Safety of ciprofloxacin therapy in children: magnetic resonance images, body fluid levels of fluoride and linear growth

Novel Bacterial Topoisomerase Inhibitor Gepotidacin Demonstrates Absence of Fluoroquinolone-Like Arthropathy in Juvenile Rats

Fluoroquinolone use in children is limited due to its potential toxicity and negative effects on skeletal development, but the actual effects/risks of fluoroquinolones on bone growth and the mechanisms behind fluoroquinolone-driven arthropathy remain unknown. Gepotidacin is a novel, bactericidal, first-in-class triazaacenaphthylene antibiotic with a unique mechanism of action that is not anticipated to have the same risks to bone growth as those of fluoroquinolones. Gepotidacin is in phase III clinical development for uncomplicated urinary tract infections (ClinicalTrials.gov identifiers NCT04020341 and NCT04187144) and urogenital gonorrhea (ClinicalTrials.gov identifier NCT04010539) in adults and adolescents ≥12 years of age. To inform arthropathy and other potential toxicity risks of gepotidacin in pediatric studies, this nonclinical study assessed oral gepotidacin toxicity in juvenile rats from postnatal day (PND) 4 to PND 32/35 (approximately equivalent to human ages from newborn to 11 years), using both in-life assessments (tolerability, toxicity, and toxicokinetics) and terminal assessments (necropsy with macroscopic and microscopic skeletal femoral head and/or stifle joint examinations). Gepotidacin doses of ≤300 mg/kg of body weight/day were well tolerated from PND 4 to PND 21, and higher doses of ≤1,250 mg/kg/day were well tolerated from PND 22 when the dose levels were escalated to maintain systemic exposure levels up to PND 35, with no observed treatment-related clinical signs, effects on mean body weight gain, or macroscopic findings on articular surfaces. A dose of 1,000 mg/kg/day was not tolerated during the dosing period from PND 4 to 21, with effects on body weight gain, fecal consistency, and body condition. Microscopic effects on articular surfaces were evaluated after 32 days of gepotidacin treatment at the highest tolerated dose. After 32 days of treatment with the highest tolerated gepotidacin dose of 300/1,250 mg/kg/day (systemic concentrations [area under the curve {AUC} values] of 93.7 μg · h/mL [males] and 121 μg · h/mL [females]), no skeletal effects on articular surfaces of the femoral head or stifle joint were observed. The absence of treatment-related clinical signs and arthropathy in juvenile rats provides evidence to support the potential future use of gepotidacin in children.

Safety of Quinolones in Children: A Systematic Review and Meta-Analysis

BACKGROUND

The results of animal experiments show that quinolone antibacterial drugs may permanently damage the soft tissues of the weight-bearing joints of young animals. Out of safety concerns, using quinolones in children has always been controversial.

OBJECTIVE

The aim of this study was to assess the risk of using quinolones in children and provide evidence for clinicians to support decision making.

DATA SOURCES

The MEDLINE (Ovid), EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), International Pharmaceutical Abstracts (Ovid), CINAHL, CNKI, VIP, and WanFang Data databases were searched from inception to 8 September 2021.

STUDY SELECTION

All types of studies that reported the safety data of quinolones in children, including clinical trials and observational studies.

DATA EXTRACTION

Data extraction and cross-checking were completed by two independent reviewers using a pilot-tested standardized data extraction form.

RESULTS

The overall incidence rate of adverse drug events (ADEs) in children using systemic quinolones was 5.39% and the most common ADEs were gastrointestinal reactions (incidence rate, 2.02%). Quinolone-induced musculoskeletal ADEs in children were uncommon (0.76%). Meta-analysis results showed that the risk of musculoskeletal ADEs in children using quinolones was higher than children in the control group (51 studies; rate ratio [RR] 2.03, 95% confidence interval [CI] 1.82-2.26; p < 0.001; I² = 18.6%; moderate-quality evidence). However, the subgroup analysis results showed that differences might only be observed in children who were followed up for 2 months to 1 year (2-6 months: RR 2.56, 95% CI 2.26-2.89; 7 months to 1 year: RR 1.35, 95% CI 0.98-1.86). Moreover, children (adolescents) aged between 13 and 18 years might be sensitive to the musculoskeletal toxicity of quinolones (RR 2.69, 95% CI 2.37-3.05; moderate-quality evidence) and the risk of levofloxacin-induced musculoskeletal ADEs might be higher (RR 1.33, 95% CI 1.00-1.77; low-quality evidence).

