concomitant use of levofloxacin and citalopram increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Clarithromycin: (Major) Concomitant use of levofloxacin and clarithromycin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Class IA Antiarrhythmics: (Major) Levofloxacin should be avoided in combination with Class IA antiarrhythmics (disopyramide, procainamide, and quinidine). Class IA antiarrhythmics are associated with QT prolongation and torsades de pointes (TdP). Levofloxacin has been associated with prolongation of the QT interval and infrequent cases of arrhythmia. Rare cases of TdP have been spontaneously reported during postmarketing surveillance in patients receiving levofloxacin. According to the manufacturer, levofloxacin should be avoided in patients taking drugs that can result in prolongation of the QT interval.
Clindamycin; Tretinoin: (Major) Avoid the concomitant use of tretinoin with other drugs known to cause photosensitivity, such as levofloxacin. Concomitant use with other photosensitizing agents may increase the risk of a photosensitivity reaction.
Clofazimine: (Moderate) Concomitant use of clofazimine and levofloxacin may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Clozapine: (Moderate) Concomitant use of levofloxacin and clozapine may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Codeine; Phenylephrine; Promethazine: (Moderate) Concomitant use of levofloxacin and promethazine may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Codeine; Promethazine: (Moderate) Concomitant use of levofloxacin and promethazine may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Cortisone: (Moderate) Quinolones have been associated with an increased risk of tendon rupture requiring surgical repair or resulting in prolonged disability; this risk is further increased in those receiving concomitant corticosteroids. Discontinue quinolone therapy at the first sign of tendon inflammation or tendon pain, as these are symptoms that may precede rupture of the tendon.
Crizotinib: (Major) Concomitant use of levofloxacin and crizotinib increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Dapagliflozin: (Moderate) Monitor blood glucose during concomitant SGLT2 inhibitor and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Dapagliflozin; Metformin: (Moderate) Monitor blood glucose carefully when systemic quinolones and antidiabetic agents, including metformin, are coadministered. Discontinue the quinolone if a hypoglycemic reaction occurs and initiate appropriate therapy immediately. Disturbances of blood glucose, including hyperglycemia and hypoglycemia, have been reported in patients treated concomitantly with quinolones and an antidiabetic agent. Hypoglycemia, sometimes resulting in coma, can occur. (Moderate) Monitor blood glucose during concomitant SGLT2 inhibitor and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Dapagliflozin; Saxagliptin: (Moderate) Monitor blood glucose during concomitant dipeptidyl peptidase-4 inhibitors and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia. (Moderate) Monitor blood glucose during concomitant SGLT2 inhibitor and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Dasatinib: (Moderate) Concomitant use of levofloxacin and dasatinib may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Deflazacort: (Moderate) Quinolones have been associated with an increased risk of tendon rupture requiring surgical repair or resulting in prolonged disability; this risk is further increased in those receiving concomitant corticosteroids. Discontinue quinolone therapy at the first sign of tendon inflammation or tendon pain, as these are symptoms that may precede rupture of the tendon.
Degarelix: (Moderate) Concomitant use of levofloxacin and androgen deprivation therapy (i.e., degarelix) may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Desflurane: (Major) Concomitant use of levofloxacin and halogenated anesthetics increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Desogestrel; Ethinyl Estradiol: (Moderate) It would be prudent to recommend alternative or additional contraception when oral contraceptives (OCs) are used in conjunction with antibiotics. It was previously thought that antibiotics may decrease the effectiveness of OCs containing estrogens due to stimulation of metabolism or a reduction in enterohepatic circulation via changes in GI flora. One retrospective study reviewed the literature to determine the effects of oral antibiotics on the pharmacokinetics of contraceptive estrogens and progestins, and also examined clinical studies in which the incidence of pregnancy with OCs and antibiotics was reported. It was concluded that the antibiotics ampicillin, ciprofloxacin, clarithromycin, doxycycline, metronidazole, ofloxacin, roxithromycin, temafloxacin, and tetracycline did not alter plasma concentrations of OCs. Antituberculous drugs (e.g., rifampin) were the only agents associated with OC failure and pregnancy. Based on the study results, these authors recommended that back-up contraception may not be necessary if OCs are used reliably during oral antibiotic use. Another review concurred with these data, but noted that individual patients have been identified who experienced significant decreases in plasma concentrations of combined OC components and who appeared to ovulate; the agents most often associated with these changes were rifampin, tetracyclines, and penicillin derivatives. These authors concluded that because females most at risk for OC failure or noncompliance may not be easily identified and the true incidence of such events may be under-reported, and given the serious consequence of unwanted pregnancy, that recommending an additional method of contraception during short-term antibiotic use may be justified. During long-term antibiotic administration, the risk for drug interaction with OCs is less clear, but alternative or additional contraception may be advisable in selected circumstances. Data regarding progestin-only contraceptives or for newer combined contraceptive deliveries (e.g., patches, rings) are not available.
Deutetrabenazine: (Moderate) Use levofloxacin with caution in patients receiving other drugs that prolong the QT interval. Levofloxacin has been associated with a risk of QT prolongation and torsade de pointes (TdP). Although extremely rare, TdP has been reported during postmarketing surveillance of levofloxacin. Deutetrabenazine may prolong the QT interval, but the degree of QT prolongation is not clinically significant when deutetrabenazine is administered within the recommended dosage range.
Dexamethasone: (Moderate) Quinolones have been associated with an increased risk of tendon rupture requiring surgical repair or resulting in prolonged disability; this risk is further increased in those receiving concomitant corticosteroids. Discontinue quinolone therapy at the first sign of tendon inflammation or tendon pain, as these are symptoms that may precede rupture of the tendon.
Dexmedetomidine: (Moderate) Concomitant use of dexmedetomidine and levofloxacin may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Dextromethorphan; Quinidine: (Major) Levofloxacin should be avoided in combination with Class IA antiarrhythmics (disopyramide, procainamide, and quinidine). Class IA antiarrhythmics are associated with QT prolongation and torsades de pointes (TdP). Levofloxacin has been associated with prolongation of the QT interval and infrequent cases of arrhythmia. Rare cases of TdP have been spontaneously reported during postmarketing surveillance in patients receiving levofloxacin. According to the manufacturer, levofloxacin should be avoided in patients taking drugs that can result in prolongation of the QT interval.
Diclofenac: (Moderate) Use quinolones and nonsteroidal anti-inflammatory drugs (NSAIDs) concomitantly with caution due to potential increased risk of CNS stimulation and convulsive seizures. NSAIDs in combination with very high doses of quinolones have been shown to provoke convulsions in preclinical studies and postmarketing.
Diclofenac; Misoprostol: (Moderate) Use quinolones and nonsteroidal anti-inflammatory drugs (NSAIDs) concomitantly with caution due to potential increased risk of CNS stimulation and convulsive seizures. NSAIDs in combination with very high doses of quinolones have been shown to provoke convulsions in preclinical studies and postmarketing.
Didanosine, ddI: (Major) Administer didanosine tablets or powder for oral solution at least 2 hours before or 2 hours after orally administered levofloxacin. Levofloxacin absorption may be reduced as it can chelate with the buffering agents contained in didanosine tablets and powder. The delayed-release didanosine capsules do not contain a buffering agent and would not be expected to interact with levofloxacin.
Dienogest; Estradiol valerate: (Moderate) It would be prudent to recommend alternative or additional contraception when oral contraceptives (OCs) are used in conjunction with antibiotics. It was previously thought that antibiotics may decrease the effectiveness of OCs containing estrogens due to stimulation of metabolism or a reduction in enterohepatic circulation via changes in GI flora. One retrospective study reviewed the literature to determine the effects of oral antibiotics on the pharmacokinetics of contraceptive estrogens and progestins, and also examined clinical studies in which the incidence of pregnancy with OCs and antibiotics was reported. It was concluded that the antibiotics ampicillin, ciprofloxacin, clarithromycin, doxycycline, metronidazole, ofloxacin, roxithromycin, temafloxacin, and tetracycline did not alter plasma concentrations of OCs. Antituberculous drugs (e.g., rifampin) were the only agents associated with OC failure and pregnancy. Based on the study results, these authors recommended that back-up contraception may not be necessary if OCs are used reliably during oral antibiotic use. Another review concurred with these data, but noted that individual patients have been identified who experienced significant decreases in plasma concentrations of combined OC components and who appeared to ovulate; the agents most often associated with these changes were rifampin, tetracyclines, and penicillin derivatives. These authors concluded that because females most at risk for OC failure or noncompliance may not be easily identified and the true incidence of such events may be under-reported, and given the serious consequence of unwanted pregnancy, that recommending an additional method of contraception during short-term antibiotic use may be justified. During long-term antibiotic administration, the risk for drug interaction with OCs is less clear, but alternative or additional contraception may be advisable in selected circumstances. Data regarding progestin-only contraceptives or for newer combined contraceptive deliveries (e.g., patches, rings) are not available.
Diflunisal: (Moderate) Use quinolones and nonsteroidal anti-inflammatory drugs (NSAIDs) concomitantly with caution due to potential increased risk of CNS stimulation and convulsive seizures. NSAIDs in combination with very high doses of quinolones have been shown to provoke convulsions in preclinical studies and postmarketing.
Dipeptidyl Peptidase-4 Inhibitors: (Moderate) Monitor blood glucose during concomitant dipeptidyl peptidase-4 inhibitors and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Diphenhydramine; Ibuprofen: (Moderate) Use quinolones and nonsteroidal anti-inflammatory drugs (NSAIDs) concomitantly with caution due to potential increased risk of CNS stimulation and convulsive seizures. NSAIDs in combination with very high doses of quinolones have been shown to provoke convulsions in preclinical studies and postmarketing.
Diphenhydramine; Naproxen: (Moderate) Use quinolones and nonsteroidal anti-inflammatory drugs (NSAIDs) concomitantly with caution due to potential increased risk of CNS stimulation and convulsive seizures. NSAIDs in combination with very high doses of quinolones have been shown to provoke convulsions in preclinical studies and postmarketing.
Disopyramide: (Major) Levofloxacin should be avoided in combination with Class IA antiarrhythmics (disopyramide, procainamide, and quinidine). Class IA antiarrhythmics are associated with QT prolongation and torsades de pointes (TdP). Levofloxacin has been associated with prolongation of the QT interval and infrequent cases of arrhythmia. Rare cases of TdP have been spontaneously reported during postmarketing surveillance in patients receiving levofloxacin. According to the manufacturer, levofloxacin should be avoided in patients taking drugs that can result in prolongation of the QT interval.
Dofetilide: (Major) Concomitant use of levofloxacin and dofetilide increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Dolasetron: (Moderate) Concomitant use of levofloxacin and dolasetron may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Dolutegravir; Rilpivirine: (Moderate) Concomitant use of levofloxacin and rilpivirine may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP. The degree of QT prolongation associated with rilpivirine is not clinically significant when administered within the recommended dosage range; QT prolongation has been described at 3 times the maximum recommended dose.
Donepezil: (Moderate) Concomitant use of levofloxacin and donepezil may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Donepezil; Memantine: (Moderate) Concomitant use of levofloxacin and donepezil may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Dronedarone: (Contraindicated) Avoid concomitant use of levofloxacin and dronedarone due to an increased risk for torsade de pointes (TdP) and QT/QTc prolongation.
Droperidol: (Major) Concomitant use of levofloxacin and droperidol increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Drospirenone: (Moderate) It would be prudent to recommend alternative or additional contraception when oral contraceptives (OCs) are used in conjunction with antibiotics. It was previously thought that antibiotics may decrease the effectiveness of OCs containing estrogens due to stimulation of metabolism or a reduction in enterohepatic circulation via changes in GI flora. One retrospective study reviewed the literature to determine the effects of oral antibiotics on the pharmacokinetics of contraceptive estrogens and progestins, and also examined clinical studies in which the incidence of pregnancy with OCs and antibiotics was reported. It was concluded that the antibiotics ampicillin, ciprofloxacin, clarithromycin, doxycycline, metronidazole, ofloxacin, roxithromycin, temafloxacin, and tetracycline did not alter plasma concentrations of OCs. Antituberculous drugs (e.g., rifampin) were the only agents associated with OC failure and pregnancy. Based on the study results, these authors recommended that back-up contraception may not be necessary if OCs are used reliably during oral antibiotic use. Another review concurred with these data, but noted that individual patients have been identified who experienced significant decreases in plasma concentrations of combined OC components and who appeared to ovulate; the agents most often associated with these changes were rifampin, tetracyclines, and penicillin derivatives. These authors concluded that because females most at risk for OC failure or noncompliance may not be easily identified and the true incidence of such events may be under-reported, and given the serious consequence of unwanted pregnancy, that recommending an additional method of contraception during short-term antibiotic use may be justified. During long-term antibiotic administration, the risk for drug interaction with OCs is less clear, but alternative or additional contraception may be advisable in selected circumstances. Data regarding progestin-only contraceptives or for newer combined contraceptive deliveries (e.g., patches, rings) are not available.
Drospirenone; Estetrol: (Moderate) It would be prudent to recommend alternative or additional contraception when oral contraceptives (OCs) are used in conjunction with antibiotics. It was previously thought that antibiotics may decrease the effectiveness of OCs containing estrogens due to stimulation of metabolism or a reduction in enterohepatic circulation via changes in GI flora. One retrospective study reviewed the literature to determine the effects of oral antibiotics on the pharmacokinetics of contraceptive estrogens and progestins, and also examined clinical studies in which the incidence of pregnancy with OCs and antibiotics was reported. It was concluded that the antibiotics ampicillin, ciprofloxacin, clarithromycin, doxycycline, metronidazole, ofloxacin, roxithromycin, temafloxacin, and tetracycline did not alter plasma concentrations of OCs. Antituberculous drugs (e.g., rifampin) were the only agents associated with OC failure and pregnancy. Based on the study results, these authors recommended that back-up contraception may not be necessary if OCs are used reliably during oral antibiotic use. Another review concurred with these data, but noted that individual patients have been identified who experienced significant decreases in plasma concentrations of combined OC components and who appeared to ovulate; the agents most often associated with these changes were rifampin, tetracyclines, and penicillin derivatives. These authors concluded that because females most at risk for OC failure or noncompliance may not be easily identified and the true incidence of such events may be under-reported, and given the serious consequence of unwanted pregnancy, that recommending an additional method of contraception during short-term antibiotic use may be justified. During long-term antibiotic administration, the risk for drug interaction with OCs is less clear, but alternative or additional contraception may be advisable in selected circumstances. Data regarding progestin-only contraceptives or for newer combined contraceptive deliveries (e.g., patches, rings) are not available.
