FULL PRESCRIBING INFORMATION
WARNING:
Fluoroquinolones, including Levofloxacin, are associated with an increased risk of tendinitis and tendon rupture in all ages. This risk is further increased in older patients usually over 60 years of age, in patients taking corticosteroid drugs, and in patients with kidney, heart or lung transplants [see WARNINGS AND PRECAUTIONS (5.1)].
Fluoroquinolones, including Levofloxacin, may exacerbate muscle weakness in persons with myasthenia gravis. Avoid Levofloxacin in patients with a known history of myasthenia gravis [see WARNINGS AND PRECAUTIONS (5.2)].
Indications and Usage for Levofloxacin
To reduce the development of drug-resistant bacteria and maintain the effectiveness of Levofloxacin and other antibacterial drugs, Levofloxacin should be used only to treat or prevent infections that are proven or strongly suspected to be caused by susceptible bacteria. When culture and susceptibility information are available, they should be considered in selecting or modifying antibacterial therapy. In the absence of such data, local epidemiology and susceptibility patterns may contribute to the empiric selection of therapy.
Levofloxacin injection is indicated for the treatment of adults (≥ 18 years of age) with mild, moderate, and severe infections caused by susceptible strains of the designated microorganisms in the conditions listed in this section. Levofloxacin injection is indicated when intravenous administration offers a route of administration advantageous to the patient (e.g., patient cannot tolerate an oral dosage form).
Culture and susceptibility testing
Appropriate culture and susceptibility tests should be performed before treatment in order to isolate and identify organisms causing the infection and to determine their susceptibility to Levofloxacin [see CLINICAL PHARMACOLOGY (12.4)]. Therapy with Levofloxacin may be initiated before results of these tests are known; once results become available, appropriate therapy should be selected.
As with other drugs in this class, some strains of Pseudomonas aeruginosa may develop resistance fairly rapidly during treatment with Levofloxacin. Culture and susceptibility testing performed periodically during therapy will provide information about the continued susceptibility of the pathogens to the antimicrobial agent and also the possible emergence of bacterial resistance.
Nosocomial Pneumonia
Levofloxacin is indicated for the treatment of nosocomial pneumonia due to methicillin-susceptible Staphylococcus aureus, Pseudomonas aeruginosa, Serratia marcescens, Escherichia coli, Klebsiella pneumoniae, Haemophilus influenzae, or Streptococcus pneumoniae. Adjunctive therapy should be used as clinically indicated. Where Pseudomonas aeruginosa is a documented or presumptive pathogen, combination therapy with an anti-pseudomonal b-lactam is recommended [see CLINICAL STUDIES (14.1)].
Community-Acquired Pneumonia: 7–14 day Treatment Regimen
Levofloxacin is indicated for the treatment of community-acquired pneumonia due to methicillin-susceptible Staphylococcus aureus, Streptococcus pneumoniae (including multi-drug-resistant Streptococcus pneumoniae [MDRSP]), Haemophilus influenzae, Haemophilus parainfluenzae, Klebsiella pneumoniae, Moraxella catarrhalis, Chlamydophila pneumoniae, Legionella pneumophila, or Mycoplasma pneumoniae [see DOSAGE AND ADMINISTRATION (2.1); CLINICAL STUDIES (14.2)].
MDRSP isolates are strains resistant to two or more of the following antibacterials: penicillin (MIC ≥ 2 mcg/mL), 2nd generation cephalosporins, e.g., cefuroxime, macrolides, tetracyclines and trimethoprim/sulfamethoxazole.
Community-Acquired Pneumonia: 5-day Treatment Regimen
Levofloxacin is indicated for the treatment of community-acquired pneumonia due to Streptococcus pneumoniae (excluding multi-drug-resistant strains [MDRSP]), Haemophilus influenzae, Haemophilus parainfluenzae, Mycoplasma pneumoniae, or Chlamydophila pneumoniae [see DOSAGE AND ADMINISTRATION (2.1); CLINICAL STUDIES (14.3)].
Acute Bacterial Sinusitis: 5-day and 10–14 day Treatment Regimens
Levofloxacin is indicated for the treatment of acute bacterial sinusitis due to Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis [see CLINICAL STUDIES (14.4)].
Acute Bacterial Exacerbation of Chronic Bronchitis
Levofloxacin is indicated for the treatment of acute bacterial exacerbation of chronic bronchitis due to methicillin‑susceptible Staphylococcus aureus, Streptococcus pneumoniae, Haemophilus influenzae, Haemophilus parainfluenzae, or Moraxella catarrhalis.