CONCLUSIONS

Although the existing evidence shows that quinolone-induced musculoskeletal ADEs seem to be only short-term and reversible, and no serious skeletal and muscular system damage cases have been reported in children, quinolones should be avoided unless necessary in children because the incidence rate of quinolone-related ADEs is not low and they are broad-spectrum antibiotics that will induce the emergence of resistant strains if used frequently.

Population pharmacokinetics of intravenous and oral ciprofloxacin in children to optimize dosing regimens

PURPOSE

This study aimed to characterize pharmacokinetics of intravenous and oral ciprofloxacin in children to optimize dosing scheme.

METHODS

Children treated with ciprofloxacin were included. Pharmacokinetics were described using non-linear mixed-effect modelling and validated with an external dataset. Monte Carlo simulations investigated dosing regimens to achieve a target AUC_0-24 h/MIC ratio ≥ 125.

RESULTS

A total of 189 children (492 concentrations) were included. A two-compartment model with first-order absorption and elimination best described the data. An allometric model was used to describe bodyweight (BW) influence, and effects of estimated glomerular filtration rate (eGFR) and age were significant on ciprofloxacin clearance.

CONCLUSION

The recommended IV dose of 10 mg/kg q8h, not exceeding 400 mg q8h, would achieve AUC_0-24 h to successfully treat bacteria with MICs ≤ 0.25 (e.g. Salmonella, Escherichia coli, Proteus, Haemophilus, Enterobacter, and Klebsiella). A dose increase to 600 mg q8h in children > 40 kg and to 15 mg/kg q8h (max 400 mg q8h, max 600 mg q8h if augmented renal clearance, i.e., eGFR > 200 mL/min/1.73 m²) in children < 40 kg would be needed for the strains with highest MIC (16% of Pseudomonas aeruginosa and 47% of Staphylococcus aureus). The oral recommended dose of 20 mg/kg q12h (not exceeding 750 mg) would cover bacteria with MICs ≤ 0.125 but may be insufficient for bacteria with higher MIC and a dose increase according bodyweight and eGFR would be needed. These doses should be prospectively confirmed, and a therapeutic drug monitoring could be used to refine them individually.

Systemic fluoroquinolone prescriptions for hospitalized children in Belgium, results of a multicenter retrospective drug utilization study

BACKGROUND

Fluoroquinolones (FQ) are increasingly prescribed for children, despite being labeled for only a limited number of labeled pediatric indications. In this multicenter retrospective drug utilization study, we analyzed indications for systemic FQ prescriptions in hospitalized children and the appropriateness of the prescribed dose.

METHODS

Using data obtained from electronic medical files, the study included all children who received a systemic FQ prescription in two Belgian university children's hospitals between 2010 and 2013. Two authors reviewed prescribed daily doses. Univariate and multivariate logistic regression models were used to analyze risk factors for inadequately dosing. Results262 FQ prescriptions for individual patients were included for analysis. 16.8% of these prescriptions were for labeled indications, and 35.1% were guided by bacteriological findings. Prescribed daily dose was considered to be inappropriate in 79 prescriptions (30.2%). Other FQ than ciprofloxacin accounted for 9 prescriptions (3.4%), of which 8 were correctly dosed. Underdosing represented 45 (56.9%) dosing errors. Infants and preschool children were at particular risk for dosing errors, with associated adjusted OR of 0.263 (0.097-0.701) and 0.254 (0.106-0.588) respectively.

CONCLUSIONS

FQ were often prescribed off-label and not guided by bacteriological findings in our study population. Dosing errors were common, particularly in infants and preschool children. FQ prescriptions for children should be improved by specific pediatric antimicrobial stewardship teams. Furthermore, pharmacokinetic studies should optimise dosing recommendations for children.

