Fluoroquinolones and tendon inflammation/ruptures

Tendonitis and tendon rupture, particularly of the Achilles tendon, may occur during treatment with fluoroquinolones. These side effects can occur within 48 hours of treatment starting, but also several months after it has ended.

Key words: Fluoroquinolones; moxifloxacin; ciprofloxacin; levofloxacin; tendon rupture; Achilles tendon
Incident data	Description
Year: 2018 Age: 70 Sex: Female Medicinal product: Moxifloxacin Indication: Pneumonia acquired in the out-patient setting ADR: Ruptured tendon	After two days of moxifloxacin treatment, the patient hit her hip against a gardening implement, causing severe hip pain. Moxifloxacin was subsequently stopped on the sixth day of treatment. An MRI revealed ruptured tendons at the tuber ischiadicum with perifocal haematoma, but no infection or abscess, and with little intra-articular effusion.
Year: 2022 Age: 73 Sex: Male Medicinal product: Ciprofloxacin Indication: Pyelitis ADR: Inflammation and rupture of Achilles tendon in both legs	The patient experienced difficulty walking on the third day of treatment and was unable to walk the next day. Ciprofloxacin was stopped. An X-ray revealed nothing conspicuous. Tendonitis was diagnosed and the patient received physiotherapy. Both Achilles tendons ruptured during the subsequent course, necessitating surgery. The patient was taking prednisone as an immunosuppressant following a kidney transplant. Other concomitant medication: Tacrolimus, doxazosin, lisinopril, dutasteride, tamsulosin, lercanidipine, atorvastatin, acetylsalicylic acid, sodium hydrogen carbonate, sulfonated copolymer and mycophenolate.
Year: 2020 Age: 25 Sex: Female Medicinal product: Levofloxacin Indication: Infection of the left ear ADR: Tendonitis of the tibialis posterior and Achilles tendons	Five days after beginning treatment, the patient experienced inflammation of the right tibialis posterior tendon and Achilles tendon, which subsequently spread to her left leg. Treatment was stopped on the eighth day. The patient required several months of physiotherapy and could still walk only a limited distance five months later.

Summary and recommendation

In view of the risk of persistent or even permanently debilitating side effects, fluoroquinolones should not be used as first-line treatment in uncomplicated infections.