Complicated Skin and Skin Structure Infections
Levofloxacin is indicated for the treatment of complicated skin and skin structure infections due to methicillin‑susceptible Staphylococcus aureus, Enterococcus faecalis, Streptococcus pyogenes, or Proteus mirabilis [see CLINICAL STUDIES (14.5)].
Uncomplicated Skin and Skin Structure Infections
Levofloxacin is indicated for the treatment of uncomplicated skin and skin structure infections (mild to moderate) including abscesses, cellulitis, furuncles, impetigo, pyoderma, wound infections, due to methicillin-susceptible Staphylococcus aureus, or Streptococcus pyogenes.
Chronic Bacterial Prostatitis
Levofloxacin is indicated for the treatment of chronic bacterial prostatitis due to Escherichia coli, Enterococcus faecalis, or methicillin-susceptible Staphylococcus epidermidis [see CLINICAL STUDIES (14.6)].
Complicated Urinary Tract Infections: 5-day Treatment Regimen
Levofloxacin is indicated for the treatment of complicated urinary tract infections due to Escherichia coli, Klebsiella pneumoniae, or Proteus mirabilis [see CLINICAL STUDIES (14.7)].
Complicated Urinary Tract Infections: 10-day Treatment Regimen
Levofloxacin is indicated for the treatment of complicated urinary tract infections (mild to moderate) due to Enterococcus faecalis, Enterobacter cloacae, Escherichia coli, Klebsiella pneumoniae, Proteus mirabilis, or Pseudomonas aeruginosa [see CLINICAL STUDIES (14.8)].
Acute Pyelonephritis: 5 or 10-day Treatment Regimen
Levofloxacin is indicated for the treatment of acute pyelonephritis caused by Escherichia coli, including cases with concurrent bacteremia [see CLINICAL STUDIES (14.7, 14.8)].
Uncomplicated Urinary Tract Infections
Levofloxacin is indicated for the treatment of uncomplicated urinary tract infections (mild to moderate) due to Escherichia coli, Klebsiella pneumoniae, or Staphylococcus saprophyticus.
Inhalational Anthrax (Post-Exposure)
Levofloxacin is indicated for inhalational anthrax (post-exposure) to reduce the incidence or progression of disease following exposure to aerosolized Bacillus anthracis. The effectiveness of Levofloxacin is based on plasma concentrations achieved in humans, a surrogate endpoint reasonably likely to predict clinical benefit. Levofloxacin has not been tested in humans for the post-exposure prevention of inhalation anthrax. The safety of Levofloxacin in adults for durations of therapy beyond 28 days or in pediatric patients for durations of therapy beyond 14 days has not been studied. Prolonged Levofloxacin therapy should only be used when the benefit outweighs the risk [see DOSAGE AND ADMINISTRATION (2.1, 2.2);CLINICAL STUDIES (14.9)].
Levofloxacin Dosage and Administration
Dosage in Adult Patients with Normal Renal Function
The usual dose of Levofloxacin injection is 250 mg or 500 mg administered by slow infusion over 60 minutes every 24 hours or 750 mg administered by slow infusion over 90 minutes every 24 hours, as indicated by infection and described in Table 1.
These recommendations apply to patients with creatinine clearance ≥ 50 mL/min. For patients with creatinine clearance < 50 mL/min, adjustments to the dosing regimen are required [see DOSAGE AND ADMINISTRATION (2.3)].
Table 1: Dosage in Adult Patients with Normal Renal Function (creatinine clearance ≥ 50 mL/min) | ||
Type of Infection1 | Dosed Every 24 hours | Duration |
Nosocomial Pneumonia | 750 mg | 7–14 |
Community Acquired Pneumonia3 | 500 mg | 7–14 |
Community Acquired Pneumonia4 | 750 mg | 5 |
Acute Bacterial Sinusitis | 750 mg | 5 |
500 mg | 10–14 | |
Acute Bacterial Exacerbation of Chronic Bronchitis | 500 mg | 7 |
Complicated Skin and Skin Structure Infections (SSSI) | 750 mg | 7–14 |
Uncomplicated SSSI | 500 mg | 7–10 |
Chronic Bacterial Prostatitis | 500 mg | 28 |
Complicated Urinary Tract Infection (cUTI) or Acute Pyelonephritis (AP)5 | 750 mg | 5 |
Complicated Urinary Tract Infection (cUTI) or Acute Pyelonephritis (AP)6 | 250 mg | 10 |
Uncomplicated Urinary Tract Infection | 250 mg | 3 |
Inhalational Anthrax (Post-Exposure), adult and pediatric patients > 50 kg and ≥ 6 months of age 7,8 Pediatric patients < 50 kg and ≥ 6 months of age 7,8 | 500 mg see Table 2 below (2.2) | 608 608 |
