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# Ciproxin (ciprofloxacin) ## Overview Ciprofloxacin is a fluoroquinolone antibiotic active against many gram-negative organisms, including **Pseudomonas aeruginosa**, and selected gram-positive organisms. It is available orally and intravenously. - Oral tablets and suspension are **not bioequivalent to extended-release tablets**; do not substitute milligram-for-milligram. - Reserve for infections where benefits outweigh serious fluoroquinolone risks and when narrower or safer alternatives are unsuitable. - Dose and duration depend on infection site, organism susceptibility, renal function, formulation, and local guidelines. ## Primary Indications Common uses include: - Complicated urinary tract infection and acute pyelonephritis - Selected uncomplicated urinary tract infections when alternatives are unsuitable - Infectious diarrhea or typhoid fever when susceptibility supports use - Complicated intra-abdominal infection **with metronidazole** - Certain bone, joint, skin, or lower respiratory infections caused by susceptible gram-negative organisms - Pseudomonas infections - Post-exposure treatment or treatment of inhalational anthrax - Plague - Gonorrhea only when isolate-specific susceptibility confirms ciprofloxacin susceptibility, according to current public-health guidance Ciprofloxacin is generally **not preferred for routine community-acquired pneumonia**, streptococcal infections, or uncomplicated sinusitis because of inadequate or unreliable pathogen coverage and safety concerns. ## Adult Dosing Doses below generally refer to immediate-release oral ciprofloxacin unless specified. - **Uncomplicated UTI:** 250 mg every 12 hours for 3 days - **Complicated UTI or pyelonephritis:** 500 mg every 12 hours for 7–14 days - Some protocols use 250–500 mg every 12 hours. - **Severe or Pseudomonas infections:** 500–750 mg every 12 hours - Maximum usual oral dose: **1,500 mg/day**. - **Complicated intra-abdominal infection:** 500 mg every 12 hours **plus metronidazole**, usually for 4–7 days after adequate source control. - **Infectious diarrhea:** 500 mg every 12 hours for 3 days; local resistance patterns may make this inappropriate. - **Typhoid fever:** 500 mg every 12 hours for 7–10 days, guided by susceptibility and local recommendations. - **Anthrax post-exposure prophylaxis:** 500 mg every 12 hours for 60 days after confirmed or suspected exposure, per public-health direction. - **Inhalational anthrax treatment:** 400 mg IV every 8 hours initially, then oral therapy when clinically appropriate; total duration is generally 60 days. - **Plague:** 500–750 mg every 12 hours for 10–14 days, depending on severity and local guidance. - **Gonorrhea:** 500 mg orally once **only if ciprofloxacin susceptibility is documented**; otherwise use the current recommended ceftriaxone-based regimen. - **Extended-release formulation:** Regimens vary by indication, commonly 500–1,000 mg once daily. Do not interchange with immediate-release tablets without checking product-specific labeling. Administer with water. Separate oral doses from aluminum-, magnesium-, calcium-, iron-, or zinc-containing products. ## Pediatric Dosing Routine use in children is generally avoided when effective alternatives exist because of musculoskeletal and other serious adverse effects. Use when benefits outweigh risks and for infections with limited alternatives. - **Complicated UTI or pyelonephritis:** 10–20 mg/kg orally every 12 hours - Maximum: **750 mg per dose** - Usual duration: 10–21 days, depending on infection and response. - **Inhalational anthrax treatment or post-exposure prophylaxis:** - Oral: 15 mg/kg every 12 hours - Maximum: **500 mg per dose** - IV: 10 mg/kg every 8 hours - Maximum: **400 mg per dose** - **Plague:** 15 mg/kg every 8 hours orally - Maximum: **500 mg per dose** - IV: 10 mg/kg every 8 hours, maximum **400 mg per dose** Pediatric dosing for other infections should follow an infectious-disease or local pediatric protocol. Avoid routine use in children with uncomplicated infections. ## Dose Adjustments ### Renal impairment in adults For immediate-release formulations, commonly used adjustments are: - **CrCl >50 mL/min:** usual dose - **CrCl 30–50 mL/min:** 250–500 mg every 12 hours - **CrCl 5–29 mL/min:** 250–500 mg every 18–24 hours - **Hemodialysis or peritoneal dialysis:** 250–500 mg every 24 hours, administered after hemodialysis on dialysis days Exact recommendations vary by indication and product labeling. Use renal function based on creatinine clearance and reassess during acute illness. ### Hepatic impairment No routine adjustment is generally required for isolated hepatic impairment, but monitor clinically. Consider other causes if liver injury develops. ### Older