Is levofloxacin (a fluoroquinolone antibiotic) suitable for treating food exacerbation suspected to be caused by a bacterial infection?

Levofloxacin for Food-Related Bacterial Infections

Levofloxacin is not recommended as a first-line treatment for suspected food-related bacterial infections due to concerns about antimicrobial resistance and should be reserved for specific situations where benefits clearly outweigh risks. 1

Appropriate Use of Levofloxacin in Gastrointestinal Infections

• Levofloxacin and other fluoroquinolones are no longer considered appropriate first-line choices for most food-related infections due to increasing resistance rates, particularly in Campylobacter species 1
• Resistance to fluoroquinolones in Campylobacter is particularly problematic in many regions globally, with resistance rates reported as high as 57% in Taiwan, 84% in Thailand, and up to 88% in Sweden 1
• For travelers' diarrhea, which was previously treated with fluoroquinolones, increasing resistance has limited their effectiveness as empiric therapy 1
• Azithromycin is now recommended as first-line therapy for dysentery and food-related infections with fever due to increasing fluoroquinolone resistance in Campylobacter, Shigella, and other enteric pathogens 1

Specific Indications Where Levofloxacin May Be Considered

• Levofloxacin (with metronidazole) may be considered for complicated intra-abdominal infections when oral step-down therapy is needed after initial IV antibiotics 1
• For adults recovering from intra-abdominal infections, completion of antimicrobial therapy with oral levofloxacin plus metronidazole is an option, but not as a first-line choice 1
• In areas with low fluoroquinolone resistance, levofloxacin may be considered for documented susceptible pathogens when first-line agents cannot be used due to allergies or resistance patterns 1

Risks and Concerns with Levofloxacin Use

• Fluoroquinolones, including levofloxacin, are associated with selection for resistant pathogens that can harm both the individual receiving treatment and the broader population 1
• The FDA and other regulatory bodies have issued warnings about fluoroquinolone use due to potential serious adverse effects, including tendinopathy, peripheral neuropathy, and central nervous system effects 1
• Unnecessary fluoroquinolone use contributes to increasing resistance rates, which limits future treatment options 2
• Levofloxacin and other fluoroquinolones can cause disruption of the microbiome and increase risk of Clostridioides difficile infection 1

Alternative Approaches for Food-Related Infections

• For suspected bacterial gastroenteritis from food, first-line empiric therapy should be azithromycin, particularly if dysentery or fever is present 1
• For intra-abdominal infections related to food contamination, beta-lactam/beta-lactamase inhibitor combinations (like amoxicillin-clavulanate) are preferred first-line options 1
• For mild community-acquired infections, amoxicillin/clavulanate remains an appropriate first-line choice 1
• In cases of severe infection requiring hospitalization, piperacillin-tazobactam or carbapenems may be more appropriate than fluoroquinolones 1

Special Considerations

• If levofloxacin must be used (due to allergies or resistance patterns), the standard dose is 500mg daily, with 750mg daily reserved for more severe infections 1, 3
• Levofloxacin has excellent bioavailability (approaching 100%), allowing for equivalent serum concentrations whether administered orally or intravenously 4
• Levofloxacin should not be administered concurrently with aluminum- or magnesium-containing antacids or ferrous sulfate, as these significantly decrease absorption; these agents should be given at least 2 hours before or after levofloxacin 4
• Patients with significant renal dysfunction require dosage adjustments of levofloxacin 4

Decision Algorithm for Suspected Food-Related Bacterial Infection

1. Assess severity: mild (no fever, no dysentery) vs. moderate-severe (fever, dysentery, systemic symptoms) 1
2. For mild cases without dysentery: Consider supportive care without antibiotics 1
3. For moderate-severe cases or dysentery: Use azithromycin as first-line therapy 1
4. Consider levofloxacin only if:
   • Patient has confirmed allergy to first-line agents AND
   • Infection is moderate-severe requiring treatment AND
   • Local resistance patterns show low fluoroquinolone resistance 1
5. If levofloxacin is used, monitor closely for adverse effects and treatment failure 1