Ciprofloxacin Dosage

Usual Adult Dose for Anthrax Prophylaxis

Prophylaxis postexposure to inhalational Bacillus anthracis:
IV: 400 mg IV every 12 hours
Oral: 500 mg orally every 12 hours

Treatment should start as soon as possible following suspected or confirmed exposure. Total duration of therapy (IV and oral combined) is 60 days.

Usual Adult Dose for Inhalation Bacillus anthracis

(Not approved by FDA)

Centers for Disease Control and Prevention (CDC) recommendations:
Treatment of inhalational anthrax associated with bioterrorism attack: 400 mg IV every 12 hours plus 1 or 2 additional antibiotics with activity against the causative organism; these drugs may include rifampin, vancomycin, penicillin, ampicillin, chloramphenicol, imipenem, clindamycin, and clarithromycin

Duration: The switch from IV to oral antimicrobial therapy (ciprofloxacin 500 mg orally every 12 hours) may be made as soon as is clinically feasible. Therapy should continue for a total of 60 days (IV and oral combined).

Usual Adult Dose for Cutaneous Bacillus anthracis

(Not approved by FDA)

CDC recommendations:
Treatment of cutaneous anthrax associated with bioterrorism attack: 500 mg orally every 12 hours for 60 days

IV therapy (ciprofloxacin 400 mg IV every 12 hours) with multiple drugs is recommended if there is evidence of systemic involvement, severe edema, or if head or neck lesions are present.

Usual Adult Dose for Bacteremia

Secondary bacteremia associated with urinary tract infections caused by Escherichia coli: 400 mg IV every 12 hours

Therapy should be continued for 7 to 14 days, depending on the nature and severity of the infection.

Usual Adult Dose for Bronchitis

Acute exacerbations of chronic bronchitis:
Mild/moderate:
IV: 400 mg IV every 12 hours
Oral: 500 mg orally every 12 hours

Severe/complicated:
IV: 400 mg IV every 8 hours
Oral: 750 mg orally every 12 hours

Duration: 7 to 14 days

Usual Adult Dose for Chancroid

(Not approved by FDA)

CDC recommendations: 500 mg orally twice a day for 3 days

The patient's sexual partner(s) should also be evaluated/treated.

Usual Adult Dose for Cholera

(Not approved by FDA)

Infectious Diseases Society of America (IDSA) recommendations: 1 g orally once, as an adjunct to fluid and electrolyte replacement

Usual Adult Dose for Cystitis

Acute uncomplicated:
Immediate-release: 250 mg orally every 12 hours
Extended-release: 500 mg orally every 24 hours

Duration: 3 days

Usual Adult Dose for Febrile Neutropenia

Empirical therapy in febrile neutropenic patients:
Severe: 400 mg IV every 8 hours for 7 to 14 days, in combination with piperacillin 50 mg/kg IV every 4 hours (maximum: 24 g/day)

Usual Adult Dose for Gonococcal Infection - Uncomplicated

Uncomplicated urethral and cervical gonococcal infections: 250 mg orally one time

Due to high rates of resistance, the CDC does not recommend fluoroquinolones for treatment of gonococcal infections in the United States. Ceftriaxone or oral cefixime is recommended as first-line treatment of gonorrhea in the United States. Antimicrobial susceptibility patterns should be monitored.

Doxycycline therapy for 7 days (if not pregnant) or single dose azithromycin is also recommended to treat possible concurrent chlamydial infection.

The patient's sexual partner(s) should also be evaluated/treated.

Usual Adult Dose for Granuloma Inguinale

(Not approved by FDA)

CDC recommendations: 750 mg orally twice a day for at least 3 weeks and until all lesions have completely healed

Ciprofloxacin is recommended as an alternate regimen by the CDC. Doxycycline is considered the drug of choice.

The patient's sexual partner(s) should also be evaluated/treated.

