What are the contraindications for Levofloxacin (fluoroquinolone antibiotic)?

Levofloxacin Contraindications

The only absolute contraindication to levofloxacin is known hypersensitivity to levofloxacin or other quinolone antibacterials 1.

Absolute Contraindication

• Hypersensitivity: Levofloxacin is contraindicated in persons with known hypersensitivity to levofloxacin or other quinolone antibacterials 1.

Situations Requiring Avoidance (Strong Relative Contraindications)

Pregnancy

• Fluoroquinolones should be avoided in pregnancy due to teratogenic effects 2.
• Use only when no alternative exists for life-threatening infections such as multidrug-resistant tuberculosis 2.

Pediatric Population

• Long-term use (more than several weeks) in children and adolescents is not approved due to concerns about effects on bone and cartilage growth 2.
• Despite theoretical concerns, no joint toxicity has been reported in children receiving long-term fluoroquinolone therapy for tuberculosis 3.
• The drug should be considered for children with multidrug-resistant tuberculosis when no alternatives exist 2.

Concomitant Corticosteroid Use

• Oral or injectable corticosteroids should not be administered concomitantly with fluoroquinolones due to markedly increased risk of tendinopathy 2.
• This combination is a particular concern in patients with renal dysfunction or age >60 years 4.

High-Risk Situations Requiring Extreme Caution

Cardiovascular Risk Factors

• Avoid in patients with known QT interval prolongation 4, 5.
• Avoid in patients with uncorrected hypokalemia or hypomagnesemia 4.
• Avoid in patients receiving class IA (quinidine, procainamide) or class III (amiodarone, sotalol) antiarrhythmic agents 4.

Central Nervous System Disorders

• Use with extreme caution in patients with known or suspected CNS disorders that predispose to seizures, including severe cerebral arteriosclerosis or epilepsy 2, 4, 5.
• Elderly patients should be monitored carefully for CNS excitatory effects including confusion, weakness, tremor, or depression 4.

Tendinopathy Risk Factors

The following patient characteristics significantly increase risk of tendinitis and tendon rupture 2, 4, 6:

• Age >60 years (well-established risk factor)
• Chronic renal disease (particularly with creatinine clearance <50 mL/minute)
• History of solid organ transplantation
• Athletes or individuals engaged in high-intensity physical activity should avoid all fluoroquinolone use unless no alternative is available 2

Athletic Population Specific Precautions

If levofloxacin must be prescribed to athletes 2:

• Reduce high-intensity and ballistic activities throughout the antibiotic course
• Cease all athletic activity at onset of any musculoskeletal symptoms
• Monitor closely for 1 month after completion (symptoms can occur up to 6 months post-exposure)

Critical Drug Interactions

Absorption Interference

• Do not administer within 2 hours of antacids or medications containing divalent cations (magnesium, aluminum, iron, calcium), as these markedly decrease fluoroquinolone absorption 2, 3.

Renal Clearance Alterations

• Cimetidine and probenecid decrease levofloxacin renal clearance and increase half-life, though these interactions are not clinically significant 7.

Dosage Adjustments Required (Not Contraindications)

Renal Impairment

• Dosage adjustment (750-1000 mg three times weekly) is required if creatinine clearance is <50 mL/minute 2, 3.
• Approximately 80% of levofloxacin is cleared by the kidney 2, 7.
• Not cleared by hemodialysis; supplemental doses after dialysis are not necessary 2.

Hepatic Disease

• Drug levels are not affected by hepatic disease 2.
• Presumed safe for use in severe liver disease, though caution is advised 2.

Common Pitfalls to Avoid

• Do not use fluoroquinolone prophylaxis followed by fluoroquinolone empirical therapy for the same infection episode, as this precludes subsequent use 2.
• Do not overlook magnesium deficiency in high-risk patients, as this may contribute to adverse effects 2.
• Do not dismiss musculoskeletal symptoms in elderly patients as age-related; these may represent fluoroquinolone toxicity 4.
• Levofloxacin and ofloxacin appear to carry higher risk of tendinopathy compared to other fluoroquinolones, with risk being exposure-dependent (higher doses and longer durations) 6.