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Hypoglycemia, sometimes resulting in coma, can occur. Disturbances of blood glucose, including hyperglycemia and hypoglycemia, have been reported in patients treated concomitantly with quinolones and an antidiabetic agent. Chelation of divalent cations with levofloxacin is less than with other quinolones. The duration of therapy is 7 to 14 days for patients with CD4 count of 200 cells/mm3 or more without bacteremia, 14 days for patients with CD4 count of 200 cells/mm3 or more and bacteremia, and 2 to 6 weeks for patients with CD4 count less than 200 cells/mm3. Based on the study results, these authors recommended that back-up contraception may not be necessary if OCs are used reliably during oral antibiotic use. Paliperidone: (Major) Concurrent use of paliperidone and levofloxacin should be avoided if possible due to an increased risk for QT prolongation and torsade de pointes (TdP). Disturbances of blood glucose, including hyperglycemia and hypoglycemia, have been reported in patients treated concomitantly with quinolones and an antidiabetic agent. Levofloxacin is recommended as an alternative therapy for postexposure prophylaxis. Calcium Gluconate: (Major) Administer oral products that contain calcium at least 2 hours before or 2 hours after orally administered levofloxacin. Antibiotics are non-selective and may result in the eradication of beneficial microorganisms while promoting the emergence of undesired ones, causing secondary infections such as oral thrush, colitis, or vaginitis. Discontinue the quinolone if a hypoglycemic reaction occurs and initiate appropriate therapy immediately. If coadministration is necessary, ECG monitoring is recommended; closely monitor the patient for QT interval prolongation. Ranolazine is associated with dose- and plasma concentration-related increases in the QTc interval. Levofloxacin is recommended as an alternative therapy for postexposure prophylaxis. Hold panobinostat if the QTcF increases to >= 480 milliseconds during therapy; permanently discontinue if QT prolongation does not resolve. NSAIDs in combination with very high doses of quinolones have been shown to provoke convulsions in preclinical studies and postmarketing. 750 mg PO every 24 hours is recommended by the CDC as alternative therapy; add an aminoglycoside for bacteremia. Vemurafenib has also been associated with QT prolongation. Ertugliflozin; Sitagliptin: (Moderate) Monitor blood glucose carefully when systemic quinolones and antidiabetic agents, including dipeptidyl peptidase-4 inhibitors, are coadministered. Levofloxacin absorption may be reduced as quinolone antibiotics can chelate with sucralfate. Almost all antibacterial agents, including levofloxacin, have been associated with pseudomembranous colitis (antibiotic-associated colitis), which may range in severity from mild to life-threatening. Sulfonylureas: (Moderate) Monitor blood glucose carefully when systemic quinolones and antidiabetic agents, including sulfonylureas, are coadministered. 6 to 11 months: 16 mg/kg/day PO/IV is FDA-approved dosage; however, doses up to 20 mg/kg/day PO/IV have been used off-label.1 to 5 months: Safety and efficacy have not been established; however, doses up to 20 mg/kg/day PO/IV have been used off-label. Discontinue quinolone therapy at the first sign of tendon inflammation or tendon pain, as these are symptoms that may precede rupture of the tendon. Glipizide; Metformin: (Moderate) Monitor blood glucose carefully when systemic quinolones and antidiabetic agents, including metformin, are coadministered. Based on the study results, these authors recommended that back-up contraception may not be necessary if OCs are used reliably during oral antibiotic use. If patients experience tendon inflammation or pain, they should rest and refrain from exercise until the diagnosis of tendonitis or tendon rupture has been confidently excluded. The MICs are defined for MSSA by the FDA as susceptible at 2 mcg/mL or less, intermediate at 4 mcg/mL, and resistant at 8 mcg/mL or more; however the MICs are defined for Staphylococcus sp. Lofexidine: (Major) Monitor ECG if lofexidine is coadministered with levofloxacin due to the potential for additive QT prolongation and torsade de pointes (TdP). NSAIDs in combination with very high doses of quinolones have been shown to provoke convulsions in preclinical studies and postmarketing. Levofloxacin has been associated with a risk of QT prolongation and TdP. Levofloxacin has been associated with a risk of QT prolongation and torsade de pointes (TdP). Discontinue the quinolone if a hypoglycemic reaction occurs and initiate appropriate therapy immediately. Disturbances of blood glucose, including hyperglycemia and hypoglycemia, have been reported in patients treated concomitantly with quinolones and an antidiabetic agent. Magnesium Sulfate; Potassium Sulfate; Sodium Sulfate: (Major) Administer quinolones at least 2 hours before or 6 hours after administration of magnesium