Does Levaquin (levofloxacin) cover pertussis?

Levaquin Does NOT Cover Pertussis

No, Levaquin (levofloxacin) is not recommended for the treatment or prophylaxis of pertussis, despite demonstrating in vitro activity against Bordetella pertussis, because clinical effectiveness has never been established. 1

Why Fluoroquinolones Are Not Recommended

The CDC explicitly states that fluoroquinolones (including levofloxacin, ciprofloxacin, ofloxacin, and moxifloxacin) exhibit in vitro inhibitory activity against B. pertussis, but in vitro activity does not predict clinical effectiveness for pertussis treatment. 1

Key Reasons for Non-Recommendation:

• No clinical effectiveness data: Unlike macrolides and TMP-SMZ, there are no published studies demonstrating that fluoroquinolones successfully eradicate B. pertussis from the nasopharynx in actual patients. 1

• Poor respiratory penetration: Similar to ampicillin and amoxicillin (which also failed clinically despite in vitro activity), fluoroquinolones may have inadequate penetration into respiratory secretions where B. pertussis colonizes. 1

• Safety concerns in children: Fluoroquinolones have potentially harmful side effects in pediatric populations, which is particularly problematic since pertussis commonly affects infants and children. 1

What DOES Cover Pertussis

First-Line Agents (Macrolides):

• Azithromycin (preferred for compliance and tolerability) 2, 3, 4
• Clarithromycin 3, 4
• Erythromycin (traditional standard, but more side effects) 2, 3, 4, 5

Alternative Agent:

• Trimethoprim-sulfamethoxazole (TMP-SMZ): This is the ONLY alternative to macrolides with proven clinical effectiveness for eradicating B. pertussis from the nasopharynx. 1
  • Use in patients >2 months old who cannot tolerate macrolides or have macrolide-resistant B. pertussis 1
  • Contraindicated in infants <2 months, pregnant women, and nursing mothers due to kernicterus risk 1

Recent Evidence on Levofloxacin

Important caveat: A 2025 prospective observational study found that levofloxacin (8-10 mg/kg/dose) was as effective as TMP-SMX for treating macrolide-resistant pertussis in pediatric outpatients, with 96.43% symptom improvement and 92% bacteriologic clearance. 6 However, this single recent study has not yet been incorporated into CDC guidelines, and the 2005 CDC recommendations remain the current standard of care. 1

Clinical Bottom Line

Use macrolides first-line for pertussis. If macrolides cannot be used (allergy, intolerance, or confirmed resistance), use TMP-SMZ as the proven alternative. 1, 2 Do not use Levaquin based on current CDC guidelines, despite emerging evidence suggesting potential efficacy. 1, 6