Should You Avoid Fluoroquinolone Antibiotics Like Ciprofloxacin?
Key takeaways:
Fluoroquinolones are antibiotic medications. They can treat many bacterial infections. But they also have some serious risks.
Fluoroquinolones can cause tendon, joint, and muscle problems. They can also cause irreversible nerve damage and severe mood changes.
Fluoroquinolones shouldn’t be used in mild infections if other treatment options are available. But they may be needed to treat severe infections like certain types of pneumonia.
Table of contents
Fluoroquinolones are antibiotic medications. They treat many bacterial infections. But prescriptions for fluoroquinolones have dropped over the years. For example, the CDC estimated that fluoroquinolones were the fourth most popular type of antibiotics in 2016. But in 2021, they weren’t even in the top five.
Why are we seeing this decline in prescriptions for fluoroquinolones like ciprofloxacin (Cipro)? And should you avoid fluoroquinolones altogether? We’ll discuss what you need to know about the risks of these antibiotics below.
What are fluoroquinolones?
Fluoroquinolones are antibiotic medications that treat bacterial infections. These are infections that occur when harmful bacteria enters the body or grows on the skin.
Read more like this
Explore these related articles, suggested for readers like you.
Fluoroquinolones are “bactericidal” antibiotics. This means they work to completely kill the bacteria they’re targeting. More specifically, fluoroquinolones work by causing a bacteria’s DNA to break. This prevents bacteria from multiplying.
Fluoroquinolones treat many types of infections. This includes urinary tract infections (UTIs), skin infections, and respiratory infections.
What are the names of some fluoroquinolones?
There are many different fluoroquinolone products. Examples include:
Ciprofloxacin (Cipro, Cetraxal, Ciloxan)
Moxifloxacin (Avelox, Vigamox)
Some fluoroquinolones come in multiple forms. For example, ciprofloxacin comes as an oral product (Cipro) and an injectable medication. It also comes as ear drops (Cetrexal) and eye drops and ointment (Ciloxan).
In this article, we’ll focus on oral and injectable forms of fluoroquinolones only.
Should you avoid fluoroquinolones?
Maybe. But it depends on what type of bacterial infection you have.
Because fluoroquinolones can treat so many types of infections, they’re popular antibiotics. But fluoroquinolones can cause dangerous side effects. These side effects can affect your tendons, muscles, and joints. They can also affect your nerves and heart.
The FDA has applied serious warnings to fluoroquinolone product labels over the years. And in 2016, they warned completely against using fluoroquinolones for mild infections. The warning included acute sinusitis, acute bronchitis, and uncomplicated UTIs.
The risks of fluoroquinolones outweigh the benefits for treating mild infections where other options are available. If you have an infection that requires antibiotics, talk to your healthcare provider about your options. If your infection is mild, it may be best to avoid fluoroquinolones.
Fluoroquinolone black box warnings
Since 2008, the FDA has announced several severe safety warnings about fluoroquinolones. These warnings are called black box warnings. They're the most serious warning the FDA can assign a prescription medication.
Here, we’ll cover these black box warnings and the years they were announced.
2008: Tendinitis and tendon rupture
In 2008, the FDA warned against tendon inflammation (tendonitis) and rupture with fluoroquinolones.
The risk of tendinitis and tendon rupture is higher in people over 60 years old. It's also higher in people with kidney, heart, or lung transplants and people taking steroid treatment.
If you experience symptoms of tendon pain or swelling, let your healthcare provider know right away. They'll likely help you stop your fluoroquinolone.
2011: Worsening of myasthenia gravis symptoms
In 2011, the FDA warned against using fluoroquinolones in people with myasthenia gravis (MG). This is an autoimmune condition that causes muscle weakness in the face, throat, and limbs.
Fluoroquinolones can make muscle weakness worse in people with MG. This can cause difficulty breathing and in severe cases, it can lead to death. Worsening muscle weakness in MG could occur any time after starting a fluoroquinolone.
2013: Nerve damage
In 2013, the FDA added a black box warning for risk of peripheral neuropathy with fluoroquinolones. Peripheral neuropathy is nerve damage that occurs outside the brain and spinal cord. It can occur anytime during fluoroquinolone treatment.
