Quinolone antibiotics constitute a large group of broad-spectrum bacteriocidals that share a bicyclic core structure related to the substance 4-quinolone. They are used in human and veterinary medicine to treat bacterial infections, as well as in animal husbandry, specifically poultry production.
Quinolone antibiotics are classified into four generations based on their spectrum of activity and chemical modifications. The first-generation quinolones, such as nalidixic acid, primarily target Gram-negative bacteria and are mainly used for urinary tract infections. Second-generation quinolones introduced fluorine atoms into their structure, creating fluoroquinolones, which significantly expanded their antibacterial activity to include some Gram-positive bacteria. Third-generation fluoroquinolones further improved Gram-positive coverage, while fourth-generation fluoroquinolones offer broad-spectrum activity, including anaerobic bacteria.
Only quinolone antibiotics in generation two and higher are considered fluoroquinolones, as they contain a fluorine atom in their chemical structure and are effective against both Gram-negative and Gram-positive bacteria. One example is ciprofloxacin, one of the most widely used antibiotics worldwide.
Medical uses
Fluoroquinolones are frequently prescribed for genitourinary tract infections and are widely used in the treatment of hospital-acquired infections associated with urinary catheters. The FDA published a 2018 safety alert recommending FQs be reserved for use only in patients who have no alternative treatment options for the following indications: uncomplicated urinary tract infection, acute bacterial exacerbation of chronic bronchitis, and acute bacterial sinusitis. In community-acquired infections, they are only recommended when risk factors for multidrug resistance are present or after other antibiotic regimens have failed. However, for serious acute cases of pyelonephritis or bacterial prostatitis where the person may need to be hospitalised, fluoroquinolones are recommended as first-line therapy.
Due to people with sickle-cell disease being at increased risk for developing osteomyelitis from Salmonella, fluoroquinolones are the "drugs of choice" for this organism due to their ability to enter bone tissue without chelating it, as tetracyclines are known to do.
In biofilm-associated infections, quinolones exhibit a good ability to penetrate the biofilm and target bacteria within it, especially during the early stages of biofilm formation. Their antibiofilm activity is generally higher than that of old beta-lactams and glycopeptides but remains lower compared to antibiotics such as tetracyclines, daptomycin, and fosfomycin, which demonstrate greater efficacy against biofilms.
Fluoroquinolones are featured prominently in guidelines for the treatment of hospital-acquired pneumonia.
Children In most countries, fluoroquinolones are only approved for use in children under narrowly defined circumstances, owing in part to the observation of high rates of musculoskeletal adverse events in fluoroquinolone-treated juvenile animals. The use of fluoroquinolones in those 18 years of age and under is only FDA approved for complicated UTI's (pyelonephritis and for postexposure prophylaxis) and treatment of inhalation anthrax. In the UK, the prescribing indications for fluoroquinolones for children are severely restricted. Only inhalational anthrax and pseudomonal infections in cystic fibrosis infections are licensed indications in the UK due to ongoing safety concerns. In a study comparing the safety and efficacy of levofloxacin to that of azithromycin or ceftriaxone in 712 children with community-acquired pneumonia, serious adverse events were experienced by 6% of those treated with levofloxacin and 4% of those treated with comparator antibiotics. Most of these were considered by the treating physician to be unrelated or doubtfully related to the study drug. Two deaths were observed in the levofloxacin group, neither of which was thought to be treatment-related. Spontaneous reports to the U.S. FDA Adverse Effects Reporting System at the time of the 20 September 2011 U.S. FDA Pediatric Drugs Advisory Committee included musculoskeletal events (39, including five cases of tendon rupture) and central nervous system events (19, including five cases of seizures) as the most common spontaneous reports between April 2005 and March 2008. An estimated 130,000 pediatric prescriptions for levofloxacin were filled on behalf of 112,000 pediatric patients during that period.
Meta-analyses conclude that fluoroquinolones pose little or no additional risk to children compared to other antibiotic classes. Fluoroquinolone use in children may be appropriate when the infection is caused by multidrug-resistant bacteria, or when alternative treatment options require parenteral administration and oral therapy is preferred.
Adverse effects On May 12, 2016 the U.S. Food and Drug Administration advised that the serious, disabling and potentially permanent side effects associated with fluoroquinolone antibiotics (Cipro, Levaquin, Avelox, etc.) generally outweigh the benefits for patients with acute sinusitis, acute bronchitis, and uncomplicated urinary tract infections. These side effects can involve tendons, muscles, joints, nerves and the central nervous system as well as cardiac, dermatologic and worsening of myasthenia gravis conditions. With fluoroquinolones these effects are sometimes collectively called floxing.
