Medical term:

Levaquin


levofloxacin

Iquix, Levaquin, Novo-Levofloxacin (CA), Oftaquix (UK), Quixin, Tavanic (UK)

Pharmacologic class: Fluoroquinolone

Therapeutic class: Anti-infective

Pregnancy risk category C

FDA Box Warning

Fluoroquinolones for systemic use are associated with an increased risk of tendinitis and tendon rupture in all ages. This risk is further increased in patients usually over age 60, with concomitant use of corticosteroids, and in kidney, heart, and lung transplant recipients.

Action

Inhibits the enzyme DNA gyrase in susceptible gram-negative and gram-positive aerobic and anaerobic bacteria, interfering with bacterial DNA synthesis

Availability

Ophthalmic solution: Quixin-0.5% (5 mg/ml), Iquix-1.5%

Premixed solution for injection: 250 mg/50 ml, 500 mg/100 ml, 750 mg/150 ml

Solution for injection (concentrated): 500 mg/20 ml

Tablets: 250 mg, 500 mg, 750 mg

Indications and dosages

➣ Acute bacterial exacerbation of chronic bronchitis

Adults: 500 mg I.V. or P.O. q 24 hours for 7 days

➣ Community-acquired pneumonia

Adults: 500 mg I.V. or P.O. q 24 hours for 7 to 14 days, or 750 mg I.V. or P.O. q 24 hours for 5 days

➣ Nosocomial pneumonia caused by methicillin-susceptible strains of Staphylococcus aureus, Pseudomonas aeruginosa, Serratia marcescens, Escherichia coli, Klebsiella pneumoniae, Haemophilus influenzae, or Streptococcus pneumoniae; complicated skin and skin-structure infections

Adults: 750 mg I.V. or P.O. q 24 hours for 7 to 14 days

➣ Acute bacterial sinusitis caused by S. pneumoniae, H. influenzae, or Moraxella catarrhalis

Adults: 500 mg I.V. or P.O. q 24 hours for 10 to 14 days or 750 mg P.O. or I.V. q 24 hours for 5 days

➣ Uncomplicated skin and skin-structure infections

Adults: 500 mg I.V. or P.O. q 24 hours for 7 to 10 days

➣ Complicated urinary tract infections; acute pyelonephritis caused by E. coli

Adults: 250 mg I.V. or P.O. q 24 hours for 10 days or 750 mg P.O. or I.V. q 24 hours for 5 days

➣ Uncomplicated urinary tract infections

Adults: 250 mg I.V. or P.O. q 24 hours for 3 days

➣ Chronic bacterial prostatitis

Adults: 500 mg I.V. or P.O. q 24 hours for 28 days.

➣ Conjunctivitis

Adults and children ages 1 and older: One or two drops of 0.5% ophthalmic solution into affected eye q 2 hours while awake on days 1 and 2 (up to eight times daily); then one or two drops q 4 hours while awake on days 3 through 7 (up to four times daily)

➣ Corneal ulcers

Adults and children ages 6 and older: On days 1 to 3, one or two drops of 1.5% ophthalmic solution instilled into affected eye(s) q 30 minutes to 1 hour while awake and q 4 to 6 hours after retiring; thereafter, one or two drops q 1 to 4 hours while awake until treatment completion

➣ Inhalational anthrax (postexposure)

Adults and children ages 6 months and older weighing more than 50 kg (110 lb): 500 mg P.O. or I.V. q 24 hours for 60 days

Children ages 6 months and older weighing less than 50 kg (110 lb): 8 mg/kg P.O. or I.V., not to exceed 250 mg/dose q 12 hours for 60 days

Dosage adjustment

• Renal impairment

Contraindications

• Hypersensitivity to drug, its components, or other quinolones

Precautions

Use cautiously in:

• bradycardia, acute myocardial ischemia, prolonged QTc interval, cirrhosis, renal impairment, underlying CNS disease, uncorrected hypocalcemia

• elderly patients

• pregnant or breastfeeding patients

• children younger than age 18 (except in ophthalmic use).

Administration

• Be aware that oral and I.V. dosages are identical.

• Give parenteral form by I.V. route only. Drug isn't for I.M., subcutaneous, intrathecal, or intraperitoneal use.

• To prepare I.V. infusion, use compatible solution, such as 0.9% sodium chloride injection, dextrose 5% and 0.9% sodium chloride injection, dextrose 5% in water, or dextrose 5% in lactated Ringer's solution.

• Infuse over 60 to 90 minutes, depending on dosage. Don't infuse with other drugs.

