What are the risks and recommendations for using Ciprofloxacin (fluoroquinolone) and Amikacin (aminoglycoside) in pregnancy?

Risks and Recommendations for Ciprofloxacin and Amikacin in Pregnancy

Ciprofloxacin and amikacin should be avoided during pregnancy unless the potential benefit clearly outweighs the risks to both mother and fetus, as both medications carry potential risks of fetal harm.

Ciprofloxacin in Pregnancy

Safety Profile

• FDA Pregnancy Category C 1
• Fluoroquinolones have been associated with arthropathies in young animals, raising concerns about potential effects on fetal cartilage development 2
• However, a meta-analysis of studies in women exposed to quinolones during the first trimester found no increased risk of malformations or musculoskeletal abnormalities 2

Recommendations

• Should generally be avoided during pregnancy 2
• Only use when no safer alternative exists and when the benefit justifies the potential risk 1
• For perianal sepsis in pregnant women with Crohn's disease, ciprofloxacin may be considered as a conditional recommendation with very low-quality evidence 2
• Fluoroquinolones should not be used during pregnancy for treatment of salmonellosis 2

Amikacin in Pregnancy

Safety Profile

• Aminoglycosides cross the placenta and may cause fetal nephrotoxicity and congenital hearing loss 2
• Specifically, amikacin is contraindicated in pregnant women due to risk of fetal nephrotoxicity and congenital hearing loss 2
• Related aminoglycoside streptomycin has been documented to cause eighth nerve damage with deficits ranging from mild hearing loss to bilateral deafness in 17% of babies exposed in utero 2

Recommendations

• Amikacin is contraindicated during pregnancy 2
• If an aminoglycoside must be used during pregnancy, gentamicin is preferred over amikacin or streptomycin due to lower risk of irreversible fetal ototoxicity 2

Alternative Antibiotics in Pregnancy

Safer Alternatives

• Penicillins and cephalosporins are considered the safest antibiotics in pregnancy 3, 4
• For serious infections requiring aminoglycosides, gentamicin with careful monitoring is preferred 2
• For infections typically treated with fluoroquinolones, consider:
  • Ampicillin or cephalosporins for urinary tract infections
  • Macrolides for respiratory infections
  • Metronidazole for anaerobic infections 4

Special Considerations

Monitoring and Dosing

• If aminoglycosides must be used:
  • Carefully monitor serum drug concentrations
  • Adjust dosing frequency (not dose) in renal impairment
  • Administer after dialysis if patient is on hemodialysis 2

Breastfeeding

• Ciprofloxacin is excreted in human milk; consider discontinuing nursing or the drug 1
• Aminoglycosides are excreted in breast milk in small amounts 5

Decision Algorithm for Use in Pregnancy

1. First question: Is the infection life-threatening or severe with no alternative treatment options?

   • If YES: Consider using these antibiotics with careful monitoring
   • If NO: Choose safer alternatives

2. For ciprofloxacin consideration:

   • Only use if infection is resistant to safer antibiotics
   • Limit to shortest effective duration
   • Avoid in first trimester if possible
   • Monitor for maternal adverse effects

3. For amikacin consideration:

   • Use only for life-threatening infections with resistant organisms
   • Consider gentamicin as a safer aminoglycoside alternative
   • Monitor renal function and drug levels closely
   • Counsel patient about risk of fetal ototoxicity

Conclusion

The risks of both ciprofloxacin and amikacin in pregnancy are significant enough that they should be avoided unless absolutely necessary. The decision to use these medications must carefully weigh the severity of maternal infection against potential fetal risks, with preference given to safer alternative antibiotics whenever possible.