Fourth-generation fluoroquinolone
Brand names: Avelox, Octegra, Vigamox
Updated · Methodology
Second line
Second-line for community-acquired pneumonia in patients with β-lactam allergy or at risk of resistant pneumococcus. /ATS 2019 and SEPAR 2024 set high-dose amoxicillin or amoxicillin + macrolide as first-line outpatient CAP. Moxifloxacin (400 mg once daily for 5 days) is used in allergy or first-line intolerance, or with risk of resistant Streptococcus pneumoniae.
Sources
ICD-10: J18.9 · ICD-11: CA40.Z
Second line
In severe bacterial COPD exacerbation in patients at Pseudomonas aeruginosa risk or after first-line failure (amoxicillin/clavulanate, cefuroxime). GesEPOC 2021 considers moxifloxacin an alternative with Anthonisen criteria and first-line failure or intolerance. Dose 400 mg once daily for 5 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
Moxifloxacin is prescribed for upper respiratory infections, influenza and atypical persistent cough without bacterial confirmation. 2024 AWaRe and 2019 confine fluoroquinolones to serious infections without alternatives. The 2018 PRAC and Drug Safety Communication 2018 additionally cited QT prolongation and aortic aneurysm risk. Use in viral infections is irrational.
Sources
ICD-10: J00 · ICD-11: CA00
Inhibits bacterial topoisomerase II (DNA gyrase) and topoisomerase IV, disrupting DNA supercoiling and replication. Spectrum broader than ciprofloxacin: covers Streptococcus pneumoniae (including penicillin-resistant strains), atypical pathogens (Mycoplasma, Chlamydia, Legionella), and anaerobes. Does not reach adequate urinary concentrations – not used in UTI. In 2019 substantially restricted fluoroquinolone indications due to severe adverse effects (tendinitis, aortic aneurysm, peripheral neuropathy).
Boxed warning
FDA boxed warning: tendinitis, tendon rupture, peripheral neuropathy, psychiatric disorders; myasthenia gravis exacerbation; increased aortic aneurysm and dissection risk. Use only when alternatives are unavailable for infections where benefit is justified.
Contraindicated in pregnancy. In pregnant patients with severe infection, β-lactams, macrolides, or cephalosporins are preferred.
Contraindicated during lactation – high milk concentrations.
Reference information, not a clinical decision. Discuss feeding pauses or changes with your physician or an IBCLC.
7 pairs found. Sorted from critical to minor.
Mechanism
Moxifloxacin is named outright in both SSRI labels. Its own SmPC forbids concomitant use with other QT-prolonging drugs and quotes the measured QTc increase of about 6 ms. 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. Moxifloxacin is the most cardiac of the fluoroquinolones, and respiratory infections have replacements outside that group. This pair is resolved on the antibiotic side.
Sources
Mechanism
Moxifloxacin is named outright in both SSRI labels. Its own SmPC forbids concomitant use with other QT-prolonging drugs and quotes the measured QTc increase of about 6 ms. The escitalopram SmPC contraindicates any QT-prolonging drug alongside it: the ban is written broadly, and the classes in brackets are examples.
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 escitalopram SmPC contraindications, so the question is which drug stays, not how far to cut the dose. Moxifloxacin is the most cardiac of the fluoroquinolones, and respiratory infections have replacements outside that group. This pair is resolved on the antibiotic side.
Sources
Mechanism
Both drugs prolong the QT interval on the electrocardiogram. The haloperidol SmPC reports QT prolongation, ventricular arrhythmias and sudden death; the risk is higher with high doses, high plasma levels and parenteral use, especially intravenous. Moxifloxacin prolongs QT more as its concentration rises, and its SmPC does not exclude an additive effect with other QT-prolonging drugs (moxifloxacin SmPC). Together they raise the risk of torsades de pointes.
Symptoms
QT prolongation on the electrocardiogram (ECG) causes no symptoms by itself. Palpitations, dizziness or fainting may occur. The dangerous complication is torsades de pointes, a ventricular tachycardia that can lead to cardiac arrest (moxifloxacin SmPC). The risk is higher in women and older people, with low potassium or magnesium, marked bradycardia or heart disease (moxifloxacin and haloperidol SmPCs).
