Third-generation fluoroquinolone
Brand names: Tavanic, Levaquin, Levofloxacino Cinfa, Levofloxacino Normon
Updated · Methodology
Second line
Second-line for community-acquired pneumonia. Dose 500–750 mg once daily for 5–7 days. /ATS 2019 and SEPAR 2024 set high-dose amoxicillin or amoxicillin + macrolide as first-line outpatient CAP. Levofloxacin is used in penicillin allergy, severe disease with resistant pneumococcus risk, or comorbidities (COPD, diabetes).
Sources
ICD-10: J18.9 · ICD-11: CA40.Z
Second line
Second-line for acute pyelonephritis per EAU 2024 and 2010. Dose 500–750 mg once daily for 5–7 days. Not used in uncomplicated cystitis in non-pregnant women – first-line is fosfomycin or nitrofurantoin ( 2019 restriction).
Sources
ICD-10: N39.0 · ICD-11: GC08
Second line
Used in severe COPD exacerbation with Pseudomonas aeruginosa risk (severe COPD with bronchiectasis, frequent antibiotic courses) per 2024 and GesEPOC 2021. Dose 500 mg once daily for 5–7 days.
Sources
ICD-10: J44.1 · ICD-11: CA22.0
The drug is promoted for these uses outside international guidelines. Each entry below is analyzed against AEMPS, FDA, EMA, Cochrane and major RCTs.
Not recommended
Levofloxacin is prescribed for bronchitis, upper respiratory infections and presumed pneumonia without radiographic confirmation. 2024 AWaRe and 2019 confine fluoroquinolones to serious infections. The 2018 PRAC and boxed warning curtailed routine use due to tendinopathy, peripheral neuropathy and aortic aneurysm risk. Use in viral infections is not indicated.
Sources
ICD-10: J00 · ICD-11: CA00
An L-isomer of ofloxacin with 2× higher activity. Inhibits bacterial topoisomerase II (DNA gyrase) and topoisomerase IV. Spectrum covers gram-negatives (E. coli, Klebsiella, Pseudomonas aeruginosa, Haemophilus influenzae), gram-positives (Streptococcus pneumoniae including penicillin-resistant, methicillin-susceptible Staphylococcus aureus), and atypical pathogens (Mycoplasma, Chlamydia, Legionella). in 2019 substantially restricted fluoroquinolone indications due to severe adverse effects.
Boxed warning
FDA boxed warning: tendinitis, tendon rupture, peripheral neuropathy, psychiatric disorders; myasthenia gravis exacerbation; raised aortic aneurysm and dissection risk. Use only when alternatives are unavailable.
Contraindicated. β-lactams, macrolides, or cephalosporins are preferred in pregnant patients with severe infection.
Contraindicated during lactation.
Reference information, not a clinical decision. Discuss feeding pauses or changes with your physician or an IBCLC.
2 pairs found. Sorted from critical to minor.
Mechanism
Levofloxacin is a fluoroquinolone, and its SmPC devotes a section to caution in patients already taking QT-prolonging drugs. The citalopram SmPC lists ongoing treatment with any drug capable of prolonging the QT interval among its contraindications, with no exceptions.
Symptoms
QTc prolongation on ECG, palpitations, dizziness, syncope. The end point is polymorphic ventricular tachycardia of the torsade type progressing to ventricular fibrillation. The risk is higher with hypokalaemia, hypomagnesaemia, bradycardia, decompensated heart failure and in women.
Management
The pair sits in the citalopram SmPC contraindications, so the question is which drug stays, not how far to cut the dose. The fluoroquinolone label says caution, the SSRI label says contraindication, and the stricter document sets the severity. For a community infection the antibiotic is picked outside this group.
Sources
Mechanism
Both can lengthen the QT interval and the effect adds up. The atomoxetine label asks for caution in patients with congenital or acquired long QT and with a family history. The levofloxacin label warns that fluoroquinolones should be used with caution where QT prolongation risk factors exist, and explicitly mentions concomitant use of QT-prolonging medicines.
Symptoms
Palpitations, dizziness, a feeling of impending faint or syncope. The serious long-QT arrhythmia, torsade de pointes, can present directly with loss of consciousness. Hypokalaemia and hypomagnesaemia, common with vomiting or diarrhoea, increase the risk.
Management
For a common infection, an antibiotic without QT effect avoids the problem; levofloxacin is reserved for when there is no alternative. If the pair is necessary, correct potassium and magnesium before starting and consider an ECG in patients with heart disease, a family history of sudden death or other QT-prolonging drugs.
