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# Ciprofloxacin
## Overview
Ciprofloxacin is a broad-spectrum fluoroquinolone antibiotic effective against many Gram-positive and Gram-negative bacteria. It inhibits bacterial DNA gyrase and topoisomerase IV, essential enzymes for DNA replication, transcription, repair, and recombination.
## Primary Indications
* Complicated urinary tract infections (cUTI)
* Prostatitis
* Gastroenteritis caused by susceptible organisms (e.g., *Shigella*, *Salmonella*, *E. coli*)
* Respiratory tract infections (when other agents are not suitable)
* Bone and joint infections
* Intra-abdominal infections (in combination with another agent)
* Infectious diarrhea
* Anthrax (prophylaxis and treatment)
* Plague
## Adult Dosing
Dosing varies significantly by indication and severity. Typical doses range from 250 mg to 750 mg every 12 hours for oral formulations, and 200 mg to 400 mg every 8-12 hours for intravenous formulations.
* **Uncomplicated UTI:** 250 mg PO BID for 3 days.
* **Complicated UTI/Prostatitis:** 500 mg PO BID for 7-28 days, or 400 mg IV BID for 7-28 days.
* **Pneumonia/Respiratory Tract Infections:** 500-750 mg PO BID for 7-14 days, or 400 mg IV BID for 7-14 days.
* **Bone and Joint Infections:** 500-750 mg PO BID for 4-12 weeks, or 400 mg IV BID for 4-12 weeks.
* **Anthrax (treatment):** 500 mg PO BID for 60 days, or 400 mg IV BID for 60 days.
* **Anthrax (prophylaxis):** 500 mg PO BID for 60 days.
* **Maximum dose:** Generally 1500 mg PO per day and 800 mg IV per day, but may vary by indication.
Specific dosing for other indications should be guided by current institutional protocols and susceptibility data.
## Pediatric Dosing
Ciprofloxacin is approved for use in children for specific indications, with dosing based on weight and indication.
* **Cystic Fibrosis Pulmonary Exacerbations:** 10 mg/kg IV every 8 hours (maximum 400 mg/dose) or 15 mg/kg PO every 12 hours (maximum 500 mg/dose).
* **Anthrax (inhalational, post-exposure prophylaxis):** 15 mg/kg PO every 12 hours (maximum 500 mg/dose) for 60 days.
* **Other indications:** Dosing varies; consult pediatric infectious disease resources. Use caution due to potential for arthropathy.
## Dose Adjustments
* **Renal Impairment:**
* CrCl > 30 mL/min: No adjustment needed.
* CrCl 5-30 mL/min: Reduce dose by 50% (for IV, give every 12 hours; for PO, give every 12-18 hours).
* CrCl < 5 mL/min (hemodialysis/peritoneal dialysis): Dose as for CrCl 5-30 mL/min, and administer post-dialysis if dose is given on dialysis days.
## Contraindications
* Hypersensitivity to ciprofloxacin, other fluoroquinolones, or any component of the formulation.
* Concomitant use with tizanidine.
## Adverse Effects
* **Common:** Nausea, vomiting, diarrhea, rash, headache, dizziness.
* **Serious:** Tendon rupture (especially Achilles), *Clostridioides difficile*-associated diarrhea, peripheral neuropathy, central nervous system effects (seizures, psychosis), QT prolongation, phototoxicity, dysglycemia (hypo- and hyperglycemia), arthralgia/arthropathy (especially in pediatrics).
## Key Drug Interactions
* **Cation-containing antacids (aluminum, magnesium), sucralfate, iron salts, calcium supplements, and multivalent cations (e.g., zinc):** Reduce absorption of ciprofloxacin. Separate administration by at least 2 hours before or 6 hours after ciprofloxacin.
* **Theophylline:** May increase theophylline levels. Monitor theophylline levels closely and adjust dose accordingly.
* **Warfarin:** May enhance the anticoagulant effect. Monitor INR closely.
* **Oral hypoglycemic agents/Insulin:** Risk of dysglycemia. Monitor blood glucose.
* **NSAIDs:** May increase risk of CNS stimulation and seizures.
* **Tizanidine:** Contraindicated due to potential for significant hypotension and somnolence.
* **CYP1A2 substrates:** Ciprofloxacin is a moderate inhibitor of CYP1A2. May increase concentrations of substrates like duloxetine, theophylline, and clozapine.
## Monitoring
* Signs and symptoms of infection.
* Renal function.
* Electrolytes, particularly potassium and magnesium, if concomitant QT-prolonging drugs are used.
* Blood glucose in patients with diabetes.
* Signs and symptoms of tendon inflammation or rupture.
* Mental status changes.
* INR if on warfarin.
* Theophylline levels if applicable.
## Clinical Pearls
* Avoid use in uncomplicated infections where other agents are effective due to risk of resistance and serious adverse events.
* Ensure adequate hydration to prevent crystalluria.
* Instruct patients to avoid excessive sunlight or artificial UV light due to phototoxicity risk.
* If a tendon disorder is suspected, discontinue ciprofloxacin immediately and initiate appropriate treatment.
* For IV administration, dilute in an appropriate IV fluid (e.g., 0.9% sodium chloride, 5% dextrose) and infuse over 60 minutes.
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**Disclaimer:** This information is intended for clinical decision support and does not replace professional clinical judgment. Always consult the most current prescribing information, institutional guidelines, and peer-reviewed literature for definitive drug management.
