Comparing Levofloxacin And Ofloxacin Health Essay
This paper is a retrograde survey conducted in Hong Kong. Although the statistical degree of grounds is non high, this is apprehensible as clinical randomized controlled test might non be executable due to ethical restraints. Besides other documents are non suited as most of them are merely in vitro tests which are non suited to use in human yet. One consequence include a meta- analysis seeking to analyze the effects of different fluoroquinolones on handling MDR-TB, but the meta-analysis consists a sum of more than 100 pages which are hard to pull out relevant information for assessment.
This paper is a instance control surveies ( retrograde analysis ) which aim at comparing levofloxacin and ofloxacin in the intervention of multidrug immune TB. It is internally valid despite the fact of low statistical grounds. The sample size is non big with merely 99 patients in entire due the low prevalence of MDR-TB in Hong Kong. Comparing Levofloxacin And Ofloxacin Health Essay.The survey besides tried to extinguish prejudices by foremost comparing demographic, clinical and bacteriologic characters among the 2 groups which are similar. The callback prejudice is besides reduced, as the information of the patient is obtained straight from medical studies instead than questioning existent patients, therefore the per centum of patients having each intervention and the intervention result can be more accurately obtained. This improves the cogency of the survey.
Methods of the survey
The information of the survey is form the medical record of Grantham Hospital, every bit good as thorax clinics under the section of Health in Hong Kong signifier July 1997 to December 2000. A sum of 99 patients, who were seronegative for HIV, were selected. The laboratory testing of drug susceptibleness was besides recorded and compared, peculiarly the proportion of each group which was confirmed to be ofloxacin resistant. The paper besides compared the other intervention regimens, such as aminoglycosides used in each group, every bit good as the dosage of levofloxacin and levofloxacin, which shows no statistically important difference. This eliminated the consequence of other drugs or dose which may change the intervention effects and cause mistakes. The intervention consequence was defined by whether the patient can run into the demand of successful bacteriological transition of civilization from positive to negative for at least 6 back-to-back months during the therapy and on surcease.
ORDER A PLAGIARISM -FREE PAPER NOW
The information was analyzed utilizing the t trial ( For numerical variables ) and Chi-square trial for categoric variables. Mantel-Haenszel common odd ratio was used to prove the significance of the consequence differences. P value & A ; lt ; 0.05 is considered to be important. Other variables such as demographical factors, age, sex, attachment, etc were analyzed by utilizing the multiple arrested development method to analyze the assorted impacts on the result. The efficaciousnesss of the 2 drugs were farther compared by their success rate stratified with the no. of inauspicious factors present.Comparing Levofloxacin And Ofloxacin Health Essay.
The intervention success rate in the group utilizing levofloxacin was significantly higher than the group utilizing ofloxacin. The success rate of the group with levofloxacin is 90.0 % overall compared with 79.7 % in ofloxacin group. The success rate is besides higher even if the TB is non susceptible to ofloxacin in the laboratory civilization ( 78.6 % vs 45.5 % ) , Mantel-Haenszel common odd ratio=4, p=0.049.
Adverse effects of 2 groups show statistically undistinguished difference ( 10.0 % vs 11.9 % , P & A ; gt ; 0.05 ) . By utilizing the multiple arrested development theoretical account, the variable of the usage of levofloxacin instead than ofloxacin shows an uneven ratio of 7.6 for favourable result ( 95 % CI=1.1-50.7, p=0.037 ) . No convergence of 1 for the assurance interval and therefore statistically important. Odd ratio was used since this is a retrograde surveies and therefore no incidence if present. It can be a good estimate of the incidence rate if the result is rare. However, since intervention failure for multiple drug immune TB is non uncommon, which constitute a important proportion as observed from the consequences, it may non be so accurately represent the incidence rate in this instance. On measuring the efficaciousness of the 2 groups with regard to the no. of inauspicious factor, the group utilizing levofloxacin tends to hold better efficaciousness when 1 to 2 inauspicious factors were present, and it is statistically important ( p=0.045 )
The consequence shows that utilizing levofloxacin in combination with other drugs achieve better success rate when compared with utilizing ofloxacin. This besides matches with the in vitro tests, which suggested more active action of levofloxacin against Mycobacterium TB. Using levofloxacin can accomplish better intervention result with no difference on side effects comparing the older agent ofloxacin statistically.
