Levofloxacin (ophthalmic)

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# Overview
Levofloxacin (ophthalmic) is an antibiotic and  fluoroquinolone that is FDA approved for the treatment of bacterial conjunctivitis caused by susceptible strains of aerobic gram positive and gram negative microorganisms.   Common adverse reactions include diarrhea , nausea, transient decreased vision, fever, foreign body sensation, headache, transient ocular burning, ocular pain or discomfort and photophobia.

# Adult Indications and Dosage

## FDA-Labeled Indications and Dosage (Adult)
- Levofloxacin Ophthalmic Solution is indicated for the treatment of bacterial conjunctivitis caused by susceptible strains of the following organisms:
- Corynebacterium species*
- Staphylococcus aureus
- Staphylococcus epidermidis
- Streptococcus pneumoniae
- Streptococcus (Groups C/F)
- Streptococcus (Group G)
- Viridans group streptococci
- Acinetobacter lwoffii
- Haemophilus influenzae
- Serratia marcescens*
- Efficacy for this organism was studied in fewer than 10 infections.

### Dosing Information
- Instill one to two drops in the affected eye(s) every 2 hours while awake, up to 8 times per day.
- Instill one to two drops in the affected eye(s) every 4 hours while awake, up to 4 times per day.

## Off-Label Use and Dosage (Adult)

### Guideline-Supported Use
There is limited information regarding Off-Label Guideline-Supported Use of Levofloxacin (ophthalmic) in adult patients.

### NonGuideline-Supported Use
There is limited information regarding Off-Label NonGuideline-Supported Use of Levofloxacin (ophthalmic) in adult patients.

# Pediatric Indications and Dosage

## FDA-Labeled Indications and Dosage (Pediatric)
There is limited information regarding Levofloxacin (ophthalmic) FDA-Labeled Indications and Dosage (Pediatric) in the drug label.

## Off-Label Use and Dosage (Pediatric)

### Guideline-Supported Use
There is limited information regarding Off-Label Guideline-Supported Use of Levofloxacin (ophthalmic) in pediatric patients.

### NonGuideline-Supported Use
There is limited information regarding Off-Label NonGuideline-Supported Use of Levofloxacin (ophthalmic) in pediatric patients.

# Contraindications
- Levofloxacin Ophthalmic Solution is contraindicated in patients with a history of hypersensitivity to levofloxacin, to other quinolones, or to any of the components of this medication.

# Warnings
- NOT FOR INJECTION. Levofloxacin Ophthalmic Solution should not be injected subconjunctially, nor should it be introduced directly into the anterior chamber of the eye.
- In patients receiving systemic quinolones, serious and occasionally fatal hypersensitivity (anaphylactic) reactions have been reported, some following the first dose. Some reactions were accompanied by cardiovascular collapse, loss of consciousness, angioedema (including laryngeal, pharyngeal or facial edema), airway obstruction, dyspnea, urticaria, and itching. If an allergic reaction to levofloxacin occurs, discontinue the drug. Serious acute hypersensitivity reactions may require immediate emergency treatment. Oxygen and airway management should be administered as clinically indicated.

### PRECAUTIONS
- As with other anti-infectives, prolonged use may result in overgrowth of non-susceptible organisms, including fungi. If superinfection occurs, discontinue use and institute alternative therapy. Whenever clinical judgment dictates, the patient should be examined with the aid of magnification, such as slitlamp biomicroscopy, and where appropriate, fluorescein staining. Patients should be advised not to wear contact lenses if they have signs and symptoms of bacterial conjunctivitis.

# Adverse Reactions

## Clinical Trials Experience
- The most frequently reported adverse events in the overall study populations were transient decreased vision, fever, foreign body sensation, headache, transient ocular burning, ocular pain or discomfort, pharyngitis and photophobia. These events occurred in approximately 1-3% of patients. Other reported reactions occurring in less than 1% of patients included allergic reactions, lid edema, ocular dryness and ocular itching.