☞ Avoid rapid or bolus I.V. administration, because this may cause severe hypotension

• Flush I.V. line before and after infusion.

• Give oral doses 2 hours before or after sucralfate, iron, antacids containing magnesium or aluminum, or multivitamins with zinc.

• Give oral form without regard to food, but don't give with milk or yogurt alone.

• Be aware that the two ophthalmic preparations have different indications.

Adverse reactions

CNS: dizziness, headache, insomnia, seizures

CV: chest pain, palpitations, hypotension

EENT: photophobia, sinusitis, pharyngitis

GI: nausea, vomiting, diarrhea, constipation, abdominal pain, dyspepsia, flatulence, pseudomembranous colitis

GU: vaginitis

Hematologic: lymphocytopenia

Metabolic: hyperglycemia, hypoglycemia

Musculoskeletal: back pain, tendon rupture, tendinitis

Skin: photosensitivity

Other: altered taste, reaction and pain at I.V. site, hypersensitivity reactions including Stevens-Johnson syndrome

Interactions

Drug-drug. Antacids containing aluminum or magnesium, didanosine (tablets), iron salts, sucralfate, zinc salts: decreased levofloxacin absorption

Cimetidine: interference with levofloxacin elimination

Nonsteroidal anti-inflammatory drugs: increased risk of CNS stimulation and seizures

Drug-diagnostic tests. Glucose: increased or decreased level

Lymphocytes: decreased count

EEG: abnormal findings

Drug-food. Concurrent tube feedings, milk, yogurt: impaired levofloxacin absorption

Drug-herbs. Dong quai, St. John's wort: phototoxicity

Fennel: decreased levofloxacin absorption

Drug-behaviors. Sun exposure: phototoxicity

Patient monitoring

• Check vital signs, especially blood pressure. Too-rapid infusion can cause hypotension.

• Closely monitor patients with renal insufficiency.

• Monitor blood glucose level closely in diabetic patients.

☞ Assess for severe diarrhea, which may indicate pseudomembranous colitis.

☞ Watch for hypersensitivity reaction. Discontinue drug immediately if rash or other signs or symptoms occur.

☞ Watch for signs and symptoms of tendinitis or tendon rupture.

Patient teaching

☞ Tell patient to stop taking drug and contact prescriber if he experiences signs or symptoms of hypersensitivity reaction (rash, hives, or other skin reactions) or severe diarrhea (which may indicate pseudomembranous colitis).

☞ Instruct patient to stop taking drug and notify prescriber immediately if tendon pain, swelling, or inflammation occurs.

• Instruct patient not to take with milk, yogurt, multivitamins containing zinc or iron, or antacids containing aluminum or magnesium.

• Teach patient proper use of eye drops. Tell him to avoid touching applicator tip to eye, finger, or any other object.

• Caution patient to avoid driving and other activities that require mental alertness until CNS effects of drug are known.

• As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs, tests, foods, herbs, and behaviors mentioned above.

McGraw-Hill Nurse's Drug Handbook, 7th Ed. Copyright © 2013 by The McGraw-Hill Companies, Inc. All rights reserved

levofloxacin

(le-voe-flox-a-sin) ,

Levaquin

(trade name)

Classification

Therapeutic: anti infectives
Pharmacologic: fluoroquinolones
Pregnancy Category: C

Indications

Oral: Intravenous: Treatment of the following bacterial infections:
  • Urinary tract infections, including cystitis, pyelonephritis, and prostatitis,
  • Respiratory tract infections, including acute sinusitis, acute exacerbations of chronic bronchitis, community-acquired pneumonia, and nosocomial pneumonia,
  • Uncomplicated and complicated skin and skin structure infections.
Post-exposure treatment of inhalational anthrax.Treatment and prophylaxis of plague

Action

Inhibits bacterial DNA synthesis by inhibiting DNA gyrase enzyme.

Therapeutic effects

Death of susceptible bacteria.
Active against gram-positive pathogens, including:
  • Staphylococcus aureus,
  • Staphylococcus epidermidis,
  • Staphylococcus saprophyticus,
  • Streptococcus pyogenes,
  • Streptococcus pneumoniae,
  • Enterococcus faecalis,
  • Bacillus anthracis.
Gram-negative spectrum notable for activity against:
  • Escherichia coli,
  • Klebsiella pneumoniae,
  • Enterobacter cloacae,
  • Proteus mirabilis,
  • Pseudomonas aeruginosa,
  • Serratia marcescens,
  • Haemophilus influenzae,
  • Moraxella catarrhalis.
Additional spectrum includes:
  • Chlamydophylia pneumoniae,
  • Legionella pneumoniae,
  • Mycoplasma pneumoniae, and Yersinia pestis

Pharmacokinetics

Absorption: Well absorbed (99%) after oral administration; IV administration results in complete bioavailability.
Distribution: Widely distributed. High tissue and urinary levels are achieved. Appears to cross the placenta.
Protein Binding: 24–38%
Metabolism and Excretion: 87% excreted unchanged in urine, small amounts metabolized.
Half-life: 8 hr.

