Risk of aortic aneurysm and aortic dissection with the use of fluoroquinolones in Korea: a nested case–control study

Safety of fluoroquinolones

Fluoroquinolones (FQs) are one of the most commonly prescribed classes of antibiotics. Although they were initially well tolerated in randomized clinical trials, subsequent epidemiological studies have reported an increased risk of threatening, severe, long-lasting, disabling and irreversible adverse effects (AEs), related to neurotoxicity and collagen degradation, such as tendonitis, Achilles tendon rupture, aortic aneurysm, and retinal detachment. This article reviews the main potentially threatening AEs, the alarms issued by regulatory agencies and therapeutic alternatives.

Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms

OBJECTIVE

The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with aneurysms of the abdominal aorta and iliac arteries in succession to the 2011 and 2019 versions, with the aim of assisting physicians and patients in selecting the best management strategy.

METHODS

The guideline is based on scientific evidence completed with expert opinion on the matter. By summarising and evaluating the best available evidence, recommendations for the evaluation and treatment of patients have been formulated. The recommendations are graded according to a modified European Society of Cardiology grading system, where the strength (class) of each recommendation is graded from I to III and the letters A to C mark the level of evidence.

RESULTS

A total of 160 recommendations have been issued on the following topics: Service standards, including surgical volume and training; Epidemiology, diagnosis, and screening; Management of patients with small abdominal aortic aneurysm (AAA), including surveillance, cardiovascular risk reduction, and indication for repair; Elective AAA repair, including operative risk assessment, open and endovascular repair, and early complications; Ruptured and symptomatic AAA, including peri-operative management, such as permissive hypotension and use of aortic occlusion balloon, open and endovascular repair, and early complications, such as abdominal compartment syndrome and colonic ischaemia; Long term outcome and follow up after AAA repair, including graft infection, endoleaks and follow up routines; Management of complex AAA, including open and endovascular repair; Management of iliac artery aneurysm, including indication for repair and open and endovascular repair; and Miscellaneous aortic problems, including mycotic, inflammatory, and saccular aortic aneurysm. In addition, Shared decision making is being addressed, with supporting information for patients, and Unresolved issues are discussed.

CONCLUSION

The ESVS Clinical Practice Guidelines provide the most comprehensive, up to date, and unbiased advice to clinicians and patients on the management of abdominal aorto-iliac artery aneurysms.

Lack of association between fluoroquinolone and aortic aneurysm or dissection

BACKGROUND AND AIMS

An increased risk of aortic aneurysm and aortic dissection (AA/AD) has been reported with fluoroquinolone (FQ) use. However, recent studies suggested confounding factors by indication. This study aimed to investigate the risk of AA/AD associated with FQ use.

METHODS

This nationwide population-based study included adults aged ≥20 years who received a prescription of oral FQ or third-generation cephalosporins (3GC) during outpatient visits from 2005 to 2016. Data source was the National Health Insurance Service reimbursement database. The primary outcome was hospitalization or in-hospital death with a primary diagnosis of AA/AD. A self-controlled case series (SCCS) and Cox proportional hazards model were used. Self-controlled case series compared the incidence of the primary outcome in the risk period vs. the control periods.

RESULTS

A total of 954 308 patients (777 109 with FQ and 177 199 with 3GC use) were included. The incidence rate ratios for AA/AD between the risk period and the pre-risk period were higher in the 3GC group [11.000; 95% confidence interval (CI) 1.420-85.200] compared to the FQ group (2.000; 95% CI 0.970-4.124). The overall incidence of AA/AD among the patients who received FQ and 3GC was 5.40 and 8.47 per 100 000 person-years. There was no significant difference in the risk between the two groups (adjusted hazard ratio 0.752; 95% CI 0.515-1.100) in the inverse probability of treatment-weighted Cox proportional hazards model. Subgroup and sensitivity analysis showed consistent results.

CONCLUSIONS

There was no significant difference in the risk of AA/AD in patients who were administered oral FQ compared to those administered 3GC. The study findings suggest that the use of FQ should not be deterred when clinically indicated.

Oral fluoroquinolones and risk of aortic aneurysm or dissection: A nationwide population-based propensity score-matched cohort study

STUDY OBJECTIVE

To investigate risk of aortic aneurysm or dissection in patients using oral fluoroquinolones compared to those using macrolides in real-world clinical practice among a large US general population.

DESIGN

Retrospective cohort study design.

DATA SOURCE

MarketScan commercial and Medicare supplemental databases.

PATIENTS

Adults patients with at least one prescription fill for fluoroquinolone or macrolide antibiotics.

