27-year-old female host died suddenly after infusion! The "silent killer" is this... commonly used in respiratory department!

Expert of this article: Liu Zhijun, Pharmacy Department, Beijing Anzhen Hospital, Capital Medical University

It was reported that Liu, a 27-year-old former TV host in Hefei, died after receiving intravenous drip in the First Affiliated Hospital of Anhui Medical University. The autopsy report showed that it was sudden cardiac death caused by moxifloxacin.

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Why does infusion of moxifloxacin cause such a serious adverse reaction as sudden death? What exactly is moxifloxacin? Can it still be taken in the future?

What is moxifloxacin?

Moxifloxacin is one of the most commonly used antibacterial drugs in respiratory medicine. It belongs to the quinolone class and is therefore also known as a "respiratory quinolone." It is mainly used to treat community-acquired pneumonia caused by common Streptococcus pneumoniae, Moraxella catarrhalis, Haemophilus influenzae, etc., and is especially suitable for infections caused by atypical pathogens such as Mycoplasma pneumoniae and Chlamydia pneumoniae.

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Clinically, moxifloxacin is contraindicated in:

① Those who are allergic to moxifloxacin;

② Pregnant women and breastfeeding women;

③Children under 18 years old;

④ Patients with severe liver dysfunction or transaminase elevation greater than 5 times the upper limit of normal value;

⑤ Patients with a history of using quinolone drugs to treat related tendon diseases;

⑥ Patients with congenital or acquired QT interval prolongation.

If these contraindications are excluded before using moxifloxacin, the use of moxifloxacin for mycoplasma pneumonia is appropriate and reasonable.

For patients using moxifloxacin for the first time, neither doctors nor patients currently have a way to determine whether they are allergic to it.

Neither the instructions nor clinical practice require a skin test before use because the incidence of allergic reactions such as rashes is extremely low.

Items ② and ③ are because quinolone drugs such as moxifloxacin may affect the cartilage development of infants and young children.

Article ④ is because moxifloxacin may cause liver damage, and liver function needs to be monitored during use (such as whether transaminase is elevated).

Article 5: Because moxifloxacin can cause Achilles tendinitis and Achilles tendon rupture, it is contraindicated for patients with a history of such diseases.

Article ⑥ QT interval prolongation is the most terrible adverse reaction. Although the incidence is low (≈1‰), the mortality rate is high.

The QT interval refers to the distance from the Q wave to the T wave on the electrocardiogram (measured in seconds or milliseconds), with a normal range of 0.32 seconds to 0.44 seconds.

Generally speaking, a QT interval of >0.45 seconds in men and >0.46 seconds in women can be considered a prolonged QT interval.

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Some individuals in the normal population may have a long QT interval (syndrome) due to congenital reasons. If the QT interval is significantly prolonged, especially when certain drugs that can cause QT interval prolongation (such as fluoroquinolones, amiodarone, quinidine) are used in combination or when hypokalemia is present, malignant arrhythmias may occur, among which "torsade de pointes" is the most terrible form that can endanger life.

Why does moxifloxacin cause sudden cardiac death?

Moxifloxacin has been shown to prolong the QT interval on the electrocardiogram in some patients.

Intravenous infusion of 0.4 g of moxifloxacin (infusion time 1 hour per day) prolonged the mean QT interval by 10 milliseconds (±22) from before medication to the first day of medication.

It is recommended that moxifloxacin should not be used in: ① patients with QT interval prolongation; ② ventricular arrhythmias, including torsades de pointes; ③ untreated/corrected hypokalemia or hypomagnesemia; ④ concomitant use of drugs that cause QT interval prolongation (mainly antiarrhythmic drugs, antipsychotics, and antidepressants).

The above situation will aggravate the QT interval prolongation caused by moxifloxacin and induce torsades de pointes ventricular arrhythmia, causing sudden cardiac death.

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Before using moxifloxacin, it is necessary to understand the patient's history of arrhythmias, hypokalemia, and whether other medications currently being taken will aggravate QT interval prolongation.

The occurrence of QT interval prolongation leading to arrhythmia is a low-probability event and can only be treated by close observation during moxifloxacin infusion and timely intervention measures.

What will happen if moxifloxacin is used improperly?

Moxifloxacin is an antibacterial drug used to treat infections caused by susceptible bacteria.

The misuse of antibiotics can easily induce drug resistance in pathogens, resulting in ineffective treatment; at the same time, the irrational use of antibiotics also increases the occurrence of drug toxic side effects.

Therefore, China currently strictly controls the use of antibiotics. Ordinary people basically do not have access to them on a daily basis. Generally, professional doctors in medical institutions choose to use them based on the infection situation.

How to use medicine safely?

① Choose quinolone drugs with caution.

Statistics

The National Adverse Drug Reaction Monitoring Annual Report (2021) released on March 30, 2022 shows:

The top three drug categories in terms of the number of adverse reaction/event reports for anti-infective drugs in 2021 were cephalosporins, quinolones, and macrolides;

Among them, the top three drug categories in terms of the number of serious adverse reactions/events reported were cephalosporins, quinolones, and anti-tuberculosis drugs.

It can be seen that the number of adverse reactions/events of quinolones, including moxifloxacin, is second only to cephalosporins among anti-infective drugs. This may be related to their widespread use, or it may be because quinolones do have more adverse reactions, including solar dermatitis, Achilles tendinitis/rupture of Achilles tendon, agitation and insomnia, chondrodysplasia (forbidden in infants, pregnant women, and lactating women), abnormal liver function (elevated transaminase), prolonged QT interval, arrhythmia, etc.

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②The patient's reaction should be closely observed within the first 30 minutes of oral or intravenous infusion of moxifloxacin.

Generally speaking, any infusion must be closely monitored in the "infusion room" within the first 30 minutes of the patient's infusion. If abnormal reactions occur, such as rash, throat tightening, wheezing, chest tightness and other symptoms, symptomatic treatment or emergency treatment should be given as soon as possible.

③ Keep in mind the contraindications of moxifloxacin.

In summary, moxifloxacin is a respiratory quinolone that is widely used in clinical practice. It is mainly used to treat respiratory infectious diseases and is also used for abdominal and pelvic infections caused by certain anaerobic bacteria.

In general, moxifloxacin is relatively safe, but it is contraindicated for certain groups of people, such as infants, pregnant women, breastfeeding women, patients with long QT syndrome, and patients with severe liver dysfunction. Hypokalemia and the combined use of drugs that can prolong QT can increase the risk of torsades de pointes.

Therefore, clinical contraindications to the use of moxifloxacin should be excluded, the risk of QT interval prolongation in patients should be assessed, and the drug should be used with caution.

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