Time/action profile (blood levels)

ROUTEONSETPEAKDURATION
POrapid1–2 hr24 hr
IVrapidend of infusion24 hr

Contraindications/Precautions

Contraindicated in: Hypersensitivity (cross-sensitivity within class may exist); QTc interval prolongation; Uncorrected hypokalemia or hypomagnesemia; Concurrent use of Class IA antiarrhythmics (disopyramide, quinidine, procainamide) or Class III antiarrhythmics (amiodarone, sotalol) (↑risk of QTc interval prolongation and torsade de pointes); History of myasthenia gravis (may worsen symptoms including muscle weakness and breathing problems); Obstetric: Pregnancy. Lactation: Not recommended.
Use Cautiously in: Known or suspected CNS disorder; Renal impairment (dose ↓ recommended if CCr ≤50 mL/min); Cirrhosis; Concurrent use of corticosteroids (↑ risk of tendonitis/tendon rupture); Kidney, heart, or lung transplant patients (↑ risk of tendonitis/tendon rupture); Dialysis patients (↑ risk of adverse reactions); Geriatric: ↑ risk of adverse reactions; Pediatric: Children <18 yr [except for inhalational anthrax (post-exposure) and anthrax] (↑ risk of arthralgia, arthritis, tendinopathy, and gait disturbances);

Adverse Reactions/Side Effects

Central nervous system

  • elevated intracranial pressure (including pseudotumor cerebri) (life-threatening)
  • seizures (life-threatening)
  • agitation
  • anxiety
  • confusion
  • depression
  • dizziness
  • drowsiness
  • hallucinations
  • headache
  • insomnia
  • nightmares
  • paranoia
  • tremor

Cardiovascular

  • torsade de pointes (life-threatening)
  • QT interval prolongation

Gastrointestinal

  • hepatotoxicity (life-threatening)
  • pseudomembranous colitis (life-threatening)
  • nausea (most frequent)
  • abdominal pain
  • diarrhea
  • vomiting

Genitourinary

  • vaginitis

Dermatologic

  • stevens-johnson syndrome (life-threatening)
  • photosensitivity
  • rash

Endocrinologic

  • hyperglycemia
  • hypoglycemia

Local

  • phlebitis at IV site

Neurologic

  • peripheral neuropathy

Musculoskeletal

  • arthralgia
  • tendinitis
  • tendon rupture

Miscellaneous

  • hypersensitivity reactions including anaphylaxis (life-threatening)

Interactions

Drug-Drug interaction

Concurrent use of amiodarone, disopyramide, procainamide, quinidine, dofetilide, or sotalol ↑ risk of torsade de pointes in susceptible individuals (avoid concurrent use).↑ serum theophylline levels and may lead to toxicity.Administration withantacids, iron salts, bismuth subsalicylate, sucralfate, and zinc salts ↓ absorption.May ↑ the effects of warfarin.Serum levels may be ↓ by antineoplastic agents.Cimetidine may interfere with elimination.Probenecid ↓ renal elimination.May ↑ the risk of nephrotoxicity from cyclosporine.Concurrent therapy with corticosteroids may ↑ the risk of tendon rupture.Absorption is impaired by concurrent enteral feeding (because of metal cations).

Route/Dosage

Oral Intravenous (Adults) Most infections—250–750 mg q 24 hr; Inhalational anthrax (post-exposure)—500 mg daily for 60 days.
Oral Intravenous (Children >50 kg) Inhalational anthrax (post-exposure)—500 mg daily for 60 days; Plague—500 mg daily for 10–14 days
Oral Intravenous (Children <50 kg and ≥6 mo) Inhalational anthrax (post-exposure)–8 mg/kg (max: 250 mg/dose) every 12 hr for 60 days. Plague—8 mg/kg (max: 250 mg/dose) every 12 hr for 10–14 days; Other infections—10 mg/kg/dose every 24 hr (max: 500 mg/dose).

