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# Ciprofloxacin (Cipro)
## Overview
Ciprofloxacin is a synthetic fluoroquinolone antibiotic effective against a broad spectrum of Gram-positive and Gram-negative bacteria, including *Pseudomonas aeruginosa*. It inhibits bacterial DNA gyrase and topoisomerase IV, enzymes essential for DNA replication, transcription, repair, and recombination.
## Primary Indications
* Urinary tract infections (complicated and uncomplicated)
* Prostatitis
* Lower respiratory tract infections (e.g., acute exacerbations of chronic bronchitis, community-acquired pneumonia)
* Skin and soft tissue infections
* Bone and joint infections
* Intra-abdominal infections (in combination with an appropriate anaerobic agent)
* Infectious diarrhea
* Typhoid fever
* Anthrax (prophylaxis and treatment)
* Plague
## Adult Dosing
* **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.
* **Prostatitis:** 500 mg orally every 12 hours for 28 days.
* **Bone and Joint Infections:** 500-750 mg orally or IV every 12 hours for 4-8 weeks (or longer depending on severity and pathogen).
* **Community-Acquired Pneumonia:** 500-750 mg orally or IV every 12 hours for 7-14 days.
* **Anthrax (Inhalational, post-exposure):** 500 mg orally every 12 hours for 60 days.
* **Other indications:** Dosing varies based on severity and site of infection. Oral doses generally range from 250 mg to 750 mg every 12 hours. IV doses range from 200 mg to 400 mg every 8-12 hours. Maximum daily dose generally 1500 mg orally or 1200 mg IV.
## Pediatric Dosing
* **Urinary Tract Infection and Pyelonephritis:** 10 mg/kg/dose IV or orally every 12 hours. Maximum dose 400 mg IV or 500 mg orally per dose. Duration 10-14 days.
* **Inhalational Anthrax:** 15 mg/kg/dose IV or orally every 12 hours. Maximum dose 500 mg per dose. Duration 60 days.
* **Cystic Fibrosis Pulmonary Exacerbations:** Dosing varies, often higher doses are used. Consult specialist literature.
* **Note:** Pediatric dosing depends on indication and weight. Use of ciprofloxacin in children is generally reserved for specific situations where benefits outweigh risks, and is often guided by specialist recommendations due to potential for arthropathy.
## Dose Adjustments
* **Renal Impairment:** For CrCl < 30 mL/min, reduce oral dose by one-third to one-half and administer every 12 hours. For IV, reduce dose by one-third and administer every 12 hours. Adjustments may not be necessary for mild to moderate impairment or short courses.
## Contraindications
* Hypersensitivity to ciprofloxacin, other quinolones, or any component of the formulation.
* Concurrent use with tizanidine.
## Adverse Effects
* **Common:** Nausea, vomiting, diarrhea, abdominal pain, headache, dizziness, rash.
* **Serious:** Tendon inflammation and rupture (especially Achilles tendon), peripheral neuropathy, CNS effects (seizures, confusion, hallucinations, depression), *Clostridioides difficile*-associated diarrhea, phototoxicity, QT interval prolongation, dysglycemia (hypoglycemia and hyperglycemia), aortic aneurysm and dissection.
## Key Drug Interactions
* **Tizanidine:** Increased tizanidine levels, potentially causing severe hypotension and somnolence. Contraindicated.
* **Warfarin:** Increased anticoagulant effect. Monitor INR closely.
* **Theophylline:** Increased theophylline levels. Monitor theophylline levels and adjust dose.
* **Caffeine:** Reduced metabolism, leading to increased caffeine levels and potential side effects.
* **Multivalent Cations (antacids containing aluminum or magnesium, sucralfate, iron supplements, calcium supplements, zinc supplements):** Reduced absorption of ciprofloxacin. Separate administration by at least 2 hours before or 6 hours after ciprofloxacin.
* **Metformin:** Increased metformin levels. Monitor blood glucose and consider metformin dose adjustment.
* **Duloxetine, Theophylline, Rivaroxaban:** Potential for increased plasma concentrations. Monitor patients closely.
## Monitoring
* Renal function (for dose adjustment).
* Signs and symptoms of tendon rupture (pain, swelling, bruising). Advise patients to stop medication and contact physician immediately if these occur.
* Signs and symptoms of *Clostridioides difficile*-associated diarrhea.
* Blood glucose levels, especially in diabetic patients or those with risk factors for dysglycemia.
* Signs and symptoms of CNS effects (seizures, hallucinations).
* ECG for QT interval prolongation, particularly in patients with risk factors.
* INR if co-administered with warfarin.
## Clinical Pearls
* Administer oral ciprofloxacin 2 hours before or 6 hours after antacids, iron, calcium, zinc, or sucralfate.
* Ensure adequate hydration to prevent crystalluria.
* Tendon rupture is a significant risk; patients should be advised to discontinue therapy if tendon pain or swelling occurs. Risk is higher in elderly, renally impaired, and those concurrently taking corticosteroids.
* Ciprofloxacin can cause CNS stimulation and dizziness; caution patients about driving or operating machinery.
* Considered an option for empirical treatment of febrile neutropenia in certain high-risk populations, but resistance is a growing concern.
* Avoid concurrent use with NSAIDs due to increased risk of CNS stimulation and seizures.
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This information is intended for healthcare professionals. Always consult the most current prescribing information and relevant guidelines before making clinical decisions.
