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Original Investigation
September 8, 2020

Association of Infections and Use of Fluoroquinolones With the Risk of Aortic Aneurysm or Aortic Dissection

Author Affiliations
  • 1Faculty of Pharmacy, National Yang-Ming University School of Pharmaceutical Science, Taipei, Taiwan
  • 2Institute of Public Health, National Yang-Ming University School of Medicine, Taipei, Taiwan
  • 3Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
  • 4Department of Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
  • 5Institute of Epidemiology and Preventive Medicine, National Taiwan University College of Public Health, Taipei, Taiwan
  • 6Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
  • 7Department of Medicine, National Cheng Kung University Medical College, Tainan, Taiwan
  • 8Department of Internal Medicine, National Taiwan University Hospital Yunlin Branch, Douliou City, Yunlin County, Taiwan
  • 9Cardiovascular Center, National Taiwan University Hospital Yunlin Branch, Douliou City, Yunlin County, Taiwan
  • 10Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
JAMA Intern Med. Published online September 8, 2020. doi:10.1001/jamainternmed.2020.4192
Key Points

Question  Is the risk of aortic aneurysm or aortic dissection independently associated with infections and fluoroquinolone use (vs other antibiotics with similar indication profiles)?

Findings  In this nationwide, nested case-control study of 28 948 cases and 289 480 matched controls identified from 21 651 176 adult patients, the odds ratio (OR) of aortic aneurysm or aortic dissection for any indicated infections, adjusted for baseline confounders and concomitant antibiotic use, was 1.73 (95% CI, 1.66-1.81). Fluoroquinolones were not associated with an increased risk of aortic aneurysm or aortic dissection when compared with amoxicillin-clavulanate or ampicillin-sulbactam (OR, 1.01; 95% CI, 0.82-1.24) or extended-spectrum cephalosporins (OR, 0.88; 95% CI, 0.70-1.11) among patients with indicated infections.

Meaning  These results highlight the importance of accounting for coexisting infections while examining the safety of antibiotics using real-world data; the concern about aortic aneurysm or aortic dissection should not deter fluoroquinolone use for patients with indicated infections.

Abstract

Importance  Prior observational studies have suggested that fluoroquinolone use may be associated with more than 2-fold increased risk of aortic aneurysm or aortic dissection (AA/AD). These studies, however, did not fully consider the role of coexisting infections and the risk of fluoroquinolones relative to other antibiotics.

Objective  To estimate the risk of AA/AD associated with infections and to assess the comparative risk of AA/AD associated with fluoroquinolones vs other antibiotics with similar indication profiles among patients with the same types of infections.

Designs, Settings, and Participants  This nested case-control study identified 21 651 176 adult patients from a nationwide population-based health insurance claims database from January 1, 2009, to November 30, 2015. Each incident case of AA/AD was matched with 10 control individuals by age, sex, and follow-up duration in the database using risk-set sampling. Analysis of the data was conducted from April 2019 to March 2020.

Exposures  Infections and antibiotic use within a 60-day risk window before the occurrence of AA/AD.

Main Outcomes and Measures  Conditional logistic regression was used to estimate the odds ratios (ORs) and 95% CIs comparing infections for which fluoroquinolones are commonly used with no infection within a 60-day risk window before outcome occurrence, adjusting for baseline confounders and concomitant antibiotic use. The adjusted ORs comparing fluoroquinolones with antibiotics with similar indication profiles within patients with indicated infections were also estimated.

Results  A total of 28 948 cases and 289 480 matched controls were included (71.37% male; mean [SD] age, 67.41 [15.03] years). Among these, the adjusted OR of AA/AD for any indicated infections was 1.73 (95% CI, 1.66-1.81). Septicemia (OR, 3.16; 95% CI, 2.63-3.78) and intra-abdominal infection (OR, 2.99; 95% CI, 2.45-3.65) had the highest increased risk. Fluoroquinolones were not associated with an increased AA/AD risk when compared with combined amoxicillin-clavulanate or combined ampicillin-sulbactam (OR, 1.01; 95% CI, 0.82-1.24) or with extended-spectrum cephalosporins (OR, 0.88; 95% CI, 0.70-1.11) among patients with indicated infections. The null findings for fluoroquinolone use remained robust in different subgroup and sensitivity analyses.

Conclusions and Relevance  These results highlight the importance of accounting for coexisting infections while examining the safety of antibiotics using real-world data; the findings suggest that concerns about AA/AD risk should not deter fluoroquinolone use for patients with indicated infections.

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