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Fluoroquinolones: Effective but Dangerous

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By Brad Spellberg, MDMay 25, 2017
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No treatment reduces death and prevents harm as effectively as antibiotics. They are easy to give, incredibly powerful, and easy for patients to take. Sounds too good to be true, doesn’t it?

In fact, it is. Every time we use an antibiotic, it increases the chance of driving bacterial resistance to it. Society has lost sight of this reality; we have become arrogant and complacent. The bacteria have not. We must learn to use antibiotics far more judiciously.

A class of antibiotics called fluoroquinolones are among the easiest and most effective to use. The one you may be most familiar with is “Cipro,” short for ciprofloxacin. Others include Levaquin and Avelox. They are effective against many bacteria, including some of the scariest, most resistant ones. And they can be taken either orally or intravenously.

No wonder they are incredibly popular among both doctors and patients. Not surprisingly, fluoroquinolones are also among the most over-used antibiotics. And this abuse has serious consequences, both for society and for you when you take them.

You must never take fluoroquinolones unless they are truly needed. Why? We have no other oral antibiotics available to treat serious kidney, abdomen, or prostate infections, or to treat lung infections acquired in hospitals or nursing homes. And the more we use them, the faster resistance to them rises.

Ten years ago, fluoroquinolones treated more than 99% of bacteria causing infections outside of hospitals. Now an appalling 20-30% of such bacteria are resistant. If you develop an infection resistant to fluoroquinolones, you may need go to the hospital and receive long-term (7 to 14 days) intravenous antibiotics. This is a really big deal.

In addition, all drugs have potentially dangerous side effects, and fluoroquinolones are no different. They are so powerful that they can wipe out most of the good, helpful bacteria in our intestines. This enables a super-infection called C. difficile colitis to occur. This infection can happen repeatedly and can be debilitating, and even fatal. Fluoroquinolones are among the antibiotics that have the highest risk of C. difficile colitis infection.

Fluoroquinolones may also cause tendons – such as the Achilles heel tendon – to rupture. Tendon rupture can be very debilitating. It may require surgery and months of therapy. In 2013, the FDA added a black box warning to the package inserts for the fluoroquinolones ciprofloxacin (Cipro), levofloxacin (Levaquin), moxifloxacin (Avelox), ofloxacin (Floxin), and gemifloxacin (Factive). The black box warning specifically calls out the risk of tendinitis and tendon rupture in patients taking these drugs.

While the absolute risk is low — about 1 in 10,000 to 1 in 20,000 patients — hundreds of thousands of patients take these drugs every year, making cases of tendon rupture common. More recently, the FDA updated the black box warning to add other side effects. These include nerve injury, hallucinations, anxiety, depression, insomnia, severe headaches, confusion, and worsening of the rare disease myasthenia gravis.

The key with all medical treatments is to balance the good and helpful with the risk of potential harm from side effects. If you have an invasive, serious bacterial infection, such as a lung, kidney, abdominal, or prostate infection, antibiotics are potentially life-saving. In these cases, the risk of side effects is low enough that taking antibiotics is absolutely the right thing to do, including a fluoroquinolone.

But if you have is a viral infection, you will get no benefit from any antibiotic — all you will get is potential harm. And the vast majority of sinus and throat infections and cases of bronchitis are caused by viruses. Even minor bacterial infections, like bladder infections, bronchitis, or sinus infections, will typically resolve themselves or can be treated with much less powerful drugs. Don’t waste fluoroquinolones on such infections.

We’ve heard the saying that “with great power comes great responsibility.” Fluoroquinolones offer great power to save lives. As a result, we have great responsibility to use them only when needed. It is bad for everyone in society to waste them. And it is bad for you to expose yourself needlessly to dangerous side effects when you don’t need them.

Brad Spellberg, MD, is Chief Medical Officer at the Los Angeles County-University of Southern California Medical Center. He is also a Professor of Clinical Medicine and Associate Dean for Clinical Affairs at the Keck School of Medicine at USC.

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