Alatrofloxacin-induced seizures during slow intravenous infusion

To report a case of seizures associated with slow infusion (1-2 h) of alatrofloxacin, the prodrug of trovafloxacin.

A 37-year-old Asian man was admitted to the hospital for a distal pancreatectomy and drainage of a pseudocyst. Postoperative complications developed, which included peritonitis and pneumonia, requiring intensive care admission. Cultures from peritoneal drainage fluid and sputum isolated Klebsiella pneumoniae and Pseudomonas aeruginosa, respectively. He was treated with multiple courses of antibiotics, including intravenous gentamicin, metronidazole, vancomycin, meropenem, and ceftazidime. After three weeks, the patient still had sepsis and began therapy with alatrofloxacin in addition to ceftazidime and vancomycin. Alatrofloxacin infusion was administered according to product information instructions. Fifteen minutes after the first dose was started, the patient developed generalized clonus. On rechallenge, infusing at half the initial rate, the seizure recurred; consequently, the infusion was discontinued and replaced with intravenous ciprofloxacin and metronidazole. The patient remained seizure free thereafter.

Fluoroquinolones have been implicated in central nervous system adverse effects, including seizures, which have been reported with other fluoroquinolones but not with alatrofloxacin or trovafloxacin. In these reports, the patients often had preexisting risk factors such as increased age and electrolyte imbalances. The only apparent predisposition in this patient was mild hyponatremia.

Alatrofloxacin may cause seizures even during slow infusion. This case highlights the need for caution when commencing parenteral fluoroquinolone therapy, particularly with a new agent.