1 Due to the designated pathogens [see INDICATIONS AND USAGE (1)].
2 Sequential therapy (intravenous to oral) may be instituted at the discretion of the physician.
3 Due to methicillin-susceptible Staphylococcus aureus, Streptococcus pneumoniae (including multi-drug‑resistant strains [MDRSP]), Haemophilus influenzae, Haemophilus parainfluenzae, Klebsiella pneumoniae, Moraxella catarrhalis, Chlamydophila pneumoniae, Legionella pneumophila, or Mycoplasma pneumoniae [see INDICATIONS AND USAGE (1.2)].
4 Due to Streptococcus pneumoniae (excluding multi-drug-resistant strains [MDRSP]), Haemophilus influenzae, Haemophilus parainfluenzae, Mycoplasma pneumoniae, or Chlamydophila pneumoniae [see INDICATIONS AND USAGE (1.3 )].
5 This regimen is indicated for cUTI due to Escherichia coli, Klebsiella pneumoniae, Proteus mirabilis and AP due to E. coli, including cases with concurrent bacteremia.
6 This regimen is indicated for cUTI due to Enterococcus faecalis, Enterococcus cloacae, Escherichia coli, Klebsiella pneumoniae, Proteus mirabilis, Pseudomonas aeruginosa; and for AP due to E. coli.
7 Drug administration should begin as soon as possible after suspected or confirmed exposure to aerosolized B. anthracis. This indication is based on a surrogate endpoint. Levofloxacin plasma concentrations achieved in humans are reasonably likely to predict clinical benefit [see CLINICAL STUDIES (14.9)].
8 The safety of Levofloxacin in adults for durations of therapy beyond 28 days or in pediatric patients for durations beyond 14 days has not been studied. An increased incidence of musculoskeletal adverse events compared to controls has been observed in pediatric patients [see WARNINGS AND PRECAUTIONS (5.10); USE IN SPECIFIC POPULATIONS (8.4); CLINICAL STUDIES (14.9)] Prolonged Levofloxacin therapy should only be used when the benefit outweighs the risk.
Dosage in Pediatric Patients
The dosage in pediatric patients ≥ 6 months of age is described below in Table 2.
Table 2: Dosage in Pediatric Patients ≥ 6 months of age | |||
Type of Infection 1 | Dose | Freq. Once Every | Duration2 |
Inhalational Anthrax (post-exposure)3,4 | |||
Pediatric patients > 50 kg and ≥ 6 months of age | 500 mg | 24 hr | 60 days4 |
Pediatric patients < 50 kg and ≥ 6 months of age | 8 mg/kg (not to exceed 250 mg per dose) | 12 hr | 60 days4 |
1 Due to Bacillus anthracis [see INDICATIONS AND USAGE (1.13)]
2 Sequential therapy (intravenous to oral) may be instituted at the discretion of the physician.
3 Drug administration should begin as soon as possible after suspected or confirmed exposure to aerosolized B. anthracis. This indication is based on a surrogate endpoint. Levofloxacin plasma concentrations achieved in humans are reasonably likely to predict clinical benefit [see CLINICAL STUDIES (14.9)]
4 The safety of Levofloxacin in pediatric patients for durations of therapy beyond 14 has not been studied. An increased incidence of musculoskeletal adverse events compared to controls has been observed in pediatric patients [see WARNINGS AND PRECAUTIONS (5.10); USE IN SPECIFIC POPULATIONS (8.4); CLINICAL STUDIES (14.9).] Prolonged Levofloxacin therapy should only be used when the benefit outweighs the risk.
Dosage Adjustment in Adults with Renal Impairment
Administer Levofloxacin with caution in the presence of renal insufficiency. Careful clinical observation and appropriate laboratory studies should be performed prior to and during therapy since elimination of Levofloxacin may be reduced.
No adjustment is necessary for patients with a creatinine clearance ≥ 50 mL/min.
In patients with impaired renal function (creatinine clearance < 50 mL/min), adjustment of the dosage regimen is necessary to avoid the accumulation of Levofloxacin due to decreased clearance[see USE IN SPECIFIC POPULATIONS (8.6)].