Management
Both Spanish SmPCs contraindicate this combination. The haloperidol SmPC contraindicates haloperidol with drugs that prolong the QT interval and names moxifloxacin, and the moxifloxacin SmPC contraindicates moxifloxacin with antipsychotics and names haloperidol. The moxifloxacin label approved by the US Food and Drug Administration () advises avoiding it with antipsychotics (moxifloxacin FDA label). The haloperidol SmPC also contraindicates other antibiotics from the same groups: levofloxacin, azithromycin, clarithromycin, erythromycin. Before haloperidol is started, an electrocardiogram (ECG) is recorded and low potassium and magnesium are corrected; if the corrected QT interval (QTc) lengthens, the haloperidol dose is reduced, and haloperidol is stopped if QTc exceeds 500 ms (haloperidol SmPC). If signs of arrhythmia appear on moxifloxacin, it is stopped and an ECG is recorded; the recommended dose is not exceeded (moxifloxacin SmPC).
Sources
Mechanism
Dual QT prolongation. Torsades de pointes.
Symptoms
QTc above 500 ms, syncope, torsades de pointes risk.
Management
Combination contraindicated.
Sources
Mechanism
Dual QT prolongation (ziprasidone 15-20 ms + moxifloxacin 10-20 ms). Torsades de pointes.
Symptoms
QTc above 500 ms, syncope, torsades de pointes risk.
Management
Combination contraindicated.
Sources
Mechanism
Additive QT prolongation.
Symptoms
QTc above 500 ms, syncope, torsades de pointes risk.
Management
Alternative – levofloxacin.
Mechanism
Methadone prolongs QT (especially above 80 mg/day). Moxifloxacin adds 10-20 ms. Torsades de pointes risk.
Symptoms
QTc above 500 ms, syncope, torsades de pointes risk.
Management
Alternative – levofloxacin or other class.
Sources
Verbatim lines from the interaction sections, in the language of the label
«Interacciones con otros medicamentos: antisicóticos (p. ej., fenotiacinas, pimocida, sertindol, haloperidol, sultoprida),»AEMPS, section 4.5 · Open on CIMA
«Interacciones con otros medicamentos: antiarrítmicos de la clase clase III (p. ej., amiodarona, sotalol, dofetilida, ibutilida),»AEMPS, section 4.5 · Open on CIMA
«Inflamación de tendones, rotura de tendones: Ante el primer signo de tendinitis (p. ej., tumefacción dolorosa, inflamación), se debe interrumpir el tratamiento con moxifloxacino y se debe considerar…»AEMPS, section 4.4 · Open on CIMA
«Interacciones con otros medicamentos: Se debe utilizar moxifloxacino con precaución en pacientes que están tomando medicación que puede reducir los niveles de potasio (p. ej., diuréticos de asa y…»AEMPS, section 4.5 · Open on CIMA
«Cambios en el INR: En pacientes tratados con agentes antibacterianos, especialmente fluoroquinolonas, macrólidos, tetraciclinas, cotrimoxazol, y algunas cefalosporinas, se han descrito numerosos…»AEMPS, section 4.5 · Open on CIMA
«Disglucemia: Al igual que con todas las fluoroquinolonas, se han reportado alteraciones en la glucosa sanguínea, incluyendo tanto hipoglucemia e hiperglucemia con moxifloxacino (ver sección 4.8). En…»AEMPS, section 4.4 · Open on CIMA
«Interacciones con otros medicamentos: Se debe utilizar moxifloxacino con precaución en pacientes que están tomando medicación que puede reducir los niveles de potasio (p. ej., diuréticos de asa y…»AEMPS, section 4.5 · Open on CIMA
«Disglucemia: Al igual que con todas las fluoroquinolonas, se han reportado alteraciones en la glucosa sanguínea, incluyendo tanto hipoglucemia e hiperglucemia con moxifloxacino (ver sección 4.8). En…»AEMPS, section 4.4 · Open on CIMA
«Disglucemia: Al igual que con todas las fluoroquinolonas, se han reportado alteraciones en la glucosa sanguínea, incluyendo tanto hipoglucemia e hiperglucemia con moxifloxacino (ver sección 4.8). En…»AEMPS, section 4.4 · Open on CIMA