Usual Adult Dose for Infection Prophylaxis

(Not approved by FDA)

Patients with neutropenia: 500 mg orally every 12 hours; alternatively, 400 mg IV every 12 hours may be given for particularly ill patients
The duration of therapy may vary with the duration of the patient's neutropenia.

Usual Adult Dose for Infectious Diarrhea

Mild/moderate/severe: 500 mg orally every 12 hours for 5 to 7 days

IDSA recommendations:
E coli species (enterotoxigenic, enteropathogenic, enteroaggregative), Aeromonas, Plesiomonas: 500 mg orally twice a day for 3 days

Usual Adult Dose for Diverticulitis

Complicated intraabdominal infection (used in combination with metronidazole):
IV: 400 mg IV every 12 hours
Oral: 500 mg orally every 12 hours

Duration: 7 to 14 days

Usual Adult Dose for Intraabdominal Infection

Complicated intraabdominal infection (used in combination with metronidazole):
IV: 400 mg IV every 12 hours
Oral: 500 mg orally every 12 hours

Duration: 7 to 14 days

Usual Adult Dose for Peritonitis

Complicated intraabdominal infection (used in combination with metronidazole):
IV: 400 mg IV every 12 hours
Oral: 500 mg orally every 12 hours

Duration: 7 to 14 days

Usual Adult Dose for Joint Infection

Mild/moderate:
IV: 400 mg IV every 12 hours
Oral: 500 mg orally every 12 hours

Severe/complicated:
IV: 400 mg IV every 8 hours
Oral: 750 mg orally every 12 hours

Duration: at least 4 to 6 weeks

Usual Adult Dose for Osteomyelitis

Mild/moderate:
IV: 400 mg IV every 12 hours
Oral: 500 mg orally every 12 hours

Severe/complicated:
IV: 400 mg IV every 8 hours
Oral: 750 mg orally every 12 hours

Duration: at least 4 to 6 weeks

Usual Adult Dose for Meningococcal Meningitis Prophylaxis

(Not approved by FDA)

CDC recommendations: 500 mg orally once

Usual Adult Dose for Mycobacterium avium-intracellulare - Treatment

(Not approved by FDA)

400 mg IV or 750 mg orally every 12 hours, in combination with at least 3 other antimycobacterial drugs (e.g., clarithromycin or azithromycin, ethambutol, rifabutin, amikacin)

Usual Adult Dose for Nosocomial Pneumonia

Mild/moderate/severe: 400 mg IV every 8 hours for 10 to 14 days

Initial empiric treatment with broad-spectrum coverage according to the hospital's and/or ICU's antibiogram is recommended if multidrug-resistant organisms are suspected.

Usual Adult Dose for Plague

(Not approved by FDA)

Treatment of plague used as a biological weapon:
Treatment, contained-casualty setting: 400 mg IV every 12 hours for 10 days; may switch to oral ciprofloxacin 500 mg twice a day when clinically indicated

The Working Group on Civilian Biodefense has recommended ciprofloxacin as an alternative to streptomycin and gentamicin if they are contraindicated, unavailable, or inactive in vitro.

Treatment, mass-casualty setting: 500 mg orally twice a day for 10 days
Postexposure prophylaxis: 500 mg orally twice a day for 7 days

The Working Group on Civilian Biodefense has recommended ciprofloxacin or doxycycline for plague treatment in a mass casualty setting and for postexposure prophylaxis.

Usual Adult Dose for Pneumonia

Lower respiratory tract infection:
Mild/moderate:
IV: 400 mg IV every 12 hours
Oral: 500 mg orally every 12 hours

Severe/complicated:
IV: 400 mg IV every 8 hours
Oral: 750 mg orally every 12 hours

Duration: 7 to 14 days

Ciprofloxacin is not considered the drug of choice for the treatment of presumed or confirmed pneumonia secondary to Streptococcus pneumoniae.