Table 3 shows how to adjust dose based on creatinine clearance.
Table 3: Dosage Adjustment in Adult Patients with Renal Impairment (creatinine clearance < 50 mL/min) | |||
Dosage in Normal Renal Function | Creatinine Clearance | Creatinine Clearance | Hemodialysis or Chronic Ambulatory Peritoneal Dialysis (CAPD) |
750 mg | 750 mg every 48 hours | 750 mg initial dose, then 500 mg every 48 hours | 750 mg initial dose, then 500 mg every 48 hours |
500 mg | 500 mg initial dose, then 250 mg every 24 hours | 500 mg initial dose, then 250 mg every 48 hours | 500 mg initial dose, then 250 mg every 48 hours |
250 mg | No dosage adjustment required | 250 mg every 48 hours. If treating uncomplicated UTI, then no dosage adjustment is required | No information on dosing adjustment is available |
Drug Interaction with Chelation Agents: Antacids, Sucralfate, Metal Cations, Multivitamins Levofloxacin Injection
Levofloxacin injection should not be co-administered with any solution containing multivalent cations, e.g., magnesium, through the same intravenous line[see DOSAGE AND ADMINISTRATION (2.6)].
Administration Instructions
Levofloxacin Injection
Caution: Rapid or bolus intravenous infusion of Levofloxacin has been associated with hypotension and must be avoided. Levofloxacin injection should be infused intravenously slowly over a period of not less than 60 or 90 minutes, depending on the dosage. Levofloxacin injection should be administered only by intravenous infusion. It is not for intramuscular, intrathecal, intraperitoneal, or subcutaneous administration.
Hydration for Patients Receiving Levofloxacin Injection
Adequate hydration of patients receiving intravenous Levofloxacin should be maintained to prevent the formation of highly concentrated urine. Crystalluria and cylindruria have been reported with quinolones [see ADVERSE REACTIONS (6.1);PATIENT COUNSELING INFORMATION (17.2)].
Preparation of Intravenous Product
Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration, whenever solution and container permit.
Because only limited data are available on the compatibility of Levofloxacin injection with other intravenous substances, additives or other medications should not be added to Levofloxacin Injection Premix in Single Dose Flexible Containers, or infused simultaneously through the same intravenous line. If the same intravenous line is used for sequential infusion of several different drugs, the line should be flushed before and after infusion of Levofloxacin injection with an infusion solution compatible with Levofloxacin injection and with any other drug(s) administered via this common line.
Levofloxacin Injection Premix in Single Dose Flexible Containers (5 mg/mL)
Levofloxacin injection is supplied in flexible containers within a foil overwrap. These contain a premixed, ready to use Levofloxacin solution in 5% dextrose (D5W) for single dose. The 50 mL premixed flexible containers contain 250 mg/50 mL, the 100 mL premixed flexible containers contain 500 mg/100 mL, and the 200 mL premixed flexible containers contain 750 mg/150 mL of Levofloxacin solution. The concentration of each container is 5 mg/mL. No further dilution of these preparations is necessary. Because the premix flexible containers are for single dose only, any unused portion should be discarded.
Instructions for the Use of Levofloxacin Injection Premix in Flexible Containers:
1. Tear outer wrap at the notch and remove solution container.
2. Check the container for minute leaks by squeezing the inner bag firmly. If leaks are found, or if the seal is not intact, discard the solution, as the sterility may be compromised.
3. Do not use if the solution is cloudy or a precipitate is present.
4. Use sterile equipment.
5. WARNING: Do not use flexible containers in series connections. Such use could result in air embolism due to residual air being drawn from the primary container before administration of the fluid from the secondary container is complete.
Preparation for Administration:
1. Close flow control clamp of administration set.
2. Remove cover from port at bottom of container.
3. Insert piercing pin of administration set into port with a twisting motion until the pin is firmly seated. NOTE: See full directions on administration set carton.
4. Suspend container from hanger.
5. Squeeze and release drip chamber to establish proper fluid level in chamber during infusion of Levofloxacin Injection Premix in Flexible Containers.
6. Open flow control clamp to expel air from set. Close clamp.
7. Regulate rate of administration with flow control clamp.
Dosage Forms and Strengths
INJECTION (5 mg/mL in 5% Dextrose) Premix in Single Dose Flexible Containers, for intravenous infusion
• 50 mL container, fill volume 50 mL (equivalent to 250 mg Levofloxacin)
• 100 mL container, fill volume 100 mL (equivalent to 500 mg Levofloxacin)
• 200 mL container, fill volume 150 mL (equivalent to 750 mg Levofloxacin)
Contraindications
Levofloxacin is contraindicated in persons with known hypersensitivity to Levofloxacin, or other quinolone antibacterials[see WARNINGS AND PRECAUTIONS (5.3)].