«Interacciones con otros medicamentos: Se debe utilizar moxifloxacino con precaución en pacientes que están tomando medicación que puede reducir los niveles de potasio (p. ej., diuréticos de asa y…»AEMPS, section 4.5 · Open on CIMA
«Disglucemia: Al igual que con todas las fluoroquinolonas, se han reportado alteraciones en la glucosa sanguínea, incluyendo tanto hipoglucemia e hiperglucemia con moxifloxacino (ver sección 4.8). En…»AEMPS, section 4.4 · Open on CIMA
«Interacciones con otros medicamentos: Se debe utilizar moxifloxacino con precaución en pacientes que están tomando medicación que puede reducir los niveles de potasio (p. ej., diuréticos de asa y…»AEMPS, section 4.5 · Open on CIMA
«Interacciones con otros medicamentos: antiarrítmicos de la clase clase III (p. ej., amiodarona, sotalol, dofetilida, ibutilida),»AEMPS, section 4.5 · Open on CIMA
«Interacciones con otros medicamentos: Se debe esperar alrededor de 6 horas entre la administración de agentes con cationes bivalentes o trivalentes (p. ej., antiácidos con magnesio o aluminio…»AEMPS, section 4.5 · Open on CIMA
«Interacciones con otros medicamentos: antiarrítmicos de la clase IA (p. ej., quinidina, hidroquinidina, disopiramida),»AEMPS, section 4.5 · Open on CIMA
«Cambios en el INR: Los ensayos clínicos han demostrado que no hay interacciones con la administración concomitante entre moxifloxacino y: ranitidina, probenecid, anticonceptivos orales, suplementos…»AEMPS, section 4.5 · Open on CIMA
«Interacciones con otros medicamentos: antidepresivos tricíclicos,»AEMPS, section 4.5 · Open on CIMA
«Interacciones con otros medicamentos: determinados antihistamínicos (terfenadina, astemizol, mizolastina),»AEMPS, section 4.5 · Open on CIMA
«Cambios en el INR: Los ensayos clínicos han demostrado que no hay interacciones con la administración concomitante entre moxifloxacino y: ranitidina, probenecid, anticonceptivos orales, suplementos…»AEMPS, section 4.5 · Open on CIMA
«Interacciones con otros medicamentos: otros (cisaprida, vincamina IV, bepridil, difemanilo).»AEMPS, section 4.5 · Open on CIMA
«Medicamentos que prolongan el intervalo QT: Debe evitarse el uso concomitante de amiodarona con fluoroquinolonas (el uso concomitante con moxifloxacino está contraindicado). Se han comunicado casos…»AEMPS, section 4.5 · Open on CIMA
«Prolongación del intervalo QT: No se han realizado estudios farmacocinéticos y farmacodinámicos con citalopram y otros medicamentos que prolonguen el intervalo QT. No se puede excluir que exista un…»AEMPS, section 4.5 · Open on CIMA
«Prolongación del intervalo QT: No se han realizado estudios farmacocinéticos ni farmacodinámicos con escitalopram combinado con otros medicamentos que prolonguen el intervalo QT. No se puede excluir…»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
«La administración conjunta de hidroxizina con fármacos que se sabe que prolongan el intervalo QT y/AEMPS, section 4.5 · Open on CIMA
«DRUG INTERACTIONS: Because pimozide prolongs the QT interval of the electrocardiogram, an additive effect on QT interval would be anticipated if administered with other drugs, such as phenothiazines…»FDA, section 7 · Open on DailyMed
«Tratamiento concomitante con medicamentos que prolonguen el intervalo QT como antiarrítmicos de Clase IA y III, trióxido de arsénico, halofantrina, acetato de levometadilo, mesoridazina, tioridazina…»AEMPS, section 4.3 · Open on CIMA
«CONTRAINDICATIONS: dofetilide, sotalol, quinidine, other Class Ia and III anti-arrhythmics, mesoridazine, thioridazine, chlorpromazine, droperidol, pimozide, sparfloxacin, gatifloxacin, moxifloxacin…»FDA, section 4 · Open on DailyMed