Usual Adult Dose for Prostatitis

Chronic bacterial prostatitis (mild/moderate):
IV: 400 mg IV every 12 hours
Oral: 500 mg orally every 12 hours

Duration: 28 days

Usual Adult Dose for Pyelonephritis

Acute uncomplicated:
Cipro(R) XR: 1000 mg orally every 24 hours for 7 to 14 days

Usual Adult Dose for Salmonella Gastroenteritis

(Not approved by FDA)

IDSA recommendations:
Non-typhi species of Salmonella: 500 mg orally twice a day for 5 to 7 days
Up to 14 days (or longer if relapsing) of treatment may be required for immunocompromised patients.

Usual Adult Dose for Shigellosis

Mild/moderate/severe infectious diarrhea: 500 mg orally every 12 hours for 5 to 7 days

IDSA recommendations: 500 mg orally twice a day for 3 days
Up to 7 to 10 days of treatment may be required for immunocompromised patients.

A single 1 gram dose may be effective for non-dysentery shigellosis.

Usual Adult Dose for Sinusitis

Mild/moderate:
IV: 400 mg IV every 12 hours
Oral: 500 mg orally every 12 hours

Duration: 10 days

Usual Adult Dose for Skin or Soft Tissue Infection

Mild/moderate:
IV: 400 mg IV every 12 hours
Oral: 500 mg orally every 12 hours

Severe/complicated:
IV: 400 mg IV every 8 hours
Oral: 750 mg orally every 12 hours

Duration: 7 to 14 days

Vibrio vulnificus: 400 mg IV every 12 hours plus ceftazidime 1 to 2 g IV every 8 hours or cefotaxime 2 g IV every 8 hours

Usual Adult Dose for Traveler's Diarrhea

(Not approved by FDA)

500 mg orally every 12 hours

Therapy should be continued for about 5 to 7 days in severely ill patients. Most cases are self-limited, and prudent withholding of antibiotics in mild cases does not appear to slow recovery in most patients. However, immunocompromised patients may require longer courses of therapy.

Usual Adult Dose for Tuberculosis - Active

(Not approved by FDA)

750 mg orally or 400 mg IV every 12 hours

May be given in combination with at least 3 other active drugs for treatment of multi-drug resistant TB, or when the patient is intolerant of first-line agents. AFB smear and culture should be monitored monthly.

Duration: Treatment for TB should generally continue for 18 to 24 months, or for 12 to 18 months after culture results are negative.

Usual Adult Dose for Tularemia

(Not approved by FDA)

Use of tularemia as a biological weapon:
Treatment, contained casualty setting: 400 mg IV twice a day for 10 days; may switch to oral ciprofloxacin 500 mg twice a day when clinically indicated

The Working Group on Civilian Biodefense has recommended ciprofloxacin as an alternative to streptomycin and gentamicin if they are contraindicated, not available, or inactive in vitro.

Treatment, mass casualty setting and postexposure prophylaxis: 500 mg orally twice a day for 14 days

The Working Group on Civilian Biodefense has recommended ciprofloxacin or doxycycline for tularemia treatment in a mass casualty setting and for postexposure prophylaxis.

Usual Adult Dose for Salmonella Enteric Fever

Mild/moderate: 500 mg orally every 12 hours for 10 days

Usual Adult Dose for Typhoid Fever

Mild/moderate: 500 mg orally every 12 hours for 10 days

Usual Adult Dose for Urinary Tract Infection

Acute uncomplicated (cystitis):
Immediate-release: 250 mg orally every 12 hours
Extended-release: 500 mg orally every 24 hours

Duration: 3 days

Mild/moderate:
IV: 200 mg IV every 12 hours
Immediate-release: 250 mg orally every 12 hours

Duration: 7 to 14 days

Severe/complicated:
IV: 400 mg IV every 12 hours (or every 8 hours)
Immediate-release: 500 mg orally every 12 hours
Cipro(R) XR: 1000 mg orally every 24 hours

Duration: 7 to 14 days

Usual Pediatric Dose for Anthrax Prophylaxis

Prophylaxis postexposure to inhalational Bacillus anthracis:
IV: 10 mg/kg IV every 12 hours (maximum dose: 400 mg/dose)
Oral: 15 mg/kg orally every 12 hours (maximum dose: 500 mg/dose)

Treatment should start as soon as possible following suspected or confirmed exposure. Total duration of therapy (IV and oral combined) is 60 days.