Drospirenone; Estradiol: (Moderate) It would be prudent to recommend alternative or additional contraception when oral contraceptives (OCs) are used in conjunction with antibiotics. It was previously thought that antibiotics may decrease the effectiveness of OCs containing estrogens due to stimulation of metabolism or a reduction in enterohepatic circulation via changes in GI flora. One retrospective study reviewed the literature to determine the effects of oral antibiotics on the pharmacokinetics of contraceptive estrogens and progestins, and also examined clinical studies in which the incidence of pregnancy with OCs and antibiotics was reported. It was concluded that the antibiotics ampicillin, ciprofloxacin, clarithromycin, doxycycline, metronidazole, ofloxacin, roxithromycin, temafloxacin, and tetracycline did not alter plasma concentrations of OCs. Antituberculous drugs (e.g., rifampin) were the only agents associated with OC failure and pregnancy. Based on the study results, these authors recommended that back-up contraception may not be necessary if OCs are used reliably during oral antibiotic use. Another review concurred with these data, but noted that individual patients have been identified who experienced significant decreases in plasma concentrations of combined OC components and who appeared to ovulate; the agents most often associated with these changes were rifampin, tetracyclines, and penicillin derivatives. These authors concluded that because females most at risk for OC failure or noncompliance may not be easily identified and the true incidence of such events may be under-reported, and given the serious consequence of unwanted pregnancy, that recommending an additional method of contraception during short-term antibiotic use may be justified. During long-term antibiotic administration, the risk for drug interaction with OCs is less clear, but alternative or additional contraception may be advisable in selected circumstances. Data regarding progestin-only contraceptives or for newer combined contraceptive deliveries (e.g., patches, rings) are not available.
Drospirenone; Ethinyl Estradiol: (Moderate) It would be prudent to recommend alternative or additional contraception when oral contraceptives (OCs) are used in conjunction with antibiotics. It was previously thought that antibiotics may decrease the effectiveness of OCs containing estrogens due to stimulation of metabolism or a reduction in enterohepatic circulation via changes in GI flora. One retrospective study reviewed the literature to determine the effects of oral antibiotics on the pharmacokinetics of contraceptive estrogens and progestins, and also examined clinical studies in which the incidence of pregnancy with OCs and antibiotics was reported. It was concluded that the antibiotics ampicillin, ciprofloxacin, clarithromycin, doxycycline, metronidazole, ofloxacin, roxithromycin, temafloxacin, and tetracycline did not alter plasma concentrations of OCs. Antituberculous drugs (e.g., rifampin) were the only agents associated with OC failure and pregnancy. Based on the study results, these authors recommended that back-up contraception may not be necessary if OCs are used reliably during oral antibiotic use. Another review concurred with these data, but noted that individual patients have been identified who experienced significant decreases in plasma concentrations of combined OC components and who appeared to ovulate; the agents most often associated with these changes were rifampin, tetracyclines, and penicillin derivatives. These authors concluded that because females most at risk for OC failure or noncompliance may not be easily identified and the true incidence of such events may be under-reported, and given the serious consequence of unwanted pregnancy, that recommending an additional method of contraception during short-term antibiotic use may be justified. During long-term antibiotic administration, the risk for drug interaction with OCs is less clear, but alternative or additional contraception may be advisable in selected circumstances. Data regarding progestin-only contraceptives or for newer combined contraceptive deliveries (e.g., patches, rings) are not available.
Drospirenone; Ethinyl Estradiol; Levomefolate: (Moderate) It would be prudent to recommend alternative or additional contraception when oral contraceptives (OCs) are used in conjunction with antibiotics. It was previously thought that antibiotics may decrease the effectiveness of OCs containing estrogens due to stimulation of metabolism or a reduction in enterohepatic circulation via changes in GI flora. One retrospective study reviewed the literature to determine the effects of oral antibiotics on the pharmacokinetics of contraceptive estrogens and progestins, and also examined clinical studies in which the incidence of pregnancy with OCs and antibiotics was reported. It was concluded that the antibiotics ampicillin, ciprofloxacin, clarithromycin, doxycycline, metronidazole, ofloxacin, roxithromycin, temafloxacin, and tetracycline did not alter plasma concentrations of OCs. Antituberculous drugs (e.g., rifampin) were the only agents associated with OC failure and pregnancy. Based on the study results, these authors recommended that back-up contraception may not be necessary if OCs are used reliably during oral antibiotic use. Another review concurred with these data, but noted that individual patients have been identified who experienced significant decreases in plasma concentrations of combined OC components and who appeared to ovulate; the agents most often associated with these changes were rifampin, tetracyclines, and penicillin derivatives. These authors concluded that because females most at risk for OC failure or noncompliance may not be easily identified and the true incidence of such events may be under-reported, and given the serious consequence of unwanted pregnancy, that recommending an additional method of contraception during short-term antibiotic use may be justified. During long-term antibiotic administration, the risk for drug interaction with OCs is less clear, but alternative or additional contraception may be advisable in selected circumstances. Data regarding progestin-only contraceptives or for newer combined contraceptive deliveries (e.g., patches, rings) are not available.
Dulaglutide: (Moderate) Monitor blood glucose during concomitant incretin mimetic and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Efavirenz: (Moderate) Concomitant use of levofloxacin and efavirenz may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Efavirenz; Emtricitabine; Tenofovir Disoproxil Fumarate: (Moderate) Concomitant use of levofloxacin and efavirenz may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Efavirenz; Lamivudine; Tenofovir Disoproxil Fumarate: (Moderate) Concomitant use of levofloxacin and efavirenz may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Elagolix; Estradiol; Norethindrone acetate: (Moderate) It would be prudent to recommend alternative or additional contraception when oral contraceptives (OCs) are used in conjunction with antibiotics. It was previously thought that antibiotics may decrease the effectiveness of OCs containing estrogens due to stimulation of metabolism or a reduction in enterohepatic circulation via changes in GI flora. One retrospective study reviewed the literature to determine the effects of oral antibiotics on the pharmacokinetics of contraceptive estrogens and progestins, and also examined clinical studies in which the incidence of pregnancy with OCs and antibiotics was reported. It was concluded that the antibiotics ampicillin, ciprofloxacin, clarithromycin, doxycycline, metronidazole, ofloxacin, roxithromycin, temafloxacin, and tetracycline did not alter plasma concentrations of OCs. Antituberculous drugs (e.g., rifampin) were the only agents associated with OC failure and pregnancy. Based on the study results, these authors recommended that back-up contraception may not be necessary if OCs are used reliably during oral antibiotic use. Another review concurred with these data, but noted that individual patients have been identified who experienced significant decreases in plasma concentrations of combined OC components and who appeared to ovulate; the agents most often associated with these changes were rifampin, tetracyclines, and penicillin derivatives. These authors concluded that because females most at risk for OC failure or noncompliance may not be easily identified and the true incidence of such events may be under-reported, and given the serious consequence of unwanted pregnancy, that recommending an additional method of contraception during short-term antibiotic use may be justified. During long-term antibiotic administration, the risk for drug interaction with OCs is less clear, but alternative or additional contraception may be advisable in selected circumstances. Data regarding progestin-only contraceptives or for newer combined contraceptive deliveries (e.g., patches, rings) are not available.
Eliglustat: (Moderate) Concomitant use of levofloxacin and eliglustat may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Empagliflozin: (Moderate) Monitor blood glucose during concomitant SGLT2 inhibitor and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Empagliflozin; Linagliptin: (Moderate) Monitor blood glucose during concomitant dipeptidyl peptidase-4 inhibitors and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia. (Moderate) Monitor blood glucose during concomitant SGLT2 inhibitor and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Empagliflozin; Linagliptin; Metformin: (Moderate) Monitor blood glucose carefully when systemic quinolones and antidiabetic agents, including metformin, are coadministered. Discontinue the quinolone if a hypoglycemic reaction occurs and initiate appropriate therapy immediately. Disturbances of blood glucose, including hyperglycemia and hypoglycemia, have been reported in patients treated concomitantly with quinolones and an antidiabetic agent. Hypoglycemia, sometimes resulting in coma, can occur. (Moderate) Monitor blood glucose during concomitant dipeptidyl peptidase-4 inhibitors and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia. (Moderate) Monitor blood glucose during concomitant SGLT2 inhibitor and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Empagliflozin; Metformin: (Moderate) Monitor blood glucose carefully when systemic quinolones and antidiabetic agents, including metformin, are coadministered. Discontinue the quinolone if a hypoglycemic reaction occurs and initiate appropriate therapy immediately. Disturbances of blood glucose, including hyperglycemia and hypoglycemia, have been reported in patients treated concomitantly with quinolones and an antidiabetic agent. Hypoglycemia, sometimes resulting in coma, can occur. (Moderate) Monitor blood glucose during concomitant SGLT2 inhibitor and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Emtricitabine; Rilpivirine; Tenofovir alafenamide: (Moderate) Concomitant use of levofloxacin and rilpivirine may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP. The degree of QT prolongation associated with rilpivirine is not clinically significant when administered within the recommended dosage range; QT prolongation has been described at 3 times the maximum recommended dose.
Emtricitabine; Rilpivirine; Tenofovir Disoproxil Fumarate: (Moderate) Concomitant use of levofloxacin and rilpivirine may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP. The degree of QT prolongation associated with rilpivirine is not clinically significant when administered within the recommended dosage range; QT prolongation has been described at 3 times the maximum recommended dose.
Encorafenib: (Major) Concomitant use of levofloxacin and encorafenib increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Enteral Feedings: (Major) Because many food products contain divalent or trivalent cations, these foods may significantly decrease the absorption of orally administered levofloxacin. Separate these foods or enteral feedings by at least 2 hours before or 2 hours after orally administered levofloxacin. Advise patients that dairy products and other high calcium- and iron-containing foods may affect the absorption of levofloxacin. The serum concentration of levofloxacin decreased by 61% when tablets were crushed and mixed with 240 mL of an enteral feeding formulation.
Entrectinib: (Major) Concomitant use of levofloxacin and entrectinib increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Eribulin: (Major) Concomitant use of levofloxacin and eribulin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Ertugliflozin: (Moderate) Monitor blood glucose during concomitant SGLT2 inhibitor and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Ertugliflozin; Metformin: (Moderate) Monitor blood glucose carefully when systemic quinolones and antidiabetic agents, including metformin, are coadministered. Discontinue the quinolone if a hypoglycemic reaction occurs and initiate appropriate therapy immediately. Disturbances of blood glucose, including hyperglycemia and hypoglycemia, have been reported in patients treated concomitantly with quinolones and an antidiabetic agent. Hypoglycemia, sometimes resulting in coma, can occur. (Moderate) Monitor blood glucose during concomitant SGLT2 inhibitor and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Ertugliflozin; Sitagliptin: (Moderate) Monitor blood glucose during concomitant dipeptidyl peptidase-4 inhibitors and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia. (Moderate) Monitor blood glucose during concomitant SGLT2 inhibitor and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Erythromycin: (Major) Concomitant use of levofloxacin and erythromycin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Escitalopram: (Moderate) Concomitant use of levofloxacin and escitalopram may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Estradiol; Levonorgestrel: (Moderate) It would be prudent to recommend alternative or additional contraception when oral contraceptives (OCs) are used in conjunction with antibiotics. It was previously thought that antibiotics may decrease the effectiveness of OCs containing estrogens due to stimulation of metabolism or a reduction in enterohepatic circulation via changes in GI flora. One retrospective study reviewed the literature to determine the effects of oral antibiotics on the pharmacokinetics of contraceptive estrogens and progestins, and also examined clinical studies in which the incidence of pregnancy with OCs and antibiotics was reported. It was concluded that the antibiotics ampicillin, ciprofloxacin, clarithromycin, doxycycline, metronidazole, ofloxacin, roxithromycin, temafloxacin, and tetracycline did not alter plasma concentrations of OCs. Antituberculous drugs (e.g., rifampin) were the only agents associated with OC failure and pregnancy. Based on the study results, these authors recommended that back-up contraception may not be necessary if OCs are used reliably during oral antibiotic use. Another review concurred with these data, but noted that individual patients have been identified who experienced significant decreases in plasma concentrations of combined OC components and who appeared to ovulate; the agents most often associated with these changes were rifampin, tetracyclines, and penicillin derivatives. These authors concluded that because females most at risk for OC failure or noncompliance may not be easily identified and the true incidence of such events may be under-reported, and given the serious consequence of unwanted pregnancy, that recommending an additional method of contraception during short-term antibiotic use may be justified. During long-term antibiotic administration, the risk for drug interaction with OCs is less clear, but alternative or additional contraception may be advisable in selected circumstances. Data regarding progestin-only contraceptives or for newer combined contraceptive deliveries (e.g., patches, rings) are not available.
Estradiol; Norethindrone: (Moderate) It would be prudent to recommend alternative or additional contraception when oral contraceptives (OCs) are used in conjunction with antibiotics. It was previously thought that antibiotics may decrease the effectiveness of OCs containing estrogens due to stimulation of metabolism or a reduction in enterohepatic circulation via changes in GI flora. One retrospective study reviewed the literature to determine the effects of oral antibiotics on the pharmacokinetics of contraceptive estrogens and progestins, and also examined clinical studies in which the incidence of pregnancy with OCs and antibiotics was reported. It was concluded that the antibiotics ampicillin, ciprofloxacin, clarithromycin, doxycycline, metronidazole, ofloxacin, roxithromycin, temafloxacin, and tetracycline did not alter plasma concentrations of OCs. Antituberculous drugs (e.g., rifampin) were the only agents associated with OC failure and pregnancy. Based on the study results, these authors recommended that back-up contraception may not be necessary if OCs are used reliably during oral antibiotic use. Another review concurred with these data, but noted that individual patients have been identified who experienced significant decreases in plasma concentrations of combined OC components and who appeared to ovulate; the agents most often associated with these changes were rifampin, tetracyclines, and penicillin derivatives. These authors concluded that because females most at risk for OC failure or noncompliance may not be easily identified and the true incidence of such events may be under-reported, and given the serious consequence of unwanted pregnancy, that recommending an additional method of contraception during short-term antibiotic use may be justified. During long-term antibiotic administration, the risk for drug interaction with OCs is less clear, but alternative or additional contraception may be advisable in selected circumstances. Data regarding progestin-only contraceptives or for newer combined contraceptive deliveries (e.g., patches, rings) are not available.