## Postmarketing Experience
There is limited information regarding Levofloxacin (ophthalmic) Postmarketing Experience in the drug label.

# Drug Interactions
- Specific drug interaction studies have not been conducted with Levofloxacin Ophthalmic Solution. However, the systemic administration of some quinolones has been shown to elevate plasma concentrations of theophylline, interfere with the metabolism of caffeine, and enhance the effects of the oral anticoagulant warfarin and its derivatives, and has been associated with transient elevations in serum creatinine in patients receiving systemic cyclosporine concomitantly.

# Use in Specific Populations

### Pregnancy
Pregnancy Category (FDA): C
- Levofloxacin at oral doses of 810 mg/kg/day in rats, which corresponds to approximately 7,000 times the highest recommended human ophthalmic dose, caused decreased fetal body weight and increased fetal mortality. No teratogenic effect was observed when rabbits were dosed orally as high as 50 mg/kg/day, which corresponds to approximately 400 times the highest recommended maximum human ophthalmic dose, or when dosed intravenously as high as 25 mg/kg/day, corresponding to approximately 200 times the highest recommended human ophthalmic dose. There are, however, no adequate and well-controlled studies in pregnant woman. Levofloxacin should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.
Pregnancy Category (AUS): 
There is no Australian Drug Evaluation Committee (ADEC) guidance on usage of Levofloxacin (ophthalmic) in women who are pregnant.

### Labor and Delivery
There is no FDA guidance on use of Levofloxacin (ophthalmic) during labor and delivery.

### Nursing Mothers
- Levofloxacin has not been measured in human milk. Based upon data from ofloxacin, it can be presumed that levofloxacin is excreted in human milk. Caution should be exercised when Levofloxacin Ophthalmic Solution is administered to a nursing mother.

### Pediatric Use
- Safety and effectiveness in infants below the age of one year have not been established. Oral administration of quinolones has been shown to cause arthropathy in immature animals. There is no evidence that the ophthalmic administration of levofloxacin has any effect on weight bearing joints.

### Geriatic Use
- No overall differences in safety or effectiveness have been observed between elderly and other adult patients.

### Gender
There is no FDA guidance on the use of Levofloxacin (ophthalmic) with respect to specific gender populations.

### Race
There is no FDA guidance on the use of Levofloxacin (ophthalmic) with respect to specific racial populations.

### Renal Impairment
There is no FDA guidance on the use of Levofloxacin (ophthalmic) in patients with renal impairment.

### Hepatic Impairment
There is no FDA guidance on the use of Levofloxacin (ophthalmic) in patients with hepatic impairment.

### Females of Reproductive Potential and Males
There is no FDA guidance on the use of Levofloxacin (ophthalmic) in women of reproductive potentials and males.

### Immunocompromised Patients
There is no FDA guidance one the use of Levofloxacin (ophthalmic) in patients who are immunocompromised.

# Administration and Monitoring

### Administration
There is limited information regarding Levofloxacin (ophthalmic) Administration in the drug label.

### Monitoring
There is limited information regarding Levofloxacin (ophthalmic) Monitoring in the drug label.

# IV Compatibility
There is limited information regarding the compatibility of Levofloxacin (ophthalmic) and IV administrations.

# Overdosage
There is limited information regarding Levofloxacin (ophthalmic) overdosage.  If you suspect drug poisoning or overdose, please contact the National Poison Help hotline (1-800-222-1222) immediately.

# Pharmacology

## Mechanism of Action
- Levofloxacin is a member of the fluoroquinolone class of antibacterial agents and its bactericidal action results from interference with the enzymes topoisomerase IV and DNA gyrase enzyme activity, which are needed for the synthesis of bacterial DNA

