(286) Safety of the Use of Fluoroquinolone Antibiotics in Patients with Kidney Disease

Background: Fluoroquinolones are common antibiotics that are effective against bacterial infections. However, their effectiveness is limited due to global resistance, and they are linked to severe adverse events, including musculoskeletal, nervous system, and eye disorders. Regulatory agencies advise against using them for less severe cases and recommend lower doses for patients with chronic kidney disease (CKD). Many physicians often prescribe higher-than-recommended doses in patients with renal impairment to prevent harm.

Objectives: To review the literature regarding the safety of fluoroquinolone use in patients with renal impairment

Methods: A systematic search was conducted in Medline and Embase using keywords related to the population with renal impairment, a list of available fluoroquinolones in the market, and adverse drug effects or drug toxicities. The available literature was reviewed and summarized.

Results: We identified 34 case reports (89%) and four population-based retrospective cohort studies (11%) that linked fluoroquinolones to adverse drug events in patients with renal impairment. Ciprofloxacin and levofloxacin were the most frequent fluoroquinolones prescribed at the median [IQR] daily dose of 1000 (500 to 1000) mg and 500 (250 to 500) mg respectively, despite product monogram and prescribing guidelines recommendations. The most frequent adverse drug events reported were nervous system or psychiatric disorders (24%), renal disorders (18%), hypoglycemia (15%), tendinopathy (12%) and arrhythmia (8%). Cohort studies also found that higher than recommended doses of fluoroquinolones were associated with a significantly higher risk of adverse events. One study showed that higher doses in older adults with advanced CKD were associated with a higher risk of delirium (RR,1.77). Other three studies conducted in hemodialysis patients found that fluoroquinolone use was associated with a higher risk of sudden cardiac death (SCD), with a higher dose linked to a greater risk of SCD (HR range 1.72 to1.95).

Conclusions: Prescribers should consider alternative antibiotics based on local antimicrobial susceptibility data and start fluoroquinolones at a lower dose adjusted for patients with renal impairment. Regulatory agencies should focus on strengthening warning labels and alerting prescribers about the potential risks. Additionally, primary care physicians should be reminded about the importance of accurately adjusting fluoroquinolone doses for patients with CKD.