Azithromycin and levofloxacin both have cardiovascular risk (cardiac arrhythmia) as compared to other fluoroquinolones and amoxycillin. In that case we can use second or third generation cephalosporins (Cefaclor, Cefuroxim or Cefixim), high dose combination therapy of trimethoprim & sulfomethoxazole for RTI (specific to upper/lower). Since azithromycin is a large molecule it is better to replace with a suitable alternative. If others are resistant then the risk benefit ratio assessment may be the matter of consideration. Azithromycin is also indicated against S. typhi and paratyphi,  skin infections, ear infections, STD, pneumonia, tonsillitis, and sore throat where for all cases we can replace an alternative.

Fluoroquinolones have other restrictions due to their safety profile that prevent their use in pediatric population. Personally my first choice would be a good old beta lactam antibiotic, you name it.

 In addition azithormycin as well as other macrolides have shown synergistic effects with beta lactams.

I would restrict the use of fluoroquinolone to multidrug resistant strains.

Dear Md. Jahir Alam & Stefano Biondi

That's the point we need an alternative to ensure both safety, efficacy and less chances for growing resistance. Azithromycin is gradually losing its efficacy over the time and the extent of resistance is becoming larger due to frequent use in almost least required symptoms!

If you look towards gemifloxacin, which is highly active than any other fluoroquinolone and has the least or very low extent of resistance due to its higher affinity to bind & inhibit bacterial topoisomerase-IV (5 times more affinity than ciprofloxacin) and has strong activity to eradicate RTI causing pathogens than any other fluoroquinolones (e.g. gatifloxacin, moxifloxacin). Even the activity is higher than that of cefuroxime+clavulanate in case of super-infections. It is also established that single gemifloxacin therapy ensures more clinical success than cefriaxone & cefuroxime switch therapy in community acquired pneumonia.

Now the question, is gemifloxacin is safe enough??? As Stefano Biondi cited, it isn't safe in pediatrics. For the adults the safety is almost safe as cefuroxime that indicates we can use it adults with confidence.

It's also true that gemifloxacin can't cover the all indications of azithromycin. That's why I said only for RTIs. USFDA also recommended gemifloxacin as the effective treatment option for AECB & CAP.

My question to Stefano Biondi, do you think that the using of fluoroquinolones to multidrug resistant strains can result in the resistance of fluoroquinoloes too to the pathogens?

With regards,

Arjya

Dear Arjya,

today the urgent unmet medical need is multidrug resistant gram negatives expecially in HAP and VAP. The antibiotic stewardship is trying to spare antibiotics in an attempt to prolongue their efficacy by delaying resistance. There is no doubt that resistance will emerge, is just a matter of time, and cross resistance among different families of quinolones is highly likely, especially for efflux mechanisms.

Personally I have no problems in using fluoroquinolone apart the above mentioned restrictions especially if an antibiotic cycling procedure is applied.