Black Tea Source, Production, and Consumption: Assessment of Health Risks of Fluoride Intake in New Zealand

In countries with fluoridation of public water, it is imperative to determine other dietary sources of fluoride intake to reduce the public health risk of chronic exposure. New Zealand has one of the highest per capita consumption rates of black tea internationally and is one of the few countries to artificially fluoridate public water; yet no information is available to consumers on the fluoride levels in tea products. In this study, we determined the contribution of black tea as a source of dietary fluoride intake by measuring the fluoride content in 18 brands of commercially available products in New Zealand. Fluoride concentrations were measured by potentiometric method with a fluoride ion-selective electrode and the contribution of black tea to Adequate Intake (AI) and Tolerable Upper Intake Level (UL) was calculated for a range of consumption scenarios. We examined factors that influence the fluoride content in manufactured tea and tea infusions, as well as temporal changes in fluoride exposure from black tea. We review the international evidence regarding chronic fluoride intake and its association with chronic pain, arthritic disease, and musculoskeletal disorders and provide insights into possible association between fluoride intake and the high prevalence of these disorders in New Zealand.

Safety Concerns Surrounding Quinolone Use in Children

Fluoroquinolones are highly effective antibiotics with many desirable pharmacokinetic and pharmacodynamic properties including high bioavailability, large volume of distribution, and a broad spectrum of antimicrobial activity. Despite their attractive profile as anti-infective agents, their use in children is limited, primarily due to safety concerns. In this review we highlight the pharmacological properties of fluoroquinolones and describe their current use in pediatrics. In addition, we provide a comprehensive assessment of the safety data associated with fluoroquinolone use in children. Although permanent or destructive arthropathy remains a significant concern, currently available data demonstrate that arthralgia and arthropathy are relatively uncommon in children and resolve following cessation of fluoroquinolone exposure without resulting in long-term sequelae. The concern for safety and risk of adverse events associated with pediatric fluoroquinolone use is likely driving the limited prescribing of this drug class in pediatrics. However, in adults, fluoroquinolones are the most commonly prescribed broad-spectrum antibiotics, resulting in the development of drug-resistant bacteria that can be challenging to treat effectively. The consequence of misuse and overuse of fluoroquinolones leading to drug resistance is a greater, but frequently overlooked, safety concern that applies to both children and adults and one that should be considered at the point of prescribing.

Options for treating resistant Shigella species infections in children

Infection due to Shigella species remains an important public health problem, especially in developing countries where it remains the most common cause of bloody diarrhea. In the United States (US), 10,000 to 15,000 cases of shigellosis are reported each year in both children and adults. US surveillance data from 2004 has demonstrated increased resistance in Shigella species to first-line antibiotics such as ampicillin and trimethoprim-sulfamethoxazole, with approximately 37% of isolates demonstrating resistance to both ampicillin and trimethoprim-sulfamethoxazole. Since approximately 69% of Shigella infections occur in children younger than 5 years of age, it is important that alternative antibiotics other than typical first-line agents such as ampicillin and trimethoprim-sulfamethoxazole be available to treat Shigella infections in this population. The American Academy of Pediatrics (AAP) recommends cefixime, ceftriaxone, azithromycin, and fluoroquinolones as alternative antibiotics for the treatment of Shigella species infections in children. This paper will review the microbiology, susceptibility, efficacy and safety data of these alternative antibiotics with regard to the treatment of Shigella species infections in children, and will attempt to define the role of each of these agents in the pediatric population.

Ciprofloxacin safety in paediatrics: a systematic review

OBJECTIVE

To determine the safety of ciprofloxacin in paediatric patients in relation to arthropathy, any other adverse events (AEs) and drug interactions.

METHODS

A systematic search of MEDLINE, EMBASE, CINAHL, CENTRAL and bibliographies of relevant articles was carried out for all published articles, regardless of design, that involved the use of ciprofloxacin in any paediatric age group ≤ 17 years. Only articles that reported on safety were included.

