moxifloxacin

REMS

Treatment of the following infections:
- Acute sinusitis (should be used only when there are no other alternative treatment options),
- Acute bacterial exacerbations of chronic bronchitis (should be used only when there are no other alternative treatment options)
- Community-acquired pneumonia (CAP),
- Uncomplicated and complicated skin and skin structure infections,
- Complicated intra-abdominal infections,
Treatment and prophylaxis of plague.

Action ⬆ ⬇

Inhibits bacterial DNA synthesis by inhibiting DNA gyrase enzyme.

Therapeutic effects:

Death of susceptible bacteria.

Spectrum:

Active against gram-positive pathogens, including:
- Staphylococcus aureus ,
- Streptococcus pyogenes,
- Streptococcus pneumoniae (including multi-drug resistant strains).
- Streptococcus anginosus,
- Streptococcus constellatus,
- Enterococcus faecalis.
Gram-negative spectrum notable for activity against:
- Escherichia coli,
- Klebsiella pneumoniae,
- Haemophilus influenzae,
- Haemophilus parainfluenzae,
- Enterobacter cloacae,
- Moraxella catarrhalis,
- Proteus mirabilis,
- Yersinia pestis.
Additional spectrum includes:
- Chlamydophylia pneumoniae,
- Mycoplasma pneumoniae,
- Bacteroides fragilis,
- Bacteroides thetaiotaomicron ,
- Peptostreptococcus,
- Clostridium perfringens.

Pharmacokinetics ⬆ ⬇

Absorption: Well absorbed (90%) following oral administration.

Distribution: Widely distributed; tissue concentrations may exceed plasma concentrations.

Metabolism/Excretion: Mostly metabolized by the liver; 20% excreted unchanged in urine, 25% excreted unchanged in feces.

Half-Life: 12 hr.

Time/Action Profile ⬆ ⬇

(blood levels)

ROUTE	ONSET	PEAK	DURATION
PO	within 1 hr	1–3 hr	24 hr
IV	rapid	end of infusion	24 hr

Contraind./Precautions ⬆ ⬇

Contraindicated in:

Hypersensitivity (cross-sensitivity within class may exist);
QTc interval prolongation;
Uncorrected hypokalemia or hypomagnesemia;
Concurrent use of Class IA antiarrhythmics (disopyramide, quinidine, procainamide) or Class III antiarrhythmics (amiodarone, sotalol) (↑risk of QTc interval prolongation and torsade de pointes);
History of myasthenia gravis (may worsen symptoms including muscle weakness and breathing problems).

Use Cautiously in:

Known or suspected CNS disorder;
Concurrent use of erythromycin, antipsychotics, and tricyclic antidepressants (↑risk of QTc interval prolongation and torsade de pointes);
Bradycardia;
Acute myocardial ischemia;
Concurrent use of corticosteroids (↑ risk of tendinitis/tendon rupture);
Hepatic dysfunction;
Kidney, heart, or lung transplant patients (↑ risk of tendinitis/tendon rupture);
Patients with or at risk for aortic aneurysms;
Diabetes;
OB: Safety not established in pregnancy;
Lactation: Use while breastfeeding only if potential maternal benefit justifies potential risk to infant;
Pedi: Safety and effectiveness not established in children;
Geri: risk for tendon disorders/rupture, aortic aneurysm/dissection (within 2 mo following discontinuation), and QT interval prolongation in older adults.

Adv. Reactions/Side Effects ⬆ ⬇

CV: QT interval prolongation, AORTIC ANEURYSM/DISSECTION, TORSADE DE POINTES

Derm: photosensitivity, STEVENS-JOHNSON SYNDROME

Endo: hyperglycemia, hypoglycemia

GI: diarrhea, nausea, ↑liver enzymes, CLOSTRIDIOIDES DIFFICILE-ASSOCIATED DIARRHEA (CDAD), abdominal pain, dyspepsia, vomiting

MS: arthralgia, myalgia, tendinitis, tendon rupture

Neuro: agitation, anxiety, confusion, depression, dizziness, ELEVATED INTRACRANIAL PRESSURE (INCLUDING PSEUDOTUMOR CEREBRI), hallucinations, headache, insomnia, nightmares, paranoia, peripheral neuropathy, SEIZURES, SUICIDAL THOUGHTS, toxic psychosis, tremor

Misc: HYPERSENSITIVITY REACTIONS (INCLUDING ANAPHYLAXIS)

Interactions ⬆ ⬇

Drug-drug:

Concurrent use ofamiodarone, disopyramide, erythromycin, procainamide, dofetilide, quinidine, some antipsychotics, sotalol, or tricyclic antidepressants↑ risk of torsade de pointes in susceptible individuals (avoid concurrent use).
May ↑ risk of bleeding with warfarin.
Iron supplements and aluminum-, calcium-, or magnesium-containing antacids, bismuth subsalicylate, sucralfate, multivitamins with zinc↓ absorption (take at least 2 hr before or 4 hr).
Serum levels of fluoroquinolones may be ↓ by antineoplastics.
Cimetidine may interfere with elimination of fluoroquinolones.
May ↑ risk of nephrotoxicity from cyclosporine.
Concurrent corticosteroid therapy may ↑ risk of tendon rupture.
May ↑ risk of hypoglycemia when used with antidiabetic agents.

