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Do Otic Quinolones Increase Risk of Achilles Tendon Rupture?

October 10, 2022

Written by Clay Smith

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Otic quinolones (OQ) were associated with an increased risk of Achilles tendon rupture and all-type tendon rupture, but this was rare. Even with this risk, sometimes an OQ is still the right choice.

Why does this matter?
Fluoroquinolones are associated with tendinopathy, long QT, aortic dissection, altered mental status, and even sudden death. Surely otic quinolones (OQ) wouldn’t have enough systemic absorption to increase risk of tendinopathy, right?

The ear bone’s connected to the, heel bone?
This was a huge insurance database with over 1.5 million patients that found the outcome of Achilles tendon rupture (ATR), Achilles tendinitis (AT) and all-type tendon rupture (ATTR) was associated with OQ use. The hazard ratio of OQ use with ATR was 4.49 and ATTR was 1.71, both of which were statistically significant. There was no significant association with AT. They used a rigorous methodology to account for potential confounding, so I find the results credible. Practically speaking, sometimes a OQ is the right drug. For example, we should avoid aminoglycoside drops (like neomycin – aka Cortisporin – or gentamicin or tobramycin otic drops) in patients with a non-intact tympanic membrane due to ototoxicity. In this case, an OQ is the right choice. Overall, the risk is very low. In absolute numbers, use of an OQ takes the risk of ATR from a baseline 1.9/100,000 to 6.2/100,000. There was a suggestion that ciprofloxacin drops were slightly less risky than ofloxacin, so if you can, go with the lower risk option.

Quinolone Ear Drops and Achilles Tendon Rupture. Clin Infect Dis. 2022 Sep 6;ciac709. doi: 10.1093/cid/ciac709. Online ahead of print.