Health care providers commonly prescribe fluoroquinolones at higher than recommended doses to patients with advanced chronic kidney disease (CKD), increasing their risk for serious adverse events, according to a recent study.

Using a 2008-2020 database of Ontario residents with universal health care coverage, investigators identified 11,917 adults aged 66 years and older with an estimated glomerular filtration rate (eGFR) of less than 30 mL/min/ 1.73 m2 (not receiving dialysis or transplant) who were newly prescribed a fluoroquinolone. Of these, 5482 (46.0%) received higher-than-recommended doses of a fluoroquinolone in CKD, defined as ciprofloxacin 501-1000 mg/d; levofloxacin 501-750 mg/d; or norfloxacin 401-800 mg/d. The other 6435 patients (54.0%) received a lower dose, defined as ciprofloxacin 500 mg/d; levofloxacin 250-500 mg/d; or norfloxacin 400 mg/d.

The primary composite outcome was the 14-day risk of a hospital visit with nervous system and/or psychiatric disorders, hypoglycemia, or collagen-associated events (eg, Achilles tendon rupture or abdominal aortic aneurysm rupture). In a weighted analysis, the primary composite outcome occurred in a higher proportion of the group prescribed a higher vs lower dose of a fluoroquinolone: 1.2% vs 0.9%, Flory Tsobo Muanda, MD, PhD, of ICES Western, Victoria Hospital, in London, Ontario, Canada and colleagues reported in JAMA Network Open. Higher-dose fluoroquinolone recipients had a significant 45% increased risk for the composite outcome. The absolute risk of experiencing one of the adverse events was low, however. For every 256 patients with advanced CKD prescribed a higher- vs lower-dose fluoroquinolone, the investigators estimated that 1 hospitalization with a serious adverse event occurred.

Continue Reading

The risk of sepsis, retinal detachment, hospitalization, all-cause mortality, and sudden cardiac death did not differ significantly between CKD groups prescribed a fluoroquinolone at higher vs lower doses.

“The findings of this cohort study suggest that fluoroquinolones should be prescribed cautiously and at lower doses among older adults with advanced CKD,” Dr Muanda’s team wrote. “All patients should be advised to watch for signs of altered mental status with fluoroquinolone use.”

The investigators noted that fluoroquinolones (except for moxifloxacin) are mostly excreted by the kidney, which slows in patients with reduced kidney function.


Tsobo Muanda F, Sood MM, Weir MA, et al. Association of higher-dose fluoroquinolone therapy with serious adverse events in older adults with advanced chronic kidney disease. JAMA Network Open. Published online August 2, 2022. doi:10.1001/jamanetworkopen.2022.24892