Estradiol; Norgestimate: (Moderate) It would be prudent to recommend alternative or additional contraception when oral contraceptives (OCs) are used in conjunction with antibiotics. It was previously thought that antibiotics may decrease the effectiveness of OCs containing estrogens due to stimulation of metabolism or a reduction in enterohepatic circulation via changes in GI flora. One retrospective study reviewed the literature to determine the effects of oral antibiotics on the pharmacokinetics of contraceptive estrogens and progestins, and also examined clinical studies in which the incidence of pregnancy with OCs and antibiotics was reported. It was concluded that the antibiotics ampicillin, ciprofloxacin, clarithromycin, doxycycline, metronidazole, ofloxacin, roxithromycin, temafloxacin, and tetracycline did not alter plasma concentrations of OCs. Antituberculous drugs (e.g., rifampin) were the only agents associated with OC failure and pregnancy. Based on the study results, these authors recommended that back-up contraception may not be necessary if OCs are used reliably during oral antibiotic use. Another review concurred with these data, but noted that individual patients have been identified who experienced significant decreases in plasma concentrations of combined OC components and who appeared to ovulate; the agents most often associated with these changes were rifampin, tetracyclines, and penicillin derivatives. These authors concluded that because females most at risk for OC failure or noncompliance may not be easily identified and the true incidence of such events may be under-reported, and given the serious consequence of unwanted pregnancy, that recommending an additional method of contraception during short-term antibiotic use may be justified. During long-term antibiotic administration, the risk for drug interaction with OCs is less clear, but alternative or additional contraception may be advisable in selected circumstances. Data regarding progestin-only contraceptives or for newer combined contraceptive deliveries (e.g., patches, rings) are not available.
Ethinyl Estradiol; Norelgestromin: (Moderate) It would be prudent to recommend alternative or additional contraception when oral contraceptives (OCs) are used in conjunction with antibiotics. It was previously thought that antibiotics may decrease the effectiveness of OCs containing estrogens due to stimulation of metabolism or a reduction in enterohepatic circulation via changes in GI flora. One retrospective study reviewed the literature to determine the effects of oral antibiotics on the pharmacokinetics of contraceptive estrogens and progestins, and also examined clinical studies in which the incidence of pregnancy with OCs and antibiotics was reported. It was concluded that the antibiotics ampicillin, ciprofloxacin, clarithromycin, doxycycline, metronidazole, ofloxacin, roxithromycin, temafloxacin, and tetracycline did not alter plasma concentrations of OCs. Antituberculous drugs (e.g., rifampin) were the only agents associated with OC failure and pregnancy. Based on the study results, these authors recommended that back-up contraception may not be necessary if OCs are used reliably during oral antibiotic use. Another review concurred with these data, but noted that individual patients have been identified who experienced significant decreases in plasma concentrations of combined OC components and who appeared to ovulate; the agents most often associated with these changes were rifampin, tetracyclines, and penicillin derivatives. These authors concluded that because females most at risk for OC failure or noncompliance may not be easily identified and the true incidence of such events may be under-reported, and given the serious consequence of unwanted pregnancy, that recommending an additional method of contraception during short-term antibiotic use may be justified. During long-term antibiotic administration, the risk for drug interaction with OCs is less clear, but alternative or additional contraception may be advisable in selected circumstances. Data regarding progestin-only contraceptives or for newer combined contraceptive deliveries (e.g., patches, rings) are not available.
Ethinyl Estradiol; Norethindrone Acetate: (Moderate) It would be prudent to recommend alternative or additional contraception when oral contraceptives (OCs) are used in conjunction with antibiotics. It was previously thought that antibiotics may decrease the effectiveness of OCs containing estrogens due to stimulation of metabolism or a reduction in enterohepatic circulation via changes in GI flora. One retrospective study reviewed the literature to determine the effects of oral antibiotics on the pharmacokinetics of contraceptive estrogens and progestins, and also examined clinical studies in which the incidence of pregnancy with OCs and antibiotics was reported. It was concluded that the antibiotics ampicillin, ciprofloxacin, clarithromycin, doxycycline, metronidazole, ofloxacin, roxithromycin, temafloxacin, and tetracycline did not alter plasma concentrations of OCs. Antituberculous drugs (e.g., rifampin) were the only agents associated with OC failure and pregnancy. Based on the study results, these authors recommended that back-up contraception may not be necessary if OCs are used reliably during oral antibiotic use. Another review concurred with these data, but noted that individual patients have been identified who experienced significant decreases in plasma concentrations of combined OC components and who appeared to ovulate; the agents most often associated with these changes were rifampin, tetracyclines, and penicillin derivatives. These authors concluded that because females most at risk for OC failure or noncompliance may not be easily identified and the true incidence of such events may be under-reported, and given the serious consequence of unwanted pregnancy, that recommending an additional method of contraception during short-term antibiotic use may be justified. During long-term antibiotic administration, the risk for drug interaction with OCs is less clear, but alternative or additional contraception may be advisable in selected circumstances. Data regarding progestin-only contraceptives or for newer combined contraceptive deliveries (e.g., patches, rings) are not available.
Ethinyl Estradiol; Norgestrel: (Moderate) It would be prudent to recommend alternative or additional contraception when oral contraceptives (OCs) are used in conjunction with antibiotics. It was previously thought that antibiotics may decrease the effectiveness of OCs containing estrogens due to stimulation of metabolism or a reduction in enterohepatic circulation via changes in GI flora. One retrospective study reviewed the literature to determine the effects of oral antibiotics on the pharmacokinetics of contraceptive estrogens and progestins, and also examined clinical studies in which the incidence of pregnancy with OCs and antibiotics was reported. It was concluded that the antibiotics ampicillin, ciprofloxacin, clarithromycin, doxycycline, metronidazole, ofloxacin, roxithromycin, temafloxacin, and tetracycline did not alter plasma concentrations of OCs. Antituberculous drugs (e.g., rifampin) were the only agents associated with OC failure and pregnancy. Based on the study results, these authors recommended that back-up contraception may not be necessary if OCs are used reliably during oral antibiotic use. Another review concurred with these data, but noted that individual patients have been identified who experienced significant decreases in plasma concentrations of combined OC components and who appeared to ovulate; the agents most often associated with these changes were rifampin, tetracyclines, and penicillin derivatives. These authors concluded that because females most at risk for OC failure or noncompliance may not be easily identified and the true incidence of such events may be under-reported, and given the serious consequence of unwanted pregnancy, that recommending an additional method of contraception during short-term antibiotic use may be justified. During long-term antibiotic administration, the risk for drug interaction with OCs is less clear, but alternative or additional contraception may be advisable in selected circumstances. Data regarding progestin-only contraceptives or for newer combined contraceptive deliveries (e.g., patches, rings) are not available.
Ethynodiol Diacetate; Ethinyl Estradiol: (Moderate) It would be prudent to recommend alternative or additional contraception when oral contraceptives (OCs) are used in conjunction with antibiotics. It was previously thought that antibiotics may decrease the effectiveness of OCs containing estrogens due to stimulation of metabolism or a reduction in enterohepatic circulation via changes in GI flora. One retrospective study reviewed the literature to determine the effects of oral antibiotics on the pharmacokinetics of contraceptive estrogens and progestins, and also examined clinical studies in which the incidence of pregnancy with OCs and antibiotics was reported. It was concluded that the antibiotics ampicillin, ciprofloxacin, clarithromycin, doxycycline, metronidazole, ofloxacin, roxithromycin, temafloxacin, and tetracycline did not alter plasma concentrations of OCs. Antituberculous drugs (e.g., rifampin) were the only agents associated with OC failure and pregnancy. Based on the study results, these authors recommended that back-up contraception may not be necessary if OCs are used reliably during oral antibiotic use. Another review concurred with these data, but noted that individual patients have been identified who experienced significant decreases in plasma concentrations of combined OC components and who appeared to ovulate; the agents most often associated with these changes were rifampin, tetracyclines, and penicillin derivatives. These authors concluded that because females most at risk for OC failure or noncompliance may not be easily identified and the true incidence of such events may be under-reported, and given the serious consequence of unwanted pregnancy, that recommending an additional method of contraception during short-term antibiotic use may be justified. During long-term antibiotic administration, the risk for drug interaction with OCs is less clear, but alternative or additional contraception may be advisable in selected circumstances. Data regarding progestin-only contraceptives or for newer combined contraceptive deliveries (e.g., patches, rings) are not available.
Etodolac: (Moderate) Use quinolones and nonsteroidal anti-inflammatory drugs (NSAIDs) concomitantly with caution due to potential increased risk of CNS stimulation and convulsive seizures. NSAIDs in combination with very high doses of quinolones have been shown to provoke convulsions in preclinical studies and postmarketing.
Etonogestrel; Ethinyl Estradiol: (Moderate) It would be prudent to recommend alternative or additional contraception when oral contraceptives (OCs) are used in conjunction with antibiotics. It was previously thought that antibiotics may decrease the effectiveness of OCs containing estrogens due to stimulation of metabolism or a reduction in enterohepatic circulation via changes in GI flora. One retrospective study reviewed the literature to determine the effects of oral antibiotics on the pharmacokinetics of contraceptive estrogens and progestins, and also examined clinical studies in which the incidence of pregnancy with OCs and antibiotics was reported. It was concluded that the antibiotics ampicillin, ciprofloxacin, clarithromycin, doxycycline, metronidazole, ofloxacin, roxithromycin, temafloxacin, and tetracycline did not alter plasma concentrations of OCs. Antituberculous drugs (e.g., rifampin) were the only agents associated with OC failure and pregnancy. Based on the study results, these authors recommended that back-up contraception may not be necessary if OCs are used reliably during oral antibiotic use. Another review concurred with these data, but noted that individual patients have been identified who experienced significant decreases in plasma concentrations of combined OC components and who appeared to ovulate; the agents most often associated with these changes were rifampin, tetracyclines, and penicillin derivatives. These authors concluded that because females most at risk for OC failure or noncompliance may not be easily identified and the true incidence of such events may be under-reported, and given the serious consequence of unwanted pregnancy, that recommending an additional method of contraception during short-term antibiotic use may be justified. During long-term antibiotic administration, the risk for drug interaction with OCs is less clear, but alternative or additional contraception may be advisable in selected circumstances. Data regarding progestin-only contraceptives or for newer combined contraceptive deliveries (e.g., patches, rings) are not available.
Etrasimod: (Moderate) Concomitant use of etrasimod and levofloxacin may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP. Etrasimod has a limited effect on the QT/QTc interval at therapeutic doses but may cause bradycardia and atrioventricular conduction delays which may increase the risk for TdP in patients with a prolonged QT/QTc interval.
Exenatide: (Moderate) Monitor blood glucose during concomitant incretin mimetic and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Fenoprofen: (Moderate) Use quinolones and nonsteroidal anti-inflammatory drugs (NSAIDs) concomitantly with caution due to potential increased risk of CNS stimulation and convulsive seizures. NSAIDs in combination with very high doses of quinolones have been shown to provoke convulsions in preclinical studies and postmarketing.
Ferric Maltol: (Moderate) Administer oral products that contain iron at least 2 hours before or 2 hours after orally administered levofloxacin. Levofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Chelation of divalent cations with levofloxacin is less than with other quinolones.
Fexinidazole: (Major) Concomitant use of fexinidazole and levofloxacin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Fingolimod: (Moderate) Concomitant use of levofloxacin and fingolimod may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Flecainide: (Major) Concomitant use of levofloxacin and flecainide increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Fluconazole: (Moderate) Concomitant use of levofloxacin and fluconazole may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Fludrocortisone: (Moderate) Quinolones have been associated with an increased risk of tendon rupture requiring surgical repair or resulting in prolonged disability; this risk is further increased in those receiving concomitant corticosteroids. Discontinue quinolone therapy at the first sign of tendon inflammation or tendon pain, as these are symptoms that may precede rupture of the tendon.
Fluocinolone; Hydroquinone; Tretinoin: (Major) Avoid the concomitant use of tretinoin with other drugs known to cause photosensitivity, such as levofloxacin. Concomitant use with other photosensitizing agents may increase the risk of a photosensitivity reaction.
Fluoxetine: (Moderate) Concomitant use of levofloxacin and fluoxetine may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Fluphenazine: (Minor) QT/QTc prolongation can occur with concomitant use of levofloxacin and fluphenazine although the risk of developing torsade de pointes (TdP) is low. Additional steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, may be considered in patients with additional risk factors for TdP.
Flurbiprofen: (Moderate) Use quinolones and nonsteroidal anti-inflammatory drugs (NSAIDs) concomitantly with caution due to potential increased risk of CNS stimulation and convulsive seizures. NSAIDs in combination with very high doses of quinolones have been shown to provoke convulsions in preclinical studies and postmarketing.
Fluvoxamine: (Moderate) Concomitant use of levofloxacin and fluvoxamine may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Foscarnet: (Major) When possible, avoid concurrent use of foscarnet with other drugs known to prolong the QT interval, such as levofloxacin. Foscarnet has been associated with postmarketing reports of both QT prolongation and torsade de pointes (TdP). Quinolones have also been associated with a risk of QT prolongation and TdP. Although extremely rare, TdP has been reported during postmarketing surveillance of levofloxacin. If these drugs are administered together, obtain an electrocardiogram and electrolyte concentrations before and periodically during treatment.
Fostemsavir: (Moderate) Concomitant use of levofloxacin and fostemsavir may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP. The degree of QT prolongation associated with fostemsavir is not clinically significant when administered within the recommended dosage range; QT prolongation has been described at 4 times the recommended daily dose.