Usual Pediatric Dose for Urinary Tract Infection

Complicated infection due to E coli:
1 to 18 years:
IV: 6 to 10 mg/kg IV every 8 hours (maximum dose: 400 mg/dose)
Oral: 10 to 20 mg/kg orally every 12 hours (maximum dose: 750 mg/dose)

Total duration of therapy (IV and oral combined) is 10 to 21 days.

Ciprofloxacin is not a drug of first choice due to a higher rate of adverse reactions in this population.

Usual Pediatric Dose for Pyelonephritis

Due to E coli:
1 to 18 years:
IV: 6 to 10 mg/kg IV every 8 hours (maximum dose: 400 mg/dose)
Oral: 10 to 20 mg/kg orally every 12 hours (maximum dose: 750 mg/dose)

Total duration of therapy (IV and oral combined) is 10 to 21 days.

Ciprofloxacin is not a drug of first choice due to a higher rate of adverse reactions in this population.

Usual Pediatric Dose for Inhalation Bacillus anthracis

(Not approved by FDA)

CDC recommendations:
Treatment of inhalational anthrax associated with bioterrorism attack:
Children: 10 to 15 mg/kg IV every 12 hours (not to exceed 1 g/day) plus 1 or 2 additional antibiotics with activity against the causative organism; these drugs may include rifampin, vancomycin, penicillin, ampicillin, chloramphenicol, imipenem, clindamycin, and clarithromycin

Duration: The switch from IV to oral antimicrobial therapy [ciprofloxacin 10 to 15 mg/kg orally every 12 hours (not to exceed 1 g/day)] should occur as soon as is clinically feasible. Therapy should continue for a total of 60 days (IV and oral combined).

Usual Pediatric Dose for Cutaneous Bacillus anthracis

(Not approved by FDA)

CDC recommendations:
Treatment of cutaneous anthrax associated with bioterrorism attack:
Children: 10 to 15 mg/kg orally every 12 hours (not to exceed 1 g/day) for 60 days

IV therapy [ciprofloxacin 10 to 15 mg/kg IV every 12 hours (not to exceed 1 g/day)] with multiple drugs is recommended if there is evidence of systemic involvement, severe edema, or if head or neck lesions are present.

Usual Pediatric Dose for Pneumonia with Cystic Fibrosis

(Not approved by FDA)

Study (n=67)
5 years or older: 10 mg/kg IV every 8 hours for 1 week followed by 20 mg/kg orally every 12 hours

Total duration of therapy: 10 to 21 days

Usual Pediatric Dose for Plague

(Not approved by FDA)

Use of plague as a biological weapon:
Treatment, contained-casualty setting: 15 mg/kg IV twice a day for 10 days (maximum dose: 1 g/day); may switch to oral ciprofloxacin when clinically indicated

The Working Group on Civilian Biodefense has recommended ciprofloxacin as an alternative to streptomycin and gentamicin if they are contraindicated, unavailable, or inactive in vitro.

Treatment, mass casualty setting: 20 mg/kg orally twice a day for 10 days (maximum dose: 1 g/day)
Postexposure prophylaxis: 20 mg/kg orally twice a day for 7 days (maximum dose: 1 g/day)

The Working Group on Civilian Biodefense has recommended ciprofloxacin or doxycycline for plague treatment in a mass casualty setting and for postexposure prophylaxis.

Usual Pediatric Dose for Tularemia

(Not approved by FDA)

Use of tularemia as a biological weapon:
Treatment, contained casualty setting: 15 mg/kg IV twice a day (maximum dose: 1 g/day) for 10 days; may switch to oral ciprofloxacin when clinically indicated

The Working Group on Civilian Biodefense has recommended ciprofloxacin as an alternative to streptomycin and gentamicin if they are contraindicated, not available, or inactive in vitro.