However, when construing the consequence, some prejudice or mistakes may really impact the internal cogency of the survey. There can be possible choice prejudice since non all instance during the declared period is selected and the paper did non advert any choice standards. Besides those informations did non include patients with intervention failure due to intervention intolerance or hypersensitivity. This besides affects the cogency of the consequence.
This consequence is applicable to my patient since this survey is conducted in Hong Kong, which hence a good external cogency. Besides the consequences match with in vitro surveies. Despite the fact of low degree of grounds, the callback prejudice is greatly reduced with the aggregation of informations by medical study. Careful analysis utilizing arrested development theoretical accounts eliminates the consequence of confounders. The comparing of other demographical, clinical factors, intervention regimen etc shows no important difference, farther better the dependability of the survey.Comparing Levofloxacin And Ofloxacin Health Essay. Therefore, the patient, utilizing levofloxacin, alternatively of ofloxacin in handling MDR-TB can significantly increase the success rate of intervention statistically. However, whether it is clinically utile remain diffident as the consequence of intervention varies from persons.
|Condition or disease||Intervention/treatment||Phase|
|Urinary Tract InfectionsPyelonephritis||Drug: levofloxacin||Phase 3|
Levofloxacin is a widely used fluoroquinolone approved for the treatment of complicated urinary tract infections and acute pyelonephritis. A comprehensive review of the medical literature identified five publications evaluating levofloxacin for the treatment of either complicated urinary tract infections or acute pyelonephritis. All trials, although variable in their inclusion criteria and levofloxacin dosing strategies, reported microbiologic, clinical, and safety-related outcomes. High microbiologic eradication rates, ranging from 79.8% to 95.3%, were observed in all studies. Escherichia coli was the most commonly isolated uropathogen. Data on levofloxacin resistance, both at baseline and after therapy, were limited. Clinical success was observed to range from 82.6% to 93% when measured after the completion of therapy.Comparing Levofloxacin And Ofloxacin Health Essay. These clinical and microbiologic results were comparable to the fluoroquinolone comparators in all trials. Insufficient data are available to evaluate the outcomes in any meaningful patient subgroups, including catheterized patients, and those with other specific complicating factors. Levofloxacin was well tolerated in these studies, with headache, gastrointenstinal effects, and dizziness being the most commonly reported adverse events. The published data support the use of levofloxacin in complicated urinary tract infections and acute pyelonephritis. Further trials are necessary to evaluate levofloxacin within specific patient sub-populations.
Urinary tract infections are one of the most frequently occurring bacterial infections. In the United States alone, they account for over 7 million office visits and approximately 15% of community-prescribed antibiotics (Mazzulli 2001; Foxman 2002). While the majority of these infections are uncomplicated, patients with complicated urinary tract infections (cUTI) are, by definition, at greater risk for adverse outcomes. Levofloxacin, a widely-used fluoroquinolone, was approved in the US for the treatment of cUTI and acute pyelonephritis (AP) in 1996 and, more recently, in 2008 a higher dose, short-course regimen was also approved for this indication. This review will examine the clinical data available to evaluate the efficacy and safety of this antimicrobial for cUTI and AP.Comparing Levofloxacin And Ofloxacin Health Essay.
Generally, a cUTI is considered to be an infection that occurs in the setting of any factor that predisposes to treatment failure or recurrence (McCue 1999). However, no true consensus has been reached within the medical community as to what specifically defines a cUTI. Traditionally, urinary tract infections in patient populations such as those with diabetes mellitus, pregnant females, and males have been considered to be complicated infections (Anderson 1996). Other descriptions of a cUTI have also included patients who are elderly, have experienced recent instrumentation or antimicrobial treatment, or possess functional or anatomic abnormalities of the genitourinary tract (Hooton and Stamm 1991). Ronald et al proposed an alternate classification scheme, in which a cUTI is characterized by the presence of structural abnormalitiesa (urinary obstructions, neurogenic bladder, etc.), metabolic and/or hormonal abnormalities (diabetes mellitus, pregnancy, renal impairment, etc.), impaired host responses (transplant recipients, neutropenic patients, etc.), or infection with an unusual pathogen (including yeasts, fungi, and antimicrobial-resistant bacteria) (Ronald and Harding 1997). Mandell’s Principles and Practice of Infectious Diseasesdefines cUTIs as urinary tract infections in men, pregnant women, children, hospitalized patients, and patients with functional or structural abnormalities of the urinary tract (Sobel and Kaye 2005).
