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# Ciprofloxacin
## Overview
Ciprofloxacin is a broad-spectrum fluoroquinolone antibiotic effective against many Gram-positive and Gram-negative bacteria, as well as atypical pathogens. It inhibits bacterial DNA gyrase and topoisomerase IV, essential enzymes for bacterial DNA replication, transcription, repair, and recombination.
## Primary Indications
* **Urinary Tract Infections (UTIs):** Complicated and uncomplicated.
* **Respiratory Tract Infections:** Including community-acquired pneumonia.
* **Skin and Soft Tissue Infections.**
* **Bone and Joint Infections.**
* **Intra-abdominal Infections.**
* **Prostatitis.**
* **Infectious Diarrhea.**
* **Anthrax prophylaxis and treatment.**
* **Plague prophylaxis and treatment.**
## Adult Dosing
Dosing varies significantly by indication and severity. Common adult doses include:
* **Uncomplicated UTIs:** 250 mg orally twice daily for 3 days.
* **Complicated UTIs:** 500 mg orally twice daily for 7-14 days.
* **Community-Acquired Pneumonia:** 500-750 mg orally twice daily for 7-14 days.
* **Bone and Joint Infections:** 500-750 mg orally twice daily for 4-12 weeks.
* **Anthrax (Inhalation exposure):** 500 mg orally twice daily for 60 days.
Maximum daily oral dose generally 1500 mg. Intravenous doses are typically higher.
## Pediatric Dosing
Pediatric dosing is weight-based and depends on the indication. It should be determined based on institutional guidelines or specific product labeling.
* **Urinary Tract Infections:** 10-20 mg/kg/day divided into two doses, maximum 750 mg/day.
* **Acute otitis media:** 10 mg/kg/day once daily for 5 days, maximum 400 mg/day.
* **Anthrax (Inhalation exposure):** 15 mg/kg/dose every 12 hours for 60 days, maximum 500 mg/dose. Dosing for other indications can range from 10-20 mg/kg/day.
## Dose Adjustments
* **Renal Impairment:**
* **CrCl > 30 mL/min:** No dose adjustment typically needed.
* **CrCl 5-30 mL/min:** Reduce dose by 1/3 to 1/2.
* **CrCl < 5 mL/min (hemodialysis/peritoneal dialysis):** Reduce dose by 1/2. Administer after dialysis if given daily.
* **Hepatic Impairment:** No standard dose adjustments, but caution recommended.
## Contraindications
* Hypersensitivity to ciprofloxacin or other fluoroquinolones.
* Use with tizanidine.
## Adverse Effects
* **Common:** Nausea, vomiting, diarrhea, abdominal pain, headache, dizziness.
* **Serious/Rare:** Tendon rupture (especially Achilles), peripheral neuropathy, CNS effects (seizures, confusion, hallucinations), QT prolongation, C. difficile-associated diarrhea, phototoxicity, arthropathy (in pediatric patients), dysglycemia.
## Key Drug Interactions
* **Theophylline:** Ciprofloxacin can significantly increase theophylline levels, increasing risk of toxicity. Monitor theophylline levels closely.
* **Warfarin:** May enhance the anticoagulant effect of warfarin. Monitor INR closely.
* **Antacids, Sucralfate, iron supplements, multivitamins with zinc, calcium supplements, dairy products (milk, yogurt):** Oral absorption of ciprofloxacin is significantly reduced. Separate administration by at least 2 hours before or 6 hours after these agents.
* **QTc-prolonging agents:** Increased risk of torsades de pointes.
* **NSAIDs:** May increase risk of CNS stimulation and seizures.
* **Probenecid:** May decrease renal clearance of ciprofloxacin.
* **Tizanidine:** Contraindicated due to increased tizanidine levels and significant hypotension.
## Monitoring
* **Renal function:** For dose adjustments.
* **Signs of tendon inflammation or rupture:** Patients should be advised to report any new pain or swelling in tendons.
* **CNS effects:** Monitor for changes in mental status.
* **Electrolytes and ECG:** If used with other QTc-prolonging agents or in patients with risk factors.
* **Blood glucose:** Especially in patients with diabetes or at risk for hypoglycemia/hyperglycemia.
* **INR:** If co-administered with warfarin.
* **Stool:** For C. difficile-associated diarrhea.
## Clinical Pearls
* Ciprofloxacin has poor activity against *Streptococcus pneumoniae*. It is not a first-line agent for community-acquired pneumonia unless alternative agents are not suitable.
* Avoid concurrent use with dairy products or calcium-fortified juices due to decreased absorption.
* Advise patients to stay well-hydrated to prevent crystalluria.
* Tendon rupture is a serious adverse event; patient education is crucial. Discontinue if tendon pain or inflammation occurs.
* Use with caution in patients with known QT prolongation, electrolyte imbalances, or those taking other QTc-prolonging medications.
* Consider gastrointestinal intolerance when selecting oral formulations.
**Disclaimer:** This information is intended for healthcare professionals and is not a substitute for professional medical advice. Always consult the most current prescribing information and relevant guidelines before making any treatment decisions.
