Ciprofloxacin

Aka: Ciprofloxacin, Cipro

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II. Indications

  1. See Second Generation Fluoroquinolone
  2. Complicated Urinary Tract Infections
  3. Specific types of Bacterial Gastroenteritis
  4. Prostatitis
  5. Sexually Transmitted Disease
  6. Avoid in Community Acquired Pneumonia
    1. Risk of pneumococcal bacteremia and Meningitis
  7. Additional Indications specific to Ciprofloxacin (not with Ofloxacin)
    1. Pseudomonas Aeruginosa
    2. Bacillus anthracis or Anthrax (first line agent)
    3. Vibrio Cholerae (Norfloxacin also covers)
    4. Yersinia Pestis or Plague (first line agent)
    5. Tularemia (alternative medication)

III. Contraindications

  1. See Fluoroquinolone
  2. Myasthenia Gravis (exacerbates motor weakness)
  3. Tizanidine use
  4. Children
    1. Relative contraindication due to risk of Arthropathy in animals
    2. Studies have not demonstrated Arthropathy (other than transient large joint Arthralgias)
    3. Ciprofloxacin is commonly used off label in children with Cystic Fibrosis (due to Pseudomonas coverage)

IV. Mechanism

  1. See Fluoroquinolone

V. Medications

  1. Tablets: 250, 500 and 750 mg
  2. Oral Suspension 250 and 500 mg per 5 ml
    1. Shake container well for 15 seconds before administering dose
    2. Do not give via nasogastric or Feeding Tube
  3. Extended release tablets: 500 and 1000 mg
    1. Not interchangeable with regular, non-extended release formulations

VI. Dosing: Adult

  1. See Anthrax
  2. Urinary Tract Infection
    1. Use higher dose of range for Pyelonephritis for 7 to 14 days
    2. Give 200 to 400 mg IV every 12 hours OR
    3. Take 250 to 500 mg orally twice daily OR
    4. Extended Release Ciprofloxacin 1000 mg orally daily
  3. Chronic Bacterial Prostatitis
    1. Take 500 mg orally twice daily for up to 28 days
  4. Diverticulitis or Complicated intraabdominal infections (with Metronidazole)
    1. Give 400 mg IV every 12 hours OR
    2. Take 500 mg orally twice daily
  5. Infectious Diarrhea
    1. Take 500 mg orally twice daily for 5 to 7 days
    2. Use 1 to 3 days (or 750 mg for one dose) for Traveler's Diarrhea
    3. Use 10 days for Typhoid Fever
  6. Malignant Otitis Externa (not FDA approved)
    1. Give 400 mg IV every 12 hours, or
    2. Take 750 mg orally every 12 hours
  7. Foot Osteomyelitis due to Pseudomonas Osteochondritis (Sweaty Tennis Shoe Syndrome)
    1. Take 750 mg orally twice daily for up to 6 to 8 weeks
  8. Bone and joint infections (based on sensitivity testing, treated for 4 to 8 weeks)
    1. Give 400 mg IV every 8 to 12 hours initially, then
    2. Take 500 to 750 mg orally twice daily
  9. Plague (treated for 14 days)
    1. Give 400 mg IV every 8 to 12 hours OR
    2. Take 500 mg orally twice daily
  10. Chancroid (not FDA approved)
    1. Take 500 mg orally twice daily for 3 days
  11. Renal Dosing (immediate release)
    1. eGFR 30 to 50 ml/min: 250 to 500 mg orally every 12 hours
    2. eGFR 5 to 29 ml/min: 200 to 400 mg IV every 18 to 24 hours OR 250 to 500 mg every 18 hours
    3. Hemodialysis: 250 to 500 mg orally every 24 hours after Dialysis

VII. Dosing: Child

  1. See Anthrax
  2. See Precautions above under contraindications
  3. Complicated Urinary Tract Infection or Pyelonephritis (age 1 to 17 years)
    1. Give 6 to 10 mg/kg IV (up to 400 mg/dose) every 8 hours, then
    2. Give 10 to 20 mg/kg (up to 750 mg/dose) orally every 12 hours
  4. Plague (age birth to 17 years, treated for 10 to 21 days)
    1. Give 10 mg/kg IV (up to 400 mg/dose) every 8 to 12 hours, then
    2. Give 15 mg/kg (up to 500 mg/dose) orally every 8 to 12 hours
  5. Acute respiratory exacerbation of Cystic Fibrosis
    1. Give 10 mg/kg IV (up to 400 mg/dose) every 8 to 12 hours for 7 days, then
    2. Give 20 mg/kg (up to 750 mg/dose) orally every 12 hours for a total course of 10 to 21 days

