Moxifloxacin is a fourth generation fluoroquinolone with expanded activity against gram-positive bacteria as well as atypical pathogens. Moxifloxacin has been linked to mild ALT elevations during therapy and to rare instances of idiosyncratic acute liver injury with symptoms and jaundice.
Moxifloxacin (mox" i flox' a sin) is a fourth generation fluoroquinolone with expanded activity against gram-positive bacteria including multidrug resistant strains of Streptococcus pneumoniae. Like other fluoroquinolones, moxifloxacin is active against a wide range of aerobic gram-positive and gram-negative organisms. The quinolones are believed to act by inhibition of type II DNA toposiomerases (gyrases) that are required for synthesis of bacterial mRNAs (transcription) and DNA replication. Moxifloxacin was approved for use in the United States in 1999 and is available generically and under the commercial names of Avelox, Moxeza and Vigamox. Current indications include mild-to-moderate bacterial infections such as sinusitis, bronchitis, community acquired pneumonia, skin infections, cellulitis, abcesses and complicated intraabdominal infections due to sensitive organisms. Moxifloxacin is available in formulations of 400 mg tablets, the usual dose being 400 mg daily for 5 to 14 days. Intravenous formulations are available for moderate to severe infections, the usual IV dosages being 400 mg daily. Common side effects include gastrointestinal upset, headaches, skin rash and allergic reactions. Less common but more severe side effects of the fluoroquinolones include prolongation of the QT interval, seizures, hallucinations, tendon rupture, angioedema and photosensitivity.
Moxifloxacin, like other fluoroquinolones, is associated with a low rate (1% to 3%) of serum enzyme elevations during therapy. These abnormalities are generally mild, asymptomatic and transient, resolving even with continuation of therapy. Moxifloxacin has been linked to rare but occasionally severe and even fatal cases of acute liver injury. The time to onset is typically short (1 day to 3 weeks) and the presentation is often abrupt with nausea, fatigue, abdominal pain and jaundice. The pattern of serum enzyme elevations can be either hepatocellular or cholestatic, cases with the shorter times to onset usually being more hepatocellular. In addition, the onset of illness may occur a few days after the medication is stopped. Many (but not all) cases have prominent allergic manifestations with fever and rash, and the liver injury may occur in the context of a generalized hypersensitivity reaction (Case 1). Autoantibodies are usually not present. Cases with a cholestatic pattern of enzymes may run a prolonged course but are usually self-limiting, although at least one case of chronic cholestatis and vanishing bile duct syndrome leading to liver failure has been published. Most reported cases have been mild with recovery within 4 to 8 weeks of onset.
Mechanism of Injury
The cause of hepatic injury is unknown, but appears to be hypersensitivity.
Outcome and Management
Mild-to-moderate injury should be followed by full recovery within 4 to 8 weeks. Fulminant cases and chronic cholestatic forms with vanishing bile duct syndrome have been described. Cross reactivity of the hepatic injury between different fluoroquinolones has not been demonstrated, but is suspected based upon the similarity of clinical patterns of injury and latency. Thus, patients who develop clinically apparent liver injury from moxifloxacin should be advised to avoid further exposure to the fluoroquinolones.
Case 1. Severe hypersensitivity reaction and hepatitis due to moxifloxacin therapy.
[Modified from Case 10 in: Orman ES, Conjeevaram HS, Vuppalanchi R, Freston JW, Rochon J, Kleiner DE, Hayashi PH; DILIN Research Group. Clinical and histopathologic features of fluoroquinolone-induced liver injury. Clin Gastroenterol Hepatol 2011; 9: 517-523. PubMed Citation]
A previously healthy 45 year old man was treated with moxifloxacin for suspected sinusitis and developed severe rash, facial edema and fever one week later. He was admitted with the diagnosis of Stevens Johnson syndrome and was treated with systemic and topical corticosteroids. He had a past medical history of allergic reactions of amoxicillin and erythromycin, but had not received fluoroquinolone antibiotics in the past. He had no history of liver disease, alcohol abuse or risk factors for viral hepatitis. He was taking ranitidine and an antihistamine but denied taking over-the-counter or herbal preparations. On admission, serum aminotransferase values were markedly elevated (~18 fold) and the day after he became jaundiced (Table). There was no eosinophilia or lymphocytosis. Tests for hepatitis A, B and C were negative as were autoantibodies. An abdominal ultrasound was normal except for somewhat echogenic texture of the liver suggesting fatty infiltration. He was treated with methylprednisolone and his skin rash and jaundice improved over three weeks. Ultimately, liver tests returned to normal values.
