According to the current World Health Organization (WHO) guidelines (2016 update), fluoroquinolones including moxifloxacin, gatifloxacin, and levofloxacin are important second-line anti-tuberculosis (anti-TB) agents.¹ A review of existing literature conducted by a group of researchers from The Netherlands suggested that these fluoroquinolones remain as core agents in case of resistance or intolerance against first-line anti-TB drugs.²

The biggest threat towards TB elimination is the increase of resistance against anti-TB agents. The latest WHO report recorded more than half a million rifampicin-resistant (RR) Mycobacterium tuberculosis (MTB) infections; while TB cases resistant against almost all second-line anti-TB agents have been reported in Italy, Iran and India.²

A clinical trial conducted in South Korea between 2010 and 2012 reported that moxifloxacin and levofloxacin (750 mg/day) were equally effective for multidrug-resistant (MDR) TB treatment success.³ An individual patient data meta-analysis has shown the association of treatment success with the incorporation of moxifloxacin or levofloxacin in a MDR/RR-TB regimen.⁴ In addition, in a 2018 rapid communication published by WHO, moxifloxacin or levofloxacin have remained as core agents in the conventional MDR/RR-TB treatment regimen.⁵

On the other hand, the use of moxifloxacin or levofloxacin for TB meningitis is based on its favourable penetration into cerebrospinal fluid (CSF).² An open-label randomised control trial observed a significant survival benefit for patients with TB meningitis treated with levofloxacin (10 mg/kg/day, maximum 500 mg/day) as compared to rifampicin, isoniazid, pyrazinamide, and ethambutol.⁶ Another sub-group analysis has also shown a lower 9-month mortality and survival benefit for patients with isoniazid-resistant TB meningitis using a combination of levofloxacin and rifampicin.^7,8

With the comprehensive summary of studies investigating the outcome of fluoroquinolone-containing treatment regimens for TB, the researchers concluded that moxifloxacin, levofloxacin, and gatifloxacin remain important second-line anti-TB agents. They also proposed the incorporation of extended pharmacokinetic/pharmacodynamic analysis into the drug development process as well as concentration-guided dosing to ensure treatment success.

Source

The role of fluoroquinolones in the treatment of tuberculosis in 2019.

PMID: 30617959

DOI: 10.1007/s40265-018-1043-y

Link: https://www.ncbi.nlm.nih.gov/pubmed/30617959

References

1. Falzon D, et al. Eur Respir J 2017;49:1602308.
2. Pranger AD, et al. Drugs 2019;79:161-171.
3. Kang YA, et al. Ann Am Thorac Soc 2016;13:364-370.
4. Ahmad N, et al. Lancet 2018;392:821-834.
5. World Health Organization. Rapid communication: Key changes to treatment of multidrug- and rifampicin-resistant tuberculosis (MDR/RR-TB). Available at: https://www.who.int/tb/publications/2018/rapid_communications_MDR/en/. Accessed 7 March 2019.
6. Kalita J, et al. J Antimicrob Chemother 2014;69:2246-2251.
7. Heemskerk AD, et al. N Engl J Med 2016;374:124-134.
8. Heemskerk AD, et al. Clin Infect Dis 2017; 65:20-28.