VIII. Adverse Effects

  1. See Fluoroquinolone
  2. Fluoroquinolones have several serious warnings (e.g. tendon rupture, Neuropathy, Aortic Dissection)
  3. QTc Prolongation
  4. Hypersensitivity
  5. Urine Crystal formation (in alkaline urine)
  6. Photosensitivity (Sunburn risk)
  7. Gastrointestinal (Nausea, Vomiting, Diarrhea, Abdominal Pain)
  8. Neurologic (Headache, Dizziness, confusion)
  9. Rash
  10. Serum transaminase increase
  11. Serum Creatinine increase
  12. White cell changes (Eosinophilia, Neutropenia)
  13. Seizure risk (class effect due to GABA inhibition)

IX. Safety

  1. Avoided in pregnancy (despite pregnancy Category C)
    1. Cartilage damage risk
  2. Considered safe in Lactation
    1. However, risk of pediatric Arthropathy

X. Pharmacokinetics

  1. Rapid but variable absorption, reaching peak levels within 1 to 2 hours of ingestion
  2. Half-Life: 4 hours
  3. Partial hepatic metabolism and renal excretion
    1. Urine concentrations remain high for many hours after dose
  4. Distributes widely (except CSF), with high concentrations in urine, stool, bile, Prostate, bone and Sputum

XI. Drug Interactions

  1. Sulfonylureas
    1. Hypoglycemia risk
  2. Warfarin
    1. May potentiate Anticoagulant effects
  3. Tizanidine
    1. Do not use with Ciprofloxacin
  4. Ciprofloxacin is a strong CYP1A2 Inhibitor and increases drug levels of its substrates
    1. Olanzapine
    2. Ropinirole
    3. Zolpidem
  5. Drugs that interfere with absorption (give at least 2 hours before or after dose)
    1. Antacids containing Calcium, aluminum or Magnesium
    2. Sucralfate
    3. Iron
    4. Zinc
    5. Yogurt, milk or Calcium fortified juice (but may take with dairy containing meals)

XII. Resources

  1. Ciprofloxacin Tablet (DailyMed)
    1. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=3e4402d4-e0d3-9846-3e81-ed46f34137fe
  2. Ciprofloxacin Injection Solution (DailyMed)
    1. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=e82f52f2-ecf8-4c04-a206-f3253b265903

XIII. References

  1. (1988) Med Lett Drugs Ther 30(758): 11-3
  2. King (2000) Am Fam Physician 61(9):2741-8 [PubMed]
  3. O'Donnell (2000) Infect Dis Clin North Am 14(2):489-513 [PubMed]
  4. Oliphant (2002) Am Fam Physician 65(3):455-64 [PubMed]
  5. Owens (2000) Med Clin North Am 84(6):1447-69 [PubMed]

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Cost: Medications

ciprofloxacin (on 12/21/2022 at Medicaid.Gov Survey of pharmacy drug pricing)
CIPROFLOXACIN 0.2% OTIC SOLN Generic $6.34 each
CIPROFLOXACIN 0.3% EYE DROP Generic $1.74 per ml
CIPROFLOXACIN HCL 250 MG TAB Generic $0.10 each
CIPROFLOXACIN HCL 500 MG TAB Generic $0.15 each
CIPROFLOXACIN HCL 750 MG TAB Generic $0.21 each
cipro (on 11/23/2022 at Medicaid.Gov Survey of pharmacy drug pricing)
CIPRO 10% SUSPENSION $1.46 per ml
CIPRO 5% SUSPENSION $1.26 per ml
CIPRO HC OTIC SUSPENSION $31.77 per ml
CIPRODEX OTIC SUSPENSION Generic $17.53 per ml
CIPROFLOX-DEXAMETH OTIC SUSP Generic $17.53 per ml
FPNotebook does not benefit financially from showing this medication data or their pharmacy links. This information is provided only to help medical providers and their patients see relative costs. Insurance plans negotiate lower medication prices with suppliers. Prices shown here are out of pocket, non-negotiated rates. See Needy Meds for financial assistance information. GoodRx is another tool for finding lower drug prices.

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