Levofloxacin for STIs
Levofloxacin is no longer recommended for the treatment of gonorrhea or other sexually transmitted infections due to widespread fluoroquinolone resistance. 1
Efficacy and Resistance Patterns
Historically, levofloxacin was included in treatment guidelines for certain STIs, particularly gonorrhea. The 2006 CDC STD Treatment Guidelines listed levofloxacin 250 mg orally in a single dose as one of the recommended regimens for uncomplicated gonococcal infections of the cervix, urethra, and rectum 2. However, this recommendation came with significant restrictions even then.
Resistance Development Timeline:
- By 2002, quinolones were already not recommended for gonorrhea acquired in Hawaii, Asia, or the Pacific Islands due to resistance 2
- By 2004, quinolone-resistant N. gonorrhoeae (QRNG) prevalence had increased significantly among men who have sex with men (MSM) 2
- By 2006,6.8% of gonococcal isolates in the US were resistant to ciprofloxacin, with higher rates (23.9%) among MSM 2
- By 2007, the CDC completely removed fluoroquinolones (including levofloxacin) from recommended treatments for gonococcal infections due to widespread resistance 1
Key Restrictions When Fluoroquinolones Were Still Used:
- Quinolones were contraindicated for:
- Infections in MSM
- Infections acquired during travel abroad
- Infections acquired in California or Hawaii
- Infections acquired in areas with increased QRNG prevalence 2
Current Treatment Approach for STIs
For Gonorrhea:
- Cephalosporins became the only recommended class of antibiotics for gonorrhea treatment after 2007 1
- The CDC specifically stated: "only one class of drugs, the cephalosporins, is still recommended and available for the treatment of gonorrhea" 1
For Chlamydia:
While levofloxacin has shown efficacy against Chlamydia trachomatis with a 94.4% bacteriological efficacy rate in one study 3, it is not typically the first-line treatment. Azithromycin or doxycycline remain the preferred agents for chlamydial infections.
Levofloxacin Properties and Considerations
Levofloxacin does have some favorable pharmacokinetic properties that made it useful before resistance emerged:
- Good tissue penetration, including in the genitourinary tract 4, 5
- High oral bioavailability allowing for transition between IV and oral therapy 4
- Once-daily dosing convenience 6
- Generally well-tolerated safety profile 4, 5
Important Clinical Considerations
Pitfalls to Avoid:
- Never use fluoroquinolones empirically for suspected gonorrhea regardless of patient population due to widespread resistance
- Do not rely on older treatment guidelines that may still list levofloxacin as an option
- Do not assume susceptibility based on patient demographics or geography, as resistance has become widespread
- Avoid using levofloxacin as monotherapy for empiric STI treatment
When Culture and Susceptibility Testing is Critical:
- For patients who fail initial recommended therapy
- For patients with persistent infection despite appropriate treatment
- When antimicrobial resistance is suspected
Conclusion for Clinical Practice
When treating STIs, particularly gonorrhea, cephalosporins should be used as first-line therapy. Levofloxacin and other fluoroquinolones should not be used for gonorrhea treatment due to high resistance rates that compromise patient outcomes. While levofloxacin may have some activity against certain STI pathogens like Chlamydia, other more effective and currently recommended options should be prioritized to ensure optimal treatment outcomes and prevent further development of antimicrobial resistance.