## Structure
- Levofloxacin Ophthalmic Solution 0.5% is a sterile topical ophthalmic solution. Levofloxacin is a fluoroquinolone antibacterial active against a broad spectrum of Gram-positive and Gram-negative ocular pathogens. Levofloxacin is the pure (-)-(s)-enantiomer of the racemic drug substance, ofloxacin. It is more soluble in water neutral pH than ofloxacin.
- Chemical Name: (-)-(s)-9-fluoro-2,3-dihydro-3-methyl-10-(4-methyl-1-piperazinyl)-7-oxo-7Hpyrido -1,4 benzoxazine-6-carboxylic acid hemihydrate. Levofloxacin (hemihydrate) is a yellowish-white crystalline powder. Each mL of Levofloxacin Ophthalmic Solution contains 5.12 mg of levofloxacin hemihydrate equivalent to 5 mg levofloxacin.
- Active: Levofloxacin 0.5% ( mg/mL); Preservative: benzalkonium chloride 0.005%;
- Inactives: sodium chloride and water for injection. May also contain hydrochloric acid and/or sodium hydroxide to adjust pH. Levofloxacin Ophthalmic Solution is isotonic and formulated at pH 6.5 with an osmolality of approximately 300 mOsm/kg. Levofloxacin is a fluorinated 4-quinolone containing a six-member (pyridobenzoxazine) ring from positions 1 to 8 of the basic ring structure.

## Pharmacodynamics

### MICROBIOLOGY:
- Levofloxacin is the L-isomer of the racemate, ofloxacin, a quinolone antimicrobial agent. The antibacterial activity of ofloxacin resides primarily in the L-isomer. The mechanism of action of levofloxacin and other fluoroquinolone antimicrobials involves the inhibition of bacterial topoisomerase IV and DNA gyrase (both of which are type II topoismerases), enzymes required for DNA replication, transcription, repair, and recombination. Levofloxacin has in vitro activity against a wide range of Gram-negative and Gram-positive microorganisms and is often bactericidal at concentrations equal to or slightly greater than inhibitory concentrations.
- Fluoroquinolones, including levofloxacin, differ in chemical structure and mode of action from -lactam antibiotics and aminoglycosides, and therefore may be active against bacteria resistant to -lactam antibiotics and aminoglycosides. Additionally, -lactam antibiotics and aminoglycosides may be active against bacteria resistant to levofloxacin. Resistance to levofloxacin due to spontaneous mutation in vitro is a rare occurrence (range: 10-9 to 10-10). Levofloxacin has been shown to be active against most strains of the following microorganisms, both in vitro and in clinical infections as described in the INDICATIONS AND USAGE section:
- Corynebacterium species
- Staphylococcus aureus
- Staphylococcus epidermidis
- Streptococcus pneumoniae
- Streptococcus (Groups C/F)
- Streptococcus (Group G)
- Viridans group streptococci
- Acinetobacter lwoffii
- Haemophilus influenzae
- Serratia marcescens*
- Efficacy for this organism was studied in fewer than 10 infections. The following in vitro data are also available, but their clinical significance in ophthalmic infections is unknown. The safety and effectiveness of levofloxacin in treating ophthalmological infections due to these microorganisms have not been established in adequate and well-controlled trials. These organisms are considered susceptible when evaluated using systemic breakpoints. However, a correlation between the in vitro systemic breakpoint and ophthalmological efficacy has not been established. The list of organisms is provided as guidance only in assessing the potential treatment of conjunctival infections.
- Levofloxacin exhibits in vitro minimal inhibitory concentrations (MICs) of 2g/mL or less (systemic susceptible breakpoint) against most (90%) strains of the following ocular pathogens:
- Enterococcus faecalis
- Streptococcus agalactiae
- Staphylococcus saprophyticus
- Streptococcus pyogenes
- Acinetobacter anitratus
- Legionella pneumophila
- Acinetobacter baumannii
- Moraxella catarrhalis
- Citrobacter diversusi
- Morganella morgqanii
- Citrobacter freudii
- Neisseria gonorrhoeae
- Enterobacter aerogenes
- Proteus mirabilis
- Enterobacter agglomerans
- Proteus vulgaris
- Enteroacter cloacae
- Providencia rettgeri
- Escherichia coli
- Providencia stuartii
- Haemophilus arainfluenzae
- Pseudomonas aeruginosa
- Klebsiella oxytoca
- Pseudomonas fluorescens
- Klebsiella pneumoniae

