What is the recommended dose of Levaquin (levofloxacin) for an adult patient with a urinary tract infection (UTI)?

Levaquin (Levofloxacin) Dosing for UTI in Adults

For uncomplicated pyelonephritis, use levofloxacin 750 mg orally once daily for 5 days, but only when local fluoroquinolone resistance is <10%. 1

Critical Pre-Treatment Assessment

Before prescribing levofloxacin for any UTI, you must determine:

• Local fluoroquinolone resistance rates - If resistance exceeds 10%, administer an initial IV dose of ceftriaxone 1 g before starting levofloxacin, or choose an alternative agent entirely 1
• Type of UTI - Uncomplicated cystitis, uncomplicated pyelonephritis, or complicated UTI 1
• Renal function - Dose adjustments required for creatinine clearance <50 mL/min 2

Dosing by UTI Type

Uncomplicated Cystitis (Simple Bladder Infection)

• Levofloxacin 250 mg orally once daily for 3 days 3, 2
• Important caveat: Fluoroquinolones should be reserved as alternative agents when first-line options (nitrofurantoin, trimethoprim-sulfamethoxazole, fosfomycin) cannot be used due to their propensity for collateral damage and antimicrobial resistance 1

Uncomplicated Pyelonephritis (Kidney Infection)

Two acceptable regimens:

• Levofloxacin 750 mg orally once daily for 5 days (preferred high-dose, short-course) 1
• Levofloxacin 250 mg orally once daily for 10 days (alternative standard regimen) 3, 2

The 750 mg for 5 days regimen is preferred because it maximizes concentration-dependent bactericidal activity and may reduce resistance emergence while improving compliance 4

Complicated UTI or Catheter-Associated UTI

• Levofloxacin 750 mg orally or IV once daily for 7-14 days 1, 2
• For mild catheter-associated UTI: Levofloxacin 750 mg once daily for 5 days may be sufficient 1
• Duration depends on clinical response: 7 days for prompt resolution, 10-14 days for delayed response 1

Renal Dose Adjustments

For creatinine clearance <50 mL/min, dose adjustments are mandatory: 2

• CrCl 20-49 mL/min: 750 mg initial dose, then 750 mg every 48 hours
• CrCl 10-19 mL/min: 750 mg initial dose, then 500 mg every 48 hours
• Hemodialysis/CAPD: 750 mg initial dose, then 500 mg every 48 hours

Administration Guidelines

• Can be taken with or without food 2
• Separate from chelating agents (antacids, iron, zinc, calcium) by at least 2 hours before or after levofloxacin 2
• Ensure adequate hydration to prevent crystalluria 2
• IV and oral formulations are bioequivalent - seamless transition between routes without dose adjustment 4, 5

Clinical Monitoring

• Reassess at 72 hours - If no clinical improvement, reevaluate diagnosis and consider changing antibiotics based on culture results 1
• Always obtain urine culture before starting therapy in pyelonephritis and complicated UTI cases 1
• If symptoms persist or recur within 2-4 weeks, obtain repeat culture and assume resistance; use a different antimicrobial 3

Critical Pitfalls to Avoid

Do not use levofloxacin if:

• Local fluoroquinolone resistance exceeds 10% without an initial IV ceftriaxone dose 1
• First-line agents (nitrofurantoin, TMP-SMX, fosfomycin) are appropriate for uncomplicated cystitis 1
• Patient has risk factors for fluoroquinolone-associated adverse effects (tendinopathy, QT prolongation, CNS effects) 2

Common prescribing errors:

• Using 500 mg dosing for pyelonephritis when 750 mg is the guideline-recommended dose 1
• Failing to adjust dose for renal impairment 2
• Prescribing fluoroquinolones as first-line for simple cystitis when better options exist 1
• Not checking local resistance patterns before empiric use 1