Sudden cardiac death (SCD) accounts for 1 in every 3 deaths among patients receiving hemodialysis (HD), according to the US Renal Data System. Now a new study finds that their underlying risk for SCD increases even more when a fluoroquinolone rather than an amoxicillin-based antibiotic is used to treat respiratory infections.

In an analysis of 264,968 Medicare beneficiaries receiving in-center maintenance HD, 626,322 antibiotic treatment episodes occurred, of which 251,726 (40.2%) involved respiratory fluoroquinolone treatment and 374,596 (59.8%) involved amoxicillin-based treatment.

Respiratory fluoroquinolone was significantly associated with a 2-fold higher risk of SCD within 5 days of treatment compared with amoxicillin, Jennifer E. Flythe, MD, MPH, of the University of North Carolina Kidney Center in Chapel Hill, North Carolina, and colleagues reported in JAMA Surgery. The absolute risk was 1 additional SCD event during a 5-day follow-up period for every 2273 respiratory fluoroquinolone treatments. Respiratory fluoroquinolone use also was significantly associated with a 1.9-fold increased risk for a composite of SCD or hospitalization for ventricular arrhythmia and 1.9- and 2.2-fold increased risks for cardiovascular mortality and all-cause death, respectively, within 5 days. Increased risks for all outcomes were also found at 7, 10, and 14 days.

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Fluoroquinolone antibiotics such as levofloxacin and amoxifloxacin are among the most common medications with QT interval-prolonging potential prescribed to patients on HD, the investigators noted. Nearly 20% of respiratory fluoroquinolone treatments in their study were concomitant with use of other medications with known torsade de pointes risk. The researchers emphasized that clinicians need to perform a thorough medication review and consider pharmacodynamic drug interactions before prescribing new drug therapies for any condition.

“Respiratory fluoroquinolones should still be prescribed to patients receiving hemodialysis when an amoxicillin-based antibiotic would be suboptimal,” Dr Flythe’s team stated. “When prescribing respiratory fluoroquinolones, clinicians should consider electrocardiographic monitoring before and during therapy, especially among high-risk individuals.”

Disclosure: Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.


Assimon MM, Pun PH, Chin-Hua Wang L, et al. Analysis of respiratory fluoroquinolones and the risk of sudden cardiac death among patients receiving hemodialysis. JAMA Cardiol. Published online October 20, 2021. doi:10.1001/jamacardio.2021.4234