RESULTS

105 articles met the inclusion criteria and involved 16 184 paediatric patients. There were 1065 reported AEs (risk 7%, 95% CI 3.2% to 14.0%). The most frequent AEs were musculoskeletal AEs, abnormal liver function tests, nausea, changes in white blood cell counts and vomiting. There were six drug interactions (with aminophylline (4) and methotrexate (2)). The only drug related death occurred in a neonate who had an anaphylactic reaction. 258 musculoskeletal events occurred in 232 paediatric patients (risk 1.6%, 95% CI 0.9% to 2.6%). Arthralgia accounted for 50% of these. The age of occurrence of arthropathy ranged from 7 months to 17 years (median 10 years). All cases of arthropathy resolved or improved with management. One prospective controlled study estimated the risk of arthropathy as 9.3 (OR 95% CI 1.2 to 195). Pooled safety data of controlled trials in this review estimated the risk of arthropathy as 1.57 (OR 95% CI 1.26 to 1.97).

CONCLUSION

Musculoskeletal AEs occur due to ciprofloxacin use. However, these musculoskeletal events are reversible with management. It is recommended that further prospective controlled studies should be carried out to evaluate the safety of ciprofloxacin, with particular focus on the risk of arthropathy.

Fluoroquinolone Antibiotics in Infants and Children

The use of fluoroquinolones in children is limited because of the potential of these agents to induce arthropathy in juvenile animals and to potentiate development of bacterial resistance. No quinolone-induced cartilage toxicity as described in animal experiments has been documented unequivocally in patients, but the risk fro rapid emergence of bacterial resistance associated with widespread, uncontrolled fluoroquinolones use in children is a realistic threat. Overall, the fluoroquinolones have been safe and effective in the treatment of selected bacterial infections in pediatric patients. There are clearly defined indications for these compounds in children who are ill.

Typhoid and paratyphoid fever

Typhoid fever is estimated to have caused 21.6 million illnesses and 216,500 deaths globally in 2000, affecting all ages. There is also one case of paratyphoid fever for every four of typhoid. The global emergence of multidrug-resistant strains and of strains with reduced susceptibility to fluoroquinolones is of great concern. We discuss the occurrence of poor clinical response to fluoroquinolones despite disc sensitivity. Developments are being made in our understanding of the molecular pathogenesis, and genomic and proteomic studies reveal the possibility of new targets for diagnosis and treatment. Further, we review guidelines for use of diagnostic tests and for selection of antimicrobials in varying clinical situations. The importance of safe water, sanitation, and immunisation in the presence of increasing antibiotic resistance is paramount. Routine immunisation of school-age children with Vi or Ty21a vaccine is recommended for countries endemic for typhoid. Vi vaccine should be used for 2-5 year-old children in highly endemic settings.

Systemic quinolone antibiotics in children: a review of the use and safety

Historically, healthcare providers have reluctantly used systemic quinolone antibiotics to treat infections in children when they have been used at all. Concerns regarding the oral or parenteral use of quinolones in children rose from research observations demonstrating cartilage and joint toxicity in juvenile animal models following the administration of this class of antibiotics to immature animals. A voluntary moratorium on the use of quinolone and fluoroquinolone antibiotics in children resulted in restricting their use to treat in infections in specific settings such as immunocompromised states due to chemotherapy, pseudomonas infections in cystic fibrosis patients, complicated urinary tract infections, and quinolone sensitive infectious disease where parenteral antibiotic administration is not available and quinolones were the only effective therapy. This article aims to review retrospective and prospective safety and efficacy data to provide a comprehensive summary of the systemic use of this class of antibiotics in children.

Safety profile of quinolone antibiotics in the pediatric population

Fluoroquinolone-induced joint/cartilage toxicity has been observed in juvenile animal studies and is species- and dose-specific with canines exhibiting the highest rate of arthralgias. These early observations led to the contraindication of fluoroquinolones in the pediatric population. Despite these recommendations fluoroquinolones continue to be prescribed for select children with difficult-to-treat infections for whom the benefit of quinolone therapy may outweigh the risk of cartilage toxicity. A review of retrospective and prospective safety data of ciprofloxacin-treated children showed that the rates of arthralgia and quinolone-induced cartilage toxicity were low. Episodes of arthralgia were mostly reversible based on published surveillance data in children. Recent data from Bayer's ciprofloxacin clinical trials database found that the incidence of arthralgia in children did not differ between the ciprofloxacin and nonquinolone antimicrobial control groups. The role of fluoroquinolones in the treatment of certain serious infections in children does not appear to be compromised by safety concerns when used appropriately.

