Infectious Disease

Use of fluoroquinolone in connection with unplanned discontinuation in PJIs

March 13, 2021

3 min read

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Disclosure:
Mahoney Reports Receiving Advisory Fees From Cepheid, Melinta, Merck, and Tetraphase; Cepheid and Tetraphase speaker’s office fees; Travel expenses from Cepheid; Research support from Merck and fees and licensing fees from the American College of Clinical Pharmacy outside of the work submitted. Swords and Vollmer do not report any relevant financial information. In the study you will find all relevant financial information from all other authors.

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Fluoroquinolone use was associated with significantly higher unplanned drug discontinuations and adverse events in patients with prosthetic joint infections, according to a study published in Clinical Infectious Diseases.

“Fluoroquinolones have been a popular antibiotic for bone and joint infections because of their high bioavailability, coverage of typical organisms, and convenient dosing.” Nicholas J. Vollmer, PharmD, A PGY2 critical care pharmacy at Mayo Clinic in Rochester, Minnesota told Healio. “However, the FDA’s publication of warnings coupled with rising rates of resistance has made many clinicians increasingly cautious about their use. Since fluoroquinolones are currently a guideline recommended antibiotic for prosthetic joint infections, we were interested to see how many patients were able to tolerate their long course due to their numerous adverse events and warnings. “

Antibiotic pills

Fluoroquinolone use has been associated with significantly high levels of unplanned drug discontinuation and adverse events in patients with prosthetic hip and knee joint infections.
Photo credit: Adobe Stock

Vollmer and colleagues examined 156 adult patients, of whom 64 had a total hip replacement (THA) and 92 had a total knee replacement (TKA), who were treated for periprosthetic joint infections with debridement, antibiotics and implant retention against staphylococci between January 1, 2007. and November 21, 2019.

According to the study, the primary outcome was the rate of unplanned drug discontinuation, and the secondary outcome included the occurrence of major adverse events, unplanned rifamycin discontinuation, mean time to discontinuation of the unplanned treatment plan, and all-cause mortality.

The study showed that 35.6% (32 out of 90) of patients receiving fluoroquinolones and 3% (2 out of 66) of patients in the non-fluoroquinolone group experienced unplanned drug discontinuation. Additionally, the rate of unplanned withdrawal of fluoroquinolones is considered to be

compared to that of non-fluoroquinolone regimens was 27.5% versus 4.2% (P = 0.021) for THA infections and 42% versus 2.4% (P <0.001) for TKA infections. The researchers also found that there was no significant difference in serious adverse events between fluoroquinolone and non-fluoroquinolone therapies for both THA and TKA infections. The overall rate of non-serious adverse events among those on the fluoroquinolone regimen versus those on the non-fluoroquinolone regimen was 43.3% versus 6.1% (P <0.001), they reported.

“Although we indicated that fluoroquinolones have a much higher incidence of adverse events and unplanned dropouts, I don’t think we should avoid them altogether,” said Vollmer. “I think they still have a place with the right patient with the right follow-up and supervision. Programs such as complex outpatient antimicrobial therapy (COpAT) may be ideal for patients receiving fluoroquinolones as they receive routine follow-up visits where their concerns and adverse events can be closely monitored and addressed. “

In a related editorial Monica V. Mahoney, PharmD, clinical pharmacy coordinator for infectious diseases and Kyleen E. Swords, DNP, One nurse – both at Beth Israel Deaconess Medical Center in Boston – described the relationship between quinolone antibiotics and infectious disease clinicians as “complicated”.

Mahoney and Swords explained the decade-long span of time to the FDA and added warnings for fluoroquinolones.

“The combination of these warnings and collateral damage has led some institutions to completely remove fluoroquinolones from their medications,” they wrote. “Alternatively there on the other end of the stewardship spectrum [are] Increasing the data and the convenience of doctors regarding the use of oral antibiotics to treat infections previously treated with IV antibiotics. “

They cited the POET study, which “showed that the transition to oral therapy is effective for endocarditis therapy” and stated that “oral step-down therapy, usually fluoroquinolones, is also effective for gram-negative bloodstream infections” . They wrote that the OVIVA study “showed similar results with oral therapy for bone and joint infections”.

Based on the complicated history and available data, they said the benefits and risks associated with fluoroquinolone therapy need to be weighed and closely monitored.

“Rather than avoiding an entire class of antibiotics, a moderate approach to carefully selecting patients for oral fluoroquinolone therapy with formalized COpAT follow-up at set time intervals could mitigate risks while maximizing benefits,” concluded Mahoney and Swords.

References:

Mahoney MV, swords KE. Clin Infect Dis. 2021; doi: 10.1093 / cid / ciab150.

Vollmer NJ et al. Clin Infect Dis. 2021; doi: 10.1093 / cid / ciab145.

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