Levofloxacin for Urology Prophylaxis
Recommended Dose
For urological prophylaxis, administer a single oral dose of 500 mg levofloxacin 1-2 hours before the procedure. 1, 2
Timing of Administration
- Oral levofloxacin must be given 1-2 hours preoperatively to ensure adequate tissue concentrations are present at the time of instrumentation or incision 1, 2
- The drug reaches peak plasma concentration (Cmax) of approximately 5.2 mg/L within 1-2 hours after oral administration of the 500 mg dose 3
- Oral bioavailability approaches 100%, making it equivalent to intravenous administration 3, 4
Specific Urological Procedures Requiring Prophylaxis
Higher-risk procedures where 500 mg levofloxacin is indicated: 1
- Any stone manipulation (including shock wave lithotripsy) 1, 2
- Transrectal prostate biopsy 1
- Any endoscopic procedures of the upper tract (ureter and kidney) 1
- Any procedure with transmural incision into the urinary tract 1
- Any procedure that includes bowel segments 1
- Transurethral resection of the prostate (TURP) 1, 5
- Cystourethroscopy with manipulation 1
Alternative Regimens When Fluoroquinolones Cannot Be Used
If levofloxacin is contraindicated, use: 1, 2
- Ampicillin 2 g IV plus gentamicin 1.5 mg/kg IV, administered 30-60 minutes preoperatively 1
- For penicillin allergy: Vancomycin 1 g IV over 1-2 hours plus gentamicin 1.5 mg/kg IV 1
- First or second-generation cephalosporins (cefazolin 1 g IV or cefuroxime 500 mg oral) 2
- Trimethoprim-sulfamethoxazole as a cost-effective alternative with similar efficacy 2, 5
Critical Administration Guidelines
- Single-dose prophylaxis is sufficient—do not extend beyond 24 hours unless treating an established infection 2
- Levofloxacin can be administered without regard to food 6
- Avoid concurrent administration with antacids containing magnesium or aluminum, sucralfate, metal cations (iron), or multivitamins with zinc—separate by at least 2 hours 6, 3
- Maintain adequate hydration to prevent crystalluria 6
Evidence Supporting Single-Dose 500 mg Regimen
- A prospective randomized multicenter study of 400 patients undergoing TURP demonstrated that single-dose 500 mg levofloxacin reduced bacteriuria rates to 21% compared to 30% in controls, with similar efficacy to trimethoprim-sulfamethoxazole 5
- In transrectal prostate biopsy, single-dose 500 mg levofloxacin resulted in only 0.27% infection rate in 377 low-risk patients 7
- The high-dose regimen maximizes concentration-dependent bactericidal activity and may reduce resistance emergence 4
Special Populations and Dosing Adjustments
Renal impairment: 6
- No adjustment needed if creatinine clearance ≥50 mL/min
- For creatinine clearance <50 mL/min, dosage reduction is required to avoid drug accumulation
- Levofloxacin is approximately 80% eliminated unchanged in urine 3
Common Pitfalls to Avoid
- Do not skip prophylaxis for "simple" stone retrieval—any stone manipulation increases bacteremia risk and requires prophylaxis 2
- Do not continue antibiotics beyond 24 hours post-procedure unless treating an established infection rather than providing prophylaxis 2
- Do not use fluoroquinolones indiscriminately—check local resistance patterns and recent patient antibiotic exposure 2
- Do not give levofloxacin at the time of procedure—it must be given 1-2 hours before to achieve adequate tissue levels 1, 2
When Prophylaxis May Not Be Indicated
Lower-risk procedures where prophylaxis is not routinely required (unless risk factors present): 1
- Simple cystourethroscopy without manipulation 1
- Catheterization for drainage or diagnostic instrumentation 1
- Urodynamic studies in patients without risk factors 1