Sources
Verbatim lines from the interaction sections, in the language of the label
«Tendinitis y rotura de tendones: A la primera señal de tendinitis (por ejemplo, hinchazón dolorosa, inflamación), se debe interrumpir el tratamiento con levofloxacino y se debe considerar un…»AEMPS, section 4.4 · Open on CIMA
«Chelation Agents: Antacids, Sucralfate, Metal Cations, Multivitamins: While the chelation by divalent cations is less marked than with other fluoroquinolones, concurrent administration of…»FDA, section 7 · Open on DailyMed
«Medicamentos con capacidad de prolongar el intervalo QT: Levofloxacino, así como otras fluoroquinolonas, se deben usar con precaución en pacientes que estén recibiendo otros medicamentos que…»AEMPS, section 4.5 · Open on CIMA
«Antagonistas de la vitamina K: Se han notificado incrementos en las pruebas de coagulación (PT/AEMPS, section 4.5 · Open on CIMA
«Medicamentos con capacidad de prolongar el intervalo QT: Levofloxacino, así como otras fluoroquinolonas, se deben usar con precaución en pacientes que estén recibiendo otros medicamentos que…»AEMPS, section 4.5 · Open on CIMA
«DRUG INTERACTIONS: Antidiabetic agents Carefully monitor blood glucose ( 5.13 , 7.3 )»FDA, section 7 · Open on DailyMed
«Medicamentos con capacidad de prolongar el intervalo QT: Levofloxacino, así como otras fluoroquinolonas, se deben usar con precaución en pacientes que estén recibiendo otros medicamentos que…»AEMPS, section 4.5 · Open on CIMA
«Medicamentos con capacidad de prolongar el intervalo QT: Levofloxacino, así como otras fluoroquinolonas, se deben usar con precaución en pacientes que estén recibiendo otros medicamentos que…»AEMPS, section 4.5 · Open on CIMA
«Pacientes con predisposición convulsiva: Las quinolonas pueden disminuir el umbral epiléptico y pueden desencadenar convulsiones. Levofloxacino está contraindicado en pacientes con antecedentes de…»AEMPS, section 4.4 · Open on CIMA
«Antagonistas de la vitamina K: Se han notificado incrementos en las pruebas de coagulación (PT/AEMPS, section 4.5 · Open on CIMA
«DRUG INTERACTIONS: Warfarin Effect may be enhanced. Monitor prothrombin time, INR and watch for bleeding ( 7.2 )»FDA, section 7 · Open on DailyMed
«Teofilina, fenbufeno o medicamentos antiinflamatorios no esteroideos similares: No se hallaron interacciones farmacocinéticas entre levofloxacino y teofilina en ningún ensayo clínico. Sin embargo, se…»AEMPS, section 4.5 · Open on CIMA
«Sales de hierro, sales de zinc, antiácidos que contienen magnesio o aluminio, didanosina»AEMPS, section 4.5 · Open on CIMA
«Ciclosporina: La vida media de ciclosporina se incrementó en un 33%, cuando se administró conjuntamente con levofloxacino.»AEMPS, section 4.5 · Open on CIMA
«Otra información relevante: Estudios de farmacología clínica han demostrado que la farmacocinética de levofloxacino no se vió afectada en ningún grado clínicamente relevante cuando se administraba…»AEMPS, section 4.5 · Open on CIMA
«Digoxin: No significant effect of levofloxacin on the peak plasma concentrations, AUC, and other disposition parameters for digoxin was detected in a clinical study involving healthy volunteers…»FDA, section 7 · Open on DailyMed
«Otra información relevante: Estudios de farmacología clínica han demostrado que la farmacocinética de levofloxacino no se vió afectada en ningún grado clínicamente relevante cuando se administraba…»AEMPS, section 4.5 · Open on CIMA
«Theophylline: No significant effect of levofloxacin on the plasma concentrations, AUC, and other disposition parameters for theophylline was detected in a clinical study involving healthy volunteers…»FDA, section 7 · Open on DailyMed
«La administración conjunta de hidroxizina con fármacos que se sabe que prolongan el intervalo QT y/AEMPS, section 4.5 · Open on CIMA
«Medicamentos asociados con prolongación del intervalo QT: Azitromicina se debe usar con precaución en pacientes que reciben medicamentos que se sabe que prolongan el intervalo QT (ver sección 4.4)…»AEMPS, section 4.5 · Open on CIMA
«Está contraindicado el uso concomitante de las siguientes sustancias: ciertos antibióticos (p. ej., eritromicina, levofloxacino, moxifloxacino, espiramicina)»AEMPS, section 4.5 · Open on CIMA
«Ciertos antibióticos (p. ej., claritromicina, eritromicina, levofloxacino, moxifloxacino)»AEMPS, section 4.5 · Open on CIMA
«Efectos cardiovasculares: Determinados antibióticos (p. ej., azitromicina, claritromicina, eritromicina, levofloxacino, moxifloxacino, telitromicina).»AEMPS, section 4.5 · Open on CIMA
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Levofloxacin is evaluated for the following indications with varying evidence strength: Community-acquired pneumonia (evidence tier A), Urinary tract infection (evidence tier A), COPD exacerbation (evidence tier B). See the full indication matrix with dosing and citations above on this page.
Common side effects of Levofloxacin (≥ 1 in 100): Nausea and diarrhea, Headache, Dizziness, Insomnia, Candidiasis, QT prolongation. See the Safety section for uncommon and serious reactions.
Contraindicated. β-lactams, macrolides, or cephalosporins are preferred in pregnant patients with severe infection.
Contraindicated during lactation.
Levofloxacin is contraindicated in: Hypersensitivity to levofloxacin or fluoroquinolones; Age under 18 (rare exceptions – inhalation anthrax); Pregnancy and lactation; Epilepsy; Prior tendinitis or tendon rupture with fluoroquinolones. Full list in the Safety section.
FDA boxed warning: tendinitis, tendon rupture, peripheral neuropathy, psychiatric disorders; myasthenia gravis exacerbation; raised aortic aneurysm and dissection risk. Use only when alternatives are unavailable.
Direct links to regulator labels. Open in a new tab.
Linezolid, Meropenem, Metronidazole, Moxifloxacin, Norfloxacin, Cefalexin, Ciprofloxacin, Doxycycline