Warnings and Precautions
Tendinopathy and Tendon Rupture
Fluoroquinolones, including Levofloxacin, are associated with an increased risk of tendinitis and tendon rupture in all ages. This adverse reaction most frequently involves the Achilles tendon, and rupture of the Achilles tendon may require surgical repair. Tendinitis and tendon rupture in the rotator cuff (the shoulder), the hand, the biceps, the thumb, and other tendon sites have also been reported. The risk of developing fluoroquinolone-associated tendinitis and tendon rupture is further increased in older patients usually over 60 years of age, in those taking corticosteroid drugs, and in patients with kidney, heart or lung transplants. Factors, in addition to age and corticosteroid use, that may independently increase the risk of tendon rupture include strenuous physical activity, renal failure, and previous tendon disorders such as rheumatoid arthritis. Tendinitis and tendon rupture have been reported in patients taking fluoroquinolones who do not have the above risk factors. Tendon rupture can occur during or after completion of therapy; cases occurring up to several months after completion of therapy have been reported. Levofloxacin should be discontinued if the patient experiences pain, swelling, inflammation or rupture of a tendon. Patients should be advised to rest at the first sign of tendinitis or tendon rupture, and to contact their healthcare provider regarding changing to a non-quinolone antimicrobial drug [seeADVERSE REACTIONS (6.3);PATIENT COUNSELING INFORMATION (17.3)].
Exacerbation of Myasthenia Gravis
Fluoroquinolones, including Levofloxacin, have neuromuscular blocking activity and may exacerbate muscle weakness in persons with myasthenia gravis. Postmarketing serious adverse events, including deaths and requirement for ventilatory support, have been associated with fluoroquinolone use in persons with myasthenia gravis. Avoid Levofloxacin in patients with a known history of myasthenia gravis [see ADVERSE REACTIONS (6.3); PATIENT COUNSELING INFORMATION (17.3)].
Hypersensitivity Reactions
Serious and occasionally fatal hypersensitivity and/or anaphylactic reactions have been reported in patients receiving therapy with fluoroquinolones, including Levofloxacin. These reactions often occur following the first dose. Some reactions have been accompanied by cardiovascular collapse, hypotension/shock, seizure, loss of consciousness, tingling, angioedema (including tongue, laryngeal, throat, or facial edema/swelling), airway obstruction (including bronchospasm, shortness of breath, and acute respiratory distress), dyspnea, urticaria, itching, and other serious skin reactions. Levofloxacin should be discontinued immediately at the first appearance of a skin rash or any other sign of hypersensitivity. Serious acute hypersensitivity reactions may require treatment with epinephrine and other resuscitative measures, including oxygen, intravenous fluids, antihistamines,corticosteroids, pressor amines, and airway management, as clinically indicated[see ADVERSE REACTIONS (6); PATIENT COUNSELING INFORMATION (17.3)].
Other Serious and Sometimes Fatal Reactions
Other serious and sometimes fatal events, some due to hypersensitivity, and some due to uncertain etiology, have been reported rarely in patients receiving therapy with fluoroquinolones, including Levofloxacin. These events may be severe and generally occur following the administration of multiple doses. Clinical manifestations may include one or more of the following:
• fever, rash, or severe dermatologic reactions (e.g., toxic epidermal necrolysis, Stevens-Johnson Syndrome);
• vasculitis; arthralgia; myalgia; serum sickness;
• allergic pneumonitis;
• interstitial nephritis; acute renal insufficiency or failure;
• hepatitis; jaundice; acute hepatic necrosis or failure;
• anemia, including hemolytic and aplastic; thrombocytopenia, including thrombotic thrombocytopenic purpura; leukopenia; agranulocytosis; pancytopenia; and/or other hematologic abnormalities.
The drug should be discontinued immediately at the first appearance of skin rash, jaundice, or any other sign of hypersensitivity and supportive measures instituted [see ADVERSE REACTIONS (6); PATIENT COUNSELING INFORMATION (17.3)].
