Use With Caution Dangers of Common Antibiotics
Abstract & Commentary
By Joseph E. Scherger, MD, MPH, Dr. Scherger reports no financial relationships relevant to this field of study.
Synopsis: Dangers of antibiotics are well known and recent research brings to light new dangers of commonly used medications. Five days of azithromycin results in 47 additional deaths from cardiovascular disease compared with amoxicillin and no antibiotic. One out of 2500 patients treated with a fluoroquinolone (ciprofloxacin, levofloxacin, and norfloxacin) suffer a retinal detachment. These antibiotics should be used only when there is a clear clinical need and with caution.
Sources: Ray WA, et al. Azithromycin and the risk of cardiovascular death. N Engl J Med 2012;366:1881-1890. Etminan M, et al. Oral fluoroquinolones and the risk of retinal detachment. JAMA 2012;307:1414-1419.
We all know we must use antibiotics with caution, especially those with potential complications such as drug resistance and colitis. Allergies from antibiotics can be life-threatening in some extreme cases. These two studies are of particular interest since they are about drugs used very commonly today. Ciprofloxacin is given for many urinary tract infections and as a travel medication on request. Azithromycin, in its convenient Z-pack, is very popular for respiratory infections, including bronchitis, which is usually a self-limited viral infection.
The study of azithromycin was from a Tennessee Medicaid cohort of patients to detect an increased risk of death related to short-term cardiac effects of medications. The cohort that took azithromycin was 347,795 prescriptions and the control group was 1,392,180. More than 1 million patients taking amoxicillin, 264,626 taking ciprofloxacin, and 193,906 taking levofloxacin were also included in the study. For those taking azithromycin, the hazard ratio for cardiovascular death was 2.88, compared with the other groups.
While overall there were 47 additional deaths per 1 million users of azithromycin, those with higher risk of cardiovascular disease were at greater risk of death, with an estimated 245 additional deaths per 1 million users in the highest decile of risk. The additional deaths began to appear within 2 days of the prescription being filled and continued for 10 days.
The fluoroquinolone study was a case-control cohort analysis of patients in British Columbia, Canada, who visited an ophthalmologist between 2000 and 2007 for a retinal detachment. From a cohort of 989,591 patients, 4384 cases of retinal detachment and 43,840 controls were identified. The hazard ratio for retinal detachment with current use of a fluoroquinolone antibiotic was 4.50, with one additional case per 2500 patients.
Commentary
While both events, cardiovascular death with azithromycin and retinal detachment with a fluoroquinolone, are uncommon, the risk should make us and our patients pause. I have already used these studies to discourage antibiotic use for frivolous reasons, such as an apparent viral infection. Taking the time to counsel patients about antibiotic use pays dividends in patient confidence in our knowledge base and concern for their welfare. Warnings are more patient-centered compared with just saying "no." While some patients may resist taking antibiotics when they really need them, we are best suited to put the risks and benefits of antibiotics into proper perspective. Our role in prescribing is best when we serve as the patient's consultant rather than giving potentially dangerous medications by reflex or simple request.
Dangers of antibiotics are well known and recent research brings to light new dangers of commonly used medications. Five days of azithromycin results in 47 additional deaths from cardiovascular disease compared with amoxicillin and no antibiotic. One out of 2500 patients treated with a fluoroquinolone (ciprofloxacin, levofloxacin, and norfloxacin) suffer a retinal detachment. These antibiotics should be used only when there is a clear clinical need and with caution.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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