{"id":2889,"date":"2012-06-24T07:19:05","date_gmt":"2012-06-24T11:19:05","guid":{"rendered":"http:\/\/blogs.nejm.org\/?p=2889"},"modified":"2015-06-04T15:14:25","modified_gmt":"2015-06-04T19:14:25","slug":"id-learning-unit-choosing-a-quinolone","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/id-learning-unit-choosing-a-quinolone\/2012\/06\/24\/","title":{"rendered":"ID Learning Unit &#8212; Choosing a Quinolone"},"content":{"rendered":"<p><a href=\"http:\/\/blogs.nejm.org\/hiv-id-observations\/wp-content\/uploads\/sites\/2\/2012\/06\/hospital-rounds1.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"alignright size-full wp-image-2894\" title=\"hospital rounds\" src=\"http:\/\/blogs.nejm.org\/hiv-id-observations\/wp-content\/uploads\/sites\/2\/2012\/06\/hospital-rounds1.jpg\" alt=\"\" width=\"249\" height=\"201\" \/><\/a>We love quinolones on medical services, and it&#8217;s easy to understand why. Advantages:<\/p>\n<ul>\n<li>Ideal spectrum for several common infections, including community-acquired pneumonia, UTIs, and more complex infections when combined with other drugs<\/li>\n<li>Great oral absorption<\/li>\n<li>Few drug-drug interactions<\/li>\n<li>Once- or twice-daily dosing<\/li>\n<li>Generally well tolerated<\/li>\n<li>Reasonable cost<\/li>\n<\/ul>\n<p>But how do you choose between them? Below, in a concise and admittedly somewhat oversimplified table, is all the medical intern\/resident\/hospitalist needs to know about our friends the quinolones:<\/p>\n<table border=\"1\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"text-align: center\" valign=\"top\" width=\"74\"><strong>Drug<\/strong><\/td>\n<td style=\"text-align: center\" valign=\"top\" width=\"74\"><strong>Activity vs gram \u2013 rods (rank)<\/strong><\/td>\n<td style=\"text-align: center\" valign=\"top\" width=\"74\"><strong>Activity vs gram + cocci (rank)<\/strong><\/td>\n<td style=\"text-align: center\" valign=\"top\" width=\"74\"><strong>Activity vs Anaerobes (rank)<\/strong><\/td>\n<td style=\"text-align: center\" valign=\"top\" width=\"74\"><strong>Metabolism<\/strong><\/td>\n<td style=\"text-align: center\" valign=\"top\" width=\"74\"><strong>Comments\/Fun facts<\/strong><\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"74\">Ciprofloxacin<\/td>\n<td style=\"text-align: center\" valign=\"top\" width=\"74\">1<\/td>\n<td style=\"text-align: center\" valign=\"top\" width=\"74\">3<\/td>\n<td style=\"text-align: center\" valign=\"top\" width=\"74\">3<\/td>\n<td style=\"text-align: center\" valign=\"top\" width=\"74\">Kidney<\/td>\n<td valign=\"top\" width=\"74\">Don\u2019t use for <em>Strep pneumo<\/em>; no association with increased cardiac death in <a href=\"http:\/\/www.nejm.org\/doi\/full\/10.1056\/NEJMoa1003833\" target=\"_blank\">recent study<\/a> (unlike levo, azithro)<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"74\">Levofloxacin<\/td>\n<td style=\"text-align: center\" valign=\"top\" width=\"74\">2<\/td>\n<td style=\"text-align: center\" valign=\"top\" width=\"74\">2<\/td>\n<td style=\"text-align: center\" valign=\"top\" width=\"74\">3<\/td>\n<td style=\"text-align: center\" valign=\"top\" width=\"74\">Kidney<\/td>\n<td valign=\"top\" width=\"74\">Active (left) enantomer of ofloxacin \u2013 hence its name. How cool is that?<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"74\">Moxifloxacin<\/td>\n<td style=\"text-align: center\" valign=\"top\" width=\"74\">3<\/td>\n<td style=\"text-align: center\" valign=\"top\" width=\"74\">1<\/td>\n<td style=\"text-align: center\" valign=\"top\" width=\"74\">1<\/td>\n<td style=\"text-align: center\" valign=\"top\" width=\"74\">Liver<\/td>\n<td valign=\"top\" width=\"74\">Not active vs. <em>Pseudomonas<\/em>; generally the preferred quinolone for mycobacterial infections<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>But it\u2019s not all sunshine and happiness with these drugs. Problems:<\/p>\n<ul>\n<li>That <a href=\"http:\/\/blogs.nejm.org\/index.php\/suppose-they-gave-a-black-box-warning-and-no-one-noticed\/2008\/07\/19\/\" target=\"_blank\">nasty tendon issue<\/a><\/li>\n<li>Can make people (especially the elderly) kind of crazy \u2013 \u201clike 5 cups of Starbucks, and not in a good way\u201d, was one patient\u2019s memorable description<\/li>\n<li>Photosensitivity<\/li>\n<li>QT prolongation<\/li>\n<li>Oral absorption blocked by concomitant iron, magnesium, calcium, aluminum, and probably also <a href=\"http:\/\/en.wikipedia.org\/wiki\/Krugerrand\" target=\"_blank\">Krugerrands<\/a> if you happen to be eating them<\/li>\n<li><em>C diff<\/em> risk, something we really didn\u2019t see until the emergence of the more virulent strain<\/li>\n<li>Ever rising rates of resistance with gram negative rods, <em>Staph aureus<\/em><\/li>\n<\/ul>\n<p>Bottom line? These are great antibiotics \u2013 but they are not\u00a0interchangeable, and not 100% safe.<\/p>\n<p><em>Extra credit:<\/em>\u00a0 Can you name the five quinolones that have been pulled by the FDA for safety reasons? Double points if you get the reason they are no longer available, triple points if you also get the brand names and match them to the actual drugs.<\/p>\n<p>Here&#8217;s a <a href=\"http:\/\/blogs.nejm.org\/index.php\/reflections-on-levofloxacin-as-it-goes-generic\/2011\/06\/24\/\" target=\"_blank\">hint<\/a> to get you started.<\/p>\n","protected":false},"excerpt":{"rendered":"<p>We love quinolones on medical services, and it&#8217;s easy to understand why. Advantages: Ideal spectrum for several common infections, including community-acquired pneumonia, UTIs, and more complex infections when combined with other drugs Great oral absorption Few drug-drug interactions Once- or twice-daily dosing Generally well tolerated Reasonable cost But how do you choose between them? Below, [&hellip;]<\/p>\n","protected":false},"author":6,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[3,5,6,8],"tags":[463,483,516,773],"class_list":["post-2889","post","type-post","status-publish","format-standard","hentry","category-health-care","category-infectious-diseases","category-medical-education","category-patient-care","tag-hospitalist","tag-id-learning-unit","tag-internal","tag-quinolones"],"post_mailing_queue_ids":[],"_links":{"self":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts\/2889","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/users\/6"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/comments?post=2889"}],"version-history":[{"count":0,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts\/2889\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/media?parent=2889"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/categories?post=2889"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/tags?post=2889"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}