title: Oral fluoroquinolone use and serious arrhythmia: bi-national cohort study.
abstract: OBJECTIVE
  To evaluate if oral fluoroquinolone use is associated with an increased risk of serious arrhythmia.
  
  
  METHODS
  Bi-national cohort study, linking register data on filled prescriptions, cases of serious arrhythmia, and patient characteristics.
  
  
  METHODS
  Denmark, 1997-2011; Sweden, 2006-13.
  
  
  METHODS
  The study cohort was derived from a source population of all Danish and Swedish adults, aged 40 to 79 years. 909,656 courses of fluoroquinolone use (ciprofloxacin 82.6%, norfloxacin 12.1%, ofloxacin 3.2%, moxifloxacin 1.2%, and other fluoroquinolones 0.9%) and 909,656 courses of penicillin V use, matched 1:1 on propensity score, were included.
  
  
  METHODS
  The main outcome was risk of serious arrhythmia (fatal and non-fatal), comparing courses of fluoroquinolone use with courses of penicillin V use (an antibiotic with no pro-arrhythmic effect). The risk period of interest was current use, defined as days 0-7 of treatment. Subgroup analyses were conducted according to country, sex, age, underlying cardiovascular disease, concomitant use of drugs known to increase the risk of torsades de pointes, fluoroquinolone type, and levels of arrhythmia risk score.
  
  
  RESULTS
  144 cases of serious arrhythmia occurred during follow-up, 66 among current fluoroquinolone users (incidence rate 3.4 per 1000 person years) and 78 among current penicillin users (4.0 per 1000 person years); comparing oral fluoroquinolone treatment with penicillin V, the rate ratio was 0.85 (95% confidence interval 0.61 to 1.18). Compared with penicillin V, the absolute risk difference was -13 (95% confidence interval -35 to 16) cases of serious arrhythmia per 1,000,000 courses of fluoroquinolones. The risk of serious arrhythmia was not statistically significantly increased in any of the subgroups, including analyses by fluoroquinolone type.
  
  
  CONCLUSIONS
  Contrary to previous reports, oral fluoroquinolone treatment was not associated with an increased risk of serious arrhythmia in the general adult populations of Denmark and Sweden. Given the statistical power of the study, even small increases in relative and absolute risk could be ruled out. Since ciprofloxacin was the most commonly used fluoroquinolone in our study, we cannot exclude that intraclass differences influence the risk of serious arrhythmia associated with other less frequently used fluoroquinolones.
authors.affiliation: Lund University, Department of Clinical Sciences Lund, Section for Infection Medicine, Lund, Sweden malin.inghammar@med.lu.se.
authors.forename: Malin
authors.initials: M
authors.lastname: Inghammar
authors.affiliation: Department of Epidemiology Research, Statens Serum Institut, 2300 Copenhagen S, Denmark.
authors.forename: Henrik
authors.initials: H
authors.lastname: Svanström
authors.affiliation: Department of Epidemiology Research, Statens Serum Institut, 2300 Copenhagen S, Denmark.
authors.forename: Mads
authors.initials: M
authors.lastname: Melbye
authors.affiliation: Department of Epidemiology Research, Statens Serum Institut, 2300 Copenhagen S, Denmark.
authors.forename: Björn
authors.initials: B
authors.lastname: Pasternak
authors.affiliation: Department of Epidemiology Research, Statens Serum Institut, 2300 Copenhagen S, Denmark.
authors.forename: Anders
authors.initials: A
authors.lastname: Hviid
mesh_terms: D000284:Administration, Oral; D000328:Adult; D000368:Aged; D000900:Anti-Bacterial Agents / Q000008:administration & dosage / Q000009:adverse effects*; D001145:Arrhythmias, Cardiac / Q000139:chemically induced* / Q000453:epidemiology; D003718:Denmark / Q000453:epidemiology; D004812:Epidemiologic Methods; D024841:Fluoroquinolones / Q000008:administration & dosage / Q000009:adverse effects*; D006801:Humans; D008875:Middle Aged; D010404:Penicillin V / Q000008:administration & dosage / Q000009:adverse effects; D013548:Sweden / Q000453:epidemiology
chemical_list: D000900:Anti-Bacterial Agents; D024841:Fluoroquinolones; D010404:Penicillin V