Fluoroquinolone safety in pediatric patients: a prospective, multicenter, comparative cohort study in France

OBJECTIVE

To evaluate the safety of fluoroquinolones (FQ) in comparison with other antibiotics in pediatric patients.

METHODS

A multicenter, observational, comparative cohort study was conducted between 1998 and 2000 in French pediatric departments. Patients who were receiving systemic FQ were included and matched to control patients who were receiving other antibiotics. Antibiotic-associated potential adverse events (PAEs) were recorded prospectively in both groups, and their rates were compared using univariate and multivariate analyses.

RESULTS

Patients were recruited from 73 centers: 276 patients were exposed to FQ, and 249 composed the control group. Among patients who were exposed to FQ, 23% were younger than 2 years, 33% had cystic fibrosis, and PAEs occurred in 52 patients, leading to withdrawal for 11. The odds ratio for PAE in the FQ group was 3.7 (95% confidence interval: 1.9-7.5) and was not significantly modified after adjustment for potential confounders. Musculoskeletal PAEs also occurred more frequently in the FQ group (3.8%) than in controls (0.4%); they were recorded in 10 patients who were receiving standard FQ doses and were of moderate intensity and transient.

CONCLUSION

The rates of PAEs and musculoskeletal PAEs were higher for the FQ group than the control group. This observation supports the American Academy of Pediatrics statement restricting off-label FQ use in pediatric patients to second-line treatment in a limited number of situations.

Ciprofloxacin for the treatment of uncomplicated gonorrhea infection in adolescents: does the benefit outweigh the risk?

The highest rates of reported gonorrhea infections occur among adolescent females aged 15-19 years. Among the Centers for Disease Control and Prevention (CDC)-recommended single-dose gonorrhea treatment regimens, ciprofloxacin, a fluoroquinolone antibiotic, is approximately half the cost of other CDC-recommended oral treatment regimens. Fluoroquinolone use in patients aged <18 years has been limited because of irreversible articular cartilage damage demonstrated in large, weight-bearing joints of young animals. We reviewed the medical literature to assess whether the risks of a single 500-mg dose of ciprofloxacin to treat uncomplicated gonorrhea infection in adolescents appears to outweigh the benefits. We found no reports of irreversible cartilage toxicity or age-associated adverse events in 5236 human children and adolescents (aged 5 days-24 years) treated with a total of 5486 courses of fluoroquinolones.

The pharmacological management of drug-induced rheumatic disorders

Many drugs can induce adverse effects such as rheumatoid disorders, which we need to be aware of in order to best detect and manage them. New drugs are constantly entering the marketplace and can cause an increasing number of disorders. Through this article, we review the prevention and pharmacological management of drug-induced rheumatic disorders. These include articular and peri-articular manifestations induced by fluoroquinolones, retinoids, cyclosporin, drug-induced disorders of bone metabolism such as corticosteroid-induced osteoporosis and drug-induced osteomalacia, and multisystemic manifestations including drug-induced lupus and arthritis induced by vaccinations and cytokines.

Drug-induced rheumatic disorders: incidence, prevention and management

The purpose of this article is to review the causes, the clinical manifestations and the management of the more frequent drug-induced rheumatic disorders. These include: (i) articular and periarticular manifestations induced by fluoroquinolones, nonsteroidal anti-inflammatory drugs, injections of corticosteroids, and retinoids; (ii) multisystemic manifestations such as drug-induced lupus and arthritis induced by vaccination, Bacillus Calmette-Guerin therapy and cytokines; (iii) drug-induced disorders of bone metabolism (corticosteroid-induced osteoporosis, drug-induced osteomalacia and osteonecrosis); and (iv) iatrogenic complex regional pain syndromes. Disorders caused by nonpharmacological and rarely used treatments have been deliberately excluded. Knowledge of these drug-induced clinical symptoms or syndromes allows an earlier diagnosis and treatment, and earlier drug withdrawal if necessary. With the introduction of new medications such as the recombinant cytokines and antiretroviral treatments, the number of drug-induced rheumatic disorders is likely to increase.

Ciprofloxacin in children: is arthropathy a limitation?