Gemtuzumab Ozogamicin: (Moderate) Concomitant use of levofloxacin and gemtuzumab ozogamicin may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Gilteritinib: (Moderate) Concomitant use of levofloxacin and gilteritinib may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Glasdegib: (Major) Concomitant use of levofloxacin and glasdegib increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Glimepiride: (Moderate) Monitor blood glucose during concomitant sulfonylurea and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Glipizide: (Moderate) Monitor blood glucose during concomitant sulfonylurea and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Glipizide; Metformin: (Moderate) Monitor blood glucose carefully when systemic quinolones and antidiabetic agents, including metformin, are coadministered. Discontinue the quinolone if a hypoglycemic reaction occurs and initiate appropriate therapy immediately. Disturbances of blood glucose, including hyperglycemia and hypoglycemia, have been reported in patients treated concomitantly with quinolones and an antidiabetic agent. Hypoglycemia, sometimes resulting in coma, can occur. (Moderate) Monitor blood glucose during concomitant sulfonylurea and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Glyburide: (Moderate) Monitor blood glucose during concomitant sulfonylurea and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Glyburide; Metformin: (Moderate) Monitor blood glucose carefully when systemic quinolones and antidiabetic agents, including metformin, are coadministered. Discontinue the quinolone if a hypoglycemic reaction occurs and initiate appropriate therapy immediately. Disturbances of blood glucose, including hyperglycemia and hypoglycemia, have been reported in patients treated concomitantly with quinolones and an antidiabetic agent. Hypoglycemia, sometimes resulting in coma, can occur. (Moderate) Monitor blood glucose during concomitant sulfonylurea and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Goserelin: (Moderate) Concomitant use of levofloxacin and androgen deprivation therapy (i.e., goserelin) may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Granisetron: (Moderate) Concomitant use of levofloxacin and granisetron may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Halobetasol; Tazarotene: (Moderate) Use tazarotene with caution in patients who are also taking drugs known to be photosensitizers, such as levofloxacin, due to the increased possibility of augmented phototoxicity.
Halogenated Anesthetics: (Major) Concomitant use of levofloxacin and halogenated anesthetics increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Haloperidol: (Moderate) Concomitant use of levofloxacin and haloperidol may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP. The intravenous route may carry a higher risk for haloperidol-induced QT/QTc prolongation than other routes of administration.
Histrelin: (Moderate) Concomitant use of levofloxacin and androgen deprivation therapy (i.e., histrelin) may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Hydrocodone; Ibuprofen: (Moderate) Use quinolones and nonsteroidal anti-inflammatory drugs (NSAIDs) concomitantly with caution due to potential increased risk of CNS stimulation and convulsive seizures. NSAIDs in combination with very high doses of quinolones have been shown to provoke convulsions in preclinical studies and postmarketing.
Hydrocortisone: (Moderate) Quinolones have been associated with an increased risk of tendon rupture requiring surgical repair or resulting in prolonged disability; this risk is further increased in those receiving concomitant corticosteroids. Discontinue quinolone therapy at the first sign of tendon inflammation or tendon pain, as these are symptoms that may precede rupture of the tendon.
Hydroxychloroquine: (Major) Concomitant use of hydroxychloroquine and levofloxacin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Hydroxyzine: (Moderate) Concomitant use of levofloxacin and hydroxyzine may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Ibuprofen: (Moderate) Use quinolones and nonsteroidal anti-inflammatory drugs (NSAIDs) concomitantly with caution due to potential increased risk of CNS stimulation and convulsive seizures. NSAIDs in combination with very high doses of quinolones have been shown to provoke convulsions in preclinical studies and postmarketing.
Ibuprofen; Famotidine: (Moderate) Use quinolones and nonsteroidal anti-inflammatory drugs (NSAIDs) concomitantly with caution due to potential increased risk of CNS stimulation and convulsive seizures. NSAIDs in combination with very high doses of quinolones have been shown to provoke convulsions in preclinical studies and postmarketing.
Ibuprofen; Oxycodone: (Moderate) Use quinolones and nonsteroidal anti-inflammatory drugs (NSAIDs) concomitantly with caution due to potential increased risk of CNS stimulation and convulsive seizures. NSAIDs in combination with very high doses of quinolones have been shown to provoke convulsions in preclinical studies and postmarketing.
Ibuprofen; Pseudoephedrine: (Moderate) Use quinolones and nonsteroidal anti-inflammatory drugs (NSAIDs) concomitantly with caution due to potential increased risk of CNS stimulation and convulsive seizures. NSAIDs in combination with very high doses of quinolones have been shown to provoke convulsions in preclinical studies and postmarketing.
Ibutilide: (Major) Concomitant use of levofloxacin and ibutilide increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Iloperidone: (Major) Concomitant use of levofloxacin and iloperidone increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Incretin Mimetics: (Moderate) Monitor blood glucose during concomitant incretin mimetic and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Indomethacin: (Moderate) Use quinolones and nonsteroidal anti-inflammatory drugs (NSAIDs) concomitantly with caution due to potential increased risk of CNS stimulation and convulsive seizures. NSAIDs in combination with very high doses of quinolones have been shown to provoke convulsions in preclinical studies and postmarketing.
Inotuzumab Ozogamicin: (Major) Concomitant use of levofloxacin and inotuzumab ozogamicin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Insulin Aspart: (Moderate) Monitor blood glucose during concomitant insulin and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Insulin Aspart; Insulin Aspart Protamine: (Moderate) Monitor blood glucose during concomitant insulin and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Insulin Degludec: (Moderate) Monitor blood glucose during concomitant insulin and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Insulin Degludec; Liraglutide: (Moderate) Monitor blood glucose during concomitant incretin mimetic and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia. (Moderate) Monitor blood glucose during concomitant insulin and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Insulin Detemir: (Moderate) Monitor blood glucose during concomitant insulin and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Insulin Glargine: (Moderate) Monitor blood glucose during concomitant insulin and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Insulin Glargine; Lixisenatide: (Moderate) Monitor blood glucose during concomitant incretin mimetic and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia. (Moderate) Monitor blood glucose during concomitant insulin and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Insulin Glulisine: (Moderate) Monitor blood glucose during concomitant insulin and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Insulin Lispro: (Moderate) Monitor blood glucose during concomitant insulin and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Insulin Lispro; Insulin Lispro Protamine: (Moderate) Monitor blood glucose during concomitant insulin and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Insulin, Inhaled: (Moderate) Monitor blood glucose during concomitant insulin and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Insulins: (Moderate) Monitor blood glucose during concomitant insulin and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Iron Salts: (Moderate) Administer oral products that contain iron at least 2 hours before or 2 hours after orally administered levofloxacin. Levofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Chelation of divalent cations with levofloxacin is less than with other quinolones.
Iron: (Moderate) Administer oral products that contain iron at least 2 hours before or 2 hours after orally administered levofloxacin. Levofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Chelation of divalent cations with levofloxacin is less than with other quinolones.
Isoflurane: (Major) Concomitant use of levofloxacin and halogenated anesthetics increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Isophane Insulin (NPH): (Moderate) Monitor blood glucose during concomitant insulin and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Itraconazole: (Moderate) Concomitant use of levofloxacin and itraconazole may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Ivosidenib: (Major) Concomitant use of levofloxacin and ivosidenib increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Ketoconazole: (Contraindicated) Avoid concomitant use of ketoconazole and levofloxacin due to an increased risk for torsade de pointes (TdP) and QT/QTc prolongation. Ketoconazole is associated with QT prolongation and TdP; levofloxacin has been associated with prolongation of the QT interval and infrequent cases of arrhythmia and rare cases of TdP have been spontaneously reported during postmarketing surveillance.
Ketoprofen: (Moderate) Use quinolones and nonsteroidal anti-inflammatory drugs (NSAIDs) concomitantly with caution due to potential increased risk of CNS stimulation and convulsive seizures. NSAIDs in combination with very high doses of quinolones have been shown to provoke convulsions in preclinical studies and postmarketing.
Ketorolac: (Moderate) Use quinolones and nonsteroidal anti-inflammatory drugs (NSAIDs) concomitantly with caution due to potential increased risk of CNS stimulation and convulsive seizures. NSAIDs in combination with very high doses of quinolones have been shown to provoke convulsions in preclinical studies and postmarketing.
Lansoprazole; Amoxicillin; Clarithromycin: (Major) Concomitant use of levofloxacin and clarithromycin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Lanthanum Carbonate: (Major) Administer lanthanum carbonate at least 2 hours before or 2 hours after orally administered levofloxacin. When oral quinolones are given for short courses, consider eliminating the lanthanum carbonate doses that would be normally scheduled near the time of quinolone intake. Levofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Chelation of divalent cations with levofloxacin is less than with other quinolones.
Lapatinib: (Moderate) Concomitant use of levofloxacin and lapatinib may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Lefamulin: (Major) Concomitant use of levofloxacin and lefamulin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Lenvatinib: (Major) Concomitant use of levofloxacin and lenvatinib increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Leuprolide: (Moderate) Concomitant use of levofloxacin and androgen deprivation therapy (i.e., leuprolide) may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Leuprolide; Norethindrone: (Moderate) Concomitant use of levofloxacin and androgen deprivation therapy (i.e., leuprolide) may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP. (Moderate) It would be prudent to recommend alternative or additional contraception when oral contraceptives (OCs) are used in conjunction with antibiotics. It was previously thought that antibiotics may decrease the effectiveness of OCs containing estrogens due to stimulation of metabolism or a reduction in enterohepatic circulation via changes in GI flora. One retrospective study reviewed the literature to determine the effects of oral antibiotics on the pharmacokinetics of contraceptive estrogens and progestins, and also examined clinical studies in which the incidence of pregnancy with OCs and antibiotics was reported. It was concluded that the antibiotics ampicillin, ciprofloxacin, clarithromycin, doxycycline, metronidazole, ofloxacin, roxithromycin, temafloxacin, and tetracycline did not alter plasma concentrations of OCs. Antituberculous drugs (e.g., rifampin) were the only agents associated with OC failure and pregnancy. Based on the study results, these authors recommended that back-up contraception may not be necessary if OCs are used reliably during oral antibiotic use. Another review concurred with these data, but noted that individual patients have been identified who experienced significant decreases in plasma concentrations of combined OC components and who appeared to ovulate; the agents most often associated with these changes were rifampin, tetracyclines, and penicillin derivatives. These authors concluded that because females most at risk for OC failure or noncompliance may not be easily identified and the true incidence of such events may be under-reported, and given the serious consequence of unwanted pregnancy, that recommending an additional method of contraception during short-term antibiotic use may be justified. During long-term antibiotic administration, the risk for drug interaction with OCs is less clear, but alternative or additional contraception may be advisable in selected circumstances. Data regarding progestin-only contraceptives or for newer combined contraceptive deliveries (e.g., patches, rings) are not available.
Levoketoconazole: (Contraindicated) Avoid concomitant use of ketoconazole and levofloxacin due to an increased risk for torsade de pointes (TdP) and QT/QTc prolongation. Ketoconazole is associated with QT prolongation and TdP; levofloxacin has been associated with prolongation of the QT interval and infrequent cases of arrhythmia and rare cases of TdP have been spontaneously reported during postmarketing surveillance.
Levonorgestrel: (Moderate) It would be prudent to recommend alternative or additional contraception when oral contraceptives (OCs) are used in conjunction with antibiotics. It was previously thought that antibiotics may decrease the effectiveness of OCs containing estrogens due to stimulation of metabolism or a reduction in enterohepatic circulation via changes in GI flora. One retrospective study reviewed the literature to determine the effects of oral antibiotics on the pharmacokinetics of contraceptive estrogens and progestins, and also examined clinical studies in which the incidence of pregnancy with OCs and antibiotics was reported. It was concluded that the antibiotics ampicillin, ciprofloxacin, clarithromycin, doxycycline, metronidazole, ofloxacin, roxithromycin, temafloxacin, and tetracycline did not alter plasma concentrations of OCs. Antituberculous drugs (e.g., rifampin) were the only agents associated with OC failure and pregnancy. Based on the study results, these authors recommended that back-up contraception may not be necessary if OCs are used reliably during oral antibiotic use. Another review concurred with these data, but noted that individual patients have been identified who experienced significant decreases in plasma concentrations of combined OC components and who appeared to ovulate; the agents most often associated with these changes were rifampin, tetracyclines, and penicillin derivatives. These authors concluded that because females most at risk for OC failure or noncompliance may not be easily identified and the true incidence of such events may be under-reported, and given the serious consequence of unwanted pregnancy, that recommending an additional method of contraception during short-term antibiotic use may be justified. During long-term antibiotic administration, the risk for drug interaction with OCs is less clear, but alternative or additional contraception may be advisable in selected circumstances. Data regarding progestin-only contraceptives or for newer combined contraceptive deliveries (e.g., patches, rings) are not available.
Levonorgestrel; Ethinyl Estradiol: (Moderate) It would be prudent to recommend alternative or additional contraception when oral contraceptives (OCs) are used in conjunction with antibiotics. It was previously thought that antibiotics may decrease the effectiveness of OCs containing estrogens due to stimulation of metabolism or a reduction in enterohepatic circulation via changes in GI flora. One retrospective study reviewed the literature to determine the effects of oral antibiotics on the pharmacokinetics of contraceptive estrogens and progestins, and also examined clinical studies in which the incidence of pregnancy with OCs and antibiotics was reported. It was concluded that the antibiotics ampicillin, ciprofloxacin, clarithromycin, doxycycline, metronidazole, ofloxacin, roxithromycin, temafloxacin, and tetracycline did not alter plasma concentrations of OCs. Antituberculous drugs (e.g., rifampin) were the only agents associated with OC failure and pregnancy. Based on the study results, these authors recommended that back-up contraception may not be necessary if OCs are used reliably during oral antibiotic use. Another review concurred with these data, but noted that individual patients have been identified who experienced significant decreases in plasma concentrations of combined OC components and who appeared to ovulate; the agents most often associated with these changes were rifampin, tetracyclines, and penicillin derivatives. These authors concluded that because females most at risk for OC failure or noncompliance may not be easily identified and the true incidence of such events may be under-reported, and given the serious consequence of unwanted pregnancy, that recommending an additional method of contraception during short-term antibiotic use may be justified. During long-term antibiotic administration, the risk for drug interaction with OCs is less clear, but alternative or additional contraception may be advisable in selected circumstances. Data regarding progestin-only contraceptives or for newer combined contraceptive deliveries (e.g., patches, rings) are not available.
