tendon ruptures and antibiotics

The travel doc I visited for travel meds before a trip to Nepal a few years ago would not even consider Cipro. At the time, I vaguely remember him saying something about it having fallen out of favor. Instead, he perscribed Azithromycin as the broad-spectrum antibiotic of choice.

don't post much any more but as a Nurse Practitioner UC/ED now, but having done research in urinary tract infections/Pyelonephritis where cipro is still a important drug I have about .5 cents of a opinion here. Tendon concerns has been long known as you have pointed out. Admittedly quinolones's use and patient groups such as represented by this board is a small subset to get good data on and I do not recall any studies with this group.

  I know ortho folks how do not like it because of the studies out with cipro and elderly that we have extrapolated to other groups (similar issue ibuprofen and bone healing/fractures) and a lot of ED folks do lean away from quinolone's in active folks just because. I had a ultrasound course last year and the cumulative exposure question was brought but no one in the group had heard of any data one way or another either.

   Problem is it is a drug of choice for atypical pneumonia's and for folks allergic to sulfa drugs. I like it though when patients come in questioning antibiotic choices, and even the need for them. It's generally though not a real common drug to be used anymore except for the aforementioned patient groups ( and I am sure something else that I do not recall at this moment).

somewhat different angle from the New York TImes article linked, (that I liked by the way) is another view about antibiotics.

www.kevinmd.com/blog/2012/08/doctors-pre...ibiotics-simple.html

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The issue of tendonitis and tendon rupture has been frequently documented in the medical literature with quinolone antibiotics such as levofloxacin and ciprofloxacin. It is an uncommon problem on the order of 0.5 cases/100,000 people treated with ciprofloxacin and 0.6 cases/100,000 people treated with levofloxacin treated although as a previous post noted, these studies focus on a broader population than the fit, active people posting on this site. Even in this groups it would not be a common problem.The risk is higher in the elderly and higher in those who are using corticosteroids.  On average, symptoms come on within about 2 weeks of taking the drug although in some cases (much less commonly) they have occurred up to 3-4 months later. The most commonly affected tendon group is the achilles tendons. Shoulder and hands can also be affected. On a quick literature search, I can't actually find any published case reports of a quadriceps rupture attributed to this class of antibiotics.

The quinolones are actually useful antibiotics for many situations. Like any antibiotic, they need to be used in the appropriate situations. Fortunately, for many problems that need to be treated with antibiotics there are typically alternatives that can be used. For example, for pneumonia that is treated as an outpatient, rather than using levofloxacin, most people can be treated with azithromycin or doxycycline. Depending on someone's allergy profile, there may not be other good options and these drugs may be needed.

They are still seen as one of the first line agents for treatment of traveler's diarrhea in the developing world and you will get different opinions in travel clinics as to whether to use them. The one case mentioned above of a travel clinic practitioner saying no to them in all circumstances would be anecdotal and not consistent practice across all travel clinics. In some parts of the world, such as SE Asia, azithromycin is being used as a first line treatment for this issue rather than flouroquinolones, not because of the tendon rupture issue but because of the fact that some of the bacteria causing this problem are showing fluoroquinolone resistance.

A good moral to take home from this is to be careful with your antibiotic use, in general, and not use them unless really warranted. There is, for example, often an expectation when people go to a physician's office for a productive cough or cold that has "gone to their chest" that they are going to leave with an antibiotic. Time crunched physicians are often too willing to write the prescription rather than take the time to counsel that they're not needed. In many cases, they are, in fact, not needed and will be of no benefit. The problem, which is often just a viral syndrome for example, would just go away on its own in the absence of antibiotics. Because the antibiotics sometimes get used inappropriately though, the perception is that they worked so the expectation the next time this occurs is that antibiotics will get used again.

Be careful to ask whether an antibiotic is really needed in the particular situation and, if you're concerned about the issue of tendon problems, be sure to ask whether there are any alternatives to this class of medications.  If you use these antibiotics, stop them if you develop tendon pain and hold off on heavy exercise until tendonitis is ruled out.

Wow! such a knowledge base here. I'm impressed.

TGR forums are full of dentists and TAY's are full of male nurses.! Shoulda guessed!

Kidding/.

Good advice. I avoid antibiotics at all cost and constantly nag my wife and co-workers that the "pill popping for everything" which is common to American heath care( and not so prevalent IMO in other developed countries) is a major problem.

Class action suit anybody.?PNWBrit ( Banned) works for a class action firm and coulda helped us get some dough here. Damn!

I performed bench top lab research on Cipro (testing its effectiveness against MRSA bacteria) as a medical student just prior to its receiving FDA approval.   Cipro was the first of the Quinolone class of antibiotics.  Quinolones are not approved for use in children because they disrupt cartilage formation in beagle puppies.  (Take a moment to thank the puppies that sacrificed their joints for our scientific knowledge.)  This drug class must somehow interfere with synthesis of collagen, or some other component of connective tissue.  The effect in adults is likely too subtle for most sedentary individuals to notice.  5.12 rock climbers, TAY skiers, that's another story.

It is harder to say if quinolones statistically make an Achilles rupture more likely.  Lots of weekend warriors not on antibiotics get Achilles ruptures in their 30s and 40s.  In my experience, the most common mechanism is jumping up for a rebound in basketball: the rupture happens on the jump, not the landing.  A class action suit for all the Achilles rupture cases seems questionable in my opinion.  Then again I'm a doctor, not a lawyer.

Having said that, even if the relative risk is slight, why take it?  Alternatives are almost always available.  Even a prolonged and productive cough is usually not bacterial and antibiotics are not likely to help.  Don't seek antibiotics for sinus congestion until you've addressed every alternative diagnosis.  Many people demand Levaquin to treat their prolonged cough or sinus symptoms, in absence of objective findings to verify bacterial infection.  For travelers' diarrhea I prefer Azithromycin-- one dose cured me after a visit to Egypt in 2008.  If someone has a bladder or kidney infection and has allergies to Sulfa and other antibiotics, Cipro may be the ticket but rarely is a quinolone the only option.  For most other situations, there is more than one antibiotic to choose from, and if you're an active skier or (especially) rock climber, avoid quinolones.

I was prescribed a course of levofloxacin for a nasty sinus infection about nine months ago and both my achilles tendons became quite sore. At first they felt cold and stiff, they then began to sting and ache. I'd never had problems before. Fortunately the symptoms have cleared up.

About the same time, an otherwise healthy neighbor ruptured his achilles while on cipro. He was playing soccer.

My two cents.