«Uso con medicamentos que prolongan el intervalo QT: Debido a que el tratamiento de deprivación de andrógenos puede prolongar el intervalo QT, se recomienda precaución cuando se administre abiraterona…»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
«Sustancias que pueden desencadenar torsades de pointes: - otros: bepridil, cisaprida, difemanil, eritromicina i.v., halofantrina, mizolastina, pentamidina, esparfloxacino, moxifloxacino, vincamina…»AEMPS, section 4.5 · Open on CIMA
«Potential for Other Drugs to Affect Clozapine: Use caution when administering concomitant medications that prolong the QT interval or inhibit the metabolism of clozapine. Drugs that cause QT…»FDA, section 7 · Open on DailyMed
«Prolongación del intervalo QT : No se han realizado estudios farmacocinéticos ni farmacodinámicos entre fluoxetina y otros medicamentos que prolongan el intervalo QT. Un efecto aditivo de fluoxetina…»AEMPS, section 4.5 · Open on CIMA
«Drugs that Prolong the QT Interval: Do not use fluoxetine in combination with thioridazine or pimozide. Use fluoxetine with caution in combination with other drugs that cause QT prolongation. These…»FDA, section 7 · Open on DailyMed
«Medicamentos que ocasionan “torsades de pointes”, pero sin limitarse a: otros fármacos: (ej. bepridil, cisaprida, difemanil, eritromicina IV, halofantrina, mizolastina, pentamidina, esparfloxacino…»AEMPS, section 4.5 · Open on CIMA
«Metadona y prolongación del intérvalo QT: El riesgo de metadona de prolongar el intervalo QT puede verse aumentado cuando se administra con medicamentos que producen alteraciones electrolíticas y con…»AEMPS, section 4.5 · Open on CIMA
«Dado que la bradicardia constituye un factor de riesgo en la aparición de torsades de pointes, se debe observar con precaución e incluso puede requerirse una monitorización clínica (ECG), si se…»AEMPS, section 4.5 · Open on CIMA
«Síndrome serotoninérgico/AEMPS, section 4.4 · Open on CIMA
«Salbutamol (u otros agonistas beta2): Existe un riesgo potencial de prolongación del intervalo QT cuando atomoxetina se administra con otros medicamentos que prolongan el intervalo QT (como…»AEMPS, section 4.5 · Open on CIMA
«Se debe valorar cuidadosamente el uso concomitante de Eftoran con medicamentos que prolongan el intervalo QT o medicamentos capaces de inducir Torsade des Pointes, tales como antiarrítmicos de clase…»AEMPS, section 4.5 · Open on CIMA
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Moxifloxacin is evaluated for the following indications with varying evidence strength: Community-acquired pneumonia (evidence tier A), COPD exacerbation (evidence tier B), Common cold (evidence tier F). See the full indication matrix with dosing and citations above on this page.
Common side effects of Moxifloxacin (≥ 1 in 100): Nausea and diarrhea, Headache, Dizziness, Insomnia, Candidiasis, QT prolongation. See the Safety section for uncommon and serious reactions.
Contraindicated in pregnancy. In pregnant patients with severe infection, β-lactams, macrolides, or cephalosporins are preferred.
Contraindicated during lactation – high milk concentrations.
Moxifloxacin is contraindicated in: Hypersensitivity to moxifloxacin or fluoroquinolones; Age under 18; Pregnancy and lactation; QT prolongation, congenital long QT syndrome; Uncontrolled bradycardia and hypokalemia. Full list in the Safety section.
FDA boxed warning: tendinitis, tendon rupture, peripheral neuropathy, psychiatric disorders; myasthenia gravis exacerbation; increased aortic aneurysm and dissection risk. Use only when alternatives are unavailable for infections where benefit is justified.
Direct links to regulator labels. Open in a new tab.
Norfloxacin, Trimethoprim, Amoxicillin + Clavulanic Acid, Amoxicillin, Azithromycin, Chloramphenicol, Daptomycin, Gentamicin