Fluoroquinolones Are Safe for Use in Pediatric Patients

Report By: Amy Bishop - Emergency Medicine Resident
Search checked by Jeffrey Jones, MD - Research Director, EM Residency Program
Institution: Grand Rapids Medical Education and Research
Date Submitted: 9th March 2009
Last Modified: 20th May 2009
Status: Blue (submitted but not checked)

Three Part Question

In [pediatric patients] do [fluoroquinolones] have an [increased risk of causing arthropathy]?

Clinical Scenario

A pediatric patient presents to the Emergency Department with pyelonephritis. You would like to use a fluoroquinolone antibiotic, but are concerned about its safety in this patient population.

Search Strategy

Medline 1950-5/09 using the OVID interface, Cochrane Library (2009), PubMed clinical queries

[(exp fluoroquinolones or fluoroquinolones.mp) AND (arthropathy.mp.)]. LIMIT to human AND English

Search Outcome

52 papers were found of which 3 were relevant to the three part question

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Salam, MA Aug. 1998 Bangladesh	120 patients (age 2-15) with shigella diarrhea, randomized to treatment with ciprofloxacin or pivmecillinam for 5 days.	Randomized, double-blinded	joint pain	No difference between the two groups.	Small sample size. Many patients lost to follow up at day 7, 30 and 6 months
Salam, MA Aug. 1998 Bangladesh		Randomized, double-blinded	arthropathy	No evidence of arthropathy/arthritis in either group at follow-up visits at
Schaad, UB 1997 Switzerland	44 pediatric patients with cystic fibrosis randomized to ciprofloxacin or ciprofloxacin plus amikacin	randomized prospective study	joint pain	1 patient in each group, that resolved without treatment	Small sample size. No placebo control, both groups received fluoroquinolones. Not blinded. Lack of detailed explanation of joint evaluation.
Church, DA 1997 United States	84 pediatric cystic fibrosis patients (age 5-17) with acute pulmonary exacerbation were randomized to ciprofloxacin or ceftazidime plus tobramycin for 10 days.	RCT	Overall adverse events	similar; 78% for ciprofloxacin, 69% for ceftazidime/tobra. p=.288	Small sample size. Special patient population (cystic fibrosis)
Church, DA 1997 United States		RCT	Musculoskeletal event	identical; 22% for ciprofloxacin, 21% for ceftazidime/tobra. p=.845

Comment(s)

Fluoroquinolones have been observed to cause arthropathy in juveniles of most animal species. Because of this, they have been used sparingly in children. Most of the human data has come from the use of fluoroquinolones in pediatric cystic fibrosis patients

Clinical Bottom Line

The use of fluorquinolones appears to be safe for use in pediatric patients and does not create an increase risk for the development of arthropathy. The studies are limited, however, due to the small sample size.

References

Salam MA. Dhar U. Khan WA. Bennish ML Randomised comparison of ciprofloxacin suspension and pivmecillinam for childhood shigellosis Lancet 352(9127):522-7, 1998 Aug 15.
Schaad UB. Wedgwood J. Ruedeberg A. Kraemer R. Hampel B. Ciprofloxacin as antipseudomonal treatment in patients with cystic fibrosis. Pediatric Infectious Disease Journal. 16(1):106-11; discussion 123-6, 1997 Jan.
Church DA. Kanga JF. Kuhn RJ. Rubio TT. Spohn WA. Stevens JC. Painter BG. Thurberg BE. Haverstock DC. Perroncel RY. Echols RM. Sequential ciprofloxacin therapy in pediatric cystic fibrosis: comparative study vs. ceftazidime/tobramycin in the treatment of acute pulmonary exacerbations he Cystic Fibrosis Study Group. Pediatric Infectious Disease Journal 16(1):97-105; discussion 123-6, 1997 Jan.