Safety of Fluoroquinolones in Lactating Mothers
Fluoroquinolones should be considered possibly safe during breastfeeding, with ciprofloxacin being the preferred agent if a fluoroquinolone is clinically indicated for a lactating mother. 1, 2, 3
Safety Profile and Considerations
Fluoroquinolones, including ciprofloxacin, are present in breast milk in concentrations two orders of magnitude lower than a therapeutic infant dose, with absorption further reduced due to high calcium concentration in breast milk which inhibits absorption 2, 3
Despite theoretical concerns about cartilage damage based on animal studies, human data suggest low risk when fluoroquinolones are used during breastfeeding 3, 4
The European Respiratory Society guidelines classify ciprofloxacin as "possibly safe" during breastfeeding 1
According to the FDA drug label for levofloxacin, "it can be presumed that levofloxacin will be excreted in human milk" and recommends that "a decision should be made whether to discontinue nursing or to discontinue the drug, taking into account the importance of the drug to the mother" 5
Recommendations for Use During Breastfeeding
If a fluoroquinolone is indicated for a breastfeeding mother, ciprofloxacin should be chosen as the preferred agent in this class 2, 3
To minimize infant exposure, breastfeeding can be timed to correspond with the lowest concentration of ciprofloxacin in breast milk, which occurs 3-4 hours after each maternal dose 2, 3
Most systemic antibiotics will be present in breast milk and could potentially cause falsely negative cultures in febrile infants or produce gastroenteritis due to alteration of intestinal flora 1, 2
Safer Antibiotic Alternatives
When possible, penicillins, cephalosporins, and macrolides are considered more compatible with breastfeeding and should be used preferentially 2
First-line options for breastfeeding mothers include penicillins (such as amoxicillin) and cephalosporins (such as cefuroxime) 2, 6
Second-line options include macrolides, such as azithromycin 2
Fluoroquinolones should be considered a third-line option when benefits clearly outweigh risks or when other antibiotics are not appropriate 2, 6
Special Considerations
For specific infections requiring fluoroquinolones, such as certain multidrug-resistant infections, the benefits of maternal treatment may outweigh the potential risks to the breastfed infant 6, 7
Breastfeeding should not be discouraged for women being treated with first-line agents, as the small concentrations of these drugs in breast milk do not typically produce toxic effects in the nursing infant 1
Drugs in breast milk should not be considered to serve as effective treatment for active tuberculosis or latent tuberculosis infection in a nursing infant 1
The administration of fluoroquinolones during breastfeeding is generally not recommended as a first-line choice, but if they are indicated, breast feeding should not be interrupted because the risk of adverse effects is low 6