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