Treatment, mass casualty setting and postexposure prophylaxis: 15 mg/kg orally twice a day (maximum dose: 1 g/day) for 14 days

The Working Group on Civilian Biodefense has recommended doxycycline or ciprofloxacin for tularemia treatment in a mass casualty setting and for postexposure prophylaxis.

Renal Dose Adjustments

Adults:
IV:
CrCl 5 to 29 mL/min: 200 to 400 mg IV every 18 to 24 hours

Oral:
Immediate-release:
CrCl 30 to 50 mL/min: 250 to 500 mg orally every 12 hours
CrCl 5 to 29 mL/min: 250 to 500 mg orally every 18 hours

Extended-release:
Cipro(R) XR:
CrCl 30 mL/min or less: 500 mg orally every 24 hours

Proquin(R) XR:
Mild to moderate renal dysfunction: No adjustment recommended.
Severe renal dysfunction: Data not available

Pediatric patients:
CrCl less than 50 mL/min: Data not available

Liver Dose Adjustments

Adults: No dosage adjustments necessary in patients with stable chronic liver cirrhosis.
Pediatric patients: Data not available

Dose Adjustments

In patients with severe infections and severe renal impairment, an oral dose of 750 mg may be given at the intervals noted. However, patients should be carefully monitored and the serum ciprofloxacin concentration should be measured periodically. Peak levels (1 to 2 hours after dosing) should generally range from 2 to 4 mcg/mL.

Precautions

Fluoroquinolones, including ciprofloxacin, have been associated with an increased risk of tendinitis and tendon rupture in all ages. The risk is further increased in older patients usually over 60 years of age, in kidney, heart, or lung transplant recipients, and with the use of concomitant corticosteroids. Independent risk factors include strenuous physical activity, renal failure, and previous tendon disorders such as rheumatoid arthritis; however, cases have been reported in patients with no known risk factors. Tendon rupture may occur during or up to several months after completion of therapy. Patients should be advised to discontinue ciprofloxacin, rest and avoid exercise, and contact their healthcare provider if they experience tendon pain, swelling, inflammation, or rupture.

Fluoroquinolones, including ciprofloxacin, have neuromuscular blocking activity and may exacerbate muscle weakness in patients with myasthenia gravis. Patients should contact their healthcare provider at once if worsening muscle weakness or breathing problems develop. Ciprofloxacin should be avoided in patients with a known history of myasthenia gravis.

Coadministration of ciprofloxacin with tizanidine is contraindicated.

Convulsions, increased intracranial pressure (including pseudotumor cerebri), and toxic psychosis have been reported with fluoroquinolones, including ciprofloxacin. Ciprofloxacin may also cause central nervous system (CNS) stimulation, resulting in tremors, restlessness/agitation, nervousness/anxiety, dizziness/lightheadedness, confusion, hallucinations, paranoia, depression, nightmares, insomnia, and rarely, suicidal thoughts or acts. These reactions may occur following the first dose. Ciprofloxacin should be discontinued and appropriate measures taken if such CNS reactions occur. Ciprofloxacin should be used with caution in patients with known or suspected CNS disorders or other risk factors that may predispose them to seizures or lower the seizure threshold (e.g., severe cerebral arteriosclerosis, epilepsy, certain drug therapy, renal dysfunction). Patients should be advised to avoid driving or engaging in other tasks that require mental alertness and coordination until they know how the drug affects them.

Serious and occasionally fatal hypersensitivity and/or anaphylactic reactions have been reported; some following the first dose. The drug should be discontinued immediately at the first appearance of a skin rash, jaundice, or any sign of hypersensitivity. Severe, acute hypersensitivity reactions may require treatment with epinephrine and other resuscitative measures including oxygen, intravenous fluids, antihistamines, corticosteroids, cardiovascular support, and airway management as clinically indicated.

