Fluoroquinolone Use in Children: Restrictions and Appropriate Indications
Fluoroquinolones should not be routinely used in children and should be restricted to specific situations where there is no safe and effective alternative to treat an infection caused by multidrug-resistant bacteria or when parenteral therapy is not feasible and no other effective oral agent is available. 1
General Restrictions on Fluoroquinolone Use in Children
- Fluoroquinolones are not recommended for routine use in children primarily due to concerns about potential arthropathy (joint damage) observed in juvenile animals 1
- Musculoskeletal adverse events occur more frequently in children receiving fluoroquinolones (9.3%) compared to those receiving control antibiotics (6.0%) 1
- Most reported musculoskeletal events in children are of moderate intensity and transient in nature, but the possibility of infrequent sustained injury has not been excluded 1
- Inappropriate use of fluoroquinolones in children contributes to increasing bacterial resistance to this class of antibiotics 1
FDA-Approved Pediatric Indications
- Complicated urinary tract infections and pyelonephritis caused by E. coli in patients 1-17 years of age (ciprofloxacin) 1
- Post-exposure treatment for inhalation anthrax (ciprofloxacin, levofloxacin) 1, 2
- Plague treatment and prophylaxis in children 6 months and older (levofloxacin) 2
Appropriate Circumstances for Fluoroquinolone Use in Children
Fluoroquinolones may be justified in special circumstances after careful risk-benefit assessment 1:
- Infections caused by multidrug-resistant pathogens with no safe and effective alternative 1, 3
- When parenteral therapy is not feasible and no other effective oral agent is available 1, 3
Specific appropriate uses include:
- Urinary tract infections caused by P. aeruginosa or other multidrug-resistant, Gram-negative bacteria 1, 4
- Chronic suppurative otitis media or malignant otitis externa caused by P. aeruginosa 1
- Chronic or acute osteomyelitis caused by P. aeruginosa 1
- Pulmonary exacerbations in cystic fibrosis patients with susceptible P. aeruginosa 1, 5
- Multidrug-resistant gastrointestinal infections (e.g., salmonellosis, shigellosis) 6, 5
Safety Concerns and Monitoring
Musculoskeletal effects: Arthralgia, arthritis, tendinopathy, and gait abnormality are the most concerning adverse events 7
Other adverse effects include 1, 3:
- Central nervous system disorders (dizziness, headache, insomnia)
- Photosensitivity
- Disorders of glucose homeostasis
- QT interval prolongation (risk of torsade de pointes)
- Hepatic dysfunction
- Rashes
Monitoring recommendations when use is necessary 3:
- Monitor for joint/tendon pain or inflammation
- Consider ECG monitoring if patient has cardiac risk factors
- Monitor blood glucose in patients with diabetes
Common Pitfalls to Avoid
- Using fluoroquinolones as first-line therapy for infections when standard alternatives are available 3, 4
- Failure to adjust dosage in renal impairment 3
- Overlooking drug interactions, particularly with divalent cations (antacids containing magnesium or aluminum) which can decrease fluoroquinolone absorption 3
- Ignoring QT prolongation risk, especially when combining with other QT-prolonging medications 3
Conclusion on Risk-Benefit Assessment
While concerns about arthropathy have historically limited fluoroquinolone use in children, recent evidence suggests that most musculoskeletal events are reversible 1, 8. However, the increasing bacterial resistance due to overuse of fluoroquinolones represents a greater safety concern 8. Therefore, judicious use following the specific guidelines outlined above is essential to preserve the effectiveness of this important class of antibiotics while minimizing risks to pediatric patients.