Renal Impairment

Oral Intravenous (Adults) Normal renal function dosing of 750 mg/day: CCr 20–49 mL/min—750 mg q 48 hr; CCr 10–19 mL/min—750 mg initially, then 500 mg q 48 hr; Normal renal function dosing of 500 mg/day: CCr 20–49 mL/min—500 mg initially then 250 mg q 24 hr; CCr 10–19 mL/min—500 mg initially then 250 mg q 48 hr. Normal renal function dosing of 250 mg/day: CCr 10–19 mL/min—250 mg q 48 hr.

Availability (generic available)

Tablets: 250 mg, 500 mg, 750 mg
Oral solution: 25 mg/mL
Solution for injection: 25 mg/mL
Premixed solution for injection: 250 mg/50 mL D5W, 500 mg/100 mL D5W, 750 mg/150 mL D5W

Nursing implications

Nursing assessment

  • Assess for infection (vital signs; appearance of wound, sputum, urine, and stool; WBC; urinalysis; frequency and urgency of urination; cloudy or foul-smelling urine) at beginning of and during therapy.
  • Obtain specimens for culture and sensitivity before initiating therapy. First dose may be given before receiving results.
  • Observe patient for signs and symptoms of anaphylaxis (rash, pruritus, laryngeal edema, wheezing). Discontinue drug and notify physician or other health care professional immediately if these problems occur. Keep epinephrine, an antihistamine, and resuscitation equipment close by in case of an anaphylactic reaction.
  • Monitor bowel function. Diarrhea, abdominal cramping, fever, and bloody stools should be reported to health care professional promptly as a sign of pseudomembranous colitis. May begin up to several weeks following cessation of therapy.
  • Assess for rash periodically during therapy. May cause Stevens-Johnson syndrome. Discontinue therapy if severe or if accompanied with fever, general malaise, fatigue, muscle or joint aches, blisters, oral lesions, conjunctivitis, hepatitis and/or eosinophilia.
  • Assess for signs and symptoms of peripheral neuropathy (pain, burning, tingling, numbness, and/or weakness or other alterations of sensation including light touch, pain, temperature, position sense, and vibratory sensation) periodically during therapy. Symptoms may be irreversible; discontinue levofloxacin if symptoms occur.
  • Lab Test Considerations: May cause ↑ serum AST, ALT, LDH, bilirubin, and alkaline phosphatase.
    • May also cause ↑ or ↓ serum glucose.

Potential Nursing Diagnoses

Risk for infection (Patient/Family Teaching)

Implementation

  • Do not confuse levofloxacin with levetiracetam.
  • Oral: May be administered without regard to meals. Products or foods containing calcium, magnesium, aluminum, iron, zinc should not be ingested for 4 hr before and 2 hr after administration.
  • Intravenous Administration
  • pH: 3.8–5.8.
  • Intermittent Infusion: Diluent: Dilute to a with 0.9% NaCl, D5W, D5/0.9% NaCl, D5/0.45% NaCl, or D5/LR. Concentration: 5 mg/mL. Also available in premixed bottles and flexible containers with D5W, which need no further dilution. Discard unused solution. Diluted solution is stable for 72 hr at room temperature and 14 days if refrigerated.
  • Rate: Administer by infusion over at least 60 min for 250–mg or 500–mg doses and over 90 min for 750–mg dose. Avoid rapid bolus injection to prevent hypotension.
  • Y-Site Compatibility: alemtuzumab, alfentanil, amifostine, amikacin, aminocaproic acid, aminophylline, ampicillin, ampicillin/sulbactam, anidulafungin, argatroban, atracurium, aztreonam, bivalirudin, bleomycin, bumetanide, buprenorphine, busulfan, butorphanol, caffeine citrate, calcium gluconate, carboplatin, carmustine, caspofungin, cefepime, cefotetan, ceftaroline, ceftazidime, ceftriaxone, cefuroxime, chlorpromazine, cisatracurium, cisplatin, clindamycin, cyclophosphamide, cyclosporine, cytarabine, dacarbazine, dactomycin, daptomycin, dexamethasone, dexmedetomidine, dexrazoxane, digoxin, diltiazem, diphenhydramine, dobutamine, docetaxel, dolasetron, dopamine, doripenem, doxacurium, doxycycline, droperidol, enalaprilat, ephedrine, epinephrine, epirubicin, eptifibatide, ertapenem, erythromycin, esmolol, etoposide, etoposide phosphate, famotidine, fenoldopam, fentanyl, filgrastim, floxuridine, fluconazole, fludarabine, foscarnet, fosphenytoin, gemcitabine, gentamicin, granisetron, haloperidol, hydrocortisone, hydromorphone, idarubicin, ifosfamide, imipenem/cilastatin, irinotecan, isoproterenol, labetalol, leucovorin, levorphanol, lidocaine, linezolid, mannitol, mechlorethamine, meperidine, mesna, methylprednisolone, metoclopramide, metronidazole, midazolam, milrinone, mitomycin, mitoxantrone, mivacurium, mycohpenolate, nalbuphine, naloxone, nesiritide, octreotide, ondansetron, oxacillin, oxaliplatin, oxytocin, paclitaxel, palonosetron, pamidronate, pancuronium, pemetrexed, penicillin G sodium, pentamidine, phenylephrine, plicamycin, potassium acetate, potassium chloride, promethazine, propranolol, quinapristin/dalfopristin, ranitidine, remifentanil, rocuronium, sargramostim, sodium acetate, sodium bicarbonate, succinylcholine, sufentanil, tacrolimus, teniposide, theophylline, thiotepa, ticarcillin/clavulanate, tigecycline, tirofiban, tobramycin, topotecan, trimethoprim/sulfamethoxazole, vancomycin, vasopressin, vecuronium, verapamil, vinblastine, vincristine, vinorelbine, voriconazole, zidovudine, zoledronic acid
  • Y-Site Incompatibility: acyclovir, alprostadil, amiodarone, amphotericin B colloidal, amphotericin B lipid complex, amphotericin B liposome, cefazolin, cefoperazone, cefoxitin, daunorubicin hydrochloride, diazepam, drotrecogin, fluorouracil, furosemide, ganciclovir, heparin, inamrinone, indomethacin, ketorolac, methotrexate, micafungin, nitroglycerin, nitroprusside, pantoprazole, pentobarbital, phenytoin, piperacillin/tazobactam, prochlorperazine, propofol, rituximab, streptozocin, telavancin, thiopental, trastuzumab

