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## Ciprofloxacin (Cipro)
### Overview
Ciprofloxacin is a broad-spectrum fluoroquinolone antibiotic effective against many Gram-positive and Gram-negative bacteria.
### Primary Indications
* Urinary Tract Infections (UTIs)
* Complicated UTIs
* Prostatitis
* Respiratory Tract Infections (certain types)
* Bone and Joint Infections
* Intra-abdominal Infections
* Infectious Diarrhea
* Anthrax prophylaxis and treatment
### Adult Dosing
Dosing is typically based on indication, severity, and renal function. Consult local protocols for specific indications not listed or for complex infections.
* **Urinary Tract Infection (Uncomplicated):** 250 mg orally every 12 hours for 3 days.
* **Urinary Tract Infection (Complicated) / Prostatitis:** 500 mg orally every 12 hours for 7-21 days.
* **Respiratory Tract Infections / Bone and Joint Infections:** 500-750 mg orally every 12 hours for 7-14 days.
* **Intra-abdominal Infections:** 500 mg orally every 12 hours for 7-14 days (often in combination with metronidazole).
* **Infectious Diarrhea:** 500 mg orally every 12 hours for 3-5 days.
* **Anthrax (Prophylaxis):** 500 mg orally every 12 hours for 60 days.
* **Anthrax (Treatment):** 500-750 mg orally/IV every 12 hours for 14 days (consider duration based on clinical response).
* **Intravenous (IV) Dosing:** Typically 200-400 mg every 8-12 hours. Conversion from IV to oral depends on clinical improvement and tolerability.
**Maximum Oral Dose:** 1500 mg daily.
**Maximum IV Dose:** 1200 mg daily.
### Pediatric Dosing
Ciprofloxacin is generally reserved for specific situations in children due to potential adverse effects. Dosing is based on indication and weight. Consult pediatric infectious disease guidelines.
* **Urinary Tract Infections / Pyelonephritis:** 10-15 mg/kg orally every 12 hours.
* **Maximum Dose:** 500 mg per dose.
* **Duration:** 7-14 days.
* **Anthrax (Prophylaxis/Treatment):** 10-15 mg/kg orally/IV every 12 hours.
* **Maximum Dose:** 500 mg per dose (oral) or 400 mg per dose (IV).
* **Duration:** 60 days for prophylaxis, 14 days for treatment (consider combination therapy).
### Dose Adjustments
* **Renal Impairment (CrCl < 30 mL/min):** Reduce dose by 50% for standard dosing regimens. For intermittent IV infusion, extend the dosing interval. If ClCr is 5-29 mL/min, a dose of 250-500 mg every 12 hours (oral) or 200-300 mg every 12 hours (IV) may be used. If CrCl < 5 ml/min, administer 250-500 mg every 24 hours (oral) or 200-300 mg every 24 hours (IV). Consult specific guidelines.
### Contraindications
* Hypersensitivity to ciprofloxacin or other quinolones.
* Concomitant use with tizanidine.
### Adverse Effects
* **Common:** Nausea, vomiting, diarrhea, abdominal pain, headache, dizziness, rash.
* **Serious:**
* **Tendonitis and Tendon Rupture:** Risk increased in older adults (>60), those taking corticosteroids, and organ transplant recipients. Discontinue at the first sign of tendon pain or inflammation.
* **Peripheral Neuropathy:** Can be irreversible.
* **Central Nervous System (CNS) Effects:** Seizures, tremors, hallucinations, confusion, anxiety, depression, suicidal thoughts.
* **QTc Prolongation:** Risk factors include hypokalemia, concurrent use of other QTc-prolonging agents.
* **Aortic Aneurysm and Dissection:** Increased risk with fluoroquinolone use, particularly in patients with pre-existing risk factors.
* **Clostridioides difficile-associated diarrhea (CDAD).**
* **Phototoxicity.**
* **Dysglycemia:** Both hypoglycemia and hyperglycemia, particularly in diabetic patients.
### Key Drug Interactions
* **Tizanidine:** Contraindicated due to significant increase in tizanidine levels and associated adverse effects (e.g., hypotension, somnolence).
* **Theophylline:** Ciprofloxacin can inhibit the metabolism of theophylline, leading to toxic levels. Monitor theophylline levels or consider alternative antibiotics.
* **Warfarin:** May potentiate the anticoagulant effect of warfarin. Monitor INR closely.
* **Cation-Containing Antacids (e.g., aluminum, magnesium), Sucralfate, Multivitamins, Calcium, Iron, Zinc:** Can significantly decrease ciprofloxacin absorption. Separate administration by at least 2 hours before or 6 hours after ciprofloxacin.
* **Divalproex Sodium:** May increase plasma concentrations of divalproex. Monitor valproic acid levels. Consider alternatives or closer monitoring.
* **Oral Hypoglycemics/Insulin:** Monitor blood glucose closely; may cause hypo- or hyperglycemia.
### Monitoring
* **Renal function:** Especially in patients with known renal impairment or those at risk.
* **Signs and symptoms of tendon rupture:** Advise patients to report any new pain or swelling.
* **CNS effects:** Assess for confusion, hallucinations, tremors, etc.
* **QTc interval:** If risk factors for QTc prolongation are present.
* **Blood glucose:** In diabetic patients.
* **Signs of C. difficile infection.**
### Clinical Pearls
* Administer oral ciprofloxacin at least 1 hour before or 2 hours after meals. Absorption is significantly reduced by food.
* Intravenous administration is typically over 60 minutes. Rapid infusion can lead to hypotension.
* Adequate hydration is important to prevent crystalluria.
* Avoid concomitant use with corticosteroids to minimize tendon rupture risk.
* Recognize ciprofloxacin's broad spectrum but consider potential for resistance and necessity for susceptibility testing, especially for serious infections.
***
**Disclaimer:** This information is intended for healthcare professionals. Always consult the most current prescribing information and relevant clinical guidelines before making treatment decisions, as drug information can change.
