Ciprofloxacin versus Levofloxacin

Based on "Antibiotic and Chemotherapy"
written by Roger G. Finch

Difference between Ciprofloxacin and Levofloxacin

	Ciprofloxacin	Levofloxacin
Drug class	• Cipro® • Cipro XR®	• Levaquin®
Drug class	Fluoroquinolone antibiotic
Half-life	4 hours	6-8 hours
Elimination	65% is excreted in the urine as unchanged drug 30% as unchanged drug in the feces	80% is excreted as unchanged drug in urine, less than 4% in feces
Spectrum of activity	Most active quinolone against Pseudomonas aeruginosa	Slightly less reliable psuedomonas coverage than ciprofloxacin
	Poor activity against Gram positive organisms Very poor S. pneumoniae coverage	Better activity against Gram positive organisms Good activity against S. pneumoniae 2
	Active against L. pneumophila	Excellent activity against atypical intracellular pathogens
Side Effects & Toxicities	• More phototoxic	• Minimally phototoxic • More likely to cause dysglycemia (glucose fluctuations) 1.
Side Effects & Toxicities	• Both less likely than other fluoroquinolones to prolong the QT interval3. • Tenotoxicity - tendinopathy, tendon rupture. Higher doses and longer duration of fluoroqinolone treatment increase the risk of tendon damage11.
Pediatric use	• Both approved for inhalational anthrax in children. • Both available in suspension formulations.
Drug interactions	Inhibits cytochrome P450 CYP3A4 and causes numerous drug interactions	Negligible effect on cytochrome P450
Pregnancy category	C (risk cannot be ruled out)

Bacterial Prostatitis

Levofloxacin and ciprofloxacin are similarly effective and well tolerated in the treatment of chronic bacterial prostatitis.

Results of randomized double-blind study of levofloxacin versus ciprofloxacin for chronic bacterial prostatitis 4.	Ciprofloxacin	Levofloxacin
Regimen	500 mg twice daily for 28 days	500 mg once daily for 28 days
Clinical success rates (cured plus improved patients)	72.8%	75%
Microbiologic eradication rates	76.8%	75%

Results of open-label, randomized controlled trial of levofloxacin versus ciprofloxacin for chronic bacterial prostatitis in China 5.	Ciprofloxacin	Levofloxacin
Regimen	500 mg twice daily for 4 weeks	500 mg once daily for 4 weeks
Bacterial clearance rate 1-4 weeks after the end of treatment	60.03%	86.06%
Clinical efficacy rate (clinical cure and clinical improvement) 1-4 weeks after the end of treatment	71.86%	93.30%
Microbiological recurrence rate	19.25%	4.00%

Pyelonephritis, Urinary Tract Infections

Levofloxacin and ciprofloxacin are the two main fluoroquinolones that are second-line treatments for UTIs12. Both have a good coverage against Gram-negative rods, including E. coli.

Levofloxacin and ciprofloxacin are similarly safe and effective in the treatment of complicated urinary tract infections and acute pyelonephritis 6.

Results of double-blind, randomized comparison of levofloxacin with ciprofloxacin for complicated URTs and acute pyelonephritis 6.	Ciprofloxacin	Levofloxacin
Regimen	400 mg I.V. and/or 500 mg orally twice daily for 10 days	750 mg I.V. or orally once daily for 5 days
Eradication rates in the modified intent-to-treat population	77.5%	79.8%
Eradication rates in the microbiologically evaluable population	86.7%	88.3%

Results of double-blind, noninferiority trial of levofloxacin vs ciprofloxacin for acute pyelonephritis 7.	Ciprofloxacin	Levofloxacin
Regimen	400 mg I.V. and/or 500 mg orally twice daily for 10 days	750 mg once daily I.V. or orally for 5 days
Microbiological eradication rate in the modified intent-to-treat population	79.6%	83%
Microbiologic eradication rate in the microbiologically evaluable population	93.4%	92.5%
Clinical success rate in the modified intent-to-treat population	80.6%	86.2%
Clinical success rate in the microbiologically evaluable population	89.5%	92.5%

Detailed information on:

UTI vs Bladder Infection

Skin and Skin Structure Infections

Ciprofloxacin and Levofloxacin are equally effective for the treatment of skin infections 8.

