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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 *Pseudomonas aeruginosa*.
## Primary Indications
* Urinary tract infections (UTIs)
* Complicated skin and skin structure infections
* Bone and joint infections
* Intra-abdominal infections
* Infectious diarrhea
* Anthrax prophylaxis and treatment
* Plague
* Pneumonia (certain types)
## Adult Dosing
Dosing is dependent on the type and severity of infection. Typical dosages include:
* **Uncomplicated UTIs:** 250 mg orally every 12 hours for 3 days.
* **Complicated UTIs, Prostatitis:** 500 mg orally every 12 hours for 7-28 days.
* **Respiratory Tract Infections, Bone and Joint Infections, Skin Infections, Intra-abdominal Infections:** 500-750 mg orally every 12 hours for 7-14 days.
* **Anthrax (Inhalational exposure):** 500 mg orally every 12 hours for 60 days.
* **Plague:** 500-750 mg orally every 12 hours for 10-14 days.
* **Intravenous Dosing:** Generally twice the oral dose, administered over 1 hour. Common doses range from 200-400 mg IV every 8-12 hours.
*Maximum oral dose is typically 1500 mg/day. Maximum IV dose is typically 1200 mg/day, but can be higher in specific indications.*
## Pediatric Dosing
Ciprofloxacin is generally reserved for specific situations in pediatrics due to potential for arthropathy. Dosing is weight-based and depends on indication.
* **Urinary Tract Infections (complicated) and other indications where benefits outweigh risks:** 10-20 mg/kg orally or IV every 8-12 hours.
* **Maximum dose:** Generally 1500 mg/day orally, or 400 mg IV per dose, but higher doses may be used under specialist guidance.
*Consult specific pediatric guidelines for exact dosing and indications.*
## Dose Adjustments
* **Renal Impairment:** Oral and IV doses require adjustment based on creatinine clearance (CrCl).
* CrCl 30-50 mL/min: Reduce dose by 33% (e.g., 500 mg q12h becomes 500 mg q18h or 250 mg q12h).
* CrCl <30 mL/min: Reduce dose by 50% (e.g., 500 mg q12h becomes 250 mg q12h).
* For IV therapy with CrCl <30 mL/min, use 200 mg q12h.
* **Hepatic Impairment:** Typically no dose adjustment needed unless severe hepatic dysfunction coexists with renal impairment.
## Contraindications
* Hypersensitivity to ciprofloxacin or other fluoroquinolones.
* Concomitant use with tizanidine.
* History of tendon disorders related to fluoroquinolone use.
## Adverse Effects
* **Common:** Nausea, vomiting, diarrhea, abdominal pain, headache, dizziness.
* **Serious:**
* Tendon rupture (especially Achilles tendon) - risk increased with age, corticosteroid use, and strenuous exercise.
* Peripheral neuropathy.
* Central nervous system effects (seizures, confusion, hallucinations, psychosis).
* QT interval prolongation, Torsades de pointes.
* *Clostridioides difficile*-associated diarrhea.
* Aortic aneurysm and dissection (risk increased with higher doses and in elderly patients).
* Hypoglycemia and hyperglycemia.
* Blood dyscrasias.
* Phototoxicity.
## Key Drug Interactions
* **Tizanidine:** Concomitant use is contraindicated due to increased tizanidine levels and potential for severe hypotension and somnolence.
* **Anticoagulants (e.g., Warfarin):** May increase INR; monitor INR closely.
* **Theophylline:** May increase theophylline levels; monitor theophylline levels and adjust dose.
* **Caffeine:** Reduced metabolism of caffeine; may lead to restlessness and insomnia.
* **Antacids, Sucralfate, Iron, Calcium, Zinc supplements:** Can decrease ciprofloxacin absorption. Administer ciprofloxacin at least 2 hours before or 6 hours after these agents. Separate administration of calcium-containing products (e.g., dairy) from oral ciprofloxacin by at least 2 hours.
* **NSAIDs:** May increase the risk of CNS stimulation and seizures.
* **Probenecid:** May decrease renal clearance of ciprofloxacin.
* **QTc-prolonging agents:** Increased risk of QT interval prolongation and arrhythmias.
## Monitoring
* Renal function (creatinine clearance) for dose adjustments.
* Signs and symptoms of tendonitis or tendon rupture.
* Neurological status for CNS effects.
* Blood glucose levels in diabetic patients.
* INR if used with warfarin.
* Theophylline levels if concurrently used.
* Signs of *C. difficile* infection.
## Clinical Pearls
* Ciprofloxacin can cause C. difficile-associated diarrhea, ranging in severity from mild diarrhea to fatal colitis.
* Avoid concurrent use with antacids containing magnesium or aluminum, or with calcium supplements, iron, or zinc, as they can significantly reduce absorption.
* A large body of evidence suggests that fluoroquinolones are associated with an increased risk of serious adverse reactions and may not be suitable for empiric treatment of uncomplicated infections where other agents are effective.
* Discontinue ciprofloxacin immediately if any signs of tendon inflammation or rupture occur.
* Patients should be advised to avoid excessive sun exposure due to potential phototoxicity.
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**Disclaimer:** This information is intended for healthcare professionals. Always consult the most current prescribing information and relevant guidelines before initiating therapy, as recommendations may change. For specific patient management, consider individual factors and local protocols.