Two hundred and nineteen children treated with Ciprofloxacin were observed for drug related adverse reactions (ADR). ADR was observed in 35/219 (15.98%) children, arthropathy in 2/219 (0.9%) children only. All the ADR were reversible even on continuation of therapy except one child with arthropathy and no permanent sequele or death occurred as a drug related ADR.

Clinical use of fluoroquinolones in children

OBJECTIVE

To review the pharmacokinetics, efficacy, and safety of fluoroquinolones in children.

DATA SOURCES

A MEDLINE search (January 1966-March 1998) was conducted for relevant literature.

STUDY SELECTION AND DATA EXTRACTION

Data from compassionate use and published studies were reviewed for the assessment of pharmacokinetics, efficacy, and safety of fluoroquinolones in children.

DATA SYNTHESIS

Fluoroquinolones have a broad spectrum coverage of gram-positive and gram-negative bacteria, including Pseudomonas aeruginosa and intracellular organisms. Fluoroquinolones are well absorbed from the gastrointestinal tract, have excellent tissue penetration, low protein binding, and long elimination half-lives. These antibiotics are effective in treating various infections and are well tolerated in adults. However, the use of fluoroquinolones in children has been restricted due to potential cartilage damage that occurred in research with immature animals. Fluoroquinolones have been used in children on a compassionate basis. Ciprofloxacin is the most frequently used fluoroquinolone in children, most often in the treatment of pulmonary infection in cystic fibrosis as well as salmonellosis and shigellosis. Other uses include chronic suppurative otitis media, meningitis, septicemia, and urinary tract infection. Safety data of fluoroquinolones in children appear to be similar to those in adults. Fluoroquinolones are associated with tendinitis and reversible arthralgia in adults and children. However, direct association between fluoroquinolones and arthropathy remains uncertain.

CONCLUSIONS

Fluoroquinolones have been found to be effective in treating certain infections in children. Additional research is needed to define the optimal dosage regimens in pediatric patients. Although fluoroquinolones appear to be well tolerated, further investigations are needed to determine the risk of arthropathy in children. However, their use in children should not be withheld when the benefits outweigh the risks.

Single-dose and steady-state pharmacokinetics of a new oral suspension of ciprofloxacin in children

OBJECTIVE

Quinolones are used ever increasingly in pediatrics, although officially they are still contraindicated. Lack of evidence of arthropathic effects in human offspring favors their use, but little is known about the pharmacokinetics of oral or parenteral ciprofloxacin in children, especially those without cystic fibrosis.

DESIGN

We studied 16 non-cystic fibrosis patients ranging in age from 0.3 to 7.1 years to whom the new suspension formulation of ciprofloxacin (10 mg/kg body weight) was given orally three times daily. Single-dose and steady-state pharmacokinetic parameters were elucidated.

RESULTS

Ciprofloxacin was rapidly absorbed. The maximum plasma concentrations, with the means varying from 1.7 to 3.6 mg/L, were reached within 1 hour, almost regardless of whether single-dose administration or steady state. The mean oral clearance was lower in children <6 years of age than in those >/=6 years. Terminal half-life values, with the means varying only between 4.2 and 5.1, suggest that dosing recommendations based on body weight are pertinent, although caution should be exercised in small infants. No arthropathic or other adverse events attributable to ciprofloxacin suspension were observed.

CONCLUSION

A dose of the suspension form of ciprofloxacin of 10 mg/kg body weight given orally three times daily seems appropriate in children, provided the drug is clearly indicated.

Effects of ciprofloxacin and ofloxacin on adult human cartilage in vitro

Chondrocyte toxicity and necrosis were seen with electron microscopy after incubation of human adult cartilage biopsy specimens in ciprofloxacin or ofloxacin. In vitro exposure of chondrocytes to fluoroquinolones did not affect apoptosis as determined by flow cytometry. While the immediate clinical significance of this finding remains unclear, the possibility of long-term cartilage damage after fluoroquinolone treatment cannot be excluded.

Oral ciprofloxacin vs. intravenous ceftazidime plus tobramycin in pediatric cystic fibrosis patients: comparison of antipseudomonas efficacy and assessment of safety with ultrasonography and magnetic resonance imaging. Cystic Fibrosis Study Group

BACKGROUND

More data on the efficacy and safety of ciprofloxacin in pediatric cystic fibrosis patients are needed.

