Clinical Inquiries

Is there much risk in using fluoroquinolones in children?

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EVIDENCE-BASED ANSWER

No, the risks seem to be minimal. Arthralgias and myalgias have been observed clinically in children and adolescents exposed to fluoroquinolones, but they’re transient, disappear when the drug is discontinued, and appear to be no more prevalent than with other antibiotics (strength of recommendation [SOR]: B, 1 structured review and 2 prospective cohort studies). No apparent long-term risk of developmental skeletal growth delay is associated with fluoroquinolone exposure (SOR: B, 1 prospective controlled study). Fluoroquinolone use in children isn’t associated with tendonopathy (SOR: B, 1 prospective controlled study), but it probably carries a very low risk of tendon rupture (SOR: C, extrapolation from a national passive postmarketing monitoring system study predominantly in adults).

Clinical commentary

Be Judicious
Stefan M. Groetsch, MD
Naval Branch Health Clinic, Atsugi, Japan

Just because you can do something doesn’t mean you should. It’s reassuring that quinolones can be given to pediatric patients if necessary inasmuch as the drugs don’t appear to cause long-term skeletal side effects, and the infrequent arthralgias and myalgias they produce seem to be transient and benign. However, in an era of increasing microbial drug resistance and escalating pharmaceutical costs, we should strive for rational prescribing and reserve quinolones for patients who truly need them.

Evidence summary

Few short-term joint complaints, no long-term skeletal harm

A 1997 database review compiled reports of skeletally immature patients ranging in age from 4 days to 26 years who were exposed to quinolones.1 Thirty-one reports met search term criteria, for a total of 7045 patients. No incidences of quinolone-associated arthralgia were documented in 30 reports (>5000 patients). The review didn’t report the incidence of tendonopathy. One report of 1795 pediatric patients documented a small incidence of arthralgias (~1.5%), which was considered to be reversible and no more than expected for a comparable quinolone-naïve population.

Follow-up data on safety and adverse findings, from as long as 12 years after treatment, were reported for 530 (28%) of the 7045 patients. Changes in skeletal growth were evaluated using various diagnostic techniques. Clinical observation was the most common method of assessment (N=357), however. The follow-up data revealed no arthropathy or abnormal skeletal growth (rate=0%; estimated 95% confidence interval [CI]=0%-0.04%).

A prospective study published in 2006 monitored joint toxicities (swelling, tenderness, or restricted movement) during acute treatment with ciprofloxacin as well as skeletal growth at follow-up based on physical examination.2 Preterm neonates with septicemia were treated with either ciprofloxacin (n=48) or other antibiotics (n=66). Forty infants in the ciprofloxacin group completed an average of 28 months of follow-up. No complaints or physical findings of osteoarticular joint abnormalities or skeletal growth delay were noted in either group during acute treatment or at follow-up. The incidence of tendonopathy was not reported.

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