Results of double-blind, randomized study comparing levofloxacin versus ciprofloxacin for uncomplicated skin and skin structure infections 8.	Ciprofloxacin	Levofloxacin
Regimen	500 mg twice daily for 10 days	500 mg once daily for 7 days
Clinical success (cure and improvement) rate	93.5%	96.1%
Bacteriological eradication rate	91.7%	93.2%
Eradication rate of S. aureus	93% (70/75)	94% (66/70)
Eradication rate of S. pyogenes	92% (12/13)	94% (17/18)
Adverse effects rate	8.2%	8.9%

Results of randomized study comparing levofloxacin and ciprofloxacin for uncomplicated skin and skin structure infections 9.	Ciprofloxacin	Levofloxacin
Regimen	500 mg twice daily	500 mg once daily
Clinical success (cure and improvement) rate	94%	98%
Bacteriological eradication rate	89%	98%
Eradication rate of S. aureus	87%	100%
Adverse effects rate	5%	6%

References

1. Aspinall SL, Good CB, Jiang R, McCarren M, Dong D, Cunningham FE. Severe dysglycemia with the fluoroquinolones: a class effect? Clin Infect Dis. 2009 Aug 1;49(3):402-8. PubMed
2. Garrison MW. Comparative antimicrobial activity of levofloxacin and ciprofloxacin against Streptococcus pneumoniae. J Antimicrob Chemother. 2003 Sep;52(3):503-6.
3. Makaryus AN, Byrns K, Makaryus MN, Natarajan U, Singer C, Goldner B. Effect of ciprofloxacin and levofloxacin on the QT interval: is this a significant "clinical" event? South Med J. 2006 Jan;99(1):52-6. PubMed
4. Bundrick W, Heron SP, Ray P, et al. Levofloxacin versus ciprofloxacin in the treatment of chronic bacterial prostatitis: a randomized double-blind multicenter study. Urology. 2003 Sep;62(3):537-41. PubMed
5. Zhang ZC, Jin FS, Liu DM, Shen ZJ, Sun YH, Guo YL. Safety and efficacy of levofloxacin versus ciprofloxacin for the treatment of chronic bacterial prostatitis in Chinese patients. Asian J Androl. 2012 Nov;14(6):870-4. PubMed
6. Peterson J, Kaul S, Khashab M, Fisher AC, Kahn JB. A double-blind, randomized comparison of levofloxacin 750 mg once-daily for five days with ciprofloxacin 400/500 mg twice-daily for 10 days for the treatment of complicated urinary tract infections and acute pyelonephritis. Urology. 2008 Jan;71(1):17-22. PubMed
7. Klausner HA, Brown P, Peterson J, Kaul S, Khashab M, Fisher AC, Kahn JB. A trial of levofloxacin 750 mg once daily for 5 days versus ciprofloxacin 400 mg and/or 500 mg twice daily for 10 days in the treatment of acute pyelonephritis. Curr Med Res Opin. 2007 Nov;23(11):2637-45. PubMed
8. Nicodemo AC, Robledo JA, Jasovich A, Neto W. A multicentre, double-blind, randomised study comparing the efficacy and safety of oral levofloxacin versus ciprofloxacin in the treatment of uncomplicated skin and skin structure infections. Int J Clin Pract. 1998 Mar;52(2):69-74. PubMed
9. Nichols RL, Smith JW, Gentry LO, Gezon J, Campbell T, Sokol P, Williams RR. Multicenter, randomized study comparing levofloxacin and ciprofloxacin for uncomplicated skin and skin structure infections. South Med J. 1997 Dec;90(12):1193-200. PubMed
10. Lewis T, Cook J. Fluoroquinolones and tendinopathy: a guide for athletes and sports clinicians and a systematic review of the literature. J Athl Train. 2014 May-Jun;49(3):422-7. PubMed
11. Bidell MR, Lodise TP. Fluoroquinolone-Associated Tendinopathy. Pharmacotherapy. 2016 Jun;36(6):679-93
12. Gupta K, Hooton TM, Naber KG, et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: a 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis. 2011;52(5):e103–e120.