Contraindications for Fluoroquinolones

Absolute Contraindications

The American Thorax Society recommends that fluoroquinolones are contraindicated in patients with a history of hypersensitivity to fluoroquinolones, tendon disorders related to previous quinolone use, pregnancy, children/growing adolescents, and patients with certain cardiac conditions that predispose to QT interval prolongation 1
Fluoroquinolones should be avoided in pregnancy due to teratogenic effects shown in animal studies, as recommended by the Centers for Disease Control and Prevention 2, 3
Breastfeeding should be avoided as fluoroquinolones are present in milk in animal studies, according to the American Thorax Society 1
Tendon disorders, including history of tendon damage or rupture related to previous quinolone use, are a contraindication for fluoroquinolone use, as stated by the American Thorax Society 1
Congenital or documented QT prolongation is a contraindication due to the risk of potentially fatal cardiac arrhythmias, as recommended by the American Thorax Society 1
Concurrent use with other QT-prolonging medications increases the risk of cardiac arrhythmias, according to the American Thorax Society 1

The American Academy of Pediatrics recommends that children and adolescents should not use fluoroquinolones due to the risk of arthropathy in weight-bearing joints, though exceptions exist for specific infections 4, 5
Elderly patients over 60 years have a higher risk of tendon inflammation and rupture, as stated by the American Thorax Society 1
Patients on corticosteroids have an increased risk of tendon disorders, according to the American Thorax Society 1
Renal disease requires dosage adjustment for most fluoroquinolones and is contraindicated in severe renal insufficiency without dose adjustment, as recommended by the Centers for Disease Control and Prevention 2, 3
Severe liver disease, particularly Child-Pugh severity score C or transaminase levels five times greater than normal, is a relative contraindication, according to the American Thorax Society 1
Seizure disorders or CNS conditions may lower the seizure threshold, as stated by the American Thorax Society 1
Myasthenia gravis is a relative contraindication due to the risk of exacerbation, according to the American Thorax Society 1
G6PD deficiency is a relative contraindication due to the risk of hemolytic reactions, as stated by the American Thorax Society 1
Uncorrected hypokalemia or hypomagnesemia increases the risk of QT prolongation, according to the American Thorax Society 1

The American Academy of Pediatrics recommends that fluoroquinolones should be used in children only in specific circumstances after careful risk-benefit assessment, including exposure to aerosolized Bacillus anthracis, complicated urinary tract infections, chronic suppurative otitis media, chronic/acute osteomyelitis, pulmonary exacerbations in cystic fibrosis patients, mycobacterial infections, and multidrug-resistant gastrointestinal infections 4, 5

Clinically relevant bradycardia is a contraindication, as stated by the American Thorax Society 1
Clinically relevant heart failure with reduced ejection fraction is a contraindication, according to the American Thorax Society 1
History of symptomatic arrhythmias is a contraindication, as stated by the American Thorax Society 1
Electrolyte disturbances, particularly uncorrected hypokalemia, increase the risk of QT prolongation, according to the American Thorax Society 1

ECG monitoring is recommended at baseline, 2 weeks after starting therapy, and after adding any new medication known to prolong QT interval, as stated by the American Thorax Society 1
Blood glucose monitoring is recommended in patients with diabetes due to the risk of hypoglycemia, according to the American Thorax Society 1
Routine laboratory monitoring, including FBC, U&Es, and LFTs, should be performed intermittently throughout treatment, as recommended by the American Thorax Society 1
Hepatic enzymes and thyroid function should be monitored at baseline and periodically, according to the Centers for Disease Control and Prevention 2

Failure to adjust dosage in renal impairment is a common pitfall, as most fluoroquinolones require dose adjustment with creatinine clearance <50 ml/minute, according to the Centers for Disease Control and Prevention 3
Drug interactions with divalent cations, such as antacids containing magnesium or aluminum, can decrease fluoroquinolone absorption and should be separated by at least 2 hours, as recommended by the Centers for Disease Control and Prevention 3
Inappropriate use in uncomplicated infections can lead to increased bacterial resistance and should be reserved for situations where no safe and effective alternatives exist, according to the American Academy of Pediatrics 4, 5
Overlooking QT prolongation risk, particularly when combining with other QT-prolonging medications, is a common pitfall, as stated by the American Thorax Society 1