Route/Dosage ⬆ ⬇

PO IV (Adults ): Bacterial sinusitis: 400 mg once daily for 10 days; CAP: 400 mg once daily for 7–14 days. Acute bacterial exacerbation of chronic bronchitis: 400 mg once daily for 5 days. Complicated intra-abdominal infection: 400 mg once daily for 5–14 days. Skin/skin structure infections: 400 mg once daily for 7–21 days. Treatment/prevention of plague: 400 mg once daily for 10–14 days.

Availability ⬆ ⬇

(Generic available)

Tablets: 400 mg
Premixed infusion: 400 mg/250 mL 0.8% NaCl

Assessment ⬆ ⬇

Assess for infection (vital signs, appearance of sputum, WBC) at beginning of and during therapy.
Obtain specimens for culture and sensitivity prior to initiating therapy. First dose may be given before receiving results.
Observe patient for signs and symptoms of anaphylaxis (rash, pruritus, laryngeal edema, wheezing). Discontinue drug and notify health care professional immediately if these problems occur. Keep epinephrine, an antihistamine, and resuscitation equipment close by in case of an anaphylactic reaction.
Monitor bowel function. Diarrhea, abdominal cramping, fever, and bloody stools should be reported to health care professional promptly as a sign of
Clostridioides difficile
-associated diarrhea (CDAD). May begin up to several wk following cessation of therapy.
Assess for rash periodically during therapy. May cause Stevens-Johnson syndrome. Discontinue therapy if severe or if accompanied with fever, general malaise, fatigue, muscle or joint aches, blisters, oral lesions, conjunctivitis, hepatitis and/or eosinophilia.
Assess for signs and symptoms of peripheral neuropathy (pain, burning, tingling, numbness, and/or weakness or other alterations of sensation including light touch, pain, temperature, position sense, and vibratory sensation) periodically during therapy. Symptoms may be irreversible; discontinue moxifloxacin if symptoms occur.

Lab Test Considerations:

Monitor for ↑ serum AST, ALT, LDH, bilirubin, and alkaline phosphatase.
- May cause hyperglycemia, hyperlipidemia, and altered prothrombin time. It may also cause ↑ WBC; ↑ serum calcium, chloride, albumin, and globulin; and ↓ hemoglobin, RBCs, neutrophils, eosinophils, and basophils.
- May also cause ↑ or ↓ glucose. Monitor blood glucose, especially in diabetic patients. If hypoglycemia occurs, discontinue moxifloxacin.

Implementation ⬆ ⬇

PO: May be administered without regard to meals. Products or foods containing calcium, magnesium, aluminum, iron, or zinc should not be ingested for 4 hr before and 8 hr after administration.

IV Administration:

Intermittent Infusion: Diluent: Premixed bags are diluted in sodium chloride 0.8% and should not be further diluted. Use transfer set whose piercing pin does not require excessive force; insert with a gentle twisting motion until pin is firmly seated.Concentration: 1.6 mg/mL.
Rate: Administer over 60 min. Avoid rapid or bolus infusion.

Patient/Family Teaching ⬆ ⬇

Instruct patient to take medication as directed at evenly spaced times and to finish drug completely, even if feeling better. Take missed doses as soon as possible, unless within 8 hr of next dose. Do not double doses. Advise patient that sharing of this medication may be dangerous.
Encourage patient to maintain a fluid intake of at least 1500–2000 mL/day to prevent crystalluria.
Advise patient that antacids or medications containing calcium, magnesium, aluminum, iron, or zinc will decrease absorption and should not be taken within 4 hr before or 8 hr after taking this medication.
May cause dizziness and drowsiness. Caution patient to avoid driving or other activities requiring alertness until response to medication is known.
Advise patient to notify health care professional of any personal or family history of QTc prolongation or proarrhythmic conditions such as recent hypokalemia, significant bradycardia, or recent myocardial ischemia or if fainting spells or palpitations occur. Patients with this history should not receive moxifloxacin.
Caution patient to use sunscreen and protective clothing to prevent phototoxicity reactions during and for 5 days after therapy. Notify health care professional if a sunburn-like reaction or skin eruption occurs.
Advise patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and to consult with health care professional before taking other medications.
Advise patient to report signs of superinfection (furry overgrowth on the tongue, vaginal itching or discharge, loose or foul-smelling stools).
Instruct patient to notify health care professional if fever and diarrhea develop, especially if stool contains blood, pus, or mucus. Advise patient not to treat diarrhea without consulting health care professional.
Instruct patient to notify health care professional immediately if rash, jaundice, sign of hypersensitivity, or tendon (shoulder, hand, Achilles, and other) pain, swelling, or inflammation occurs. If tendon symptoms occur, avoid exercise and use of the affected area. Increased risk in >65 yr old, kidney, heart and lung transplant recipients, and patients taking corticosteroids concurrently. Therapy should be discontinued.
Advise patient to notify health care professional if pregnancy is planned or suspected or if breastfeeding.

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Pronunciation ⬇

Classifications ⬆ ⬇

Indications ⬆ ⬇