Antibiotics and Tendon Injury

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Are you on a course of antibiotics? A certain class of antibiotics, the quinolones, may put you at risk for increased incidence of tendon injury.

By Jim Winger, MD 
Member AMSSM

Flouroquinolone (quinolone) antibiotics comprise a class of anti-microbial agents with broad ability to kill many types of disease causing and symbiotic/harmless bacteria.  They have been widely available since the 1980s.  Members of this class include ciprofloxacin (Cipro), levofloxacin (Levaquin), moxifloxacin (Avelox) as well as many others.  Their pharmokinetics, which include excellent GI absorption, tissue diffusion, and long half-lives, have allowed healthcare providers to treat many infections in the outpatient setting that previously required hospitalization, such as pneumonia, or kidney infections.  The first reports of quinolone-associated tendon injury was reported in 1983 and since then it has become known that tendinopathy and tendon rupture are rare side effects of these medications, especially when paired with oral steroids, such as prednisone.       

What the studies suggest

A recent Canadian study in the journal Clinical Infectious Disease, by Khaliq and Zhanel, studied 98 cases of quinolone associated tendinopathy.  The majority of cases were associated with pefloxacin, a drug from this class which is not available in the United States, but is prescribed extensively in France and Canada.  The average length of treatment in individuals who developed tendon injury was approximately 8 days.  The Achilles tendon was the most common tendon injured, but other sites such as the rotator cuff, finger, thumb, patellar and quadriceps tendons were also injured.  Injuries were found on both sides of the body up to fifty percent of the time.  The exact injury was most frequently tendon degeneration but tendon rupture was also very common.  Recovery, on average, lasted just under two months, but could take as long as twenty months.  The average patient was 59 years old, with the majority of reported ruptures occurring in men.   Other suggested risk factors include: use of therapeutic steroids, kidney disease or transplantation, joint disease, diabetes, thyroid or parathyroid disease and sports participation.  

Williams, et al, examined dog tendon cells that were grown in a culture with ciprofloxacin.  They discovered that ciprofloxacin increased the activity of enzymes that break down tendons and inhibited tendon cell growth and multiplication.  Their conclusion was that these mechanisms may account for the increased tendon problems seen in patients who take flouroquinolones.

The risk to an otherwise healthy individual taking quinolone antibiotics is low, estimated to be approximately 14 to 40 injured tendons per 10,000 prescriptions.  The risk of tendon damage with quinolone use is approximately double that risk from other commonly prescribed oral antibiotics. 

Decreasing your chance for injury

The ways to decrease risk of tendon injury with these medications are to decrease the dose or decrease the duration of treatment.  Sports participation remains a risk factor for tendon injury up to six months after completion of a course of these antibiotics.  A clear way to decrease the risk of quinolone-associated tendon damage is to not take quinolones in the first place.   

To the athlete in training, time spent out sick is time wasted.  Our desire to compete and to continue training is so strong that we look for any boost to help us get back after an illness.  This drive may lead us to request certain treatments that are perceived to speed recovery. 

The most common acute illnesses seen in healthcare providers’ offices are upper respiratory illnesses, including sinusitis, pharyngitis/tonsillitis (sore throat) and bronchitis.  According to the Infectious Disease Society of America and the American College of Physicians, these illnesses are nearly always caused by viruses.  Viruses, unlike bacterial infections, are not susceptible to antibiotics and will go away by themselves, usually without serious consequences.  Taking a course of antibiotics when you have a viral illness will not make you get better faster, and more importantly, it increases antibiotic resistance in the community, leading to bacteria that cannot be killed by any antibiotic.  Consider this the next time you are ill and faced with a prescription for antibiotics from your doctor – consider waiting it out and don’t risk the complications if your infection does not appear to be bacterial.
                            

Jim Winger, MD                           
Loyola Stritch School of Medicine, Maywood, IL
         

References
1. Stinner DJ, Orr JD, Hsu JR. Fluoroquinolone-associated bilateral patellar tendon rupture: a case report and review of the literature.   Military Medicine. 2010 [cited 2010 Jun];175(6):457-9.

2. Durey A, Baek YS, Park JS, Lee K, Ryu JS, Lee JS, Cheong MH. Levofloxacin-induced Achilles tendinitis in a young adult in the absence of predisposing conditions.   Yonsei Medical Journal. 2010 [cited 2010 May];51(3):454-6.

3. Van Bambeke F, Tulkens PM. Safety profile of the respiratory fluoroquinolone moxifloxacin: comparison with other fluoroquinolones and other antibacterial classes..   Drug Safety. 2009 [cited 2009];32(5):359-78.

4.  Karistinos A, Paulos LE. ‘‘Ciprofloxacin-Induced’’ Bilateral Rectus Femoris Tendon Rupture. Clin J Sport Med. 2007;17:406-407.

5.  Khaliq Y, Zhanel GG. Fluoroquinolone-associated tendinopathy: a critical review of the literature. Clin.Infect.Dis. 2003 Jun 1;36(11):1404-1410.

6. Williams, et al, The effect of Ciprofloxacin on tendon, paratenon, and capsular fibroblast metabolism. Am J Sports Med. 2000,28,364-369

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date: October 11, 2010