Is levofloxacin (a fluoroquinolone antibiotic) a suitable treatment option for facial erysipelas?

Levofloxacin for Facial Erysipelas

Levofloxacin is NOT recommended as first-line therapy for facial erysipelas, as beta-lactam antibiotics (particularly penicillin) remain the treatment of choice for this streptococcal infection. 1

Etiology and First-Line Treatment

Erysipelas is a superficial skin infection characterized by a fiery red, tender, painful plaque with well-demarcated edges. It is predominantly caused by streptococcal species, particularly Streptococcus pyogenes (Group A Streptococcus). Most facial erysipelas infections are specifically attributed to Group A Streptococcus, with Staphylococcus aureus rarely being implicated as a causative agent. 1

The recommended first-line treatment for erysipelas includes:

• Penicillin (oral or parenteral depending on severity) 1
• For penicillin-allergic patients: clindamycin or macrolides 1

Role of Fluoroquinolones in Erysipelas

Fluoroquinolones, including levofloxacin, should be reserved for specific situations:

1. When first-line agents have failed
2. In patients with severe penicillin allergies who cannot tolerate alternative agents
3. When there is suspicion of complicated infection with gram-negative organisms

According to the 2018 WSES/SIS-E consensus guidelines, fluoroquinolones have been approved for treatment of uncomplicated cellulitis but "are not adequate for treatment of MRSA infections" 1. Since facial erysipelas is predominantly caused by streptococci, fluoroquinolones would not be the optimal first choice.

Concerns with Levofloxacin Use

Several concerns exist regarding levofloxacin use for facial erysipelas:

1. Antimicrobial stewardship concerns: Fluoroquinolones should be reserved for situations where other antibiotics cannot be used due to increasing resistance rates 1

2. Safety profile: Quinolones carry risks of serious adverse effects including:

   • Tendinitis and tendon rupture (within 48 hours to several months after treatment)
   • Neurological adverse effects (convulsions, toxic psychosis, anxiety, hallucinations)
   • QT interval prolongation
   • Gastrointestinal and hepatic complications 2

3. Resistance concerns: Inappropriate use of fluoroquinolones contributes to increasing antimicrobial resistance 1

Clinical Evidence

Studies specifically examining levofloxacin for facial erysipelas are limited. However, retrospective studies of erysipelas treatment have shown:

• Penicillin treatment resulted in shorter duration of fever compared to non-penicillin regimens (1.7 vs 4.5 days) 3
• No advantage was found in using antibiotics other than penicillin for treating erysipelas 4

Treatment Algorithm for Facial Erysipelas

1. Assess severity:

   • Mild to moderate: outpatient treatment
   • Severe (extensive involvement, high fever, toxic appearance): hospitalization 5

2. First-line treatment:

   • Penicillin (IV for severe cases, oral for mild cases) 1
   • Duration: 7-10 days 5

3. For penicillin-allergic patients:

   • Mild allergy: First-generation cephalosporin
   • Severe allergy: Clindamycin 1

4. When to consider levofloxacin:

   • Only after failure of first-line agents
   • In patients with severe penicillin allergies who cannot tolerate alternatives
   • When complicated infection with gram-negative organisms is suspected

Conclusion

While levofloxacin has FDA approval for uncomplicated skin and skin structure infections 6, it should not be used as first-line therapy for facial erysipelas. The clear predominance of streptococcal etiology in facial erysipelas and the excellent response to penicillin therapy make beta-lactams the treatment of choice, with levofloxacin reserved only for specific situations where first-line agents cannot be used.