AP is commonly described as an infection of the upper urinary tract that encompasses fever and flank pain and/or tenderness that are accompanied by dysuria and urinary urgency and frequency, although it is more accurately diagnosed based on the presence of these symptoms along with bacteriuria and acute renal infection (Sobel and Kaye 2005). AP was formerly treated largely on an inpatient basis, but a recent trend towards outpatient management of this condition has been noted (Czaja et al 2007). As seen in cUTI, the most common pathogen causing AP is Escherichia coli (Nicolle 1997; Czaja et al 2007).Comparing Levofloxacin And Ofloxacin Health Essay.
Currently available fluoroquinolones that are approved by the US Food and Drug Administration (FDA) for the treatment of cUTI and/or AP include ciprofloxacin, levofloxacin, norfloxacin, and ofloxacin. The fluoroquinolones gemifloxacin and moxifloxacin are not approved for either condition. Gatifloxacin was awarded FDA approval for the management of cUTI and AP, but this agent was withdrawn from the US market in 2006. Levofloxacin, approved by the US FDA in 1996, is the Senantiomer of the racemate ofloxacin. The S enantiomer of ofloxacin displays antibacterial activity that is approximately 2 orders of magnitude greater than that of the R enantiomer; this enhanced activity is due to greater binding to and saturation of the binding site on the DNA gyrase enzyme (Morrissey et al 1996). Studies of ofloxacin were not included in the present analysis.
The Infectious Diseases Society of America (IDSA) has published guidelines for the management of acute uncomplicated cystitis and AP (Warren et al 1999). For cases of AP that are manageable on an outpatient basis using oral antimicrobial therapy, the IDSA recommends a fluoroquinolone as the preferred empiric therapy, with trimethoprim/sulfamethoxazole (TMP/SMX) offered as an alternative. In patients that are to be hospitalized, the guidelines recommend the use of intravenous therapy with a fluoroquinolone, an aminoglycoside with or without ampicillin, or an extended-spectrum penicillin with or without an aminoglycoside. After such patients are stabilized, the IDSA recommends that the course of treatment be completed with an oral fluoroquinolone or oral TMP/SMX. Alternatives are recommended for each of the above patient populations if the infecting organism is known to be a Gram-positive coccus. Recommended first-line agents for the treatment of uncomplicated cystitis include a fluoroquinolone or TMP/SMX, depending on the local rate of TMP/SMX resistance in E. coli. IDSA is currently working towards assembling guidelines for the treatment of cUTI, and publication is anticipated in late 2008. The European Association of Urology (EAU) has published guidelines that include recommendations for cUTI, which advise the use of fluoroquinolones with mainly renal excretion when empiric therapy is necessary. The EAU recommends avoiding TMP/SMX as first-line treatment because of the increasingly high prevalence of resistance to that antimicrobial agent (Grabe et al 2008).
Fluoroquinolones have been extensively used in the management of genitourinary infections, especially acute uncomplicated cystitis. While fluoroquinolone resistance in uropathogens was once rare, resistance in E. coli has emerged and continues to increase. Fluoroquinolone resistance occurs through multiple mechanisms including chromosomal point mutations in the genes encoding DNA gyrase and/or topoisomerase iv, mutations that cause decreased expression of outer membrane proteins (OMPs), alterations in the lipopolysaccharide (LPS) component of the cell envelope, and enhanced fluoroquinolone efflux by efflux pumps such as AcrAB (Chenia et al 2006; Chang et al 2007). Plasmid-borne resistance has also recently been discovered, and is caused by protection of DNA gyrase and topoisomerase IV by Qnr-like proteins, including QnrA (Chenia et al 2006). Surveillance of urinary isolates collected between 1989 and 1997 found that fluoroquinolone resistance in E. coli was essentially nonexistent during this time frame (Gupta et al 1999a; Gupta et al 1999b). More recently, results of the North American Urinary Tract Infection Collaborative Alliance (NAUTICA) study, a multicenter surveillance study performed between 2003 and 2004 in the US and Canada, reported that overall resistance rates to ciprofloxacin and levofloxacin were 5.5% and 5.1%, respectively (Zhanel et al 2006). Comparing Levofloxacin And Ofloxacin Health Essay.Similar increases in fluoroquinolone resistance have been noted in the setting of AP (Czaja et al 2007). Also, among the emerging extended-spectrum beta-lactamase (ESBL)-producing E. coli, higher rates of fluoroquinolone resistance have been reported. In China, levofloxacin resistance among ESBL-producing E. coli was reported in 86% of isolates (Xiong et al 2002). In the US, one healthcare system reported that 56% of ESBL-producing E. coli and Klebsiella pneumoniae were resistant to fluoroquinolones (Lautenbach et al 2001).
