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# Ciprofloxacin (Cipro)
## Overview
Ciprofloxacin is a broad-spectrum fluoroquinolone antibiotic effective against a wide range of Gram-positive and Gram-negative bacteria, including many anaerobes. It works by inhibiting bacterial DNA gyrase and topoisomerase IV.
## Primary Indications
* Urinary tract infections (complicated and uncomplicated)
* Prostatitis
* Lower respiratory tract infections (e.g., pneumonia)
* Skin and skin structure infections
* Bone and joint infections
* Intra-abdominal infections
* Infectious diarrhea
* Anthrax (prophylaxis and treatment)
* Plague (treatment)
* Gonococcal infections (certain types)
## Adult Dosing
Dosing is dependent on the site and severity of infection.
* **Urinary Tract Infections (Uncomplicated):** 250 mg PO BID for 3 days.
* **Urinary Tract Infections (Complicated):** 500 mg PO BID for 7-14 days or 250 mg IV q12h.
* **Cystitis (Female):** 250 mg PO BID for 3 days.
* **Prostatitis:** 500 mg PO BID for 28 days.
* **Pneumonia (Community-Acquired):** 500-750 mg PO BID for 7-14 days or 400 mg IV q8-12h.
* **Skin/Soft Tissue Infections:** 500-750 mg PO BID for 7-14 days or 400 mg IV q8-12h.
* **Bone/Joint Infections:** 500-750 mg PO BID for 28 days or longer or 400 mg IV q8-12h.
* **Intra-abdominal Infections:** 500 mg PO BID for 7-14 days or 400 mg IV q8-12h (often in combination with metronidazole).
* **Infectious Diarrhea:** 500 mg PO BID for 5-7 days.
* **Anthrax (Prophylaxis):** 500 mg PO BID for 60 days or 400 mg IV q12h for 60 days.
* **Anthrax (Treatment):** 500 mg PO BID for 60 days or 400 mg IV q12h for 60 days.
* **Plague:** 500 mg PO BID for 10-14 days or 400 mg IV q8-12h for 10-14 days.
* **Gonococcal Infections:** Not typically first-line due to resistance; consult guidelines.
**Maximum Dose:** Generally 1500 mg/day PO or 1200-1600 mg/day IV (depending on specific indication and renal function).
## Pediatric Dosing
Dosing is based on weight and indication. Consult pediatric infectious disease guidelines for specific recommendations.
* **Urinary Tract Infections/Pyelonephritis:** 10-20 mg/kg/day divided into two doses (max 1000 mg/day for oral; max 800 mg/day for IV). Duration varies (e.g., 10-14 days).
* **Osteomyelitis:** 10-20 mg/kg/day divided into two doses (max 1000 mg/day for oral; max 800 mg/day for IV). Duration varies (e.g., 4 weeks or longer).
* **Anthrax (Prophylaxis/Treatment):** 10-15 mg/kg per dose PO or IV q12h (max 500 mg per dose for oral; max 400 mg per dose for IV) for 60 days.
## Dose Adjustments
* **Renal Impairment (CrCl < 30 mL/min):** Reduce dose by 50% if standard dosing is q12h; increase dose interval by 50% if standard dosing is q8h. Monitor drug levels if possible. IV doses need adjustment.
* **Hepatic Impairment:** No specific dose adjustment is generally recommended, but caution is advised.
## Contraindications
* Hypersensitivity to ciprofloxacin or other fluoroquinolones.
* Use with tizanidine.
## Adverse Effects
* **Common:** Nausea, vomiting, diarrhea, abdominal pain, headache, dizziness.
* **Serious:** Tendon rupture/tendinitis (especially Achilles), peripheral neuropathy, central nervous system effects (e.g., seizures, confusion, hallucinations), *Clostridioides difficile*-associated diarrhea, QT interval prolongation, dysglycemia (hypoglycemia and hyperglycemia), phototoxicity, arthralgia, psychiatric effects (e.g., anxiety, depression, suicidal thoughts).
## Key Drug Interactions
* **Tizanidine:** Coadministration is contraindicated due to a significant increase in tizanidine levels.
* **Theophylline:** Ciprofloxacin can significantly increase theophylline levels; monitor theophylline levels and adjust dose.
* **Warfarin:** May potentiate the anticoagulant effect of warfarin; monitor INR closely.
* **Antacids, Sucralfate, Iron Supplements, Calcium Supplements, Multivitamins (containing Zinc):** Oral absorption of ciprofloxacin can be significantly decreased. Separate administration by at least 2 hours before or 6 hours after these agents.
* **Divalproex Sodium:** May increase serum valproate levels. Monitor valproate levels and consider dose adjustment.
* **CYP1A2 Substrates:** Ciprofloxacin is a moderate inhibitor of CYP1A2, potentially increasing serum concentrations of drugs metabolized by this enzyme (e.g., clozapine, ropinirole, duloxetine).
## Monitoring
* Signs and symptoms of infection resolution.
* Renal and hepatic function.
* Blood glucose levels, especially in diabetic patients or those with known risk factors for dysglycemia.
* Signs and symptoms of tendon disorders.
* For prolonged use, patients should be monitored for adverse effects, including CNS, hepatic, and renal toxicity.
## Clinical Pearls
* Avoid concurrent administration with dairy products or calcium-fortified juices when taken orally, as calcium can inhibit absorption. However, calcium in the diet (e.g., in a meal) does not significantly affect absorption.
* Ensure adequate hydration to prevent crystalluria.
* Discontinue immediately if tendon pain or inflammation occurs.
* Use with caution in patients with a history of CNS disorders, pyridoxine deficiency, or underlying risk factors for seizures.
* Ciprofloxacin carries a black box warning for serious adverse reactions including tendinitis and tendon rupture, peripheral neuropathy, CNS effects, and exacerbation of myasthenia gravis.
* Consider local resistance patterns when selecting therapy.
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*Disclaimer: This information is intended for healthcare professionals and is not a substitute for professional medical advice. Always consult the most current prescribing information, institutional guidelines, and a pharmacist or physician for any questions regarding drug therapy.*