## Pharmacokinetics
- Levofloxacin concentration in plasma was measured in 15 healthy adult volunteers at various time points during a 15 day course of treatment with Levofloxacin Ophthalmic Solution. The mean levofloxacin concentration in plasma 1 hour postdose, ranged from 0.86 ng/mL on Day 1 to 2.05 ng/mL on Day 15. The highest maximum mean levofloxacin concentration of 2.5 ng/mL was measured on Day 4 following 2 days of dosing every 2 hours for a total of 8 doses per day. Maximum mean levofloxacin concentrations increased from 0.94 ng/mL on Day 1 to 2.15 ng/mL on Day 15, which is more than 1,000 times lower than those reported after standard oral doses of levofloxacin. Levofloxacin concentration in tears was measured in 30 healthy adult volunteers at various time points following instillation of a single drop of Levofloxacin Ophthalmic Solution. Mean levofloxacin concentrations in tears ranged from 34.9 to 221.1 g/mL during the 60-minute period following the single dose. The mean tear concentrations measured 4 and 6 hours postdose were 17.0 and 6.6 g/mL. The clinical significance of these concentrations is unknown.

## Nonclinical Toxicology
- In a long term carcinogenicity study in rats, levofloxacin exhibited no carcinogenic or tumorigenic potential following daily dietary administration; the highest dose (100 mg/kg/day) was 875 times the highest recommended human ophthalmic dose. Levofloxacin was not mutagenic in the following assays: Ames bacterial mutation assay (S. typhimurium and E. coli), CHO/HGPRT forward mutation assay, mouse micronucleus test, mouse dominant lethal test, rat unscheduled DNA synthesis assay, and the in vivo mouse sister chromatid exchange assay. It was positive in the in vitro chromosomal aberration (CHL cell line) and in vitro sister chromatid exchange (CHL/IU cell line) assays. Levofloxacin caused no impairment of fertility or reproduction in rats at oral doses as high as 360 mg/kg/day, corresponding to 3,150 times the highest recommended human ophthalmic dose.

# Clinical Studies
- In randomized, double-masked, multicenter controlled clinical trial where patients were dosed for 5 days, Levofloxacin Ophthalmic Solution demonstrated clinical cures in 79% of patients treated for bacterial conjunctivitis on the final study visit day (day 6-10). Microbial outcome for the same clinical trials demonstrated an eradication rate for presumed pathogens of 90%.

# How Supplied
Levofloxacin Ophthalmic Solution 0.5% is supplied in a natural, low density polyethylene bottle with a controlled dropper tip and a tan, high density polyethylene cap in the following size:
Bottles of 5 mL    NDC 16571-150-50
Rx Only
Manufactured in India for:
Nexus Pharmaceuticals Inc.,
Vernon Hills, IL 60061.
Distributed by:
Pack Pharmaceuticals,
LLC, Buffalo Grove, IL 60089.

## Storage
- Store at 20-25C (68-77F)

# Images

## Drug Images

## Package and Label Display Panel
NDC  16571-150-50
PACK Pharmaceuticals, LLC
LEVOFLOXACIN OPHTHALMIC SOLUTION
FOR TOPICAL APPLICATION IN THE EYE
Rx only                                        (5 mL) Sterile

# Patient Counseling Information
- Avoid contaminating the applicator tip with material from the eye, fingers or other source. Systemic quinolones have been associated with hypersensitivity reactions, even following a single dose. Discontinue use immediately and contact your physician at the first sign of a rash or allergic reactions.

# Precautions with Alcohol
Alcohol-Levofloxacin (ophthalmic) interaction has not been established. Talk to your doctor about the effects of taking alcohol with this medication.

# Brand Names
- Levaquin
- Quixin
- Iquix

# Look-Alike Drug Names
- Levaquin - Lariam
- levofloxacin - levetiracetam
- levofloxacin - Levophed

# Drug Shortage Status

# Price