Hepatotoxicity
Post-marketing reports of severe hepatotoxicity (including acute hepatitis and fatal events) have been received for patients treated with Levofloxacin. No evidence of serious drug-associated hepatotoxicity was detected in clinical trials of over 7,000 patients. Severe hepatotoxicity generally occurred within 14 days of initiation of therapy and most cases occurred within 6 days. Most cases of severe hepatotoxicity were not associated with hypersensitivity [see WARNINGS AND PRECAUTIONS (5.4)]. The majority of fatal hepatotoxicity reports occurred in patients 65 years of age or older and most were not associated with hypersensitivity. Levofloxacin should be discontinued immediately if the patient develops signs and symptoms of hepatitis [see ADVERSE REACTIONS (6);PATIENT COUNSELING INFORMATION (17.3)].
Central Nervous System Effects
Convulsions, toxic psychoses, increased intracranial pressure (including pseudotumor cerebri) have been reported in patients receiving fluoroquinolones, including Levofloxacin. Fluoroquinolones may also cause central nervous system stimulation which may lead to tremors, restlessness, anxiety, lightheadedness, confusion, hallucinations, paranoia, depression, nightmares, insomnia, and, rarely, suicidal thoughts or acts. These reactions may occur following the first dose. If these reactions occur in patients receiving Levofloxacin, the drug should be discontinued and appropriate measures instituted. As with other fluoroquinolones, Levofloxacin should be used with caution in patients with a known or suspected central nervous system (CNS) disorder that may predispose them to seizures or lower the seizure threshold (e.g., severe cerebral arteriosclerosis, epilepsy) or in the presence of other risk factors that may predispose them to seizures or lower the seizure threshold (e.g., certain drug therapy, renal dysfunction) [see ADVERSE REACTIONS (6); DRUG INTERACTIONS (7.4, 7.5); PATIENT COUNSELING INFORMATION (17.3)].
Clostridium difficile-Associated Diarrhea
Clostridium difficile-associated diarrhea (CDAD) has been reported with use of nearly all antibacterial agents, including Levofloxacin, and may range in severity from mild diarrhea to fatal colitis. Treatment with antibacterial agents alters the normal flora of the colon leading to overgrowth of C. difficile.
C. difficile produces toxins A and B which contribute to the development of CDAD. Hypertoxin producing strains of C. difficile cause increased morbidity and mortality, as these infections can be refractory to antimicrobial therapy and may require colectomy. CDAD must be considered in all patients who present with diarrhea following antibiotic use. Careful medical history is necessary since CDAD has been reported to occur over two months after the administration of antibacterial agents.
If CDAD is suspected or confirmed, ongoing antibiotic use not directed against C. difficile may need to be discontinued. Appropriate fluid and electrolyte management, protein supplementation, antibiotic treatment of C. difficile, and surgical evaluation should be instituted as clinically indicated [see ADVERSE REACTIONS (6.2); PATIENT COUNSELING INFORMATION (17.3)].
Peripheral Neuropathy
Rare cases of sensory or sensorimotor axonal polyneuropathy affecting small and/or large axons resulting in paresthesias, hypoesthesias, dysesthesias and weakness have been reported in patients receiving fluoroquinolones, including Levofloxacin. Levofloxacin should be discontinued if the patient experiences symptoms of neuropathy including pain, burning, tingling, numbness, and/or weakness or other alterations of sensation including light touch, pain, temperature, position sense, and vibratory sensation in order to prevent the development of an irreversible condition [see ADVERSE REACTIONS (6); PATIENT COUNSELING INFORMATION (17.3)].
Prolongation of the QT Interval
Some fluoroquinolones, including Levofloxacin, have been associated with prolongation of the QT interval on the electrocardiogram and infrequent cases of arrhythmia. Rare cases of torsade de pointes have been spontaneously reported during postmarketing surveillance in patients receiving fluoroquinolones, including Levofloxacin. Levofloxacin should be avoided in patients with known prolongation of the QT interval, patients with uncorrected hypokalemia, and patients receiving Class IA (quinidine, procainamide), or Class III (amiodarone, sotalol) antiarrhythmic agents. Elderly patients may be more susceptible to drug-associated effects on the QT interval [see ADVERSE REACTIONS (6.3); USE IN SPECIFIC POPULATIONS (8.5); PATIENT COUNSELING INFORMATION (17.3)].
Musculoskeletal Disorders in Pediatric Patients and Arthropathic Effects in Animals
Levofloxacin is indicated in pediatric patients (≥ 6 months of age) only for the prevention of inhalational anthrax (post‑exposure) [see INDICATIONS AND USAGE (1.13)]. An increased incidence of musculoskeletal disorders (arthralgia, arthritis, tendinopathy, and gait abnormality) compared to controls has been observed in pediatric patients receiving Levofloxacin[see USE IN SPECIFIC POPULATIONS (8.4)].
