Antibiotic‐induced Cardiac Arrhythmias

Abstract

SUMMARYThis review aims to clarify the underlying risk of arrhythmia associated with the use of macrolides and fluoroquinolones antibiotics. Torsades de pointes (TdP) is a rare potential side effect of fluoroquinolones and macrolide antibiotics. However, the widespread use of these antibiotics compounds the problem. These antibiotics prolong the phase 3 of the action potential and cause early after depolarization and dispersion of repolarization that precipitate TdP. The potency of these drugs, as potassium channel blockers, is very low, and differences between them are minimal. Underlying impaired cardiac repolarization is a prerequisite for arrhythmia induction. Impaired cardiac repolarization can be congenital in the young or acquired in adults. The most important risk factors are a prolonged baseline QTc interval or a combination with class III antiarrhythmic drugs. Modifiable risk factors, including hypokalemia, hypomagnesemia, drug interactions, and bradycardia, should be corrected. In the absence of a major risk factor, the incidence of TdP is very low. The use of these drugs in the appropriate settings of infection should not be altered because of the rare risk of TdP, except among cases with high-risk factors.

Prophylactic Azithromycin Therapy After Lung Transplantation: Post hoc Analysis of a Randomized Controlled Trial

“…Lately, much attention was be given to possible cardiovascular events with macrolides, particularly arrhythmias, mainly in case of concomitant use of other QT-prolonging medicines or underlying structural heart disease. However, azithromycin may be considered the safest of all macrolides in this respect since serum levels in healthy volunteers are >3000 times lower than drug concentrations required for cardiomyocyte potassium channel (hERG/IKr)-blockade, action potential prolongation and QTc prolongation (22)(23)(24). Caution is nevertheless required for toxic accumulation of azithromycin in patients with impaired hepatic function.…”

Azithromycin and Other Macrolides for Prevention of Bronchopulmonary Dysplasia: A Systematic Review and Meta-Analysis

“…Several studies in adults have highlighted the association between macrolide use and cardiovascular events, notably arrhythmias and death [35,36]. In 2013, the United States Food and Drug Administration issued drug alert regarding the use of azithromycin especially in high-risk patients such as those with known prolonged QTc syndromes, on drugs known to prolong QTc and proarrhythmogenic conditions.…”

The Use of Systemic and Topical Fluoroquinolones

“…33 No cases of cardiotoxicity or torsades de pointes in children associated with fluoroquinolones have been reported to date. 34 …”