adults Use the lowest effective dose and assess renal function, tendon risk, QT risk, CNS vulnerability, and interacting medicines. ## Contraindications - Serious hypersensitivity to ciprofloxacin or another quinolone - Concomitant **tizanidine** - Previous severe fluoroquinolone-associated reaction, such as tendon rupture, severe neuropathy, or significant CNS toxicity, unless specialist-directed - Avoid or use only with strong justification in patients with: - Myasthenia gravis - Known prolonged QT interval or significant ventricular arrhythmia risk - Aortic aneurysm or major risk factors for aortic aneurysm/dissection - History of fluoroquinolone-associated tendinopathy ## Adverse Effects ### Common - Nausea, diarrhea, abdominal discomfort - Headache, dizziness, insomnia - Rash or photosensitivity - Oral or vaginal candidiasis ### Serious or potentially persistent - **Tendinitis and tendon rupture**, especially Achilles tendon; risk increases with age, corticosteroids, renal disease, and transplantation - Peripheral neuropathy, which may be rapid in onset and potentially irreversible - CNS effects: anxiety, agitation, confusion, hallucinations, seizures - Dysglycemia, including severe hypoglycemia - QT prolongation and torsades de pointes - *Clostridioides difficile*–associated diarrhea - Hepatotoxicity - Aortic aneurysm or dissection - Severe hypersensitivity or anaphylaxis - Exacerbation of myasthenia gravis - Rare retinal or other connective-tissue complications Stop treatment and seek urgent evaluation for tendon pain or swelling, neuropathy symptoms, severe allergic symptoms, marked hypoglycemia, palpitations/syncope, severe watery or bloody diarrhea, or sudden chest/abdominal/back pain. ## Key Drug Interactions - **Tizanidine:** contraindicated; markedly increases tizanidine exposure and hypotension/sedation. - **Antacids and mineral supplements:** aluminum, magnesium, calcium, iron, and zinc reduce absorption. Give ciprofloxacin at least **2 hours before** or **4–6 hours after** these products. - **Dairy or calcium-fortified drinks:** avoid taking alone with milk or yogurt; calcium-containing meals may be acceptable depending on product labeling. - **Warfarin:** may increase INR; monitor closely. - **Theophylline:** ciprofloxacin can substantially increase concentrations and toxicity; avoid if possible or monitor levels closely. - **QT-prolonging drugs:** increased arrhythmia risk with agents such as amiodarone, sotalol, certain antipsychotics, macrolides, and some antidepressants. - **Systemic corticosteroids:** increased tendon-rupture risk. - **NSAIDs:** may increase CNS stimulation or seizure risk. - **Antidiabetic drugs, including insulin and sulfonylureas:** monitor glucose closely. - **CYP1A2 substrates** such as caffeine, clozapine, olanzapine, and tizanidine: ciprofloxacin may increase exposure. - **Methotrexate, phenytoin, ciclosporin, and duloxetine:** clinically important changes in concentrations or toxicity are possible; monitor or avoid as appropriate. ## Monitoring - Clinical response, culture results, and susceptibility testing - Renal function and dose appropriateness - Diarrhea, including possible *C. difficile* infection - Tendon pain, neuropathy, CNS changes, and glucose disturbances - Blood glucose in patients with diabetes or those receiving insulin/sulfonylureas - INR after initiation or discontinuation in patients taking warfarin - ECG and electrolytes when QT risk is significant - Liver tests if symptoms or risk factors for hepatotoxicity are present - Theophylline or other narrow-therapeutic-index drug concentrations when applicable - Avoid unnecessary prolonged courses; reassess therapy when culture results are available ## Clinical Pearls - Use culture-directed therapy whenever feasible, particularly for urinary, systemic, or Pseudomonas infections. - Do not use ciprofloxacin for empiric gonorrhea treatment without documented susceptibility. - Oral bioavailability is good, but absorption is significantly reduced by polyvalent cations. - Fluoroquinolones carry boxed warnings for disabling and potentially permanent adverse effects; reserve use when clinically justified. - Avoid strenuous exercise if tendon symptoms occur and discontinue promptly pending evaluation. - Ciprofloxacin does not reliably cover anaerobes; add metronidazole when indicated for intra-abdominal infection. - Dose by renal function, especially in older adults and acutely ill patients. - Duration should follow the infection-specific guideline and source control status rather than a fixed default. *Educational information only; verify the current product labeling, local antimicrobial-resistance data, institutional protocols, and specialist recommendations before prescribing or dispensing.*