|Medication:|| Moxifloxacin, 400 mg daily|
|Pattern:|| Hepatocellular (R=11.4)|
|| 3+ (jaundice and hospitalization)
|| 10 days
|| Approximately 3 weeks
|Other medications:|| Antihistamines, ranitidine|
|Days After Starting
||Days After Stopping
||Alk P (U/L)
||Generalized rash with desquamation
This patient developed symptoms of generalized hypersensitivity approximately 9 days after starting moxifloxacin. He had an accompanying hepatitis and jaundice that was not severe. Some degree of hepatic involvement is common with severe hypersensitivity reactions to antibiotics, but usually the allergic manifestations dominate the clinical picture. Notice that the liver injury worsened for a week after stopping the implicated medication before beginning to resolve. The patient should be advised strongly to avoid further exposure to fluoroquinolone antibiotics.
REPRESENTATIVE TRADE NAMES
Moxifloxacin – Avelox®
Product labeling at DailyMed, National Library of Medicine, NIH
||CAS REGISTRY NO
References updated: 16 February 2014
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463-82. (Review of hepatotoxicity of antibiotics mentions that hepatocellular and cholestatic forms of injury have been reported due to the quinolones including cases of ductopenia, acute liver failure and death).
Petri WA Jr. The quinolones. Sulfonamides, trimethoprim-sulfamethoxazole, quinolones, and agents for urinary tract infections. In, Brunton LL, Chabner BA, Knollman BC, eds. Goodman & Gilman’s the pharmacological basis of therapeutics. 12th ed. New York: McGraw-Hill, 2011, pp. 1470-4. (Textbook of pharmacology and therapeutics).
Soto S, López-Rosés L, Avila S, et al. Moxifloxacin-induced acute liver injury. Am J Gastroenterol 2002; 97: 1853-4. PubMed Citation (69 year old man developed jaundice 3 weeks after completing a 5 day course of moxifloxacin for bronchitis [bilirubin 28.5 mg/dL, ALT 58 U/L, Alk P 249 U/L], resolving within 2 months of onset).
Moxifloxacin--a new fluoroquinolone antibacterial. Drug Ther Bull 2004; 42: 61-2. PubMed Citation (Concise review of moxifloxacin shortly after its approval in the United States states that it has no advantage over other, safer and less expensive antibiotics; ALT elevations mentioned as a potential side effect).
Nori S, Bebesio C, Brashear R, Travers JB. Moxifloxacin-associated drug hypersensitivity syndrome with toxic epidermal necrolysis and fulminant hepatitis failure. Arch Dermatol 2004; 140: 1537-8. PubMed Citation (23 year old woman developed fever, rash and abdominal pain 3 days after starting moxifloxacin [bilirubin 2.7 mg/dL, ALT 3453 U/L, lymphocytosis], with progression to toxic epidermal necrolysis and acute liver failure and death despite liver transplantation within 2 weeks).
Iannini PB. The safety profile of moxifloxacin and other fluoroquinolones in special patient populations. Curr Med Res Opin 2007; 23: 1403-13. PubMed Citation (Systematic review of the literature on the safety of moxifloxacin; serum enzyme elevations were reported in occur 2-3% of patients, but were usually mild and self-limited even with continuing therapy; clinically apparent liver injury has been reported with trovafloxacin, gatifloxacin, and levofloxacin, but not with moxifloxacin).
Van Bambeke F, Tulkens PM. Safety profile of the respiratory fluoroquinolone Moxifloxacin. Comparison with other fluoroquinolones and other antibacterial classes. Drug Safety 2009; 32: 359-78. PubMed Citation (Review of safety of moxifloxacin in comparison to other antibiotics and other fluoroquinolones; rare instances of acute liver failure have been attributed to moxifloxacin [0.7 per million prescriptions based upon FDA reporting rate]).