Levonorgestrel; Ethinyl Estradiol; Ferrous Bisglycinate: (Moderate) Administer oral products that contain iron at least 2 hours before or 2 hours after orally administered levofloxacin. Levofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Chelation of divalent cations with levofloxacin is less than with other quinolones. (Moderate) It would be prudent to recommend alternative or additional contraception when oral contraceptives (OCs) are used in conjunction with antibiotics. It was previously thought that antibiotics may decrease the effectiveness of OCs containing estrogens due to stimulation of metabolism or a reduction in enterohepatic circulation via changes in GI flora. One retrospective study reviewed the literature to determine the effects of oral antibiotics on the pharmacokinetics of contraceptive estrogens and progestins, and also examined clinical studies in which the incidence of pregnancy with OCs and antibiotics was reported. It was concluded that the antibiotics ampicillin, ciprofloxacin, clarithromycin, doxycycline, metronidazole, ofloxacin, roxithromycin, temafloxacin, and tetracycline did not alter plasma concentrations of OCs. Antituberculous drugs (e.g., rifampin) were the only agents associated with OC failure and pregnancy. Based on the study results, these authors recommended that back-up contraception may not be necessary if OCs are used reliably during oral antibiotic use. Another review concurred with these data, but noted that individual patients have been identified who experienced significant decreases in plasma concentrations of combined OC components and who appeared to ovulate; the agents most often associated with these changes were rifampin, tetracyclines, and penicillin derivatives. These authors concluded that because females most at risk for OC failure or noncompliance may not be easily identified and the true incidence of such events may be under-reported, and given the serious consequence of unwanted pregnancy, that recommending an additional method of contraception during short-term antibiotic use may be justified. During long-term antibiotic administration, the risk for drug interaction with OCs is less clear, but alternative or additional contraception may be advisable in selected circumstances. Data regarding progestin-only contraceptives or for newer combined contraceptive deliveries (e.g., patches, rings) are not available.
Levonorgestrel; Ethinyl Estradiol; Ferrous Fumarate: (Moderate) Administer oral products that contain iron at least 2 hours before or 2 hours after orally administered levofloxacin. Levofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Chelation of divalent cations with levofloxacin is less than with other quinolones. (Moderate) It would be prudent to recommend alternative or additional contraception when oral contraceptives (OCs) are used in conjunction with antibiotics. It was previously thought that antibiotics may decrease the effectiveness of OCs containing estrogens due to stimulation of metabolism or a reduction in enterohepatic circulation via changes in GI flora. One retrospective study reviewed the literature to determine the effects of oral antibiotics on the pharmacokinetics of contraceptive estrogens and progestins, and also examined clinical studies in which the incidence of pregnancy with OCs and antibiotics was reported. It was concluded that the antibiotics ampicillin, ciprofloxacin, clarithromycin, doxycycline, metronidazole, ofloxacin, roxithromycin, temafloxacin, and tetracycline did not alter plasma concentrations of OCs. Antituberculous drugs (e.g., rifampin) were the only agents associated with OC failure and pregnancy. Based on the study results, these authors recommended that back-up contraception may not be necessary if OCs are used reliably during oral antibiotic use. Another review concurred with these data, but noted that individual patients have been identified who experienced significant decreases in plasma concentrations of combined OC components and who appeared to ovulate; the agents most often associated with these changes were rifampin, tetracyclines, and penicillin derivatives. These authors concluded that because females most at risk for OC failure or noncompliance may not be easily identified and the true incidence of such events may be under-reported, and given the serious consequence of unwanted pregnancy, that recommending an additional method of contraception during short-term antibiotic use may be justified. During long-term antibiotic administration, the risk for drug interaction with OCs is less clear, but alternative or additional contraception may be advisable in selected circumstances. Data regarding progestin-only contraceptives or for newer combined contraceptive deliveries (e.g., patches, rings) are not available.
Linagliptin: (Moderate) Monitor blood glucose during concomitant dipeptidyl peptidase-4 inhibitors and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Linagliptin; Metformin: (Moderate) Monitor blood glucose carefully when systemic quinolones and antidiabetic agents, including metformin, are coadministered. Discontinue the quinolone if a hypoglycemic reaction occurs and initiate appropriate therapy immediately. Disturbances of blood glucose, including hyperglycemia and hypoglycemia, have been reported in patients treated concomitantly with quinolones and an antidiabetic agent. Hypoglycemia, sometimes resulting in coma, can occur. (Moderate) Monitor blood glucose during concomitant dipeptidyl peptidase-4 inhibitors and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Liraglutide: (Moderate) Monitor blood glucose during concomitant incretin mimetic and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Lithium: (Moderate) Concomitant use of levofloxacin and lithium may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Lixisenatide: (Moderate) Monitor blood glucose during concomitant incretin mimetic and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Lofexidine: (Major) Concomitant use of levofloxacin and lofexidine increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Loperamide: (Moderate) Concomitant use of levofloxacin and loperamide may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Loperamide; Simethicone: (Moderate) Concomitant use of levofloxacin and loperamide may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Lopinavir; Ritonavir: (Major) Concomitant use of lopinavir and levofloxacin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Macimorelin: (Major) Concomitant use of levofloxacin and macimorelin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Magnesium Citrate: (Moderate) Administer magnesium citrate at least 2 hours before or 2 hours after orally administered levofloxacin. Levofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Chelation of divalent cations with levofloxacin is less than with other quinolones.
Magnesium Hydroxide: (Moderate) Administer magnesium hydroxide at least 2 hours before or 2 hours after orally administered levofloxacin. Levofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Chelation of divalent cations with levofloxacin is less than with other quinolones.
Magnesium Salicylate: (Moderate) Administer magnesium salicylate at least 2 hours before or 2 hours after orally administered levofloxacin. Levofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Chelation of divalent cations with levofloxacin is less than with other quinolones.
Magnesium Salts: (Moderate) Administer oral products that contain magnesium at least 2 hours before or 2 hours after orally administered levofloxacin. Levofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Chelation of divalent cations with levofloxacin is less than with other quinolones.
Magnesium Sulfate; Potassium Sulfate; Sodium Sulfate: (Major) Administer quinolones at least 2 hours before or 6 hours after administration of magnesium sulfate; potassium sulfate; sodium sulfate. The absorption of quinolones may be reduced by chelation with magnesium sulfate.
Magnesium: (Moderate) Administer oral products that contain magnesium at least 2 hours before or 2 hours after orally administered levofloxacin. Levofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Chelation of divalent cations with levofloxacin is less than with other quinolones.
Maprotiline: (Moderate) Concomitant use of levofloxacin and maprotiline may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Meclofenamate Sodium: (Moderate) Use quinolones and nonsteroidal anti-inflammatory drugs (NSAIDs) concomitantly with caution due to potential increased risk of CNS stimulation and convulsive seizures. NSAIDs in combination with very high doses of quinolones have been shown to provoke convulsions in preclinical studies and postmarketing.
Mefenamic Acid: (Moderate) Use quinolones and nonsteroidal anti-inflammatory drugs (NSAIDs) concomitantly with caution due to potential increased risk of CNS stimulation and convulsive seizures. NSAIDs in combination with very high doses of quinolones have been shown to provoke convulsions in preclinical studies and postmarketing.
Mefloquine: (Moderate) Concomitant use of levofloxacin and mefloquine may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Meglitinides: (Moderate) Monitor blood glucose carefully when systemic quinolones and antidiabetic agents, including meglitinides, are coadministered. Discontinue the quinolone if a hypoglycemic reaction occurs and initiate appropriate therapy immediately. Disturbances of blood glucose, including hyperglycemia and hypoglycemia, have been reported in patients treated concomitantly with quinolones and an antidiabetic agent. Hypoglycemia, sometimes resulting in coma, can occur.
Meloxicam: (Moderate) Use quinolones and nonsteroidal anti-inflammatory drugs (NSAIDs) concomitantly with caution due to potential increased risk of CNS stimulation and convulsive seizures. NSAIDs in combination with very high doses of quinolones have been shown to provoke convulsions in preclinical studies and postmarketing.
Metformin: (Moderate) Monitor blood glucose carefully when systemic quinolones and antidiabetic agents, including metformin, are coadministered. Discontinue the quinolone if a hypoglycemic reaction occurs and initiate appropriate therapy immediately. Disturbances of blood glucose, including hyperglycemia and hypoglycemia, have been reported in patients treated concomitantly with quinolones and an antidiabetic agent. Hypoglycemia, sometimes resulting in coma, can occur.
Metformin; Repaglinide: (Moderate) Monitor blood glucose carefully when systemic quinolones and antidiabetic agents, including meglitinides, are coadministered. Discontinue the quinolone if a hypoglycemic reaction occurs and initiate appropriate therapy immediately. Disturbances of blood glucose, including hyperglycemia and hypoglycemia, have been reported in patients treated concomitantly with quinolones and an antidiabetic agent. Hypoglycemia, sometimes resulting in coma, can occur. (Moderate) Monitor blood glucose carefully when systemic quinolones and antidiabetic agents, including metformin, are coadministered. Discontinue the quinolone if a hypoglycemic reaction occurs and initiate appropriate therapy immediately. Disturbances of blood glucose, including hyperglycemia and hypoglycemia, have been reported in patients treated concomitantly with quinolones and an antidiabetic agent. Hypoglycemia, sometimes resulting in coma, can occur.
Metformin; Saxagliptin: (Moderate) Monitor blood glucose carefully when systemic quinolones and antidiabetic agents, including metformin, are coadministered. Discontinue the quinolone if a hypoglycemic reaction occurs and initiate appropriate therapy immediately. Disturbances of blood glucose, including hyperglycemia and hypoglycemia, have been reported in patients treated concomitantly with quinolones and an antidiabetic agent. Hypoglycemia, sometimes resulting in coma, can occur. (Moderate) Monitor blood glucose during concomitant dipeptidyl peptidase-4 inhibitors and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Metformin; Sitagliptin: (Moderate) Monitor blood glucose carefully when systemic quinolones and antidiabetic agents, including metformin, are coadministered. Discontinue the quinolone if a hypoglycemic reaction occurs and initiate appropriate therapy immediately. Disturbances of blood glucose, including hyperglycemia and hypoglycemia, have been reported in patients treated concomitantly with quinolones and an antidiabetic agent. Hypoglycemia, sometimes resulting in coma, can occur. (Moderate) Monitor blood glucose during concomitant dipeptidyl peptidase-4 inhibitors and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Methadone: (Major) Concomitant use of levofloxacin and methadone increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Methylprednisolone: (Moderate) Quinolones have been associated with an increased risk of tendon rupture requiring surgical repair or resulting in prolonged disability; this risk is further increased in those receiving concomitant corticosteroids. Discontinue quinolone therapy at the first sign of tendon inflammation or tendon pain, as these are symptoms that may precede rupture of the tendon.
Metronidazole: (Moderate) Concomitant use of metronidazole and levofloxacin may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Midostaurin: (Major) Concomitant use of levofloxacin and midostaurin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Mifepristone: (Major) Concomitant use of levofloxacin and mifepristone increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Miglitol: (Moderate) Monitor blood glucose carefully when systemic quinolones and antidiabetic agents, including alpha-glucosidase inhibitors, are coadministered. Discontinue the quinolone if a hypoglycemic reaction occurs and initiate appropriate therapy immediately. Disturbances of blood glucose, including hyperglycemia and hypoglycemia, have been reported in patients treated concomitantly with quinolones and an antidiabetic agent. Hypoglycemia, sometimes resulting in coma, can occur.
Mirtazapine: (Moderate) Concomitant use of levofloxacin and mirtazapine may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Mobocertinib: (Major) Concomitant use of mobocertinib and levofloxacin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Nabumetone: (Moderate) Use quinolones and nonsteroidal anti-inflammatory drugs (NSAIDs) concomitantly with caution due to potential increased risk of CNS stimulation and convulsive seizures. NSAIDs in combination with very high doses of quinolones have been shown to provoke convulsions in preclinical studies and postmarketing.
Naproxen: (Moderate) Use quinolones and nonsteroidal anti-inflammatory drugs (NSAIDs) concomitantly with caution due to potential increased risk of CNS stimulation and convulsive seizures. NSAIDs in combination with very high doses of quinolones have been shown to provoke convulsions in preclinical studies and postmarketing.
Naproxen; Esomeprazole: (Moderate) Use quinolones and nonsteroidal anti-inflammatory drugs (NSAIDs) concomitantly with caution due to potential increased risk of CNS stimulation and convulsive seizures. NSAIDs in combination with very high doses of quinolones have been shown to provoke convulsions in preclinical studies and postmarketing.
Naproxen; Pseudoephedrine: (Moderate) Use quinolones and nonsteroidal anti-inflammatory drugs (NSAIDs) concomitantly with caution due to potential increased risk of CNS stimulation and convulsive seizures. NSAIDs in combination with very high doses of quinolones have been shown to provoke convulsions in preclinical studies and postmarketing.
Nateglinide: (Moderate) Monitor blood glucose carefully when systemic quinolones and antidiabetic agents, including meglitinides, are coadministered. Discontinue the quinolone if a hypoglycemic reaction occurs and initiate appropriate therapy immediately. Disturbances of blood glucose, including hyperglycemia and hypoglycemia, have been reported in patients treated concomitantly with quinolones and an antidiabetic agent. Hypoglycemia, sometimes resulting in coma, can occur.
Nilotinib: (Major) Concomitant use of levofloxacin and nilotinib increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Nonsteroidal antiinflammatory drugs: (Moderate) Use quinolones and nonsteroidal anti-inflammatory drugs (NSAIDs) concomitantly with caution due to potential increased risk of CNS stimulation and convulsive seizures. NSAIDs in combination with very high doses of quinolones have been shown to provoke convulsions in preclinical studies and postmarketing.
