How do you counsel patients and doctors on antibiotic avoidance in myasthenia gravis?

I generally recommend avoiding aminoglycosides and most macrolides in MG. The rationale is that there are alternative effective antibiotics for most of the infections covered by the above categories. With fluoroquinolones, however, it's not that simple, because there are some infections that are uniquely sensitive to this category of antibiotics, and great alternatives may not exist. Given the low real-life frequency of MG exacerbations in individuals receiving fluoroquinolones, as described in ...

The Uysal et al., PMID 40166923 paper shows a 1.5-2.5% risk of MG exacerbation with quinolones and/or azithromycin. Even amoxicillin had a 1.3% rate of exacerbations. A good third had more severe relapses requiring hospitalization. My reading of this is that the risks are small but real, that almost any antibiotic (cephalosporins may be an exception) can cause a relapse, and that risk/benefit discussion is crucial. I've had a couple of patients who relapsed with levaquin and required urgent trea...