Is levofloxacin (a fluoroquinolone antibiotic) safe to use during breastfeeding?

Levofloxacin Use During Breastfeeding

Levofloxacin should not be used as a first-line antibiotic during breastfeeding, but if clearly indicated when safer alternatives are ineffective or contraindicated, breastfeeding does not need to be discontinued because the risk of adverse effects to the infant is low. 1, 2

Safety Classification and Evidence

• The European Respiratory Society classifies fluoroquinolones (including levofloxacin) as requiring caution during breastfeeding, stating they should not be used as first-line treatment. 1
• If a fluoroquinolone is absolutely necessary, ciprofloxacin is the preferred agent over levofloxacin because it has lower concentrations in breast milk (two orders of magnitude lower than therapeutic infant doses) and calcium in breast milk further inhibits its absorption. 3, 4
• The FDA drug label states that based on limited data, levofloxacin is presumed to be excreted in human milk, and a decision should be made whether to discontinue nursing or discontinue the drug, taking into account the importance of the drug to the mother. 2

Clinical Decision Algorithm

Step 1: Consider safer first-line alternatives

• Penicillins (amoxicillin, amoxicillin/clavulanate) are classified as "compatible" with breastfeeding and should be used preferentially. 1
• Cephalosporins (cephalexin, ceftriaxone) are also "compatible" and represent excellent first-line options. 1
• Macrolides (azithromycin, erythromycin) are classified as "probably safe" and are appropriate second-line choices. 1

Step 2: If fluoroquinolone is specifically indicated

• Choose ciprofloxacin over levofloxacin as the preferred fluoroquinolone during breastfeeding. 1, 3
• Levofloxacin should only be used when benefits clearly outweigh risks or when other antibiotics have failed. 1

Step 3: If levofloxacin must be used

• Breastfeeding can continue with appropriate infant monitoring. 5, 6
• The theoretical risk of cartilage damage based on animal studies has not been observed in clinical practice with the low levels present in breast milk. 4, 5

Important Monitoring Considerations

• Monitor all breastfed infants for gastrointestinal effects (diarrhea, gastroenteritis) due to alteration of intestinal flora. 1
• Be aware that antibiotics in breast milk could potentially cause falsely negative cultures if the infant develops fever requiring evaluation. 1, 3
• Premature or compromised infants may require altered maternal dosing considerations to avoid drug accumulation. 7

Common Pitfalls to Avoid

• Do not automatically discontinue breastfeeding if levofloxacin is prescribed—the decision should weigh the importance of the antibiotic to the mother against the well-established benefits of continued breastfeeding. 2, 5
• Do not use levofloxacin as routine empiric therapy when safer alternatives like amoxicillin or cephalosporins would be appropriate. 1
• Do not ignore the option of ciprofloxacin if a fluoroquinolone is truly needed—it has a better safety profile during breastfeeding than levofloxacin. 1, 3

Special Circumstances

• For bioterrorism exposures (anthrax, plague), ciprofloxacin remains the preferred fluoroquinolone for breastfeeding mothers, and the mother's antimicrobial regimen should match the infant's regimen when possible. 8, 3
• Recent data from exposed pregnancies and breastfeeding women have not confirmed earlier fears about fluoroquinolone toxicity, allowing their use when clearly indicated. 5, 6