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# Ciprofloxacin (Cipro)
## Overview
Ciprofloxacin is a synthetic fluoroquinolone antibiotic with broad-spectrum activity against many Gram-positive and Gram-negative bacteria, including Pseudomonas aeruginosa.
## Primary Indications
* Urinary tract infections (complicated and uncomplicated)
* Respiratory tract infections
* Bone and joint infections
* Intra-abdominal infections
* Infectious diarrhea
* Prostatitis
* Anthrax (prophylaxis and treatment)
* Plague
## Adult Dosing
Dosing varies significantly based on indication and severity.
* **Urinary Tract Infection (Uncomplicated):** 250 mg orally every 12 hours for 3 days.
* **Urinary Tract Infection (Complicated):** 500 mg orally every 12 hours for 7-14 days.
* **Respiratory Tract Infections:** 500-750 mg orally or intravenously every 12 hours for 7-14 days.
* **Bone and Joint Infections:** 500-750 mg orally or intravenously every 12 hours for 4-8 weeks.
* **Anthrax (Inhalational Post-exposure Prophylaxis):** 500 mg orally every 12 hours for 60 days.
* **Maximum Oral Dose:** Generally 1500 mg per day.
* **Maximum Intravenous Dose:** Generally 1200 mg per day (e.g., 400 mg IV q8h or 750 mg IV q12h).
## Pediatric Dosing
Dosing is typically based on weight and indication.
* **Urinary Tract Infections:** 10-20 mg/kg orally or intravenously every 12 hours. Maximum dose 750 mg per dose.
* **Complicated UTI/Pyelonephritis:** 10-15 mg/kg intravenously every 8 hours. Maximum dose 400 mg per dose.
* **Anthrax (Inhalational Post-exposure Prophylaxis):** 15 mg/kg orally every 12 hours for 60 days. Maximum dose 500 mg per dose.
**Note:** Use in pediatric patients is generally reserved for situations where the benefits outweigh the risks due to potential for arthropathy.
## Dose Adjustments
* **Renal Impairment:** Dose reduction is necessary if CrCl < 30 mL/min.
* Oral: If initial dose is 500 mg BID, reduce to 250 mg BID. If initial dose is 250 mg BID, reduce to 250 mg QD.
* IV: If initial dose is 400 mg q8h, reduce to 200 mg q8h. If initial dose is 400 mg q12h, reduce to 200 mg q12h.
* **Hepatic Impairment:** No specific dose adjustments are typically recommended, but caution is advised.
## Contraindications
* Hypersensitivity to ciprofloxacin, other fluoroquinolones, or any component of the formulation.
* Concomitant use with tizanidine.
## Adverse Effects
Common: Nausea, vomiting, diarrhea, abdominal pain, headache, dizziness, rash.
Serious:
* **Tendonitis and Tendon Rupture:** Increased risk, especially in elderly, those on corticosteroids, and post-transplant patients. Discontinue immediately if tendon pain or swelling occurs.
* **Peripheral Neuropathy:** May be permanent.
* **Central Nervous System (CNS) Effects:** Seizures, tremors, confusion, hallucinations, depression, suicidal thoughts. Use with caution in patients with known CNS disorders.
* **QTc Prolongation:** Risk of torsades de pointes, particularly with other QTc-prolonging agents or in patients with risk factors.
* **Clostridioides difficile-Associated Diarrhea (CDAD).**
* **Hepatotoxicity.**
* **Photosensitivity.**
* **Aortic Aneurysm and Dissection:** Increased risk, particularly in elderly patients with hypertension or atherosclerosis.
## Key Drug Interactions
* **Antacids, Sucralfate, Iron Supplements, Calcium Supplements, Zinc Supplements, Multivitamins:** These can significantly reduce ciprofloxacin absorption. Administer ciprofloxacin at least 2 hours before or 6 hours after these agents.
* **Theophylline:** Ciprofloxacin can inhibit the metabolism of theophylline, increasing serum levels and risk of toxicity. Monitor theophylline levels and consider dose reduction.
* **Warfarin:** May enhance the anticoagulant effect of warfarin. Monitor INR closely.
* **Tizanidine:** Contraindicated due to increased risk of severe hypotension and CNS effects.
* **Corticosteroids:** Increased risk of tendonitis and tendon rupture.
* **CYP1A2 Substrates (e.g., clozapine, ropinirole, duloxetine):** Ciprofloxacin is a moderate inhibitor of CYP1A2 and may increase serum concentrations of these drugs.
## Monitoring
* Renal function (CrCl) for dose adjustment.
* Signs and symptoms of tendonitis or tendon rupture.
* CNS effects (confusion, hallucinations, seizures).
* Diarrhea for signs of CDAD.
* INR if co-administered with warfarin.
* Theophylline levels if co-administered.
## Clinical Pearls
* Administer oral ciprofloxacin on an empty stomach (1 hour before or 2 hours after meals) to maximize absorption. However, it can be taken with food if GI upset occurs.
* Intravenous solutions should be administered as a slow infusion over 60 minutes. Do not administer as a bolus injection.
* Avoid co-administration with dairy products or calcium-fortified juices when taken orally, as they can decrease absorption.
* Ensure adequate hydration to prevent crystalluria.
* Discontinue ciprofloxacin and institute alternative therapy if CNS effects or tendon symptoms develop.
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**Disclaimer:** This information is intended for clinical use and does not replace comprehensive drug information resources. Always consult the most current prescribing information and institutional protocols for definitive guidance.
