Fourth-generation fluoroquinolone
ATC code: J01MA14 (Moxifloxacin)
Brand names
Avelox, Octegra, Vigamox
Inhibits bacterial topoisomerase II (DNA gyrase) and topoisomerase IV, disrupting DNA supercoiling and replication. Spectrum broader than ciprofloxacin: covers Streptococcus pneumoniae (including penicillin-resistant strains), atypical pathogens (Mycoplasma, Chlamydia, Legionella), and anaerobes. Does not reach adequate urinary concentrations – not used in UTI. In 2019 substantially restricted fluoroquinolone indications due to severe adverse effects (tendinitis, aortic aneurysm, peripheral neuropathy).
Second line
Second-line for community-acquired pneumonia in patients with β-lactam allergy or at risk of resistant pneumococcus. /ATS 2019 and SEPAR 2024 set high-dose or amoxicillin + macrolide as first-line outpatient CAP. Moxifloxacin (400 mg once daily for 5 days) is used in allergy or first-line intolerance, or with risk of resistant Streptococcus pneumoniae.
Second line
In severe bacterial COPD exacerbation in patients at Pseudomonas aeruginosa risk or after first-line failure (amoxicillin/clavulanate, cefuroxime). GesEPOC 2021 considers moxifloxacin an alternative with Anthonisen criteria and first-line failure or intolerance. Dose 400 mg once daily for 5 days.
The drug is promoted for these uses outside international guidelines. Each entry below is analyzed against AEMPS, FDA, EMA, Cochrane and major RCTs.
Not recommended
Moxifloxacin is prescribed for upper respiratory infections, influenza and atypical persistent cough without bacterial confirmation. 2024 AWaRe and 2019 confine fluoroquinolones to serious infections without alternatives. The 2018 PRAC and Drug Safety Communication 2018 additionally cited QT prolongation and aortic aneurysm risk. Use in viral infections is irrational.
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Boxed warning
FDA boxed warning: tendinitis, tendon rupture, peripheral neuropathy, psychiatric disorders; myasthenia gravis exacerbation; increased aortic aneurysm and dissection risk. Use only when alternatives are unavailable for infections where benefit is justified.
Contraindicated in pregnancy. In pregnant patients with severe infection, β-lactams, macrolides, or cephalosporins are preferred.
Contraindicated during lactation – high milk concentrations.
Reference information, not a clinical decision. Discuss feeding pauses or changes with your physician or an IBCLC.
Moxifloxacin is evaluated for the following indications with varying evidence strength: Community-acquired pneumonia (evidence tier A), COPD exacerbation (evidence tier B), Acute viral upper respiratory infection (evidence tier F). See the full indication matrix with dosing and citations above on this page.
Common side effects of Moxifloxacin (≥ 1 in 100): Nausea and diarrhea, Headache, Dizziness, Insomnia, Candidiasis, QT prolongation. See the Safety section for uncommon and serious reactions.
FDA category C. Contraindicated in pregnancy. In pregnant patients with severe infection, β-lactams, macrolides, or cephalosporins are preferred.
Contraindicated during lactation – high milk concentrations.
Moxifloxacin is contraindicated in: Hypersensitivity to moxifloxacin or fluoroquinolones; Age under 18; Pregnancy and lactation; QT prolongation, congenital long QT syndrome; Uncontrolled bradycardia and hypokalemia. Full list in the Safety section.
FDA boxed warning: tendinitis, tendon rupture, peripheral neuropathy, psychiatric disorders; myasthenia gravis exacerbation; increased aortic aneurysm and dissection risk. Use only when alternatives are unavailable for infections where benefit is justified.