INTERVENTION

Fluoroquinolone or macrolide antibiotics.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was estimated incidence of aortic aneurysm or dissection associated with the use of fluoroquinolones compared with macrolides during a 60-day follow-up period in a 1:1 propensity score-matched cohort. We identified 3,174,620 patients (1,587,310 in each group) after 1:1 propensity score matching. Crude incidence of aortic aneurysm or dissection was 1.9 cases per 1000 person-years among fluoroquinolone users and 1.2 cases per 1000 person-years among macrolide users. In multivariable Cox regression, compared with macrolides, the use of fluoroquinolones was associated with an increased risk of aortic aneurysm or dissection (aHR: 1.34; 95% CI: 1.17-1.54). The association was primarily driven by a high incidence of aortic aneurysm cases (95.8%). Results of sensitivity (e.g., fluoroquinolone exposure ranging from 7 to 14 days (aHR: 1.47; 95% CI: 1.26-1.71)) and subgroup analyses (e.g., ciprofloxacin (aHR: 1.26; 95% CI: 1.07-1.49) and levofloxacin (aHR: 1.44; 95% CI: 1.19-1.52)) remained consistent with main findings.

CONCLUSIONS

Fluoroquinolone use was associated with a 34% increased risk of aortic aneurysm or dissection compared with macrolide use among a general US population.

A single dose of ciprofloxacin reduces the duration of diarrhea among service members deployed in Africa

OBJECTIVES

To assess the effectiveness of the adjunction of a one-gram single dose of ciprofloxacin to a symptomatic treatment for the early treatment of uncomplicated diarrhea during military operations of the French service members in Africa.

PATIENTS AND METHODS

This phase IV, multicentric, randomized, open-label, controlled trial was conducted in Chad, Mali, and in Central African Republic. A total of 267 French service members having at least one loose stool in the previous 24 hours were enrolled from May 2015 to June 2016. Participants were randomized to receive ciprofloxacin 1 g and a symptomatic treatment (racecadotril 100 mg three times a day and ad libidum oral rehydration solution) or a symptomatic treatment alone. The primary outcome was the duration of the diarrhea. Secondary outcomes were evaluated at the 72-hour endpoint and included recovery status, number of loose stools, frequency and duration of associated symptoms and safety of treatments.

RESULTS

Among 267 participants, 242 completed the trial. Participants receiving ciprofloxacin and a symptomatic treatment (n = 124) were significantly more likely to be cured at the endpoint than those who only received a symptomatic treatment (118): 94.4 % versus 74.6 % (OR = 5.7; 95 %CI: [2.4-13.6]; p < 10^-3). The antibiotic therapy reduced the average diarrhea duration by 30 % (p = 10^-4). Fever at inclusion was associated with a longer episode (HR = 0.61; 95 %CI: [0.41-0.89]; p = 0.012). No adverse event of medications was reported.

CONCLUSION

A single dose of ciprofloxacin was effective and safe in treating uncomplicated diarrhea among service members in Africa.

Do fluoroquinolones increase aortic aneurysm or dissection incidence and mortality? A systematic review and meta-analysis

Objective

The aim of this study was to determine the association between fluoroquinolones (FQs) use, the risk of de novo aortic aneurysm or dissection (AAD), and the prognosis of patients with pre-existing AAD.

Materials and methods

We searched PubMed, EMBASE, CENTRAL, Scopus, and Web of Science on 31 March 2022. Observational studies that evaluated the association of FQs with AAD risk in the general population or FQs with the prognosis of patients with preexisting AAD and presented adjusted effect estimates were included. Two reviewers assessed study eligibility, extracted data, and assessed the risk of bias and certainty of evidence using GRADE.

Results

Of the 13 included studies, 11 focused on the association of FQs with de novo AAD incidence, and only one study investigated the association of FQs with the patient with AAD prognosis. FQ use was associated with an increased risk of de novo AAD within 30 days (RR: 1.42; 95% CI: 1.11–1.81; very low certainty) and 60 days (RR: 1.44; 95% CI: 1.26–1.64; low certainty). Specifically, the association was significant when compared with amoxicillin, azithromycin, doxycycline, or no antibiotic use. Furthermore, patients with preexisting AAD exposure to FQ had an increased risk of all-cause mortality (RR: 1.61; 95% CI: 1.50–1.73; moderate certainty) and aortic-specific mortality (RR: 1.80; 95% CI: 1.50–2.15; moderate certainty), compared to the non-exposed FQ group within a 60-day risk period.

Conclusion

FQs were associated with an increased incidence of AAD in the general population and a higher risk of adverse outcomes in patients with preexisting AAD. Nevertheless, the results may be affected by unmeasured confounding factors. This should be considered by physicians contemplating using FQs in patients with aortic dilation and those at high risk of AAD.

Systematic Review Registration

[https://www.crd.york.ac.uk/prospero/], identifier [CRD42021230171].