METHODS

One hundred eight pediatric cystic fibrosis patients (ages 5 to 17 years) with acute bronchopulmonary exacerbations entered a randomized multicenter trial designed to compare the safety and efficacy of antipseudomonas therapy with oral ciprofloxacin (15 mg/kg twice daily; maximum dosage 750 mg twice daily) or intravenous ceftazidime plus tobramycin (CAZ/TM) for 14 days.

RESULTS

Clinical improvement was observed in 93% of patients treated with oral ciprofloxacin and in 96% of those receiving parenteral therapy. Transient suppression of Pseudomonas aeruginosa was achieved in 63% of patients at the end of the course of iv CAZ/TM therapy and in 24% receiving ciprofloxacin. Ultrasound examination and nuclear magnetic resonance imaging scans showed no evidence of cartilage toxicity in any of the ciprofloxacin-treated patients. Musculoskeletal adverse events were reported with similar frequency in the two groups of patients (7% in the group receiving ciprofloxacin therapy and 11% in the IV CAZ/TM group). The only sustained musculoskeletal symptom was a case of synovitis in a patient receiving parenteral CAZ/TM.

CONCLUSION

Ciprofloxacin thus appears to be safe and effective for use in young patients with bronchopulmonary exacerbation of cystic fibrosis.

Pediatric dermatology: advances in therapy

Several recent therapeutic advances in pediatric dermatology have been made. Of particular importance are new developments in the use of antimicrobials, antivirals, antifungals, retinoids, calcipotriene, and intravenous gamma globulin. We review safety and efficacy data of these drugs in their use in children with cutaneous disease.

Dermatologic drug use during pregnancy and lactation

Physicians are often asked to prescribe medication for women during the childbearing years. This article reviews which dermatologic drugs have been reported to interfere with contraceptive efficacy, which should be avoided, and which have the fewest contraindications for use during pregnancy and lactation. Corticosteroids and tretinoin are discussed in detail. Sources and guidelines for choices of dermatologic drugs for women of childbearing age are presented.

Ciprofloxacin. An updated review of its pharmacology, therapeutic efficacy and tolerability

Ciprofloxacin is a broad spectrum fluoroquinolone antibacterial agent. Since its introduction in the 1980s, most Gram-negative bacteria have remained highly susceptible to this agent in vitro; Gram-positive bacteria are generally susceptible or moderately susceptible. Ciprofloxacin attains therapeutic concentrations in most tissues and body fluids. The results of clinical trials with ciprofloxacin have confirmed its clinical efficacy and low potential for adverse effects. Ciprofloxacin is effective in the treatment of a wide variety of infections, particularly those caused by Gram-negative pathogens. These include complicated urinary tract infections, sexually transmitted diseases (gonorrhoea and chancroid), skin and bone infections, gastrointestinal infections caused by multiresistant organisms, lower respiratory tract infections (including those in patients with cystic fibrosis), febrile neutropenia (combined with an agent which possesses good activity against Gram-positive bacteria), intra-abdominal infections (combined with an antianaerobic agent) and malignant external otitis. Ciprofloxacin should not be considered a first-line empirical therapy for respiratory tract infections if penicillin-susceptible Streptococcus pneumoniae is the primary pathogen; however, it is an appropriate treatment option in patients with mixed infections (where S. pneumoniae may or may not be present) or in patients with predisposing factors for Gram-negative infections. Clinically important drug interactions involving ciprofloxacin are well documented and avoidable with conscientious prescribing. Recommended dosage adjustments in patients with impaired renal function vary between countries; major adjustments are not required until the estimated creatinine clearance is < 30 ml/min/1.73m2 (or when the serum creatinine level is > or = 2 mg/dl). Ciprofloxacin is one of the few broad spectrum antibacterials available in both intravenous and oral formulations. In this respect, it offers the potential for cost savings with sequential intravenous and oral therapy in appropriately selected patients and may allow early discharge from hospital in some instances. In conclusion, ciprofloxacin has retained its excellent activity against most Gram-negative bacteria, and fulfilled its potential as an important antibacterial drug in the treatment of a wide range of infections. Rational prescribing will help to ensure the continued clinical usefulness of this valuable antimicrobial drug.