AAP Reviews Use of Systemic and Topical Fluoroquinolones

Posted by: admin on: November 29, 2011

Disappropiate use of quinolones in pediatrics age group has led to resistance and adverse effects which has prompted the AAP to give a few guidelines pertaining to its use.


Fluoroquinolones are favorable for treating a wide variety of infections because they are highly active in vitro against both gram-positive and gram-negative pathogens. Appropriate prescribing practices for fluoroquinolones are essential as evolving resistance patterns are considered, additional treatment indications are identified, and the toxicity profile of fluoroquinolones in children becomes better defined.

Currently, fluoroquinolones are approved by the US Food and Drug Administration (FDA) for the following indications: nalidixic acid for urinary tract infections (UTIs), ciprofloxacin for inhalational anthrax and complicated UTI and pyelonephritis, and levofloxacin for inhalational anthrax. Moxifloxacin is currently being investigated for treatment of complicated intra-abdominal infections in children.

The 2006 recommendations by the American Academy of Pediatrics (AAP) for systemic therapy are still valid. However, the aim of this current AAP report was to present the expanded uses of fluoroquinolones for the treatment of certain infections in children.

Study Highlight:

  • To date, no published evidence has supported the occurrence of sustained injury to developing bones or joints in children treated with fluoroquinolone agents. However, an FDA analysis suggests the possibility of increased musculoskeletal adverse effects in children.
  • Other potential toxicities of fluoroquinolone do not occur commonly in children but include central nervous system adverse effects, peripheral neuropathy, hypersensitivity reactions, photosensitivity and other rashes, disorders of glucose homeostasis, prolongation of the QT interval, and hepatic dysfunction.
  • Use of a fluoroquinolone in a child or adolescent may be indicated in special circumstances in which (1) infection is caused by a multidrug-resistant pathogen for which there is no safe and effective alternative; and (2) the options for treatment include either parenteral nonfluoroquinolone therapy or oral fluoroquinolone therapy, and oral therapy is preferred.
  • Clinical situations are outlined as follows:
    1. For acute conjunctivitis, the FDA has approved the use of levofloxacin, moxifloxacin, gatifloxacin, ciprofloxacin, and besifloxacin in children older than 12 months.
    2. For external otitis and tympanostomy tube–associated otorrhea, quinolone and nonquinolone agents are similar in both microbiological and clinical cure rates.
    3. For respiratory tract infections in children, pharmacokinetic data for children 6 months and older are well studied for levofloxacin.
    4. Levofloxacin is effective and well tolerated in children with acute bacterial otitis media.
    5. For children with pneumonia, although fluoroquinolones may be effective, they are not recommended as first-line agents because other better-studied and safer antimicrobial agents are available to treat a majority of currently isolated pathogens.
    6. Treatment options for multidrug-resistant shigellosis, depending on the antimicrobial susceptibilities of the particular stain, include ciprofloxacin, azithromycin, and parenteral ceftriaxone.
    7. For UTIs, fluoroquinolones remain a potential first-line agent only in the setting of pyelonephritis or complicated UTI when recommended agents are not appropriate on the basis of susceptibility data, allergy, or adverse-event history.
    8. The AAP 2006 policy statement supported the use of ciprofloxacin as oral therapy for UTI and pyelonephritis caused by P aeruginosa or other multidrug-resistant gram-negative bacteria in children 1 through 17 years old.
    9. Ciprofloxacin is effective in eradicating nasal carriage of Neisseria meningitidis (20 mg/kg for children > 1 month) and can be considered as an alternative to rifampin.
    10. Fluoroquinolones may be a treatment option for multidrug-resistant gram-negative meningitis for which no other agents are suitable.
    11. For children who need systemic therapy for P aeruginosa skin infections, fluoroquinolone agents offer an oral treatment option that may be preferred to parenteral nonfluoroquinolone antimicrobial therapy.
  • Appropriate use of fluoroquinolones in children should limit the development and spread of resistance.
  • Similar to all antimicrobial agents, providers should verbally review common, anticipated potential adverse events, and indicate why a fluoroquinolone is the most appropriate antibiotic agent for treatment of a child’s infection.

Clinical implications:

  • Currently, fluoroquinolones are FDA approved for the following indications in children: nalidixic acid for UTIs, ciprofloxacin for inhalational anthrax and complicated UTI and pyelonephritis, and levofloxacin for inhalational anthrax.
  • Use of fluoroquinolones in children should continue to be limited to treatment of infections for which no safe and effective alternative exists. Although fluoroquinolones are reasonably safe in children, clinicians should be aware of the specific adverse reactions.

Reference: http://www.medscape.org/viewarticle/750441?src=cmemp

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