Fluroquinone prescribing - a big ciproh-no-no from the MHRA

Sometimes it feels like everyone in general practice is fed up. Our next patient, Jane, is 67 years old and no exception. She’s in with symptoms of UTI; exasperated, unwell and demanding ciprofloxacin. It’s the ‘only thing’ that actually works, and everything else makes her feel terrible. Your next patient Dave, is 70 and has recurrent chronic non-bacterial prostatitis. He also says that cipro is the only thing that works, and he usually has it for a 6 week course!

Of course, it’s always tempting to prescribe something that has helped before, and we want to make our patients better and happy. But, in light of last months strengthened MHRA Drug Safety Alert, should these consults be more a case of ciproh-no-no? 

In January the MHRA published a new and strengthened Drug Safety Alert focusing on these fluoroquinolone antibiotics. This alert means that, despite often being very effective drugs, the ‘oxacins’ (including cipro, levo, moxi or ofloxacin) are very much out of fashion. So last season in fact, they’re now pretty much only a last resort, saved for when ‘other antibiotics, that are commonly recommended for the infection, are inappropriate.’ Whether that’s due to resistance, contraindications, side effects or treatment failure, it's otherwise very much a case of fluroquino-no. 

The crux of the issue is what the MRHA describes as ‘long lasting, disabling and potentially irreversible side effects’ associated with these drugs. Sounds nasty right? 

Well indeed – and since the 2018 EMA Alert it’s been clear the risks of fluroquinones extend beyond the usual concerns about antibiotic stewardship.  Most of us are aware of tendonitis and tendon rupture, which commonly involves the Achilles, but can in fact affect any tendon. Perhaps fewer of us are aware that the tendon damage can occur within 48hrs of starting the drug, or even several months after the treatment is completed. Of course, being a ‘C-drug’ means cipro can also predispose to C.difficile, as summarised here by NICE. But it doesn’t stop there – other serious side effects include QT prolongation, arthropathy, neuropathy, AAA rupture, sleep disorders, memory impairment and psychiatric reactions. A Drug Safety Update in September 2023 focused specifically on this risk of psychiatric reactions, which including a worsening of pre-existing psychiatric symptoms, depression, psychosis and even suicidal thoughts or attempts. Being aged over 60, like Jane and Dave, increases the risk further of serious adverse events so extra caution is needed in these older patients. Similarly, having kidney disease or taking corticosteroids increases your risk of this smorgasbord of side effects even further. In particular, coadministration of a corticosteroid with a quinolone can exacerbate tendon rupture and is an absolute ciproh-no-no.

So, in light of this, it’s important that we only use these drugs as a last resort. If we do go ahead and prescribe, patients should be counselled appropriately, and it's worth having the MHRA Patient Information Leaflet loaded ready to share. Patients need to be well informed about what to look out for (and this warning should be documented in the notes), and their friends and families should also be alert to any changes in their mood and behaviour too. Of course, the drug should also be stopped at the first sign of adverse effects and side effects reported via the Yellow Card app or website. 

But, what about patients with acute bacterial prostatitis? This is one clinical area where quinolones have previously been recommended as a first-line treatment NICE, NG110, but in light of this new MHRA warning NICE are now ‘assessing the impact of this warning’ on these recommendations. While we wait for this assessment, it would be prudent to use trimethoprim instead and of course to urgently refer if you suspect abscess or sepsis. 

So, what shall we do with Jane and Dave? Well, after discussion and sharing the information leaflet, it turns out that neither of them are particularly keen on the possibility of ruptured tendons or long-term neuropsychiatric side effects so are happy to accept alternatives. If you’re struggling to know which alternatives to prescribe instead, as well as checking your local formulary, we cover James’ brilliant 4 step plan to choosing the right antibiotics for UTI’s in the new urgent care course. Do join us on the 22^nd March for this and many more urgent care pearls, or the course is available on demand now.