Some fluoroquinolones, including ciprofloxacin, have been associated with QT interval prolongation and infrequent cases of arrhythmia. Ciprofloxacin should be avoided in patients with known QT interval prolongation, patients with uncorrected hypokalemia, and in patients treated with Class IA or Class III antiarrhythmic agents. Patients should be advised to contact their physician if they experience syncope, irregular heartbeats, or palpitations.

Ciprofloxacin has been associated with rare cases of sensory or sensorimotor axonal polyneuropathy resulting in paresthesias, hypoesthesias, dysesthesias, and weakness. To prevent development of an irreversible condition, treatment should be discontinued if symptoms of neuropathy develop or if deficits in light touch, pain, temperature, position sense, vibratory sensation, and/or motor strength are observed.

Patients should be advised to avoid excessive exposure to sunlight or artificial ultraviolet light during and for several days after treatment. The drug should be discontinued if photosensitivity or signs of phototoxicity (e.g., sunburn-like reaction, redness, oozing, burning, itching, rash, blistering, edema) occur.

Clostridium difficile associated diarrhea (CDAD) has been reported with almost all antibiotics and may potentially be life-threatening. Therefore, it is important to consider this diagnosis in patients who present with diarrhea following quinolone therapy. Mild cases generally improve with discontinuation of the drug, while severe cases may require supportive therapy and treatment with an antimicrobial agent effective against C difficile. Hypertoxin producing strains of C difficile cause increased morbidity and mortality; these infections can be resistant to antimicrobial treatment and may necessitate colectomy.

The patient should be well hydrated and urinary alkalinity should be avoided to avoid crystalluria.

Renal, hepatic, and hematopoietic function should be monitored periodically during prolonged therapy.

Dosage adjustments are recommended for renally impaired patients. Caution and monitoring is recommended for elderly patients, who may be at a greater risk of adverse reactions due to declining renal function.

For patients with changing renal function or for patients with renal impairment and hepatic insufficiency, careful monitoring is recommended.

Due to an increased incidence of side effects compared to controls, immediate-release ciprofloxacin should not be used in pediatric patients less than 18 years for indications other than complicated urinary tract infections and pyelonephritis due to E coli and inhalational anthrax (postexposure). Safety and effectiveness of extended-release ciprofloxacin have not been established in pediatric patients (less than 18 years of age).

Dialysis

Hemodialysis, peritoneal dialysis:
Adults:
IV: Data not available

Oral:
Immediate-release: 250 to 500 mg orally every 24 hours (administered after dialysis session)

Extended-release:
Cipro(R) XR: 500 mg orally every 24 hours (administered after dialysis session)
Proquin(R) XR: Data not available

Pediatric patients: Data not available

Other Comments

The manufacturer's Medication Guide should be dispensed with each new and refill prescription.

Generally ciprofloxacin should be continued for at least 2 days after the signs and symptoms of infection have disappeared.

IV ciprofloxacin should be infused over at least 60 minutes. Local IV site reactions have been reported and are more common with infusions lasting less than 30 minutes or with use of small veins of the hand.

Oral ciprofloxacin should be taken at least 2 hours before or 6 hours after magnesium/aluminum antacids, polymeric phosphate binders (e.g., sevelamer, lanthanum carbonate), sucralfate, buffered didanosine, other highly buffered drugs, or other products containing calcium, iron, or zinc.

Oral ciprofloxacin may be taken with meals that include dairy products or calcium-fortified juices; however, it should not be taken with such products alone. Extended-release ciprofloxacin (Proquin(R) XR) should be taken with a main meal, preferably the evening meal. Patients should be advised to drink plenty of fluids.

Ciprofloxacin extended-release tablets are not interchangeable with immediate-release tablets or oral suspension. Extended-release tablets made by different manufacturers are not interchangeable due to different pharmacokinetics (e.g., Cipro(R) XR and Proquin(R) XR).

The extended-release tablets should not be split, crushed, or chewed.

The microcapsules in the suspension should not be chewed. The suspension should not be administered through feeding or nasogastric tubes.

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