Patient/Family Teaching

  • Instruct patient to take medication as directed at evenly spaced times and to finish drug completely, even if feeling better. Take missed doses as soon as possible, unless almost time for next dose. Do not double doses. Advise patient that sharing of this medication may be dangerous.
  • Advise patients to notify health care professional immediately if they are taking theophylline.
  • Encourage patient to maintain a fluid intake of at least 1500–2000 mL/day to prevent crystalluria.
  • Advise patient that antacids or medications containing calcium, magnesium, aluminum, iron, or zinc will decrease absorption and should not be taken within 4 hr before and 2 hr after taking this medication.
  • May cause dizziness and drowsiness. Caution patient to avoid driving or other activities requiring alertness until response to medication is known.
  • Advise patient to notify health care professional of any personal or family history of QTc prolongation or proarrhythmic conditions such as recent hypokalemia, significant bradycardia, or recent myocardial ischemia or if fainting spells or palpitations occur. Patients with this history should not receive levofloxacin.
  • Advise patient to stop taking levofloxacin and notify health care professional immediately if signs and symptoms of peripheral neuropathy occur.
  • Caution patient to use sunscreen and protective clothing to prevent phototoxicity reactions during and for 5 days after therapy. Notify health care professional if a sunburn-like reaction or skin eruption occurs.
  • Advise patient to report signs of superinfection (furry overgrowth on the tongue, vaginal itching or discharge, loose or foul-smelling stools).
  • Advise patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and to consult with health care professional before taking other medications.
  • Instruct patient to notify health care professional if fever and diarrhea develop, especially if stool contains blood, pus, or mucus. Advise patient not to treat diarrhea without consulting health care professional.
  • Instruct patient to notify health care professional immediately if rash, jaundice, signs of hypersensitivity, or tendon (shoulder, hand, Achilles, and other) pain, swelling, or inflammation occur. If tendon symptoms occur, avoid exercise and use of the affected area. Increased risk in >65 yr old, kidney, heart and lung transplant recipients, and patients taking corticosteroids concurrently. Therapy should be discontinued.

Evaluation/Desired Outcomes

  • Resolution of the signs and symptoms of bacterial infection. Time for complete resolution depends on organism and site of infection.
  • Avoidance of signs and symptoms of inhalational anthrax (postexposure treatment).
  • Prevention and treatment of plague.
Drug Guide, © 2015 Farlex and Partners

Levaquin

(lĕv′ə-kwĭn′)
A trademark for the drug levofloxacin.
The American Heritage® Medical Dictionary Copyright © 2007, 2004 by Houghton Mifflin Company. Published by Houghton Mifflin Company. All rights reserved.

Levaquin®

Levofloxacin, see there.
McGraw-Hill Concise Dictionary of Modern Medicine. © 2002 by The McGraw-Hill Companies, Inc.

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