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# Ciprofloxacin
## Overview
Ciprofloxacin is a broad-spectrum fluoroquinolone antibiotic effective against a wide range of Gram-positive and Gram-negative bacteria, including *Pseudomonas aeruginosa*. It acts by inhibiting bacterial DNA gyrase and topoisomerase IV.
## Primary Indications
* Urinary tract infections (complicated and uncomplicated)
* Prostatitis
* Bone and joint infections
* Intra-abdominal infections (in combination with other agents)
* Lower respiratory tract infections (e.g., community-acquired pneumonia)
* Infectious diarrhea
* Anthrax (prophylaxis and treatment)
* Plague
## Adult Dosing
* **Urinary Tract Infections (Uncomplicated):** 250 mg orally every 12 hours for 3 days.
* **Urinary Tract Infections (Complicated):** 500 mg orally every 12 hours for 7-14 days.
* **Prostatitis:** 500 mg orally every 12 hours for 28 days.
* **Bone and Joint Infections:** 500-750 mg orally every 12 hours for 7-14 days or longer.
* **Intra-abdominal Infections:** 500 mg orally every 12 hours (in combination with metronidazole) for 7-14 days.
* **Lower Respiratory Tract Infections:** 500-750 mg orally every 12 hours for 7-14 days.
* **Infectious Diarrhea:** 500 mg orally every 12 hours for 5 days.
* **Anthrax (Inhalational, post-exposure):** 500 mg orally every 12 hours for 60 days.
* **Anthrax (Cutaneous, treatment):** 500 mg orally every 12 hours for 7-14 days.
* **Plague:** 500-750 mg orally every 12 hours for 10-14 days.
Intravenous (IV) doses typically range from 200 mg to 400 mg every 8-12 hours, adjusted based on indication and severity. Consult specific guidelines for IV dosing.
## Pediatric Dosing
* **Cystic Fibrosis (pulmonary exacerbations):** 10-20 mg/kg IV every 8 hours (max 400 mg/dose) or 10-15 mg/kg PO every 12 hours (max 500 mg/dose).
* **Anthrax (post-exposure prophylaxis):** 10-15 mg/kg PO every 12 hours (max 500 mg/dose) for 60 days.
* **For other indications, dosing depends on specific indication, severity, and local protocol.** Specific pediatric IV doses can range from 5-15 mg/kg per dose every 8-12 hours.
## Dose Adjustments
* **Renal Impairment:** Adjust oral and IV doses based on creatinine clearance (CrCl).
* CrCl 30-60 mL/min: Halve the usual dose.
* CrCl < 30 mL/min: Administer the usual dose every 12 hours (oral) or every 18 hours (IV).
* Hemodialysis/Peritoneal Dialysis: Administer 250-375 mg PO every 12 hours or 200-300 mg IV every 12 hours after dialysis.
* **Hepatic Impairment:** No specific dose adjustment is generally required, but caution is advised.
## Contraindications
* Hypersensitivity to ciprofloxacin, other quinolones, or any component of the formulation.
* Use in patients with a history of tendon disorders related to fluoroquinolone administration.
## Adverse Effects
Common: Nausea, vomiting, diarrhea, abdominal pain, headache, dizziness.
Serious:
* **Tendinopathy and tendon rupture:** Risk increased with concurrent corticosteroid use, in elderly patients, and in patients with renal impairment.
* **QT interval prolongation:** Risk increased with other QT-prolonging drugs and in patients with electrolyte abnormalities.
* **Clostridioides difficile-associated diarrhea (CDAD).**
* **Central nervous system effects:** Seizures, tremors, hallucinations, depression, confusion.
* **Peripheral neuropathy:** Can be irreversible.
* **Phototoxicity/Photosensitivity.**
* **Hepatotoxicity.**
* **Aortic dissection/aneurysm:** Increased risk observed with fluoroquinolone use.
## Key Drug Interactions
* **Antacids, Sucralfate, Calcium, Iron, Zinc Supplements:** May decrease absorption of ciprofloxacin. Separate administration by at least 2 hours before or 6 hours after ciprofloxacin.
* **Theophylline:** Ciprofloxacin can inhibit the metabolism of theophylline, increasing plasma levels and risk of toxicity. Use with caution and monitor theophylline levels.
* **Warfarin:** May potentiate the anticoagulant effect of warfarin. Monitor INR closely.
* **Corticosteroids:** Increased risk of tendinopathy and tendon rupture.
* **QT-Prolonging Agents:** Increased risk of ventricular arrhythmias.
* **NSAIDs:** May increase the risk of CNS stimulation and seizures.
* **Metoclopramide:** May reduce plasma concentrations of ciprofloxacin.
* **CYP1A2 substrates:** Ciprofloxacin inhibits CYP1A2, increasing concentrations of drugs like duloxetine, theophylline, and tizanidine.
## Monitoring
* Renal function (for dose adjustment).
* Signs and symptoms of tendon inflammation or rupture.
* Signs and symptoms of QT prolongation (e.g., ECG).
* Signs and symptoms of *C. difficile* infection.
* For patients on concurrent theophylline or warfarin, monitor drug levels/INR.
* Monitor for CNS effects.
## Clinical Pearls
* Administer oral ciprofloxacin at least 2 hours before or 6 hours after antacids, iron supplements, calcium supplements, zinc supplements, or sucralfate.
* Ciprofloxacin can cause dizziness and affect judgment; patients should be advised to refrain from driving or operating machinery until they know how the drug affects them.
* Discontinue ciprofloxacin immediately if signs of tendinitis or tendon rupture occur.
* Ensure adequate hydration during treatment to prevent crystalluria.
* Consider the potential for QTc prolongation, especially in at-risk patients or when co-administered with other QTc-prolonging agents.
* Be aware of the risk of secondary infections, including fungal infections.
* For severe infections or when oral therapy is not feasible, IV administration should be considered.
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*Disclaimer: This information is intended for healthcare professionals and does not replace professional medical advice. Always consult the most current prescribing information (package insert) and institutional guidelines before administering any medication.*