Levofloxacin possesses activity against a variety of uropathogens, including E. coli(Davis and Bryson 1994). The pharmacokinetics of levofloxacin have been reviewed elsewhere, and a comprehensive evaluation of levofloxacin’s pharmacokinetics is beyond the scope of this review (Fish and Chow 1997). The bioavailability of levofloxacin is 100%, although absorption is delayed in the presence of food; the degree of protein binding ranges from 24 to 38%. Levofloxacin displays linear pharmacokinetics, and an elimination half-life of 7.6 hours after multiple doses of 500 mg. The primary route of elimination is renal, with approximately 71% of a dose eliminated as unchanged drug within 24 hours. Tissue distribution is extensive; urinary levofloxacin concentrations have been reported to be as high as 128–343 mg/L (the corresponding plasma maximum concentration (Cmax) after a single 500 mg dose ranges from 4.5 to 5.2 mg/L) (Langtry and Lamb 1998). Levofloxacin also attains adequate penetration into the prostate, with a mean 2.96:1 prostate: plasma concentration ratio, and this agent has demonstrated success in the management of chronic bacterial prostatitis, including equivalent efficacy to ciprofloxacin (Drusano et al 2000; Bundrick et al 2003; Naber et al 2008). The urinary excretion of levofloxacin (84%) is higher than that of ciprofloxacin (43%), gatifloxacin (80%), gemifloxacin (28%), and moxifloxacin (20%) (Naber 2001). Renal clearance of levofloxacin (but not the plasma Cmax) is reduced in the presence of renal impairment.
Few current guidelines describing the optimal treatment of cUTI and AP are available, and the role of levofloxacin in comparison to alternate antimicrobials (including other fluoroquinolones) in the management of these conditions must be further defined. The objective of this review is to provide a summary of the clinical efficacy and safety of levofloxacin in the treatment of cUTI and AP.
The PubMed search engine was used to query the National Library of Medicine database using the following search terms: “fluoroquinolone,” “levofloxacin,” “complicated urinary tract infection,” “complicated UTI,” “cystitis,” “pyelonephritis,” “urinary tract infection,” and “UTI.” This query was also limited to English-language publications. The search criteria were chosen to maximize the sensitivity of the search. The same search criteria were used to query the Cochrane Database of Clinical Trials and the Clinical Trials.gov database. We included all English-language publications of either randomized controlled trials or analytical observational studies of the efficacy of levofloxacin in treating cUTI and/or AP that were published before February 1, 2008. We excluded studies performed in pediatric patients or that included no comparator group. For each publication, the authors’ definition of cUTI and AP were used. The citations of all included publications were also considered for inclusion in this review. All publications were assessed for potential duplication of reported data.
For each of the included publications, two authors extracted data on the study design and methods, the definitions of key variables (cUTI, AP, microbiologic eradication, and clinical cure), timing of outcome assessments, efficacy and safety results, infecting pathogens, and the presence and/or development of antibiotic resistance.Comparing Levofloxacin And Ofloxacin Health Essay. Data extraction was conducted in this manner so as to evaluate not only the safety and efficacy but also the generalizability of the studies to general practice.
The PubMed query yielded 385 publications. Of these, five publications met the inclusion and exclusion criteria. However, one of these publications reported the findings of a subset of patients (those with AP) and these data were also subsequently published with the results of the full trial (Klausner et al 2007; Peterson et al 2008). Thus, only the latter publication was included in this review (Peterson et al 2008). Of the publications that were excluded, 86% were excluded because they were not human subjects-based research (including, for example, systematic reviews), did not include levofloxacin as a study drug, or were not evaluating therapies for cUTI or AP.
