Safety of ciprofloxacin in children with cystic fibrosis

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.

Diagnosis and Management of Infectious Arthritis in Children

PURPOSE OF REVIEW

Septic arthritis is limb and life-threatening condition which necessitates rapid diagnosis and treatment. It is important for a medical practitioner to be familiar with this condition. This review summarizes the epidemiology, risk factors, diagnosis and differential diagnosis, complications, as well as treatment and the following-up of this condition.

RECENT FINDINGS

Different causative organisms require unique diagnostic and treatment approaches. Establishing the diagnosis often requires multiple diagnostic modalities, some of which are new and innovative. Differential diagnosis requires excluding non-infectious inflammatory causes, such as reactive arthritis, juvenile rheumatoid arthritis, transient synovitis, and pericapsular pyomyositis. There is no consensus regarding the nature or duration of pharmacological or surgical treatment. Treatment includes administration of appropriate antimicrobial therapy and including the use of steroids and drainage. The most common complications are osteonecrosis of the femoral head and chronic osteomyelitis. Complications of septic arthritis are mostly due to a missed diagnosis. Further studies are required to better evaluate the diagnostic and therapeutic choice.

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.

Use of ciprofloxacin in neonatal sepsis: lack of adverse effects up to one year

AIM

To investigate the adverse effects of ciprofloxacin administered to neonates with sepsis on the hematologic indices, the hepatic and renal function and the joints and growth at 1 year follow-up.

METHODS

In this observational prospective study, 2 groups of septic neonates were studied, 116 neonates who received ciprofloxacin and 100 neonates matched for gestational age and birth weight who did not receive ciprofloxacin. In all neonates the leukocyte and platelet counts as well as the serum concentrations of transaminases, bilirubin, albumin, urea and creatinine were measured before initiation of treatment and on the 10th and 15th to 20th days after treatment initiation. In 77 and 83 infants of the ciprofloxacin and control groups, respectively, the growth at the end of the first year of life was evaluated.

RESULTS

No significant differences between the two groups were found in the hematologic and biochemical indices as well as growth at the end of the first year of life. Also no clinical evidence of arthropathy was observed.

CONCLUSIONS

Treatment of neonatal sepsis with ciprofloxacin resulted in no short term hematologic, renal or hepatic adverse effects and did not appear to be associated with clinical arthropathy or growth impairment at 1 year follow-up evaluation.

Rheumatologic aspects of pediatric cystic fibrosis patients treated with fluoroquinolones

BACKGROUND

The recommended and approved use of fluoroquinolones, including ciprofloxacin, is limited to adult patients because of concerns about the association of joint toxicity in young animals with quinolone administration and rare reports of joint complaints or findings in humans. Despite these warnings some quinolones have been used in children for many years, with seemingly minimal joint sequelae.

OBJECTIVE

This brief review will clarify the association of quinolones with arthropathy, particularly ciprofloxacin because of its widespread use, and subsequently discuss the problem of defining that association in a population of children with cystic fibrosis.

RESULTS

Examination of available clinical data to date provides no absolute evidence that ciprofloxacin induces significant arthropathy in children, in contrast to data reported in some animal species. Specifically short term ciprofloxacin-induced joint toxicity appears to be low in cystic fibrosis patients who have a significant background prevalence of arthralgias and arthritis. However, the level of detection of joint toxicity in these small trials may be insufficient to define rare or late adverse effects.

CONCLUSIONS

Ciprofloxacin-associated arthropathy appears to occur infrequently, particularly in children with cystic fibrosis.