In which patient populations are fluoroquinolones contraindicated?

Contraindications for Fluoroquinolones

Fluoroquinolones are contraindicated in children and adolescents under 18 years of age, pregnant or breastfeeding women, patients with history of tendon disorders, elderly patients with renal dysfunction, and patients with QT interval prolongation. 1, 2

Pediatric Population

Fluoroquinolones should not be routinely used in children and adolescents under 18 years due to:

• Risk of arthropathy (joint damage) demonstrated consistently in juvenile animal studies 1
• Potential for irreversible cartilage damage in developing joints 1, 3
• FDA restrictions limiting pediatric use to specific circumstances only 1

Limited Exceptions for Pediatric Use

Fluoroquinolones may be considered in children only when:

1. Treating infections caused by multidrug-resistant pathogens with no safe alternatives
2. When parenteral therapy is not feasible and no other effective oral agent is available 1

Specific FDA-approved pediatric indications include:

• Complicated urinary tract infections caused by P. aeruginosa or multidrug-resistant gram-negative bacteria
• Post-exposure prophylaxis for inhalation anthrax 1, 4

Pregnant and Breastfeeding Women

• Contraindicated due to potential effects on fetal cartilage development 3
• Should only be used when benefits clearly outweigh risks 2

Patients with Tendon Disorders

• Contraindicated in patients with history of tendon disorders related to quinolone use 2
• Risk factors for tendinopathy include:
  • Concomitant corticosteroid use
  • Renal dysfunction
  • Advanced age (elderly patients) 1, 2

Elderly Patients with Risk Factors

• Use with extreme caution in elderly patients, particularly those with:
  • Renal dysfunction (requiring dosage adjustment)
  • Concomitant corticosteroid use
  • History of tendon disorders 2

Patients with QT Prolongation

• Contraindicated in patients with known QT interval prolongation
• Risk of torsade de pointes (potentially fatal ventricular arrhythmia) 1, 2, 5

Additional Contraindications and Precautions

Drug Interactions

• Avoid in patients taking medications that can interact with fluoroquinolones:
  • Theophylline (risk of CNS toxicity)
  • QT-prolonging medications
  • Antacids, calcium, iron, magnesium, aluminum supplements (decreased absorption) 2, 3

Patients with Myasthenia Gravis

• Contraindicated due to risk of exacerbation 2

Patients with Photosensitivity Risk

• Use with caution in patients with planned UV light exposure, especially with pefloxacin 6, 5

Monitoring and Management

• Discontinue immediately if signs of tendinopathy, hypersensitivity reactions, or CNS effects occur 2
• Monitor QT interval in patients with risk factors for QT prolongation 2
• Advise patients to maintain hydration and avoid strenuous physical activity during treatment 2

Adverse Effects to Monitor

• Arthralgia/arthritis (9.3% at 6 weeks, 13.7% at 1 year)
• CNS effects (dizziness, insomnia, headache)
• Gastrointestinal reactions (nausea, dyspepsia, vomiting)
• Photosensitivity reactions
• QT interval prolongation 1, 2, 6

Despite growing evidence suggesting that the risk of musculoskeletal complications in children may be lower than initially feared 4, the contraindications remain in place due to the potential for serious adverse effects and the availability of safer alternatives in most clinical scenarios.