sulfate; potassium sulfate; sodium sulfate. Evidence supporting sustained injury to developing joints in humans is lacking at this time; however, the possibility of rare occurrences has not been excluded. Metformin; Repaglinide: (Moderate) Monitor blood glucose carefully when systemic quinolones and antidiabetic agents, including meglitinides, are coadministered. Chelation of divalent cations with levofloxacin is less than with other quinolones. The absorption of quinolones may be reduced by chelation with magnesium sulfate. One retrospective study reviewed the literature to determine the effects of oral antibiotics on the pharmacokinetics of contraceptive estrogens and progestins, and also examined clinical studies in which the incidence of pregnancy with OCs and antibiotics was reported. Discontinue the quinolone if a hypoglycemic reaction occurs and initiate appropriate therapy immediately. Calcium: (Major) Administer oral products that contain calcium at least 2 hours before or 2 hours after orally administered levofloxacin. Levofloxacin has also been associated with a risk of QT prolongation and torsade de pointes (TdP). Initiate appropriate therapy and perform follow-up testing as recommended based upon sexually transmitted disease diagnosis. Levofloxacin is bactericidal via inhibition of DNA gyrase (topoisomerase II), an enzyme responsible for counteracting the excessive supercoiling of DNA during replication or transcription and topoisomerase IV, an enzyme that helps separate the daughter DNA molecules. If use together is necessary, obtain an ECG at baseline to assess initial QT interval and determine frequency of subsequent ECG monitoring, avoid any non-essential QT prolonging drugs, and correct electrolyte imbalances. Sunitinib can prolong the QT interval. Although extremely rare, TdP has been reported during postmarketing surveillance of levofloxacin. Systemic quinolones cause arthropathy in juvenile animals of several species. Lefamulin has a concentration dependent QTc prolongation effect. Disturbances of blood glucose, including hyperglycemia and hypoglycemia, have been reported in patients treated concomitantly with quinolones and an antidiabetic agent. Levofloxacin has been associated with a risk of QT prolongation and TdP. Methylprednisolone: (Moderate) Quinolones have been associated with an increased risk of tendon rupture requiring surgical repair or resulting in prolonged disability; this risk is further increased in those receiving concomitant corticosteroids. Ibuprofen: (Moderate) Use quinolones and nonsteroidal anti-inflammatory drugs (NSAIDs) concomitantly with caution due to potential increased risk of CNS stimulation and convulsive seizures. Budesonide; Formoterol: (Moderate) Quinolones have been associated with an increased risk of tendon rupture requiring surgical repair or resulting in prolonged disability; this risk is further increased in those receiving concomitant corticosteroids. Although extremely rare, TdP has been reported during postmarketing surveillance of levofloxacin. In a nested, case-control study (n = 87,020 controls; 8,702 cases) within the Quebec Pregnancy Cohort, quinolone use during early pregnancy was associated with an increased risk of spontaneous abortion (adjusted odds ratio (aOR) 2.72; 95% CI: 2.27 to 3.27; 160 exposed cases); residual confounding by severity of infection may be a potential limitation of this study. Additional prophylaxis to complete an antimicrobial course of up to 60 days may be required. Another review concurred with these data, but noted that individual patients have been identified who experienced significant decreases in plasma concentrations of combined OC components and who appeared to ovulate; the agents most often associated with these changes were rifampin, tetracyclines, and penicillin derivatives. For systemic infection without CNS involvement, dual combination IV therapy with levofloxacin and a protein synthesis inhibitor (i.e., clindamycin, linezolid, doxycycline) or rifampin is recommended. Levofloxacin has also been associated with prolongation of the QT interval and infrequent cases of arrhythmia. Levofloxacin has been associated with prolongation of the QT interval and infrequent cases of arrhythmia. 500 mg PO once daily plus clarithromycin or azithromycin and ethambutol. (Moderate) Monitor blood glucose carefully when systemic quinolones and antidiabetic agents, including thiazolidinediones, are coadministered. NSAIDs in combination with very high doses of quinolones have been shown to provoke convulsions in preclinical studies and postmarketing. Although extremely rare, TdP has been reported during postmarketing surveillance of levofloxacin. Semaglutide: (Moderate) Monitor blood glucose carefully when systemic quinolones and antidiabetic agents, including incretin mimetics, are coadministered. Administering rilpivirine with levofloxacin cytarabine and daunorubicin chelation by the CDC as therapy! 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