Suicide Fluoroquinolones can increase the risk of psychiatric symptoms, including depression and psychotic reactions. These may potentially lead to thoughts of suicide or suicide attempts.Medicines and Healthcare products Regulatory Agency|title=Fluoroquinolone antibiotics: suicidal thoughts and behaviour|journal=Drug Safety Updates|year=2023|volume=17|issue=2|pages=5-6|url=https://assets.publishing.service.gov.uk/media/6512d31e3d3718000d6d0bdd/September-2023-DSU-PDF.pdf
Recent reports from coroners on two suicides show the risks of fluoroquinolones in everyday life. Neither victim had a history of depression or mental health problems. However, both men had been prescribed ciprofloxacin shortly before they killed themselves.=Bedford PJ (coroner). "Regulation 28 Report to Prevent Future Deaths." January 11, 2017. https://www.judiciary.uk/wp-content/uploads/2017/02/Rendell-2017-0006.pdf/Fleming HM (coroner). "Regulation 28 Report to Prevent Future Deaths." May 5, 2023. https://www.judiciary.uk/wp-content/uploads/2023/06/Robert-Stevenson-Prevention-of-future-deaths-report-2023-0180_Published.pdf
In a "Report to Prevent Future Deaths", mandated by UK law, one of the coroners noted that there is no compelling reason why patients should expect to risk becoming suicidal from an antibiotic unless this fact and potential symptoms were brought to their attention by the prescriber.
A 2024 review from the UK's Medicines & Healthcare Products Regulatory Agency examined the effectiveness of current measures to reduce these identified risks of fluoroquinolones. It concluded, "Systemic fluoroquinolones must now only be prescribed when other commonly recommended antibiotics are inappropriate."UK's Medicines & Healthcare Products Regulatory Agency https://www.gov.uk/drug-safety-update/fluoroquinolone-antibiotics-must-now-only-be-prescribed-when-other-commonly-recommended-antibiotics-are-inappropriate
Other nervous system side effects Nervous-system effects include insomnia, restlessness, and rarely, seizure, convulsions, and psychosis. Other rare and serious adverse events have been observed with varying degrees of evidence for causation.
Chronology of boxed warnings In 2008, the U.S. FDA added black box warnings on all fluoroquinolones, advising of the increased risk of tendon damage. In 2016, the FDA found that systemic use (by mouth or injection) of fluoroquinolones was associated with "disabling and potentially permanent serious side effects" involving the tendons, muscles, joints, nerves, and central nervous system, concluding that these side effects generally outweigh the benefits for people with acute sinusitis, acute bronchitis, and uncomplicated urinary tract infections when other treatment options are available. Concerns regarding low blood sugar and mental health problems were added in 2018. In December 2018, the FDA issued a warning regarding an increased risk of aortic aneurysms and aortic dissections associated with fluoroquinolone use. This warning specifically targeted older adults and patients with conditions such as hypertension, Marfan syndrome, Ehlers–Danlos syndrome, atherosclerosis, peripheral vascular disease, and a history of aneurysms.
Tendons Quinolones are associated with a risk of tendonitis and tendon rupture; a 2013 review found the incidence of tendon injury among those taking fluoroquinolones to be between 0.08 and 0.20%. The risk appears to be higher among people older than 60 and those also taking corticosteroids; the risk also may be higher among people who are male, have a pre-existing joint or tendon issue, have kidney disease, or are highly active. Some experts have advised avoidance of fluoroquinolones in athletes. If tendonitis occurs, it generally appears within one month, and the most common tendon injured appears to be the Achilles tendon. The cause is not well understood.
Aortic dissection Fluoroquinolones can increase the rate of rare but serious tears in the aorta by 31% compared to other antibiotics. People at increased risk include those with aortic aneurysm, hypertension, certain genetic conditions such as Marfan syndrome and Ehlers–Danlos syndrome, and the elderly. For these people, fluoroquinolones should be used only when no other treatment options are available. One year after the warning announcement, prescribing behaviors were reported to have remained unchanged.
Colitis Clostridioides difficile colitis may occur in connection with the use of any antibacterial drug, especially those with a broad spectrum of activity such as clindamycin, cephalosporins, and fluoroquinolones. Fluoroquinoline treatment is associated with risk that is similar to or less than that associated with broad spectrum cephalosporins. Fluoroquinolone administration may be associated with the acquisition and outgrowth of a particularly virulent Clostridium strain.
Other More generally, fluoroquinolones are tolerated, with typical drug side effects being mild to moderate. Common side effects include gastrointestinal effects such as nausea, vomiting, and diarrhea, as well as headache and insomnia. Postmarketing surveillance has revealed a variety of relatively rare but serious adverse effects associated with all members of the fluoroquinolone antibacterial class. Among these, tendon problems and exacerbation of the symptoms of the neurological disorder myasthenia gravis are the subject of "black box" warnings in the United States.
A 2018 EU-wide review of fluoroquinolones concluded that they are associated with serious side effects including tendonitis, tendon rupture, arthralgia, pain in extremities, gait disturbance, neuropathies associated with paraesthesia, depression, fatigue, memory impairment, sleep disorders, and impaired hearing, vision, taste and smell. Tendon damage (especially to Achilles tendon but also other tendons) can occur within 48 hours of starting fluoroquinolone treatment but the damage may be delayed several months after stopping treatment.