Norethindrone Acetate; Ethinyl Estradiol; Ferrous fumarate: (Moderate) Administer oral products that contain iron at least 2 hours before or 2 hours after orally administered levofloxacin. Levofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Chelation of divalent cations with levofloxacin is less than with other quinolones. (Moderate) It would be prudent to recommend alternative or additional contraception when oral contraceptives (OCs) are used in conjunction with antibiotics. It was previously thought that antibiotics may decrease the effectiveness of OCs containing estrogens due to stimulation of metabolism or a reduction in enterohepatic circulation via changes in GI flora. One retrospective study reviewed the literature to determine the effects of oral antibiotics on the pharmacokinetics of contraceptive estrogens and progestins, and also examined clinical studies in which the incidence of pregnancy with OCs and antibiotics was reported. It was concluded that the antibiotics ampicillin, ciprofloxacin, clarithromycin, doxycycline, metronidazole, ofloxacin, roxithromycin, temafloxacin, and tetracycline did not alter plasma concentrations of OCs. Antituberculous drugs (e.g., rifampin) were the only agents associated with OC failure and pregnancy. Based on the study results, these authors recommended that back-up contraception may not be necessary if OCs are used reliably during oral antibiotic use. Another review concurred with these data, but noted that individual patients have been identified who experienced significant decreases in plasma concentrations of combined OC components and who appeared to ovulate; the agents most often associated with these changes were rifampin, tetracyclines, and penicillin derivatives. These authors concluded that because females most at risk for OC failure or noncompliance may not be easily identified and the true incidence of such events may be under-reported, and given the serious consequence of unwanted pregnancy, that recommending an additional method of contraception during short-term antibiotic use may be justified. During long-term antibiotic administration, the risk for drug interaction with OCs is less clear, but alternative or additional contraception may be advisable in selected circumstances. Data regarding progestin-only contraceptives or for newer combined contraceptive deliveries (e.g., patches, rings) are not available.
Norethindrone: (Moderate) It would be prudent to recommend alternative or additional contraception when oral contraceptives (OCs) are used in conjunction with antibiotics. It was previously thought that antibiotics may decrease the effectiveness of OCs containing estrogens due to stimulation of metabolism or a reduction in enterohepatic circulation via changes in GI flora. One retrospective study reviewed the literature to determine the effects of oral antibiotics on the pharmacokinetics of contraceptive estrogens and progestins, and also examined clinical studies in which the incidence of pregnancy with OCs and antibiotics was reported. It was concluded that the antibiotics ampicillin, ciprofloxacin, clarithromycin, doxycycline, metronidazole, ofloxacin, roxithromycin, temafloxacin, and tetracycline did not alter plasma concentrations of OCs. Antituberculous drugs (e.g., rifampin) were the only agents associated with OC failure and pregnancy. Based on the study results, these authors recommended that back-up contraception may not be necessary if OCs are used reliably during oral antibiotic use. Another review concurred with these data, but noted that individual patients have been identified who experienced significant decreases in plasma concentrations of combined OC components and who appeared to ovulate; the agents most often associated with these changes were rifampin, tetracyclines, and penicillin derivatives. These authors concluded that because females most at risk for OC failure or noncompliance may not be easily identified and the true incidence of such events may be under-reported, and given the serious consequence of unwanted pregnancy, that recommending an additional method of contraception during short-term antibiotic use may be justified. During long-term antibiotic administration, the risk for drug interaction with OCs is less clear, but alternative or additional contraception may be advisable in selected circumstances. Data regarding progestin-only contraceptives or for newer combined contraceptive deliveries (e.g., patches, rings) are not available.
Norethindrone; Ethinyl Estradiol: (Moderate) It would be prudent to recommend alternative or additional contraception when oral contraceptives (OCs) are used in conjunction with antibiotics. It was previously thought that antibiotics may decrease the effectiveness of OCs containing estrogens due to stimulation of metabolism or a reduction in enterohepatic circulation via changes in GI flora. One retrospective study reviewed the literature to determine the effects of oral antibiotics on the pharmacokinetics of contraceptive estrogens and progestins, and also examined clinical studies in which the incidence of pregnancy with OCs and antibiotics was reported. It was concluded that the antibiotics ampicillin, ciprofloxacin, clarithromycin, doxycycline, metronidazole, ofloxacin, roxithromycin, temafloxacin, and tetracycline did not alter plasma concentrations of OCs. Antituberculous drugs (e.g., rifampin) were the only agents associated with OC failure and pregnancy. Based on the study results, these authors recommended that back-up contraception may not be necessary if OCs are used reliably during oral antibiotic use. Another review concurred with these data, but noted that individual patients have been identified who experienced significant decreases in plasma concentrations of combined OC components and who appeared to ovulate; the agents most often associated with these changes were rifampin, tetracyclines, and penicillin derivatives. These authors concluded that because females most at risk for OC failure or noncompliance may not be easily identified and the true incidence of such events may be under-reported, and given the serious consequence of unwanted pregnancy, that recommending an additional method of contraception during short-term antibiotic use may be justified. During long-term antibiotic administration, the risk for drug interaction with OCs is less clear, but alternative or additional contraception may be advisable in selected circumstances. Data regarding progestin-only contraceptives or for newer combined contraceptive deliveries (e.g., patches, rings) are not available.
Norethindrone; Ethinyl Estradiol; Ferrous fumarate: (Moderate) Administer oral products that contain iron at least 2 hours before or 2 hours after orally administered levofloxacin. Levofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Chelation of divalent cations with levofloxacin is less than with other quinolones. (Moderate) It would be prudent to recommend alternative or additional contraception when oral contraceptives (OCs) are used in conjunction with antibiotics. It was previously thought that antibiotics may decrease the effectiveness of OCs containing estrogens due to stimulation of metabolism or a reduction in enterohepatic circulation via changes in GI flora. One retrospective study reviewed the literature to determine the effects of oral antibiotics on the pharmacokinetics of contraceptive estrogens and progestins, and also examined clinical studies in which the incidence of pregnancy with OCs and antibiotics was reported. It was concluded that the antibiotics ampicillin, ciprofloxacin, clarithromycin, doxycycline, metronidazole, ofloxacin, roxithromycin, temafloxacin, and tetracycline did not alter plasma concentrations of OCs. Antituberculous drugs (e.g., rifampin) were the only agents associated with OC failure and pregnancy. Based on the study results, these authors recommended that back-up contraception may not be necessary if OCs are used reliably during oral antibiotic use. Another review concurred with these data, but noted that individual patients have been identified who experienced significant decreases in plasma concentrations of combined OC components and who appeared to ovulate; the agents most often associated with these changes were rifampin, tetracyclines, and penicillin derivatives. These authors concluded that because females most at risk for OC failure or noncompliance may not be easily identified and the true incidence of such events may be under-reported, and given the serious consequence of unwanted pregnancy, that recommending an additional method of contraception during short-term antibiotic use may be justified. During long-term antibiotic administration, the risk for drug interaction with OCs is less clear, but alternative or additional contraception may be advisable in selected circumstances. Data regarding progestin-only contraceptives or for newer combined contraceptive deliveries (e.g., patches, rings) are not available.
Norgestimate; Ethinyl Estradiol: (Moderate) It would be prudent to recommend alternative or additional contraception when oral contraceptives (OCs) are used in conjunction with antibiotics. It was previously thought that antibiotics may decrease the effectiveness of OCs containing estrogens due to stimulation of metabolism or a reduction in enterohepatic circulation via changes in GI flora. One retrospective study reviewed the literature to determine the effects of oral antibiotics on the pharmacokinetics of contraceptive estrogens and progestins, and also examined clinical studies in which the incidence of pregnancy with OCs and antibiotics was reported. It was concluded that the antibiotics ampicillin, ciprofloxacin, clarithromycin, doxycycline, metronidazole, ofloxacin, roxithromycin, temafloxacin, and tetracycline did not alter plasma concentrations of OCs. Antituberculous drugs (e.g., rifampin) were the only agents associated with OC failure and pregnancy. Based on the study results, these authors recommended that back-up contraception may not be necessary if OCs are used reliably during oral antibiotic use. Another review concurred with these data, but noted that individual patients have been identified who experienced significant decreases in plasma concentrations of combined OC components and who appeared to ovulate; the agents most often associated with these changes were rifampin, tetracyclines, and penicillin derivatives. These authors concluded that because females most at risk for OC failure or noncompliance may not be easily identified and the true incidence of such events may be under-reported, and given the serious consequence of unwanted pregnancy, that recommending an additional method of contraception during short-term antibiotic use may be justified. During long-term antibiotic administration, the risk for drug interaction with OCs is less clear, but alternative or additional contraception may be advisable in selected circumstances. Data regarding progestin-only contraceptives or for newer combined contraceptive deliveries (e.g., patches, rings) are not available.
Norgestrel: (Moderate) It would be prudent to recommend alternative or additional contraception when oral contraceptives (OCs) are used in conjunction with antibiotics. It was previously thought that antibiotics may decrease the effectiveness of OCs containing estrogens due to stimulation of metabolism or a reduction in enterohepatic circulation via changes in GI flora. One retrospective study reviewed the literature to determine the effects of oral antibiotics on the pharmacokinetics of contraceptive estrogens and progestins, and also examined clinical studies in which the incidence of pregnancy with OCs and antibiotics was reported. It was concluded that the antibiotics ampicillin, ciprofloxacin, clarithromycin, doxycycline, metronidazole, ofloxacin, roxithromycin, temafloxacin, and tetracycline did not alter plasma concentrations of OCs. Antituberculous drugs (e.g., rifampin) were the only agents associated with OC failure and pregnancy. Based on the study results, these authors recommended that back-up contraception may not be necessary if OCs are used reliably during oral antibiotic use. Another review concurred with these data, but noted that individual patients have been identified who experienced significant decreases in plasma concentrations of combined OC components and who appeared to ovulate; the agents most often associated with these changes were rifampin, tetracyclines, and penicillin derivatives. These authors concluded that because females most at risk for OC failure or noncompliance may not be easily identified and the true incidence of such events may be under-reported, and given the serious consequence of unwanted pregnancy, that recommending an additional method of contraception during short-term antibiotic use may be justified. During long-term antibiotic administration, the risk for drug interaction with OCs is less clear, but alternative or additional contraception may be advisable in selected circumstances. Data regarding progestin-only contraceptives or for newer combined contraceptive deliveries (e.g., patches, rings) are not available.
Olanzapine: (Moderate) Concomitant use of levofloxacin and olanzapine may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Olanzapine; Fluoxetine: (Moderate) Concomitant use of levofloxacin and fluoxetine may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP. (Moderate) Concomitant use of levofloxacin and olanzapine may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Olanzapine; Samidorphan: (Moderate) Concomitant use of levofloxacin and olanzapine may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Ondansetron: (Major) Concomitant use of ondansetron and levofloxacin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Oral Contraceptives: (Moderate) It would be prudent to recommend alternative or additional contraception when oral contraceptives (OCs) are used in conjunction with antibiotics. It was previously thought that antibiotics may decrease the effectiveness of OCs containing estrogens due to stimulation of metabolism or a reduction in enterohepatic circulation via changes in GI flora. One retrospective study reviewed the literature to determine the effects of oral antibiotics on the pharmacokinetics of contraceptive estrogens and progestins, and also examined clinical studies in which the incidence of pregnancy with OCs and antibiotics was reported. It was concluded that the antibiotics ampicillin, ciprofloxacin, clarithromycin, doxycycline, metronidazole, ofloxacin, roxithromycin, temafloxacin, and tetracycline did not alter plasma concentrations of OCs. Antituberculous drugs (e.g., rifampin) were the only agents associated with OC failure and pregnancy. Based on the study results, these authors recommended that back-up contraception may not be necessary if OCs are used reliably during oral antibiotic use. Another review concurred with these data, but noted that individual patients have been identified who experienced significant decreases in plasma concentrations of combined OC components and who appeared to ovulate; the agents most often associated with these changes were rifampin, tetracyclines, and penicillin derivatives. These authors concluded that because females most at risk for OC failure or noncompliance may not be easily identified and the true incidence of such events may be under-reported, and given the serious consequence of unwanted pregnancy, that recommending an additional method of contraception during short-term antibiotic use may be justified. During long-term antibiotic administration, the risk for drug interaction with OCs is less clear, but alternative or additional contraception may be advisable in selected circumstances. Data regarding progestin-only contraceptives or for newer combined contraceptive deliveries (e.g., patches, rings) are not available.
Osilodrostat: (Moderate) Concomitant use of levofloxacin and osilodrostat may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Osimertinib: (Major) Concomitant use of osimertinib and levofloxacin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Oxaliplatin: (Major) Concomitant use of oxaliplatin and levofloxacin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Oxaprozin: (Moderate) Use quinolones and nonsteroidal anti-inflammatory drugs (NSAIDs) concomitantly with caution due to potential increased risk of CNS stimulation and convulsive seizures. NSAIDs in combination with very high doses of quinolones have been shown to provoke convulsions in preclinical studies and postmarketing.
Ozanimod: (Major) Concomitant use of levofloxacin and ozanimod increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary. Ozanimod has a limited effect on the QT/QTc interval at therapeutic doses but may cause bradycardia and atrioventricular conduction delays which may increase the risk for TdP in patients with a prolonged QT/QTc interval.
Pacritinib: (Major) Concomitant use of pacritinib and levofloxacin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Paliperidone: (Major) Concomitant use of paliperidone and levofloxacin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Panobinostat: (Major) Concomitant use of panobinostat and levofloxacin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Pasireotide: (Moderate) Concomitant use of levofloxacin and pasireotide may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Pazopanib: (Major) Concomitant use of pazopanib and levofloxacin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Pentamidine: (Major) Concomitant use of pentamidine and levofloxacin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Perphenazine: (Minor) QT/QTc prolongation can occur with concomitant use of levofloxacin and perphenazine although the risk of developing torsade de pointes (TdP) is low. Additional steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, may be considered in patients with additional risk factors for TdP.
Perphenazine; Amitriptyline: (Minor) QT/QTc prolongation can occur with concomitant use of levofloxacin and perphenazine although the risk of developing torsade de pointes (TdP) is low. Additional steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, may be considered in patients with additional risk factors for TdP.
Pimavanserin: (Major) Concomitant use of pimavanserin and levofloxacin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Pimozide: (Contraindicated) Avoid concomitant use of pimozide and levofloxacin due to an increased risk for torsade de pointes (TdP) and QT/QTc prolongation.