The query of the Cochrane Database of Clinical Trials yielded 55 publications. Of these, eight studies were not included because levofloxacin was not evaluated, seven were excluded because they were not studies of cUTI or AP, 13 were non-English publications, and the remaining 27 studies had already been identified for consideration in the PubMed query. Similarly, the ClinicalTrials.gov query yielded 60 registered trials (some on-going). Of these trials, 47 were not studies of cUTI or AP, four were conducted in pediatric patients, five were studies not including levofloxacin, and one was an uncontrolled study. Only three trials were identified as having met inclusion and exclusion criteria. The findings of these trials were published, either in whole or in part, in the publications identified through PubMed. Thus, the summary data available through ClinicalTrials.gov were not included in this review. Review of the cited publications yielded one additional, previously unidentified publication that met inclusion and exclusion criteria.
Five publications met all inclusion and exclusion criteria and are included in this review (Klimberg et al 1998; Richard et al 1998a, b; Peng 1999; Peterson et al 2008). Table 1 summarizes the design of the trials reported in these publications. All five publications reported the findings of randomized controlled trials. One reported the results of two such trials (Richard et al 1998b); thus six trials were described among the five publications. We should also note that three of the publications included in this review arise from two trials. Comparing Levofloxacin And Ofloxacin Health Essay. More specifically, data from two trials for the subset of AP patients were published in one publication (Richard et al 1998b) and the data pertaining to the cUTI patients from each of these trials were published separately (Klimberg et al 1998; Richard et al 1998a). From this point forward, we will consider these three publications as presenting the results of four distinct trials.
|Population||Study design||Treatment||Comparator||No. subjects randomized||Microbiologic outcome definition||Clinical outcome definition||Endpoints|
|Klimberg et al 1998||Adult (18 yrs or older) outpatients with cUTI||Open-label, multi-center RCT||Levofloxacin 250 mg po once daily for 7–10 days||vs||Lomefloxacin 400 mg po once daily for 14 days||461||Eradication (<104 cfu/mL) of uropathogen(s) identified at study entry||Clinical success (cure or improvement)
||Post-therapy: 5–9 days after completion of therapy|
|Long-term follow-up: 4–6 weeks after completion of therapy|
|Peng 1999||Persons age 16 and older with cUTI and AP||Double-blind, single-center RCT||Levofloxacin 100 mg po 3 times daily for 10 days||vs||Ofloxacin 200 mg po three times daily for 10 days||46||Cleared or decreased bacteriuria (<104 cfu/mL)||Clinical cure based on combined results on effect on pyuria, bacteriuria, and subjective symptoms.||Endpoint evaluation: study day 5|
|Peterson et al 2008||Adults (18 yrs or older) with AP or cUTI||Double-blind, multi-center RCT||Levofloxacin 750 mg iv/po once daily for 5 days||vs||Ciprofloxacin 400 mg iv/500 mg po twice daily for 10 days||1093||Eradication (<104 cfu/mL) of uropathogen(s) identified at study entry||Clinical success (cure or improvement)
||End of blinded therapy: study day 11 ± 1|
|Post-therapy: study days 15–19|
|Post-study: study days 38–45|
|Richard et al 1998aa||Adults (18 yrs or older) with AP||
||Levofloxacin 250 mg po once a day for 10 days||vs||Ciprofloxacin 500 mg po twice daily for 10 days||185||Eradication (<104 cfu/mL) of uropathogen(s) identified at study entry||Clinical cure
||Post-therapy: 5–9 days after completion of therapy|
|Levofloxacin 250 mg po once daily for 7–10 days||vs||Lomefloxacin 400 mg po once daily for 14 days||Long-term follow-up: 4–6 weeks after therapy|
|Richard et al 1998b||Adult (18 yrs or older) outpatients with cUTI||Double-blind, multi-center RCT||Levofloxacin 250 mg po once a day for 10 days||vs||Ciprofloxacin 500 mg po twice daily for 10 days||380||Eradication (<104 cfu/mL) of uropathogen(s) identified at study entry||Clinical Success (cured or improved)
||Days 3–5 of therapy|
|Post-therapy: 5–9 days after completion of therapy|
|Long-term follow-up: 4–6 weeks after therapy|
Abbreviations: AP, acute pyelonephritis; cUTI, complicated urinary tract infection; RCT, randomized controlled trial; cfu, colony-forming units.
