A risk-benefit assessment of levofloxacin in respiratory, skin and skin structure, and urinary tract infections

As a class, the quinolone antibacterials can no longer be assumed to be bot h effective and relatively free of significant adverse effects. Recent safe ty issues with newer generation fluoroquinolones, and concerns regarding dr ug-use associated bacterial resistance have made all drugs in this class su bject to intense scrutiny and further study. Levofloxacin is a second gener ation fluoroquinolone with a post marketing history of well tolerated and s uccessful use in a variety of clinical situations. Quinolones as a class cause a variety of adverse effects, including phototo xicity, seizures and other CNS disturbances, tendonitis and arthropathies, gastrointestinal effects, nephrotoxicity, prolonged QT(c) interval and tors ade de pointes, hypo- or hyperglycaemia. and hypersensitivity reactions. Le vofloxacin has been involved in only a few case reports of adverse events, which include QT(c) prolongation, seizures, glucose disturbances, and tendo nitis. Levofloxacin has been shown to be effective at dosages of 250mg to 500mg on ce-daily in clinical trials in the management of acute maxillary sinusitis, acute bacterial exacerbations of chronic bronchitis, community-acquired pn eumonia, skin and skin structure infections, and urinary tract infections. There are data suggesting that levofloxacin may promote fluoroquinolone res istance among the Streptococcus pneumoniae, and that clinical failures may result from this therapy. Other data suggest that fluoroquinolones with low er potency against Pseudomonas aeruginosa than ciprofloxacin, such as levof loxacin, may drive class-wide resistance to this pathogen. Levofloxacin is an effective drug in many clinical situations, but its cost is significantly higher than amoxicillin, erythromycin, or first and secon d generation cefalosporins. Because of the propensity to select for fluoroq uinolone resistance in the pneumococcus and potentially other pathogens, le vofloxacin should be an alternative agent rather than a drug-of-choice in r outine community-acquired respiratory tract, urinary tract, and skin or ski n structure infections. In areas with increasing pneumococcal beta -lactam resistance, levofloxacin may be a reasonable empiric therapy in community-a cquired respiratory tract infections. Similarly, in patients with risk fact ors for infectious complications or poor outcome, levofloxacin may be an ex cellent empiric choice in severe community-acquired respiratory tract infec tions, urinary tract infections, complicated skin or skin structure infecti ons, and nosocomial respiratory and urinary tract infections. Better clinic al data are needed to identify the true place in therapy of the newer fluor oquinolones in common community-acquired and nosocomial infections. Until t hen, these agents, including levofloxacin, might best be reserved for compl icated infections, infection recurrence, and infections caused by beta -lac tam or macrolide-resistant pathogens.