In immature rats and dogs, the oral and intravenous administration of Levofloxacin resulted in increased osteochondrosis. Histopathological examination of the weight-bearing joints of immature dogs dosed with Levofloxacin revealed persistent lesions of the cartilage. Other fluoroquinolones also produce similar erosions in the weight-bearing joints and other signs of arthropathy in immature animals of various species [see Animal Toxicology and/or Pharmacology (13.2)].
Blood Glucose Disturbances
As with other fluoroquinolones, disturbances of blood glucose, including symptomatic hyper- and hypoglycemia, have been reported with Levofloxacin, usually in diabetic patients receiving concomitant treatment with an oral hypoglycemic agent (e.g., glyburide) or with insulin. In these patients, careful monitoring of blood glucose is recommended. If a hypoglycemic reaction occurs in a patient being treated with Levofloxacin, Levofloxacin should be discontinued and appropriate therapy should be initiated immediately [see ADVERSE REACTIONS (6.2); DRUG INTERACTIONS (7.3); PATIENT COUNSELING INFORMATION (17.4)].
Photosensitivity/Phototoxicity
Moderate to severe photosensitivity/phototoxicity reactions, the latter of which may manifest as exaggerated sunburn reactions (e.g., burning, erythema, exudation, vesicles, blistering, edema) involving areas exposed to light (typically the face, “V” area of the neck, extensor surfaces of the forearms, dorsa of the hands), can be associated with the use of fluoroquinolones after sun or UV light exposure. Therefore, excessive exposure to these sources of light should be avoided. Drug therapy should be discontinued if photosensitivity/phototoxicity occurs [see ADVERSE REACTIONS (6.3); PATIENT COUNSELING INFORMATION (17.3)].
Development of Drug Resistant Bacteria
Prescribing Levofloxacin in the absence of a proven or strongly suspected bacterial infection or a prophylactic indication is unlikely to provide benefit to the patient and increases the risk of the development of drug‑resistant bacteria [see PATIENT COUNSELING INFORMATION (17.1)].
Adverse Reactions
Serious and Otherwise Important Adverse Reactions
The following serious and otherwise important adverse drug reactions are discussed in greater detail in other sections of labeling:
• Tendon Effects [see WARNINGS AND PRECAUTIONS (5.1)]
• Exacerbation of Myasthenia Gravis [see WARNINGS AND PRECAUTIONS (5.2)]
• Hypersensitivity Reactions [see WARNINGS AND PRECAUTIONS (5.3)]
• Other Serious and Sometimes Fatal Reactions [see WARNINGS AND PRECAUTIONS (5.4)]
• Hepatotoxicity [see WARNINGS AND PRECAUTIONS (5.5)]
• Central Nervous System Effects [see WARNINGS AND PRECAUTIONS (5.6)]
• Clostridium difficile-Associated Diarrhea [see WARNINGS AND PRECAUTIONS (5.7)]
• Peripheral Neuropathy [see WARNINGS AND PRECAUTIONS (5.8)]
• Prolongation of the QT Interval [see WARNINGS AND PRECAUTIONS (5.9)]
• Musculoskeletal Disorders in Pediatric Patients [see WARNINGS AND PRECAUTIONS (5.10)]
• Blood Glucose Disturbances [see WARNINGS AND PRECAUTIONS (5.11)]
• Photosensitivity/Phototoxicity [see WARNINGS AND PRECAUTIONS (5.12)]
• Development of Drug Resistant Bacteria [see WARNINGS AND PRECAUTIONS (5.13)]
Hypotension has been associated with rapid or bolus intravenous infusion of Levofloxacin. Levofloxacin should be infused slowly over 60 to 90 minutes, depending on dosage [see DOSAGE AND ADMINISTRATION (2.5)].
Crystalluria and cylindruria have been reported with quinolones, including Levofloxacin. Therefore, adequate hydration of patients receiving Levofloxacin should be maintained to prevent the formation of a highly concentrated urine [see DOSAGE AND ADMINISTRATION (2.5)].
Clinical Trial Experience
Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.
The data described below reflect exposure to Levofloxacin in 7537 patients in 29 pooled Phase 3 clinical trials. The population studied had a mean age of 50 years (approximately 74% of the population was < 65 years of age), 50% were male, 71% were Caucasian, 19% were Black. Patients were treated with Levofloxacin for a wide variety of infectious diseases [see INDICATIONS AND USAGE (1)]. Patients received Levofloxacin doses of 750 mg once daily, 250 mg once daily, or 500 mg once or twice daily. Treatment duration was usually 3–14 days, and the mean number of days on therapy was 10 days.