Franco Hidalgo S, Prieto de Paula JM, García Lorenzo R, Salado Valdivieso I. [Moxifloxacin and hepatic toxicity]. Gastroenterol Hepatol 2009; 32: 719-20. Spanish. PubMed Citation (44 year old man developed jaundice following a 4 day course of moxifloxacin for sinusitis [bilirubin 5.8 mg/dL, ALT 862 U/L, Alk P 421 U/L], resolving within one month of stopping).
Puerto Alonso JL, Díaz Souza P, Chamorro Mohedano J, Rojas Martín E. [Fatal acute hepatitis and cholestasis associated with liver disease]. Med Clin (Barc) 2010; 134: 375-6. Spanish. PubMed Citation (58 year old man devloped jaundice 1 week after completing a 5 day course of moxifloxacin [bilirubin 27 mg/dL, ALT 2589 U/L, Alk P 94 U/L, prothrombin index 36%], with progressive liver failure and death one month later).
Orman ES, Conjeevaram HS, Vuppalanchi R, Freston JW, Rochon J, Kleiner DE, Hayashi PH; DILIN Research Group. Clinical and histopathologic features of fluoroquinolone-induced liver injury. Clin Gastroenterol Hepatol 2011; 9: 517-523. PubMed Citation (Among 679 cases of drug induced liver injury presenting between 2004 and 2010 at 8 US medical centers, 12 [1.8%] were attributed to fluoroquinolones including 6 cipro-, 4 moxi-, 1 levo-, and 1 gati-floxacin; the average time to onset was 4 days [range 1-39], with both hepatocellular and cholestatic enzyme patterns, seven with rash or fever, mortality was limited to those with hepatocellular injury and jaundice; hepatic injury was class specific; moxifloxacin cases included 3 men,1 women, ages 45-71 years, onset after 1-7 days, 1 with fever and 2 with rash [bilirubin 0.9-5.3 mg/dL, ALT 220-1311 U/L, Alk P 253-837 U/L], one patient developed vanishing bile duct syndrome and underwent liver transplantation: Case 1).
Roberts CH, Smith C, Breen R, Gadhok R, Murphy M, Aryee A, Cropley I, et al. Hepatotoxicity in the treatment of tuberculosis using
moxifloxacin-containing regimens. Int J Tuberc Lung Dis 2011; 15: 1275-6.
PubMed Citation (Retrospective analysis of liver test abnormalities in 194 patients on tuberculosis therapies, found no increase in liver abnormalities with moxifloxacin based therapies).
Paterson JM, Mamdani MM, Manno M, Juurlink DN; Canadian Drug Safety and
Effectiveness Research Network. Fluoroquinolone therapy and idiosyncratic acute
liver injury: a population-based study. CMAJ 2012; 184: 1565-70. PubMed Citation (Population based, case control study of antibiotic exposure and subsequent hospitalization for liver injury within 30 days in elderly Canadian outpatients found weak associations with ciprofloxacin [adjusted odds ratio 1.56]), levofloxacin [2.06] and moxifloxacin [2.44], but not clarithromycin or cefuroxime).
Hayashi PH, Chalasani NP. Liver injury in the elderly due to fluoroquinolones: should these drugs be avoided? CMAJ 2012; 184: 1555-6. PubMed Citation (Editorial in response to Paterson  stressing the low absolute risk of liver injury from the fluoroquinolones [4-9 per 100,000 exposures]).
Björnsson ES, Bergmann OM, Björnsson HK, Kvaran RB, Olafsson S. Incidence,
presentation and outcomes in patients with drug-induced liver injury in the
general population of Iceland. Gastroenterology 2013; 144: 1419-25. PubMed Citation (In a population
based study of drug induced liver injury from Iceland, 96 cases were identified
over a 2 year period, including 26 due to antibiotics, but none were attributed to moxifloxacin or other fluoroquinolones).
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