Is it safe to use ciprofloxacin (Cipro) in a patient with a known allergy to levofloxacin (Levaquin)?

From the Guidelines

No, ciprofloxacin should not be used in patients with a levofloxacin allergy. Both medications belong to the same class of antibiotics called fluoroquinolones, and there is significant cross-reactivity between them 1. If you've experienced an allergic reaction to levofloxacin, you have a risk of experiencing a similar or potentially more severe reaction to ciprofloxacin. This cross-reactivity occurs because fluoroquinolones share similar chemical structures and mechanisms of action.

Key Considerations

• The literature agrees on the existence of both immediate as well as delayed-type allergies to fluoroquinolones, with moxifloxacin posing the highest risk of anaphylaxis compared with other frequently used fluoroquinolones, such as levofloxacin and ciprofloxacin 1.
• The absolute risk of a severe reaction is low with reported anaphylaxis in 1.8-2.3/100,000 days of treatment 1.
• Instead, patients with fluoroquinolone allergies should be prescribed antibiotics from different classes, such as penicillins, cephalosporins, macrolides, or tetracyclines, depending on the infection being treated and other patient-specific factors.

Alternative Treatment Options

• Penicillins can be used in a clinical setting in patients with a suspected non-severe, delayed-type allergy to monobactams or carbapenems and no history of penicillin allergy, irrespective of time since the index reaction 1.
• Cephalosporins can be administered in a clinical setting in patients with a suspected non-severe, delayed-type allergy to a monobactam or carbapenem and no history of cephalosporin allergy, irrespective of the time since the index reaction 1.

Patient Safety

• Always inform all healthcare providers about your levofloxacin allergy to ensure it's documented in your medical records and to prevent accidental prescription of any fluoroquinolone antibiotics.
• In cases where a fluoroquinolone is deemed necessary, the use of beta-lactam antibiotics should be discussed in a multidisciplinary team, especially in patients with suspected severe, delayed-type allergy to cephalosporins, monobactams, or carbapenems 1.

From the FDA Drug Label

4 CONTRAINDICATIONS Levofloxacin tablets are contraindicated in persons with known hypersensitivity to levofloxacin, or other quinolone antibacterials [see Warnings and Precautions (5.3)].

The answer is no, we cannot use ciprofloxacin with a levofloxacin allergy, because:

• Ciprofloxacin is also a quinolone antibacterial
• The patient has a known hypersensitivity to levofloxacin, which is a quinolone antibacterial
• The label states that levofloxacin is contraindicated in persons with known hypersensitivity to other quinolone antibacterials 2

From the Research

Allergy to Levofloxacin and Cross-Reactivity with Ciprofloxacin

• Patients with a confirmed levofloxacin hypersensitivity reaction may tolerate ciprofloxacin, as studies suggest a low cross-reactivity between the two fluoroquinolones 3, 4, 5.
• A study found that most ciprofloxacin-reactive patients (4/5) tolerated levofloxacin, and similarly, 3 of 4 levofloxacin-reactive patients tolerated ciprofloxacin 5.
• However, another study reported a high degree of cross-reactivity among fluoroquinolones, including ciprofloxacin and levofloxacin, and recommended avoiding the group altogether 6.

Clinical Implications

• The decision to use ciprofloxacin in a patient with a levofloxacin allergy should be made on a case-by-case basis, taking into account the patient's medical history and the severity of the allergic reaction 3, 4.
• Oral challenge testing may be necessary to confirm tolerance to ciprofloxacin before prescribing it as a safe alternative 5.
• Clinicians should be aware of the potential for cross-reactivity between fluoroquinolones and use caution when prescribing these medications to patients with a history of allergic reactions 3, 4, 6, 5.