Pioglitazone: (Moderate) Monitor blood glucose during concomitant thiazolidinedione and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Pioglitazone; Glimepiride: (Moderate) Monitor blood glucose during concomitant sulfonylurea and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia. (Moderate) Monitor blood glucose during concomitant thiazolidinedione and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Pioglitazone; Metformin: (Moderate) Monitor blood glucose carefully when systemic quinolones and antidiabetic agents, including metformin, are coadministered. Discontinue the quinolone if a hypoglycemic reaction occurs and initiate appropriate therapy immediately. Disturbances of blood glucose, including hyperglycemia and hypoglycemia, have been reported in patients treated concomitantly with quinolones and an antidiabetic agent. Hypoglycemia, sometimes resulting in coma, can occur. (Moderate) Monitor blood glucose during concomitant thiazolidinedione and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Piroxicam: (Moderate) Use quinolones and nonsteroidal anti-inflammatory drugs (NSAIDs) concomitantly with caution due to potential increased risk of CNS stimulation and convulsive seizures. NSAIDs in combination with very high doses of quinolones have been shown to provoke convulsions in preclinical studies and postmarketing.
Pitolisant: (Major) Concomitant use of pitolisant and levofloxacin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Polycarbophil: (Major) Administer calcium polycarbophil at least 2 hours before or 2 hours after orally administered levofloxacin. Levofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Chelation of divalent cations with levofloxacin is less than with other quinolones.
Polyethylene Glycol; Electrolytes: (Major) Administer quinolones at least 2 hours before or 6 hours after administration of magnesium sulfate; potassium sulfate; sodium sulfate. The absorption of quinolones may be reduced by chelation with magnesium sulfate.
Polyethylene Glycol; Electrolytes; Ascorbic Acid: (Major) Administer quinolones at least 2 hours before or 6 hours after administration of magnesium sulfate; potassium sulfate; sodium sulfate. The absorption of quinolones may be reduced by chelation with magnesium sulfate.
Polysaccharide-Iron Complex: (Moderate) Administer oral products that contain iron at least 2 hours before or 2 hours after orally administered levofloxacin. Levofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Chelation of divalent cations with levofloxacin is less than with other quinolones.
Ponesimod: (Major) Concomitant use of levofloxacin and ponesimod increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary. Ponesimod has a limited effect on the QT/QTc interval at therapeutic doses but may cause bradycardia and atrioventricular conduction delays which may increase the risk for TdP in patients with a prolonged QT/QTc interval.
Porfimer: (Major) Avoid the concomitant use of porfimer with other drugs known to cause photosensitivity, such as levofloxacin. Concomitant use with other photosensitizing agents may increase the risk of a photosensitivity reaction.
Posaconazole: (Moderate) Concomitant use of levofloxacin and posaconazole may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Pramlintide: (Moderate) Monitor blood glucose carefully when systemic quinolones and antidiabetic agents, including pramlintide, are coadministered. Discontinue the quinolone if a hypoglycemic reaction occurs and initiate appropriate therapy immediately. Disturbances of blood glucose, including hyperglycemia and hypoglycemia, have been reported in patients treated concomitantly with quinolones and an antidiabetic agent. Hypoglycemia, sometimes resulting in coma, can occur.
Prednisolone: (Moderate) Quinolones have been associated with an increased risk of tendon rupture requiring surgical repair or resulting in prolonged disability; this risk is further increased in those receiving concomitant corticosteroids. Discontinue quinolone therapy at the first sign of tendon inflammation or tendon pain, as these are symptoms that may precede rupture of the tendon.
Prednisone: (Moderate) Quinolones have been associated with an increased risk of tendon rupture requiring surgical repair or resulting in prolonged disability; this risk is further increased in those receiving concomitant corticosteroids. Discontinue quinolone therapy at the first sign of tendon inflammation or tendon pain, as these are symptoms that may precede rupture of the tendon.
Primaquine: (Moderate) Concomitant use of levofloxacin and primaquine may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Procainamide: (Major) Levofloxacin should be avoided in combination with Class IA antiarrhythmics (disopyramide, procainamide, and quinidine). Class IA antiarrhythmics are associated with QT prolongation and torsades de pointes (TdP). Levofloxacin has been associated with prolongation of the QT interval and infrequent cases of arrhythmia. Rare cases of TdP have been spontaneously reported during postmarketing surveillance in patients receiving levofloxacin. According to the manufacturer, levofloxacin should be avoided in patients taking drugs that can result in prolongation of the QT interval.
Prochlorperazine: (Minor) QT/QTc prolongation can occur with concomitant use of levofloxacin and prochlorperazine although the risk of developing torsade de pointes (TdP) is low. Additional steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, may be considered in patients with additional risk factors for TdP.
Promethazine: (Moderate) Concomitant use of levofloxacin and promethazine may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Promethazine; Dextromethorphan: (Moderate) Concomitant use of levofloxacin and promethazine may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Promethazine; Phenylephrine: (Moderate) Concomitant use of levofloxacin and promethazine may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Propafenone: (Major) Concomitant use of levofloxacin and propafenone increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Pyridoxine, Vitamin B6: (Moderate) Administer oral products that contain calcium at least 2 hours before or 2 hours after orally administered levofloxacin. Levofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Chelation of divalent cations with levofloxacin is less than with other quinolones. Examples of compounds that may interfere with quinolone bioavailability include antacids and multivitamins that contain calcium.
Quetiapine: (Major) Concomitant use of levofloxacin and quetiapine increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Quinapril: (Moderate) Administer quinapril tablets, which contain magnesium, at least 2 hours before or 2 hours after orally administered levofloxacin. Levofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Chelation of divalent cations with levofloxacin is less than with other quinolones.
Quinapril; Hydrochlorothiazide, HCTZ: (Moderate) Administer quinapril tablets, which contain magnesium, at least 2 hours before or 2 hours after orally administered levofloxacin. Levofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Chelation of divalent cations with levofloxacin is less than with other quinolones.
Quinidine: (Major) Levofloxacin should be avoided in combination with Class IA antiarrhythmics (disopyramide, procainamide, and quinidine). Class IA antiarrhythmics are associated with QT prolongation and torsades de pointes (TdP). Levofloxacin has been associated with prolongation of the QT interval and infrequent cases of arrhythmia. Rare cases of TdP have been spontaneously reported during postmarketing surveillance in patients receiving levofloxacin. According to the manufacturer, levofloxacin should be avoided in patients taking drugs that can result in prolongation of the QT interval.
Quinine: (Major) Concomitant use of quinine and levofloxacin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Quizartinib: (Major) Concomitant use of quizartinib and levofloxacin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Ranolazine: (Moderate) Concomitant use of levofloxacin and ranolazine may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Regular Insulin: (Moderate) Monitor blood glucose during concomitant insulin and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Regular Insulin; Isophane Insulin (NPH): (Moderate) Monitor blood glucose during concomitant insulin and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Relugolix: (Moderate) Concomitant use of levofloxacin and androgen deprivation therapy (i.e., relugolix) may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Relugolix; Estradiol; Norethindrone acetate: (Moderate) Concomitant use of levofloxacin and androgen deprivation therapy (i.e., relugolix) may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP. (Moderate) It would be prudent to recommend alternative or additional contraception when oral contraceptives (OCs) are used in conjunction with antibiotics. It was previously thought that antibiotics may decrease the effectiveness of OCs containing estrogens due to stimulation of metabolism or a reduction in enterohepatic circulation via changes in GI flora. One retrospective study reviewed the literature to determine the effects of oral antibiotics on the pharmacokinetics of contraceptive estrogens and progestins, and also examined clinical studies in which the incidence of pregnancy with OCs and antibiotics was reported. It was concluded that the antibiotics ampicillin, ciprofloxacin, clarithromycin, doxycycline, metronidazole, ofloxacin, roxithromycin, temafloxacin, and tetracycline did not alter plasma concentrations of OCs. Antituberculous drugs (e.g., rifampin) were the only agents associated with OC failure and pregnancy. Based on the study results, these authors recommended that back-up contraception may not be necessary if OCs are used reliably during oral antibiotic use. Another review concurred with these data, but noted that individual patients have been identified who experienced significant decreases in plasma concentrations of combined OC components and who appeared to ovulate; the agents most often associated with these changes were rifampin, tetracyclines, and penicillin derivatives. These authors concluded that because females most at risk for OC failure or noncompliance may not be easily identified and the true incidence of such events may be under-reported, and given the serious consequence of unwanted pregnancy, that recommending an additional method of contraception during short-term antibiotic use may be justified. During long-term antibiotic administration, the risk for drug interaction with OCs is less clear, but alternative or additional contraception may be advisable in selected circumstances. Data regarding progestin-only contraceptives or for newer combined contraceptive deliveries (e.g., patches, rings) are not available.
Repaglinide: (Moderate) Monitor blood glucose carefully when systemic quinolones and antidiabetic agents, including meglitinides, are coadministered. Discontinue the quinolone if a hypoglycemic reaction occurs and initiate appropriate therapy immediately. Disturbances of blood glucose, including hyperglycemia and hypoglycemia, have been reported in patients treated concomitantly with quinolones and an antidiabetic agent. Hypoglycemia, sometimes resulting in coma, can occur.
Ribociclib: (Major) Concomitant use of ribociclib and levofloxacin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Ribociclib; Letrozole: (Major) Concomitant use of ribociclib and levofloxacin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Rilpivirine: (Moderate) Concomitant use of levofloxacin and rilpivirine may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP. The degree of QT prolongation associated with rilpivirine is not clinically significant when administered within the recommended dosage range; QT prolongation has been described at 3 times the maximum recommended dose.
Risperidone: (Moderate) Concomitant use of levofloxacin and risperidone may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Romidepsin: (Moderate) Concomitant use of levofloxacin and romidepsin may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Rosiglitazone: (Moderate) Monitor blood glucose during concomitant thiazolidinedione and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Saquinavir: (Major) Concomitant use of levofloxacin and saquinavir increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Saxagliptin: (Moderate) Monitor blood glucose during concomitant dipeptidyl peptidase-4 inhibitors and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Segesterone Acetate; Ethinyl Estradiol: (Moderate) It would be prudent to recommend alternative or additional contraception when oral contraceptives (OCs) are used in conjunction with antibiotics. It was previously thought that antibiotics may decrease the effectiveness of OCs containing estrogens due to stimulation of metabolism or a reduction in enterohepatic circulation via changes in GI flora. One retrospective study reviewed the literature to determine the effects of oral antibiotics on the pharmacokinetics of contraceptive estrogens and progestins, and also examined clinical studies in which the incidence of pregnancy with OCs and antibiotics was reported. It was concluded that the antibiotics ampicillin, ciprofloxacin, clarithromycin, doxycycline, metronidazole, ofloxacin, roxithromycin, temafloxacin, and tetracycline did not alter plasma concentrations of OCs. Antituberculous drugs (e.g., rifampin) were the only agents associated with OC failure and pregnancy. Based on the study results, these authors recommended that back-up contraception may not be necessary if OCs are used reliably during oral antibiotic use. Another review concurred with these data, but noted that individual patients have been identified who experienced significant decreases in plasma concentrations of combined OC components and who appeared to ovulate; the agents most often associated with these changes were rifampin, tetracyclines, and penicillin derivatives. These authors concluded that because females most at risk for OC failure or noncompliance may not be easily identified and the true incidence of such events may be under-reported, and given the serious consequence of unwanted pregnancy, that recommending an additional method of contraception during short-term antibiotic use may be justified. During long-term antibiotic administration, the risk for drug interaction with OCs is less clear, but alternative or additional contraception may be advisable in selected circumstances. Data regarding progestin-only contraceptives or for newer combined contraceptive deliveries (e.g., patches, rings) are not available.
Selpercatinib: (Major) Concomitant use of selpercatinib and levofloxacin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Semaglutide: (Moderate) Monitor blood glucose during concomitant incretin mimetic and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Sertraline: (Moderate) Concomitant use of levofloxacin and sertraline may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP. The degree of QT prolongation associated with sertraline is not clinically significant when administered within the recommended dosage range; QT prolongation has been described at 2 times the maximum recommended dose.
Sevelamer: (Major) Administer sevelamer at least 2 hours before or 2 hours after orally administered levofloxacin. Levofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Chelation of divalent cations with levofloxacin is less than with other quinolones.
Sevoflurane: (Major) Concomitant use of levofloxacin and halogenated anesthetics increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
SGLT2 Inhibitors: (Moderate) Monitor blood glucose during concomitant SGLT2 inhibitor and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Siponimod: (Major) Concomitant use of siponimod and levofloxacin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Sitagliptin: (Moderate) Monitor blood glucose during concomitant dipeptidyl peptidase-4 inhibitors and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Sodium Ferric Gluconate Complex; ferric pyrophosphate citrate: (Moderate) Administer oral products that contain iron at least 2 hours before or 2 hours after orally administered levofloxacin. Levofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Chelation of divalent cations with levofloxacin is less than with other quinolones.
Sodium picosulfate; Magnesium oxide; Anhydrous citric acid: (Major) Prior or concomitant use of antibiotics with sodium picosulfate; magnesium oxide; anhydrous citric acid may reduce efficacy of the bowel preparation as conversion of sodium picosulfate to its active metabolite bis-(p-hydroxy-phenyl)-pyridyl-2-methane (BHPM) is mediated by colonic bacteria. If possible, avoid coadministration. Certain antibiotics (i.e., tetracyclines and quinolones) may chelate with the magnesium in sodium picosulfate; magnesium oxide; anhydrous citric acid solution. Therefore, these antibiotics should be taken at least 2 hours before and not less than 6 hours after the administration of sodium picosulfate; magnesium oxide; anhydrous citric acid solution.
Sodium Stibogluconate: (Moderate) Concomitant use of sodium stibogluconate and levofloxacin may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Sodium Sulfate; Magnesium Sulfate; Potassium Chloride: (Moderate) Administer oral products that contain magnesium at least 2 hours before or 2 hours after orally administered levofloxacin. Levofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Chelation of divalent cations with levofloxacin is less than with other quinolones.