Three trials were conducted in the US (Klimberg et al 1998; Richard et al 1998b; Peterson et al 2008), two trials in the US and Canada (Richard et al 1998b), and one trial was conducted in Taiwan (Peng 1999). The latter was also the only single-center trial. Only two publications specifically stated that the targeted sample size was selected to show equivalence within a margin of 15% (Richard et al 1998a; Peterson et al 2008). One of these publications did not achieve the sample size targeted by their power calculation (Richard et al 1998a).Comparing Levofloxacin And Ofloxacin Health Essay. The remaining trials, which were all of smaller sample sizes, did not specifically describe the statistical power, sample size, or margin of equivalence that the trial was designed to target.
The definition of cUTI varied across the four trials including these patients. The trials performed by Peng and Peterson et al stated only that a diagnosis of cUTI was required, although females in the latter trial were also required to have at least one of the following complicating factors: neurogenic bladder or urinary retention; partial obstruction, renal tumor or fibrosis, distorted urethral structure; and/or intermittent catheterization (Peng 1999; Peterson et al 2008). The studies of cUTI published by Klimberg et al and Richard et al required that all subjects possess an anatomic or functional abnormality of the urinary tract and at least one of the following symptoms: urgency frequency, dysuria, hematuria, or fever or history of fever (Klimberg et al 1998; Richard et al 1998a). Klimberg et al also required that patients present with a baseline urinary sample with more than five urinary white blood cells/high-power field (Klimberg et al 1998). Three trials also required that study participants present with 105 or more colony-forming units (cfu)/mL of at least one species of uropathogen (Klimberg et al 1998; Richard et al 1998a; Peterson et al 2008), although Peterson et al excluded patients with more than two species of uropathogen present at baseline (Peterson et al 2008).
Four trials included AP patients. In three of the trials, the definitions of AP were similar and required that patients present with 105 or more cfu/mL of at least one species of uropathogen and two or more of the following symptoms: fever, flank pain or costovertebral angle tenderness, peripheral white blood cell count (WBC) more than 12,500/mm3 or 10% or greater bands, and/or WBC casts in the urine, or, in the case of Peterson et al a positive antibody-coated bacteria test (Richard et al 2002; Peterson et al 2008). Similar to the definition of cUTI, Peterson et al required that subjects with AP have at least one of the following symptoms: urgency frequency, dysuria, hematuria, or fever or history of fever (Peterson et al 2008). In contrast, Peng required only a diagnosis of AP (Peng 1999). All trials assessed the outcomes of microbiologic eradication and clinical success. These definitions were similar across all trials (Table 1).
ORDER A PLAGIARISM -FREE PAPER NOW
In each of the six trials, another fluoroquinolone was selected as the comparator treatment (ciprofloxacin in three trials, lomefloxacin in two trials, and ofloxacin in one trial). One trial allowed patients to be administered either oral or intravenous formulations. The efficacy and safety results of this trial were not stratified by formulation, although 97% of the intention to treat group were started on an oral formulation of either levofloxacin or the comparator (Peterson et al 2008). The five remaining trials evaluated oral administration of levofloxacin. Of these, four trials were specifically limited to outpatients and/or patients deemed appropriate candidates for oral therapy (Klimberg et al 1998; Richard et al 1998a, b). Five trials specifically included in their definitions of cUTI and AP that patients’ urine cultures at the time of enrollment must contain at least 105 cfu/mL of a uropathogen (Klimberg et al 1998; Richard et al 1998a, b; Peterson et al 2008).Comparing Levofloxacin And Ofloxacin Health Essay. Four of these trials excluded subjects with previous infections with organisms known to be resistant to any study medication (Klimberg et al 1998; Richard et al 1998a, b). The fifth excluded subjects if the UTI was caused by a pathogen resistant to either study medication (Peterson et al 2008).
Four trials also excluded patients with decreased renal function. Peng excluded patients with renal failure (and other extremely severe underlying diseases) (Peng 1999). Of the two trials described in Richard et al, one excluded all patients with a creatinine clearance less than 50 mL/min and the second excluded those with a creatinine clearance less than 20 mL/min (Richard et al 1998b). In the latter trial, dosing was altered for those with a creatinine clearance between 20 and 50 mL/min. This same exclusion criteria (creatinine clearance of less than 20 mL/min) and altered dosing scheme was also applied in the study by Klimberg et al (Klimberg et al 1998). In both publications, no data were provided as to the number of patients receiving altered dosing, nor were the efficacy and safety results reported within this subset of subjects. Richard et al’s cUTI trial also excluded .Comparing Levofloxacin And Ofloxacin Health Essay.