To : Jeanne Mitchell
Re : Levaquin
Levofloxacin is a pure (S) enantiomer of the racemic fluoroquinolone Ofloxacin.
So in essence it one of the active ingredients in Ofloxacin. Ofloxacin breast
milk levels have been published and are low. Levaquin kinetics including milk
levels should be identical. Breastmilk concentrations of ofloxacin are reported
equal to maternal plasma levels, so a Milk/Plasma ratio of 1 is to be expected,
but remember if the plasma levels are low, so too are milk levels. In one study
in lactating women who received 400 mg oral doses twice daily, drug
concentrations in breastmilk averaged 0.05-2.41 mg/L in milk at 24 hours and 2
hours post-dose respectively.
I calculate the Theoretic Peak Infant Dose to be 0.4 mg/Kg/day. The actual
dose would probably be much less throughout the day.
In pediatric patients, fluoroquinolone antibiotics are generally contraindicated
because of a theoretical risk of arthropathy (swelling of the synovium). But
this is so unusual, and generally has only been seen in Cystic Fibrosis patients
receiving huge oral doses, that its not even reasonable to assume it would occur
in an infant receiving small doses via milk.
Secondly, the only other risk (slight) is a change in gut flora, diarrhea and a
remote risk of overgrowth of C. Difficle. This has been reported in only one
infant receiving ciprofloxacin, but as you all know, can occur with any
antibiotic. Ofloxacin levels in breastmilk are consistently lower (37%) than
ciprofloxacin. If a fluoroquinolone is required, ofloxacin, levofloxacin, or
norfloxacin are probably the better choices for breastfeeding mothers.
So I'm not overly concerned about mothers breastfeeding using ofloxacin,
levofloxacin, or norfloxacin if the doses are moderate, the infant is reasonably
stable, and the mom observes for a bad diarrhea. In older infants, the risk
should be even less.
Regards
Tom Hale, Ph.D.
Associate Professor of Pediatrics
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