Levofloxacin

Aka: Levofloxacin, Levaquin

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II. Indications

  1. Conditions
    1. Community Acquired Pneumonia
    2. Refractory acute Bacterial Sinusitis (third line agent)
  2. Activity Spectrum
    1. Moderate to good Gram Positive activity (includes Streptococcus Pneumoniae)
    2. Aerobic Gram Negative Rod coverage (see other Fluoroquinolones)
      1. Enterobacteriaceae
      2. Includes Pseudomonas coverage (similar to Ciprofloxacin)
    3. Atypical Bacteria (similar to other Fluoroquinolones)
      1. Legionella pneumophila
      2. Chlamydophila pneumoniae
      3. Mycoplasma pneumoniae

III. Contraindications

  1. See Fluoroquinolone
  2. Myasthenia Gravis (exacerbates motor weakness)
  3. Children
    1. Relative contraindication due to risk of Arthropathy in animals
    2. Studies have not demonstrated Arthropathy (other than transient large joint Arthralgias)

IV. Mechanism

  1. See Fluoroquinolone

V. Medications

  1. Tablets: 250, 500 and 750 mg
  2. Oral Solution: 25 mg/ml

VI. Dosing: Adult

  1. See Anthrax
  2. Community Acquired Pneumonia
    1. Take 750 mg orally or IV daily for 5 days OR
    2. Take 500 mg orally or IV daily for 7 to 14 days
  3. Nosocomial Pneumonia
    1. Take 750 mg orally or IV daily for 7 to 14 days
  4. Pyelonephritis (or other complicated Urinary Tract Infection)
    1. Take 750 mg orally or IV daily for 5 days OR
    2. Take 250 mg orally or IV daily for 10 days
  5. Chronic Bacterial Prostatitis
    1. Take 500 mg orally or IV daily for up to 28 days
  6. Plague
    1. Take 500 mg orally or IV daily for 10 to 14 days
  7. Travelers Diarrhea (not FDA approved)
    1. Take 500 mg orally or IV daily for 1 to 3 days
  8. Legionnaires Disease
    1. Start: 1000 mg orally or IV on day 1
    2. Next: 500 mg orally or IV daily
  9. Renal Dosing
    1. eGFR 20 to 49 ml/min
      1. Dose 750 mg: Give 750 mg orally or IV every 48 hours
      2. Dose 500 mg: Give 500 mg orally or IV once for loading dose, then 250 mg every 24 hours
    2. eGFR 10 to 19 ml/min (or Hemodialysis)
      1. Dose 750 mg: Give 750 mg orally or IV once for loading dose, then 500 mg every 48 hours
      2. Dose 500 mg: Give 500 mg orally or IV once for loading dose, then 250 mg every 48 hours
      3. Dose 250 mg: Give 250 mg orally or IV every 48 hours

VII. Dosing: Child

  1. See Anthrax
  2. See Plague
  3. See Precautions above under contraindications
  4. Community Acquired Pneumonia (not FDA Approved)
    1. Age 6 months to 5 years
      1. Give 8 to 10 mg/kg orally or IV twice daily
    2. Age 5 to 16 years
      1. Give 8 to 10 mg/kg (maximum 750 mg/day) orally or IV once daily

VIII. Adverse Effects

  1. See Fluoroquinolone
  2. Fluoroquinolones have several serious warnings (e.g. tendon rupture, Neuropathy, Aortic Dissection)
  3. QT Prolongation with Levofloxacin (Levaquin)
    1. Avoid in known Prolonged QT, Hypokalemia or in combination of Class 1 or Class 3 Antiarrhythmics
    2. Three fold increased risk of Sudden Cardiac Death while on Levofloxacin
    3. This appears to be a class effect with most Fluoroquinolones except Ciprofloxacin
    4. Ray (2013) N Engl J Med 366(20): 1881-90 [PubMed]
  4. Neurologic Effects
    1. Seizure risk (all Quinolones inhibit GABA)
    2. CNS stimulation
    3. Suicidality

IX. Safety

  1. Avoided in pregnancy (despite pregnancy Category C)
    1. Cartilage damage risk
  2. Unknown Safety in Lactation
    1. However, risk of pediatric Arthropathy

X. Pharmacokinetics

  1. Excellent oral Bioavailability
    1. Oral and Intravenous dosing are the same

XI. Drug Interactions

  1. Sulfonylureas and other antidiabetic medications
    1. Hypoglycemia risk
  2. Warfarin
    1. May potentiate Anticoagulant effects
  3. Class 1 or Class 3 Antiarrhythmics
    1. See Prolonged QT Interval due to Medication
    2. QT Prolongation risk when combined with Levofloxacin
  4. Urine Drug Screen
    1. False Positive Opiate urine screen
  5. Drugs that interfere with absorption (give at least 2 hours before or after dose)
    1. Antacids containing Calcium, aluminum or Magnesium
    2. Sucralfate
    3. Iron
    4. Zinc
    5. Yogurt, milk or Calcium fortified juice (but may take with dairy containing meals)

XII. Resources

  1. Levofloxacin Tablet (DailyMed)
    1. https://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=4181a7ac-2e84-68d4-e054-00144ff88e88
  2. Levofloxacin Injection Solution (DailyMed)
    1. https://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=70c87464-1806-480a-8ebd-3f02987ff436

XIII. References

  1. (2019) Comparison Table: Some Systemic Fluoroquinolones, Med Lett Drugs Ther, p. e57
  2. King (2000) Am Fam Physician 61(9):2741-8 [PubMed]
  3. O'Donnell (2000) Infect Dis Clin North Am 14(2):489-513 [PubMed]
  4. Oliphant (2002) Am Fam Physician 65(3):455-64 [PubMed]
  5. Owens (2000) Med Clin North Am 84(6):1447-69 [PubMed]

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Related Studies

Cost: Medications

levofloxacin (on 12/21/2022 at Medicaid.Gov Survey of pharmacy drug pricing)
LEVOFLOXACIN 25 MG/ML SOLUTION Generic $0.98 per ml
LEVOFLOXACIN 250 MG TABLET Generic $0.14 each
LEVOFLOXACIN 500 MG TABLET Generic $0.17 each
LEVOFLOXACIN 750 MG TABLET Generic $0.31 each
FPNotebook does not benefit financially from showing this medication data or their pharmacy links. This information is provided only to help medical providers and their patients see relative costs. Insurance plans negotiate lower medication prices with suppliers. Prices shown here are out of pocket, non-negotiated rates. See Needy Meds for financial assistance information. GoodRx is another tool for finding lower drug prices.

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