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# Ciprofloxacin (Cipro)
## Overview
Ciprofloxacin is a broad-spectrum fluoroquinolone antibiotic effective against many Gram-positive and Gram-negative bacteria, including *Pseudomonas aeruginosa*. It inhibits bacterial DNA gyrase and topoisomerase IV, essential enzymes for DNA replication, transcription, repair, and recombination.
## Primary Indications
* Urinary tract infections (UTIs), including complicated UTIs and prostatitis
* Lower respiratory tract infections (e.g., community-acquired pneumonia)
* Bone and joint infections
* Intra-abdominal infections
* Infectious diarrhea
* Anthrax (prophylaxis and treatment)
* Certain skin and soft tissue infections
## Adult Dosing
* **UTIs (uncomplicated):** 250 mg orally every 12 hours for 3 days.
* **UTIs (complicated), prostatitis:** 500 mg orally every 12 hours for 7-14 days, or 250 mg IV every 12 hours.
* **Bone and joint infections:** 500-750 mg orally or IV every 12 hours for 4-12 weeks.
* **Community-acquired pneumonia:** 500-750 mg orally or IV every 12 hours for 7-14 days.
* **Anthrax (treatment):** 500 mg orally or IV every 12 hours for 60 days.
* **Intra-abdominal infections:** 500 mg orally or 400 mg IV every 12 hours, often in combination with metronidazole. Duration is typically 7-14 days.
**Maximum daily oral dose:** 1500 mg.
**Maximum daily IV dose:** 800 mg.
## Pediatric Dosing
Ciprofloxacin is generally reserved for specific indications in children due to potential for arthropathy. Dosing is based on indication and weight.
* **Urinary tract infections and pyelonephritis:** 10-15 mg/kg/dose orally or IV every 12 hours.
* **Maximum dose:** 500 mg per dose for oral, 400 mg per dose for IV.
* **Duration:** Typically 10-14 days.
* **Anthrax (post-exposure prophylaxis):** 15 mg/kg/dose orally every 12 hours.
* **Maximum dose:** 500 mg per dose.
* **Duration:** 60 days.
* **Cystic Fibrosis pulmonary exacerbations:** 10-15 mg/kg/dose IV every 8 hours (may be dosed more frequently in severe infections).
* **Maximum dose:** 400 mg per dose.
## Dose Adjustments
* **Renal Impairment:**
* **CrCl > 30 mL/min:** No adjustment needed.
* **CrCl 5-30 mL/min:** Reduce usual maintenance dose by 50% or increase dosing interval to every 18 hours.
* **CrCl < 5 mL/min (hemodialysis/peritoneal dialysis):** Reduce usual maintenance dose by 50-75% or increase dosing interval to every 24 hours. Administer after dialysis.
## 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.
* Concomitant use with tizanidine.
## Adverse Effects
* **Common:** Nausea, vomiting, diarrhea, abdominal pain, headache, dizziness.
* **Serious:**
* **Tendonitis and tendon rupture:** Risk increased in elderly, those on corticosteroids, and post-transplant patients. Discontinue immediately if tendon pain or swelling occurs.
* **Peripheral neuropathy:** Can be irreversible. Discontinue if symptoms develop.
* **Central nervous system effects:** Seizures, increased intracranial pressure, psychosis, tremors, confusion.
* **QT prolongation:** Risk with other QT-prolonging agents or in patients with risk factors.
* **Clostridioides difficile-associated diarrhea (CDAD).**
* **Hypoglycemia/Hyperglycemia:** Especially in diabetic patients on oral hypoglycemics.
* **Phototoxicity/Photosensitivity.**
* **Aortic aneurysm and dissection:** Risk increased in patients with pre-existing risk factors.
## Key Drug Interactions
* **Theophylline:** Ciprofloxacin can significantly increase theophylline levels, potentially leading to toxicity. Monitor theophylline levels closely and consider dose reduction.
* **Warfarin:** May potentiate the anticoagulant effect of warfarin. Monitor INR closely.
* **Antacids, Sucralfate, Multivitamins (containing zinc or iron), Calcium supplements:** Decrease oral absorption of ciprofloxacin. Separate administration by at least 2 hours before or 6 hours after ciprofloxacin.
* **Tizanidine:** Contraindicated due to significant increase in tizanidine levels and associated adverse effects (hypotension, somnolence).
* **Pohl-Potter medications:** Ciprofloxacin can increase serum concentrations of drugs metabolized by CYP1A2 (e.g., clozapine, olanzapine, ropinirole).
* **Diabetes Medications:** Risk of significant hypoglycemia or hyperglycemia. Monitor blood glucose closely.
## Monitoring
* Renal function (CrCl) for dose adjustment.
* Signs and symptoms of tendonitis/rupture.
* Neurological status for CNS effects.
* Blood glucose in diabetic patients.
* INR in patients taking warfarin.
* Signs and symptoms of CDAD.
## Clinical Pearls
* Administer oral ciprofloxacin 2 hours before or 6 hours after cation-containing antacids, supplements, or multivitamins.
* IV ciprofloxacin should be infused over at least 60 minutes.
* Ensure adequate hydration to prevent crystalluria.
* Discontinue ciprofloxacin immediately if any signs of serious adverse reactions (tendon rupture, peripheral neuropathy, CNS effects) occur.
* Consider the spectrum of activity and local resistance patterns when choosing ciprofloxacin.
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*This information is intended for healthcare professionals. Always consult the most current prescribing information and relevant clinical guidelines before making treatment decisions.*