If you develop symptoms of neuropathy, let your healthcare provider know immediately. This includes a burning, tingling, or painful sensation in the arms or legs.
You will likely stop taking fluoroquinolone. But neuropathy can last months to years after you stop taking it. Or it could even be permanent.
2016: Avoid fluoroquinolone use unless there’s no alternative treatment options
As discussed in the previous section, the FDA warned against using fluoroquinolones for mild infections in 2016. They recommended saving it for situations where there are no other treatment options. This is because fluoroquinolones may cause various serious side effects all at once. These side effects most often affect the:
Tendons, muscles, joints
Nerves
Brain
We’ve discussed fluoroquinolone side effects that may affect the tendons, muscles, and nerves. But it may also affect the brain.
They can cause changes in mood and behavior including nervousness, agitation, and confusion. They can also cause depression and psychosis (a break with reality). This may lead to suicidal thoughts or behaviors. If you experience changes in your mood or behavior, contact your healthcare provider.
If you or someone you know is having thoughts of suicide, you’re not alone. Help is available. Call the National Suicide Prevention Lifeline at 988, or text HOME to 741-741 to reach the Crisis Text Line.
Other severe safety warnings for fluoroquinolones
In July 2018, the FDA reiterated the risks of mental health issues with fluoroquinolones. This warning included information about severe brain side effects with fluoroquinolones. If you experience a loss of consciousness or seizures, get emergency care.
The warning also included information about blood sugar problems associated with fluoroquinolones. This includes low (hypoglycemia) or high blood sugar (hyperglycemia).
Hypoglycemia can be serious because it can lead to a coma. It’s more likely to happen if you take a diabetes medication that lowers blood sugar like insulin or if you’re of older age.
Then in December 2018, the FDA warned of a greater risk of ruptures (tears) in the aorta (the main artery of the body). This could cause dangerous bleeding and possibly death.
You're more likely to experience this if you have a history of blockages or aneurysms in any blood vessel. If you have high blood pressure or a medical condition affecting your blood vessels, you may also be at higher risk.
Other fluoroquinolone side effects
In addition to the warnings discussed above, fluoroquinolones have other possible side effects. Some are usually mild, including:
Abdominal side effects like nausea, vomiting, and diarrhea
Changes in taste
Headache
Dizziness
Fatigue
Skin sensitivity after sun exposure
Other fluoroquinolone side effects that may be more severe include:
Abnormal heart rhythms (arrhythmias): Fluoroquinolones can make the QT interval longer. This is a period of rest during a heartbeat that’s longer than it should be, which can lead to arrhythmia.
Severe allergic reactions: This includes skin reactions like Steven Johnson's syndrome and toxic epidermal necrolysis.
Severe diarrhea: Clostridium difficile (C. difficile) is a bacteria that can cause diarrhea. C. difficile-associated diarrhea (CDAD) can happen with nearly all antibiotics. But it may not be as likely with fluoroquinolones. CDAD can be mild, but it can also cause serious problems like an infected or inflamed colon.
Complications in children: It’s rarely recommended to use fluoroquinolones in people less than 18 years old. They have a greater chance of side effects, including joint and tendon problems.
This isn’t a complete list of fluoroquinolone side effects. And individual fluoroquinolone products may have their own risks as well.
So, does anyone actually need fluoroquinolones?
Even though fluoroquinolones have serious risks, they may be needed in some situations. For some bacterial infections, including different types of pneumonia, fluoroquinolones may be necessary.
Your healthcare provider will let you know if you have a bacterial infection that requires a fluoroquinolone. They can help you weigh the risks and benefits depending on your type of infection, medical history, and personal preferences.
Who should avoid fluoroquinolone antibiotics?