Solifenacin: (Moderate) Concomitant use of levofloxacin and solifenacin may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Sorafenib: (Major) Concomitant use of sorafenib and levofloxacin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Sotagliflozin: (Moderate) Monitor blood glucose during concomitant SGLT2 inhibitor and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Sotalol: (Major) Concomitant use of levofloxacin and sotalol increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Sucralfate: (Moderate) Administer sucralfate at least 2 hours before or 2 hours after orally administered levofloxacin. Levofloxacin absorption may be reduced as quinolone antibiotics can chelate with sucralfate. This interaction appears to be the result of chelation by the aluminum content of sucralfate. Chelation of divalent cations with levofloxacin is less than with other quinolones.
Sulfonylureas: (Moderate) Monitor blood glucose during concomitant sulfonylurea and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Sulindac: (Moderate) Use quinolones and nonsteroidal anti-inflammatory drugs (NSAIDs) concomitantly with caution due to potential increased risk of CNS stimulation and convulsive seizures. NSAIDs in combination with very high doses of quinolones have been shown to provoke convulsions in preclinical studies and postmarketing.
Sumatriptan; Naproxen: (Moderate) Use quinolones and nonsteroidal anti-inflammatory drugs (NSAIDs) concomitantly with caution due to potential increased risk of CNS stimulation and convulsive seizures. NSAIDs in combination with very high doses of quinolones have been shown to provoke convulsions in preclinical studies and postmarketing.
Sunitinib: (Moderate) Concomitant use of levofloxacin and sunitinib may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Tacrolimus: (Moderate) Concomitant use of levofloxacin and tacrolimus may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Tamoxifen: (Moderate) Concomitant use of tamoxifen and levofloxacin may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Tazarotene: (Moderate) Use tazarotene with caution in patients who are also taking drugs known to be photosensitizers, such as levofloxacin, due to the increased possibility of augmented phototoxicity.
Telavancin: (Moderate) Concomitant use of levofloxacin and telavancin may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Tetrabenazine: (Major) Concomitant use of tetrabenazine and levofloxacin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Thiazolidinediones: (Moderate) Monitor blood glucose during concomitant thiazolidinedione and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Thioridazine: (Contraindicated) Avoid concomitant use of thioridazine and levofloxazin due to an increased risk for torsade de pointes (TdP) and QT/QTc prolongation.
Tirzepatide: (Moderate) Monitor blood glucose during concomitant incretin mimetic and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Tolmetin: (Moderate) Use quinolones and nonsteroidal anti-inflammatory drugs (NSAIDs) concomitantly with caution due to potential increased risk of CNS stimulation and convulsive seizures. NSAIDs in combination with very high doses of quinolones have been shown to provoke convulsions in preclinical studies and postmarketing.
Tolterodine: (Moderate) Levofloxacin should be used cautiously with tolterodine as concurrent use may increase the risk for QT prolongation. Tolterodine has been associated with dose-dependent prolongation of the QT interval, especially in poor CYP2D6 metabolizers. Levofloxacin has been associated with a risk of QT prolongation and TdP. Although extremely rare, torsade de pointes (TdP) has been reported during postmarketing surveillance of levofloxacin.
Toremifene: (Major) Concomitant use of toremifene and levofloxacin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Trazodone: (Major) Concomitant use of levofloxacin and trazodone increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Tretinoin, ATRA: (Major) Avoid the concomitant use of tretinoin with other drugs known to cause photosensitivity, such as levofloxacin. Concomitant use with other photosensitizing agents may increase the risk of a photosensitivity reaction.
Tretinoin; Benzoyl Peroxide: (Major) Avoid the concomitant use of tretinoin with other drugs known to cause photosensitivity, such as levofloxacin. Concomitant use with other photosensitizing agents may increase the risk of a photosensitivity reaction.
Triamcinolone: (Moderate) Quinolones have been associated with an increased risk of tendon rupture requiring surgical repair or resulting in prolonged disability; this risk is further increased in those receiving concomitant corticosteroids. Discontinue quinolone therapy at the first sign of tendon inflammation or tendon pain, as these are symptoms that may precede rupture of the tendon.
Triclabendazole: (Moderate) Concomitant use of triclabendazole and levofloxacin may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Trifluoperazine: (Minor) QT/QTc prolongation can occur with concomitant use of levofloxacin and trifluoperazine although the risk of developing torsade de pointes (TdP) is low. Additional steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, may be considered in patients with additional risk factors for TdP.
Triptorelin: (Moderate) Concomitant use of levofloxacin and androgen deprivation therapy (i.e., triptorelin) may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Vandetanib: (Major) Concomitant use of vandetanib and levofloxacin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Vardenafil: (Moderate) Concomitant use of levofloxacin and vardenafil may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Vemurafenib: (Major) Concomitant use of vemurafenib and levofloxacin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Venlafaxine: (Moderate) Concomitant use of levofloxacin and venlafaxine may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Verteporfin: (Moderate) Concomitant use of verteporfin with other photosensitizing agents, such as levofloxacin, may increase the potential for skin photosensitivity reactions.
Voclosporin: (Moderate) Concomitant use of levofloxacin and voclosporin may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP. The degree of QT prolongation associated with voclosporin is not clinically significant when administered within the recommended dosage range; QT prolongation has been described at 3 times the maximum recommended dose.
Vonoprazan; Amoxicillin; Clarithromycin: (Major) Concomitant use of levofloxacin and clarithromycin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Voriconazole: (Moderate) Concomitant use of levofloxacin and voriconazole may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Vorinostat: (Moderate) Concomitant use of levofloxacin and vorinostat may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Warfarin: (Moderate) Closely monitor the INR and for evidence of bleeding if levofloxacin is administered concomitantly with warfarin. There have been postmarketing reports that levofloxacin enhances the effects of warfarin. Elevations of prothrombin time in the setting of concomitant levofloxacin and warfarin use have been associated with episodes of bleeding.
Zinc Salts: (Major) Administer oral products that contain zinc at least 2 hours before or 2 hours after orally administered levofloxacin. Levofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Chelation of divalent cations with levofloxacin is less than with other quinolones. Examples of compounds that may interfere with quinolone bioavailability include multivitamins that contain zinc.
Zinc: (Major) Administer oral products that contain zinc at least 2 hours before or 2 hours after orally administered levofloxacin. Levofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Chelation of divalent cations with levofloxacin is less than with other quinolones. Examples of compounds that may interfere with quinolone bioavailability include multivitamins that contain zinc.
Ziprasidone: (Major) Concomitant use of ziprasidone and levofloxacin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Levofloxacin is bactericidal via inhibition of DNA gyrase (topoisomerase II), an enzyme responsible for counteracting the excessive supercoiling of DNA during replication or transcription and topoisomerase IV, an enzyme that helps separate the daughter DNA molecules. In gram-negative bacteria, the primary target is the DNA gyrase A subunit, while the primary target in gram-positive bacteria is generally topoisomerase IV. Levofloxacin exhibits concentration-dependent pharmacodynamics where the ratio of area under the concentration curve of free drug to minimal inhibitory concentration (free AUC:MIC) appears to best correlate with antibacterial activity. Additionally, levofloxacin and other quinolones exhibit a prolonged post-antibiotic effect (PAE) for gram-negative organisms.
The susceptibility interpretive criteria for levofloxacin are delineated by pathogen. The MICs are defined for S. pneumoniae, beta-hemolytic streptococci, Enterococcus sp., S. viridans group, Acinetobacter sp., B. cepacia complex, S. maltophilia, Aerococcus sp., Gemella sp., Abiotrophia sp., Granulicatella sp., Bacillus sp. (excluding B. anthracis), Aggregatibacter sp., Cardiobacterium sp., E. corrodens, Kingella sp., Lactococcus sp., Aeromonas sp., Vibrio sp., and other non-Enterobacterales as susceptible at 2 mcg/mL or less, intermediate at 4 mcg/mL, and resistant at 8 mcg/mL or more. The MICs are defined for R. mucilaginosa as susceptible at 1 mcg/mL or less, intermediate at 2 mcg/mL, and resistant at 4 mcg/mL or more. The MICs are defined for P. aeruginosa as susceptible at 1 mcg/mL or less, intermediate at 2 mcg/mL, and resistant at 4 mcg/mL or more (based on a dosage of 750 mg every 24 hours). The MICs are defined for Enterobacterales (except Salmonella sp.) as susceptible at 0.5 mcg/mL or less, intermediate at 1 mcg/mL, and resistant at 2 mcg/mL or more (based on a dosage of 750 mg every 24 hours). The MICs are defined for Salmonella sp. as susceptible at 0.12 mcg/mL or less, intermediate at 0.25 to 1 mcg/mL, and resistant at 2 mcg/mL or more. The Clinical and Laboratory Standards Institute (CLSI) and the FDA differ on MIC interpretation for Staphylococcus sp. The MICs are defined for MSSA by the FDA as susceptible at 2 mcg/mL or less, intermediate at 4 mcg/mL, and resistant at 8 mcg/mL or more; however the MICs are defined for Staphylococcus sp. by CLSI as susceptible at 1 mcg/mL or less, intermediate at 2 mcg/mL, and resistant at 4 mcg/mL or more. The MICs are defined for H. influenzae, H. parainfluenzae, E. rhusiopathiae, and M. catarrhalis as susceptible at 2 mcg/mL or less. The MICs are defined for F. tularensis as susceptible at 0.5 mcg/mL or less. The MICs are defined for B. anthracis and Y. pestis as susceptible at 0.25 mcg/mL or less. The MICs are defined for Pasteurella sp. as susceptible at 0.06 mcg/mL or less. The MICs are defined for N. meningitidis as susceptible at 0.03 mcg/mL or less, intermediate at 0.06 mcg/mL, and resistant at 0.12 mcg/mL or more.
Resistance to quinolones, including levofloxacin, can occur due to multiple-step mutations in defined regions of the target bacterial enzymes topoisomerase IV and DNA gyrase, referred to as Quinolone-Resistance Determining Regions (QRDRs), or through altered efflux.
Levofloxacin can be administered orally, intravenously, or ophthalmically. Levofloxacin is about 24% to 38% bound to serum proteins, primarily albumin, and is widely distributed into body tissues; lung tissue concentrations are approximately 2 to 5 times higher than plasma concentrations. Levofloxacin undergoes limited metabolism and approximately 87% of a dose is excreted unchanged in urine. Less than 4% of the dose is recovered in the feces. The only metabolites identified in humans are the desmethyl and N-oxide metabolites; these inactive metabolites account for less than 5% of a dose. Renal clearance of levofloxacin is greater than glomerular filtration, suggesting active tubular secretion. The mean elimination half-life in adults is 6 to 8 hours.
Affected cytochrome P450 isoenzymes and drug transporters: none
-Route-Specific Pharmacokinetics
Oral Route
After oral administration, levofloxacin is rapidly absorbed and has an absolute bioavailability of about 99%. Peak plasma concentrations are achieved approximately 1 to 2 hours after an oral dose. Levofloxacin pharmacokinetics are linear and predictable after single and multiple oral dosing regimens. Food prolongs the time to peak by approximately 1 hour and decreases the peak concentration by approximately 14% after tablet administration and 25% after oral solution administration.
Intravenous Route
The plasma concentration after IV administration is similar and comparable in extent of exposure (AUC) to that observed with tablet administration. Levofloxacin pharmacokinetics are linear and predictable after single and multiple IV dosing regimens.
Other Route(s)
Ophthalmic Route
After ophthalmic administration, a small amount of levofloxacin is systemically absorbed. In a study of 15 healthy adults, the mean maximum plasma concentrations ranged from 0.94 ng/mL on day 1 to 2.15 ng/mL on day 15.
-Special Populations
Hepatic Impairment
Due to the limited extent of levofloxacin metabolism, its pharmacokinetics are not expected to be affected by hepatic impairment.
Renal Impairment
The clearance of levofloxacin is substantially reduced and the plasma elimination half-life is substantially prolonged in adults with impaired renal function. Neither hemodialysis nor continuous ambulatory peritoneal dialysis (CAPD) is effective in the removal of levofloxacin from the body.
Pediatrics
Infants 6 to 11 months, Children, and Adolescents
A single-dose pharmacokinetic study in children (n = 85) ages 6 months to 16 years found that pediatric patients cleared levofloxacin faster compared to adult patients, resulting in lower plasma exposures than adults for a given mg/kg dose. After a 7 mg/kg (Max: 500 mg) intravenous (IV) or oral (PO) dose, children younger than 5 years of age cleared levofloxacin nearly twice as fast as adults. Clearance consistently decreased with age until approximately 10 years, where it stabilized at a rate slightly above reported adult values. The mean elimination half-lives (hours) for different age groups were reported as: 6 months to 2 years = 4.1 (IV) and 5 (PO); 2 to 5 years = 4 (IV) and 4.6 (PO); 5 to 10 years = 4.8 (IV) and 5.3 (PO); 10 to 12 years = 5.4 (IV) and 5.5 (PO); 12 to 16 years = 6 (IV) and 5.8 (PO). Based on the pharmacokinetic data from this study entered into a pharmacokinetic/pharmacodynamic model, the authors recommend a dose of 10 mg/kg twice daily for children 6 months to 4 years and 10 mg/kg once daily for children 5 years and older to achieve levofloxacin exposures comparable to those associated with safety and effectiveness in adults. Another single-dose pharmacokinetic analysis predicted that pediatric patients 6 months to 17 years receiving 8 mg/kg/dose orally every 12 hours, not exceeding 250 mg per dose, would achieve comparable steady state plasma exposure as observed in adult patients receiving a daily dose of 500 mg orally.
Geriatric
There are no significant differences in levofloxacin pharmacokinetics between young and elderly patients when differences in creatinine clearance are taken into consideration.
Gender Differences
After intravenous dosing, women appear to have increased exposure to levofloxacin compared to men. A pharmacokinetic study in healthy men and women reported that women had a 24% greater exposure to levofloxacin and a slower clearance. Dose adjustment based on gender alone is not necessary.
Ethnic Differences
Pharmacokinetic parameters are not affected by ethnicity.
Other
Pregnancy
In a pharmacokinetic study in which C-section patients were administered a single 500 mg IV dose prior to incision, transplacental passage rate of levofloxacin was 67% and transfetal passage rate was 84%. In another pharmacokinetic study (n = 10) in which patients were administered a single 500 mg oral dose prior to amniocentesis, the mean levofloxacin amniotic fluid passage rate was 16%.