Fluoroquinolones (ciprofloxacin, norfloxacin and moxifloxacin) have serious potential side effects,  and are best used only for directed therapy of serious multi-resistant Gram negative infections where no other safer alternatives are available.

14 of our 32 hospital facilities in HNELHD overuse these agents with 2016 average FQ usage above our current benchmark of 30 defined daily doses per 1000 patient-days.

Here are some pointers to situations where better alternatives to FQ exist:

Gram negatives

In hospital practice, FQ are often used for proven susceptible infections due to Pseudomonas aeruginosa,  Enterobacter cloacae and Enterobacter aerogenes, Serratia marcescens, Citrobacter freundii, Proteus vulgaris, Providentia species and Morganella morganii (the so called ‘ESCPPM’ group) because there are few or no other oral antibiotic alternatives.

Alternatives:

• Trimethoprim+sulfamethoxazole is an attractive alternative for ESCPMM organisms as susceptibility is high in HNELHD (avoid this drug in the elderly however).
• In uncomplicated UTI, use trimethoprim for susceptible ESCPPM group organisms.
• For non-typhoidal Salmonella infection, use oral amoxycillin or trimethoprim+sulfamethoxazole- local strains are nearly always susceptible to one or both

Always consider whether these organisms are really causing infection since they frequently colonise the skin, respiratory tract,  other mucous membranes and urinary catheters or bladder.

Gram positives

With the possible exception of anthrax, ciprofloxacin should not be used as first line treatment for any Gram positive infections. Treatment of Staphylococcus aureus infection with a ciprofloxacin is discouraged because resistance emerges rapidly.

Alternatives:

• Staphylococcus aureus – methicillin susceptible – use di/flucloxaxillin
• MRSA – use non betalactam – vancomycin for sepsis/bacteraemia, trimethoprim+sulpha or doxycycline for skin/soft tissue infection
• Streptococcus pneumoniae – use amoxycillin or benzylpenicillin  or doxycycline for non-meningeal infections
• Beta-haemolytic streptococci (eg S. pyogenes) use penicillin or di/flucloxacillin, erythromycin or doxycycline

Avoid the use of FQ in community respiratory tract infection including pneumonia; there are better alternatives with less adverse ecological effects.

Miscellaneous indications

• Ciprofloxacin is indicated prior to TRUS biopsy, though a risk assessment is required to identify those patients who may be carrying FQ-resistant organisms.
• Campylobacter enteritis – most do not require antibiotics. Erythromycin rather than norfloxacin is preferred.
• Ciprofloxacin is an alternative for oral prophylaxis of persons who have had close and prolonged contact with a case of meningococcal disease– defer to the advice from Public Health in this case.
• More exotic second line indications include chancroid, cholera and typhoid.

FQ Resistance – how frequently is it detected locally?

Current FQ resistance rates are relatively low compared with international data but have inched up at John Hunter (JHH) and Calvary Mater Hospitals (CMN) – here is a snapshot from our recent 2015 antibiograms– urinary isolates % susceptibility to norfloxacin at major HNELHD facility locations: