From the Guidelines
Fluoroquinolone toxicity can cause severe and potentially permanent adverse effects, including tendon rupture, peripheral neuropathy, and central nervous system disorders, and therefore, these antibiotics should be used with caution and only when absolutely necessary, as supported by the most recent evidence 1. The effects of fluoroquinolone toxicity can be devastating, with common symptoms including tendon pain or rupture, joint pain, peripheral neuropathy, central nervous system effects, and cardiac issues.
- Tendon rupture, particularly of the Achilles tendon, is a rare but serious complication, with a reported rate of 15 to 20 per 100,000 treated patients in the adult population 1.
- Peripheral neuropathy can cause numbness, tingling, or weakness, and central nervous system effects can include anxiety, insomnia, confusion, and even seizures 1.
- The toxicity occurs because fluoroquinolones affect mitochondrial function and can damage collagen and connective tissues throughout the body, as suggested by studies on the use of systemic fluoroquinolones in pediatric patients 2. Some patient populations are at higher risk of fluoroquinolone toxicity, including:
- Older adults
- Patients with kidney disease
- Patients taking steroid medications
- Patients with previous tendon disorders In these cases, alternative antibiotic classes should be considered when possible.
- The treatment of fluoroquinolone toxicity is primarily supportive, focusing on symptom management, physical therapy, pain management, and in some cases, antioxidant supplements like CoQ10 and magnesium, though evidence for these supplements remains limited 1. It is essential to discontinue the medication immediately and contact a healthcare provider if fluoroquinolone toxicity is suspected.
- Recovery time can vary significantly between individuals, from weeks to months or even years in severe cases, highlighting the importance of careful consideration before prescribing fluoroquinolone antibiotics 1.
From the Research
Effects of Fluoroquinolone Toxicity
- Fluoroquinolone antibiotics are associated with a wide spectrum of musculoskeletal complications, including tendon, cartilage, bone, and muscle damage 3.
- The pathoetiology of fluoroquinolone toxicity on musculoskeletal tissues is multifactorial, involving alterations in cell signaling proteins and direct toxic effects on musculoskeletal tissues 3.
- Increasing age and concomitant systemic corticosteroid use appear to significantly increase the risk of adverse events 3.
- Fluoroquinolone usage can lead to complete rupture of the tendon and substantial subsequent disability 4.
- Fluoroquinolone-associated disability (FQAD) is a less recognized yet profoundly debilitating complication, characterized by impacting at least two systems (neurological, musculoskeletal, psychiatric, and/or cardiovascular) for at least 30 days post-cessation of a fluoroquinolone 5.
- FQAD patients often undergo extensive diagnostic testing, leading to unnecessary costs to the patient and the healthcare system 5.
- Fluoroquinolone-induced serious, persistent, multisymptom adverse effects can involve tendinopathy, muscle weakness, peripheral neuropathy, autonomic dysfunction, sleep disorder, cognitive dysfunction, and psychiatric disturbance 6.
Risk Factors and Prevention
- Clinicians, athletes, athletic trainers, and their medical support teams should be aware of the need to discuss and possibly discontinue fluoroquinolones if adverse effects arise 4.
- The US Food and Drug Administration (FDA) has strengthened the "black box" warning for fluoroquinolones, recommending avoidance of fluoroquinolones for uncomplicated infections 7.
- Inpatient antimicrobial stewardship programs (ASPs) have developed initiatives to promote avoidance of quinolones due to concerns over safety and the association with Clostridiodes difficile infection 7.
Treatment and Management
- Fluoroquinolone tendinopathy may not respond well to current popular eccentric training regimes and may require an alternative, staged treatment approach 4.
- Hyperbaric oxygen, IV magnesium, and IV glutathione therapy may be beneficial for FQAD patients, but further research is needed to confirm their effectiveness 5.