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# Ciprofloxacin (Cipro)
## Overview
Ciprofloxacin is a broad-spectrum fluoroquinolone antibiotic effective against many Gram-positive and Gram-negative bacteria, including many anaerobes. It inhibits bacterial DNA gyrase and topoisomerase IV, enzymes essential for DNA replication, transcription, repair, and recombination.
## Primary Indications
* Urinary tract infections (UTIs), including complicated UTIs and prostatitis
* Lower respiratory tract infections (e.g., acute exacerbations of chronic bronchitis, community-acquired pneumonia)
* Skin and skin structure infections
* Bone and joint infections
* Intra-abdominal infections
* Anthrax (prophylaxis and treatment)
* Certain types of infectious diarrhea
* Ophthalmic infections (topical formulations)
* Prophylaxis against *Pseudomonas aeruginosa* in immunocompromised patients with cystic fibrosis (less common; individualized)
## Adult Dosing
Dosing is highly dependent on the type and severity of infection, as well as renal function.
* **Urinary Tract Infections (Uncomplicated):** 250 mg PO BID for 3 days.
* **Urinary Tract Infections (Complicated)/Prostatitis:** 500 mg PO BID for 7-28 days, or 400 mg IV BID for 7-28 days.
* **Community-Acquired Pneumonia:** 500-750 mg PO BID for 7-14 days, or 400 mg IV BID for 7-14 days.
* **Skin/Bone/Joint Infections:** 500-750 mg PO BID for 7-14 days (skin) or 4-12 weeks (bone/joint), or 400 mg IV BID for similar durations.
* **Intra-abdominal Infections:** 500 mg PO BID for 7-14 days, or 400 mg IV BID for 7-14 days (often in combination with metronidazole).
* **Anthrax (Inhalational):** 500 mg PO BID for 60 days, or 400 mg IV BID for 60 days.
* **Maximum Oral Dose:** Generally 1500 mg daily.
* **Maximum IV Dose:** Generally 1200 mg daily.
Consult local guidelines as specific dosing may vary.
## Pediatric Dosing
Ciprofloxacin is generally reserved for specific indications in pediatrics due to safety concerns (tendinopathy, arthropathy).
* **Urinary Tract Infections (Complicated):** 10-15 mg/kg/dose PO BID, not to exceed 1000 mg/day. Or 5-10 mg/kg/dose IV BID, not to exceed 600 mg/day. Duration varies by indication, typically 7-14 days.
* **Inhalational Anthrax:** 15 mg/kg/dose PO BID, not to exceed 1000 mg/day. Or 10 mg/kg/dose IV BID, not to exceed 400 mg/day. Duration is 60 days.
* **Cystic Fibrosis (prophylaxis/treatment of *Pseudomonas*):** Dosing varies widely; often higher doses (e.g., 15-20 mg/kg/dose PO Q12H or Q8H for younger children, adjusted based on pharmacokinetic studies).
Parenteral therapy is generally preferred for severe infections in children.
## Dose Adjustments
* **Renal Impairment:** For CrCl < 30 mL/min, reduce dose by 50%. For hemodialysis or peritoneal dialysis patients, administer standard dose after dialysis. Consult product labeling for specific recommendations.
* **Hepatic Impairment:** No dose adjustment is typically required for hepatic impairment alone.
## Contraindications
* Hypersensitivity to ciprofloxacin, other fluoroquinolones, or any component of the formulation.
* Concurrent use with tizanidine.
* History of tendon disorders related to fluoroquinolone administration.
## Adverse Effects
* **Common:** Nausea, vomiting, diarrhea, abdominal pain, headache, dizziness, rash.
* **Serious:** Tendinopathy and tendon rupture (especially Achilles tendon), peripheral neuropathy, central nervous system effects (seizures, tremors, confusion), *Clostridioides difficile*-associated diarrhea (CDAD), QT interval prolongation, hypersensitivity reactions, phototoxicity, dysglycemia (hypoglycemia and hyperglycemia, particularly in diabetic patients).
* **Ophthalmic (topical):** Burning, stinging, blurred vision, conjunctival irritation.
## Key Drug Interactions
* **Antacids, Sucralfate, Iron Supplements, Multivitamins (containing Zinc/Calcium), Didanosine (chewable/buffered):** Decrease absorption of ciprofloxacin. Separate administration by at least 2 hours before or 6 hours after.
* **Theophylline:** Increased theophylline levels, potentially leading to toxicity. Monitor theophylline levels and adjust dose as needed.
* **Warfarin:** Increased anticoagulant effect. Monitor INR closely.
* **Tizanidine:** Contraindicated due to risk of severe hypotension and somnolence.
* **CYP1A2 Substrates:** Increased concentrations of drugs metabolized by CYP1A2 (e.g., clozapine, duloxetine, ropivacaine). Use with caution.
* **Oral Hypoglycemics/Insulin:** Risk of dysglycemia. Monitor blood glucose closely.
* **NSAIDs:** May increase the risk of CNS stimulation and seizures.
## Monitoring
* Renal function (for dose adjustments).
* Signs and symptoms of tendon inflammation or rupture.
* Neurological status (especially in patients with risk factors for seizures).
* Blood glucose levels (especially in diabetic patients).
* INR if co-administered with warfarin.
* *Clostridioides difficile* infection symptoms.
* QT interval on ECG if risk factors for torsades de pointes present.
## Clinical Pearls
* Administer oral ciprofloxacin at least 2 hours before or 6 hours after products containing polyvalent cations (antacids, iron, calcium, etc.) to ensure adequate absorption.
* Patients should avoid excessive sun exposure and wear protective clothing due to photosensitivity risk.
* Discontinue ciprofloxacin immediately if tendon pain or swelling occurs.
* Use with caution in patients with CNS disorders, seizure history, or significant QT prolongation risk factors.
* The risk of *C. difficile* infection should be considered with any persistent or severe diarrhea.
* Ciprofloxacin is often considered a "last resort" or reserve agent for many infections due to growing resistance patterns.
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*This information is for educational purposes only and does not substitute for professional medical advice. Always consult current prescribing information, product monographs, and healthcare provider guidance before making any decisions regarding patient care.*