Some people are at greater risk of severe side effects from fluoroquinolones. These include people who:
Had have side effects (including an allergic reaction) from fluoroquinolones in the past
Take steroids, such as prednisone or dexamethasone
Have a history of tendon problems
Have a history of neuropathy
Are at greater risk of arrhythmia
Have low potassium levels or a slow heart rate
Take other medications that can prolong the QT intervals, including some antiarrhythmic medications like amiodarone (Pacerone)
Have myasthenia gravis (MG)
Have had a prior aortic aneurysm
Are at risk of an aortic aneurysm, like people with high blood pressure
Fluoroquinolones should also be used more carefully in people who:
Are older
Have kidney disease
Have had an organ transplant
Take diabetes medications
The bottom line
Fluoroquinolones are antibiotic medications that treat many bacterial infections. But they should be avoided in mild infections if other antibiotic options are available.
This is because fluoroquinolones have serious risks associated with them. Examples include tendonitis and tendon rupture, peripheral neuropathy, and severe mood changes.
But fluoroquinolones may be necessary for some serious bacterial infections. This includes some cases of pneumonia. If you’re wondering whether you need fluoroquinolone, talk to your healthcare provider. They can help you weigh the risks and benefits.
Why trust our experts?
References
Bernatová, S., et al. (2013). Following the mechanisms of bacteriostatic versus bactericidal action using raman spectroscopy. Molecules.
Centers for Disease Control and Prevention. (2022). Outpatient antibiotic prescriptions— United States, 2021.
Centers for Disease Control and Prevention. (2018). Outpatient antibiotic prescriptions— United States, 2016.
European Medicines Agency. (2018). Disabling and potentially permanent side effects lead to suspension or restrictions of quinolone and fluoroquinolone antibiotics.
Kalil, A. C., et al. (2016). Management of adults with hospital-acquired and ventilator-associated pneumonia: 2016 Clinical practice guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clinical Infectious Diseases.
Metlay, J. P., et al. (2019). Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. American Journal of Respiratory and Critical Care Medicine.
Olig, E. J., et al. (2017). Antibiotics that aggravate myasthenia gravis. Pharmacy Times.
Oliphant, C. M., et al. (2002). Quinolones: A comprehensive review. American Family Physician.
Patel, K., et al. (2017). Safety concerns surrounding quinolone use in children. Journal of Clinical Pharmacology.
Sankar, A., et al. (2021). Association of fluoroquinolone prescribing rates with black box warnings from the US Food and Drug Administration. JAMA.
Tanne, J. H. (2008). FDA adds “black box” warning label to fluoroquinolone antibiotics. The British Medical Journal.
The American College of Obstetricians and Gynecologists. (2022). FDA warning about fluoroquinolones and risk of aortic ruptures or tears.
U.S. Food and Drug Administration. (n.d.). Drugs@FDA: FDA-approved drugs.
U.S. Food and Drug Administration. (2018). FDA drug safety communication: FDA advises restricting fluoroquinolone antibiotic use for certain uncomplicated infections; warns about disabling side effects that can occur together.
U.S. Food and Drug Administration. (2013). FDA drug safety communication: FDA requires label changes to warn of risk for possibly permanent nerve damage from antibacterial fluoroquinolone drugs taken by mouth or by injection.
U.S. Food and Drug Administration. (2018). FDA reinforces safety information about serious low blood sugar levels and mental health side effects with fluoroquinolone antibiotics; requires label changes.
U.S. Food and Drug Administration. (2018). FDA updates warnings for fluoroquinolone antibiotics on risks of mental health and low blood sugar adverse reactions.
U.S. Food and Drug Administration. (2018). FDA warns about increased risk of ruptures or tears in the aorta blood vessel with fluoroquinolone antibiotics in certain patients.
U.S. Food and Drug Administration. (2013). Information for healthcare professionals: Fluoroquinolone antimicrobial drugs [ciprofloxacin (marketed as Cipro and generic ciprofloxacin), ciprofloxacin extended-release (marketed as Cipro XR and Proquin XR), gemifloxacin (marketed as Factive), levofloxacin (marketed as Levaquin), moxifloxacin (marketed as Avelox), norfloxacin (marketed as Noroxin), and ofloxacin (marketed as Floxin)].
Wang, J., et al. (2022). Association between initiation of fluoroquinolones and hospital admission or emergency department visit for suicidality: Population based cohort study. The British Medical Journal.