The overall incidence, type and distribution of adverse reactions was similar in patients receiving Levofloxacin doses of 750 mg once daily, 250 mg once daily, and 500 mg once or twice daily. Discontinuation of Levofloxacin due to adverse drug reactions occurred in 4.3% of patients overall, 3.8% of patients treated with the 250 mg and 500 mg doses and 5.4% of patients treated with the 750 mg dose. The most common adverse drug reactions leading to discontinuation with the 250 and 500 mg doses were gastrointestinal (1.4%), primarily nausea (0.6%); vomiting (0.4%); dizziness (0.3%); and headache (0.2%). The most common adverse drug reactions leading to discontinuation with the 750 mg dose were gastrointestinal (1.2%), primarily nausea (0.6%), vomiting (0.5%); dizziness (0.3%); and headache (0.3%).
Adverse reactions occurring in ≥ 1% of Levofloxacin-treated patients and less common adverse reactions, occurring in 0.1 to < 1% of Levofloxacin-treated patients, are shown in Table 4 and Table 5, respectively. The most common adverse drug reactions (≥ 3%) are nausea, headache, diarrhea, insomnia, constipation, and dizziness.
Table 4: Common (≥ 1%) Adverse Reactions Reported in Clinical Trials with Levofloxacin | ||
System/Organ Class | Adverse Reaction | % |
Infections and Infestations | moniliasis | 1 |
Psychiatric Disorders | insomniaa[see WARNINGS AND PRECAUTIONS (5.6)] | 4 |
Nervous System Disorders | headache | 6 |
Respiratory, Thoracic and Mediastinal Disorders | dyspnea [see WARNINGS AND PRECAUTIONS (5.3)] | 1 |
Gastrointestinal Disorders | nausea | 7 |
Skin and Subcutaneous Tissue Disorders | rash [see WARNINGS AND PRECAUTIONS (5.3)] | 2 |
Reproductive System and Breast Disorders | vaginitis | 1b |
General Disorders and Administration Site Conditions | edema | 1 |
a N = 7274
b N = 3758 (women)
Table 5: Less Common (0.1 to 1%) Adverse Reactions Reported in Clinical Trials with Levofloxacin (N = 7537) | |
System/Organ Class | Adverse Reaction |
Infections and Infestations | genital moniliasis |
Blood and Lymphatic System Disorders | anemia |
Immune System Disorders | allergic reaction [see WARNINGS AND PRECAUTIONS (5.3, 5.4)] |
Metabolism and Nutrition Disorders | hyperglycemia |
Psychiatric Disorders | anxiety |
Nervous System Disorders | tremor |
Respiratory, Thoracic and Mediastinal Disorders | epistaxis |
Cardiac Disorders | cardiac arrest |
Vascular Disorders | phlebitis |
Gastrointestinal Disorders | gastritis |
Hepatobiliary Disorders | abnormal hepatic function |
Skin and Subcutaneous Tissue Disorders | urticaria [see WARNINGS AND PRECAUTIONS (5.3)] |
Musculoskeletal and Connective Tissue Disorders | arthralgia |
Renal and Urinary Disorders | abnormal renal function |
a N = 7274
In clinical trials using multiple-dose therapy, ophthalmologic abnormalities, including cataracts and multiple punctate lenticular opacities, have been noted in patients undergoing treatment with quinolones, including Levofloxacin. The relationship of the drugs to these events is not presently established.
Postmarketing Experience
Table 6 lists adverse reactions that have been identified during post-approval use of Levofloxacin. Because these reactions are reported voluntarily from a population of uncertain size, reliably estimating their frequency or establishing a causal relationship to drug exposure is not always possible.
Table 6: Postmarketing Reports Of Adverse Drug Reactions | |
System/Organ Class | Adverse Reaction |
Blood and Lymphatic System Disorders | pancytopenia |
Immune System Disorders | hypersensitivity reactions, sometimes fatal including: |
Psychiatric Disorders | psychosis |
Nervous System Disorders | exacerbation of myasthenia gravis [see WARNINGS AND PRECAUTIONS (5.2)] pseudotumor cerebri [see WARNINGS AND PRECAUTIONS (5.6)] |
Eye Disorders | vision disturbance, including diplopia |
Ear and Labyrinth Disorders | hypoacusis |
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