Levofloxacin Treatment for Sexually Transmitted Infections
Levofloxacin is used to treat two specific STIs: gonorrhea (as an alternative regimen) and chlamydia (as an alternative regimen), but it is NOT a first-line treatment for either infection.
Gonorrhea Treatment
Levofloxacin 250 mg orally as a single dose was listed as an alternative regimen for uncomplicated urogenital and anorectal gonorrhea in the 2002 CDC guidelines 1. However, this recommendation is now outdated and should not be used in current practice due to widespread quinolone resistance.
Critical Limitations for Gonorrhea:
- Quinolones (including levofloxacin) should NOT be used for gonorrhea in men who have sex with men, patients with recent foreign travel, or infections acquired in areas with high quinolone-resistant N. gonorrhoeae (QRNG) prevalence 1, 2
- The CDC advises against using quinolones for gonorrhea treatment in most areas of the United States due to emergence of quinolone-resistant strains 2
- Current first-line treatment for gonorrhea is ceftriaxone, not fluoroquinolones 1
Chlamydia Treatment
Levofloxacin 500 mg orally once daily for 7 days is an alternative regimen for chlamydia, not a first-line treatment 1, 3.
First-Line Chlamydia Treatment:
- Azithromycin 1 g orally as a single dose OR doxycycline 100 mg orally twice daily for 7 days are the recommended first-line treatments, with 97-98% efficacy 1, 3
When to Use Levofloxacin for Chlamydia:
- Levofloxacin is reserved for patients who cannot tolerate first-line medications 1, 3
- The pharmacology and in vitro microbiologic activity of levofloxacin are similar to ofloxacin, allowing substitution at 500 mg once daily for 7 days 1
- Clinical studies demonstrate 94.4% bacteriological efficacy for cervical chlamydial infections with levofloxacin 500 mg daily for 7 days 4
Important Contraindications:
- Levofloxacin is contraindicated during pregnancy 3
- For pregnant women with chlamydia, use azithromycin 1 g as a single dose or amoxicillin 500 mg three times daily for 7 days 3
Clinical Considerations
Advantages of Levofloxacin:
- Broad spectrum activity against both Gram-positive and Gram-negative bacteria, including Chlamydia 5
- Excellent oral bioavailability approaching 100% 5
- Favorable pharmacokinetics with wide tissue distribution 1, 5
Disadvantages:
- More expensive than doxycycline with no dosing advantage over first-line options 1
- Requires 7-day course (no compliance advantage over doxycycline) 1
- Less efficacious than azithromycin or doxycycline for chlamydia 1
- Increasing concerns about antibiotic resistance with fluoroquinolone use 6
Common Pitfall to Avoid:
Do not use levofloxacin as first-line treatment for either gonorrhea or chlamydia. It should only be considered when patients cannot tolerate azithromycin, doxycycline, or erythromycin for chlamydia, and it should generally be avoided entirely for gonorrhea due to resistance patterns 1, 3.