AAP updates guidelines for fluoroquinolone use
Fluoroquinolone use should continue to be limited to treating those infections in children for which there are few safe alternatives, but data in recent years are supporting their use in both gram-positive and gram-negative infections, according to a report published online this week.
In the report, the AAP’s Committee on Infectious Diseases updates a 2006 AAP policy statement that summarized recommended uses for fluoroquinolones in children. The updated paper notes newer data that highlights the value of fluoroquinolones to treat certain gram-negative pathogens and highlights the fact that there have been no compelling reports of clinician-diagnosed cartilage problems among children in the United States.
“Use of a fluoroquinolone in a child or adolescent may be justified in special circumstances in which (1) infection is caused by a multidrug-resistant pathogen for which there is no safe and effective alternative and (2) the options for treatment include either parenteral nonfluoroquinolone therapy or oral fluoroquinolone therapy, and oral therapy is preferred,” Infectious Diseases in Children Editorial Board member John S. Bradley, MD, and colleagues wrote. “Fluoroquinolones may also represent a preferred option or an acceptable alternative to standard therapy because of concerns for antimicrobial resistance, toxicity or characteristics of tissue penetration.”
The researchers said the currently approved fluoroquinolones available for pediatric use are ciprofloxacin for inhalational anthrax, complicated urinary tract infections and pyelonephritis; nalidixic acid for urinary tract infections; and levofloxacin for inhalational anthrax. Moxifloxacin is being examined as a potential treatment for complicated intra-abdominal infections in children. A number of these fluoroquinolones have also been approved for treating acute conjunctivitis in children.
Disclosure: The researchers report no relevant financial disclosures.
The clinical report from the AAP's Committee on Infectious Diseases (COID) on the use of systemic and topical fluoroquinolones is very timely and useful for practicing physicians. We have all been there with the non-ill appearing toddler with a chronic draining ear (tympanostomy tube-associated otorrhea) and the decision of what to do included the difficult decision over systemic antibiotic therapy. We have all been there with the child with a Pseudomonas-positive urine culture in a child with spina bifida who is not sick. We are more and more being confronted with the advance of multidrug-resistant bacterial etiologies in our patients. The availability of oral and topical fluoroquinolone antibiotics have been a welcome addition for clinicians, but the animal data and anecdotal temporal association potential of musculoskeletal adverse events have continued to concern many of us related to the widespread use of this class of antibiotics in children. As in a lot of areas of pediatrics, we do not have the data we need to make clear decisions at the time much needed medications are made available and are approved for use in adults. The clinical report from COID provides an updated recommendation for consideration of their use as "essential for evolving resistance patterns," and "additional treatment indications," with the caveat that toxicity profiles will become better defined. In their summary, the COID provides excellent advice for considerations of systemic and topical therapy using fluoroquinolones. They conclude that "no compelling published evidence to date supports the occurrence of sustained injury to developing bones or joints in children treated with available fluoroquinolone agents; however, FDA analysis of ciprofloxacin safety data, as well as post-treatment and 12-month follow-up safety data for levofloxacin, suggest the possibility of increased musculoskeletal adverse events in children who receive fluoroquinolones compared with agents of other classes."
As always in pediatrics, we balance the advantage vs. the risk and strive to judiciously use antibiotics in all children. The COID report is a very welcome update.
Richard F. Jacobs, MD
Infectious Diseases in Children Chief Medical Editor
Disclosure: Dr. Jacobs reports no relevant financial disclosures.
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