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Ciprofloxacin Hydrochloride

Pronunciation

Class: Quinolones
VA Class: AM900
Chemical Name: 1-Cyclopropyl-6-fluoro-1,4-dihydro-4-oxo-7-(1-piperazinyl)-3-quinolinecarboxylic acid
CAS Number: 85721-33-1
Brands: Cipro

Warning(s)

  • Systemic fluoroquinolones, including ciprofloxacin, are associated with an increased risk of tendinitis and tendon rupture in all age groups.1 579 715 851 852 This risk is further increased in older adults (usually those >60 years of age), individuals receiving concomitant corticosteroids, and kidney, heart, or lung transplant recipients.1 579 715 851 852 (See Tendinopathy and Tendon Rupture under Cautions.)

  • Fluoroquinolones, including ciprofloxacin, may exacerbate muscle weakness in patients with myasthenia gravis.1 579 715 Avoid ciprofloxacin in patients with known history of myasthenia gravis.1 579 715

Introduction

Antibacterial; fluoroquinolone.1 181 205 206 479 481 579 715

Uses for Ciprofloxacin Hydrochloride

Bone and Joint Infections

Treatment of bone and joint infections (including osteomyelitis)205 296 326 362 365 367 368 369 370 371 375 474 479 535 706 caused by susceptible Pseudomonas aeruginosa,1 205 296 300 326 359 362 368 369 370 371 380 433 474 479 535 579 Enterobacter cloacae,1 362 369 370 375 380 474 579 706 or Serratia marcescens;1 296 362 368 369 370 380 474 579 also has been used in bone and joint infections caused by E. aerogenes,369 370 706 Escherichia coli,362 368 369 370 474 535 Klebsiella pneumoniae,326 368 371 Morganella morganii,369 370 or Proteus mirabilis.368 369 371 380 474 706

Has been used for treatment of bone and joint infections caused by susceptible gram-positive bacteria, including Staphylococcus aureus,296 326 370 474 535 S. epidermidis,326 474 535 other coagulase-negative staphylococci,326 370 or Enterococcus faecalis.370 Other anti-infectives generally preferred for these gram-positive infections,522 538 but ciprofloxacin may be a useful alternative for treatment of infections caused by susceptible oxacillin-resistant (methicillin-resistant) staphylococci.522 538

Endocarditis

Alternative for treatment of native or prosthetic valve endocarditis caused by fastidious gram-negative bacilli known as the HACEK group (Actinobacillus actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, Haemophilus aphrophilus, H. influenzae, H. parainfluenzae, H. paraphrophilus, Kingella denitrificans, K. kingae).768 AHA and IDSA recommend ceftriaxone or ampicillin-sulbactam as drugs of choice,768 but a fluoroquinolone (ciprofloxacin, levofloxacin, moxifloxacin) may be considered when β-lactam anti-infectives cannot be used.768 Consultation with an infectious disease specialist is recommended.768

Alternative for treatment of uncomplicated right-sided S. aureus native valve endocarditis.768 For native valve staphylococcal endocarditis, AHA and IDSA recommend IV nafcillin or oxacillin (with or without gentamicin) as regimen of choice and IV cefazolin (with or without gentamicin) as an alternative; IV vancomycin is recommended when staphylococci are oxacillin-resistant.768 An oral regimen of ciprofloxacin and rifampin can be considered in IV drug abusers who will not comply with a parenteral regimen.768 769

Alternative to gentamicin in regimens used for treatment of coagulase-negative staphylococcal endocarditis in the presence of prosthetic valves or materials.768 For prosthetic valve staphylococcal endocarditis, AHA and IDSA recommend IV nafcillin or oxacillin with oral or IV rifampin and parenteral gentamicin; IV vancomycin with oral or IV rifampin and parenteral gentamicin is recommended when staphylococci are oxacillin-resistant.768 If causative organism is resistant to aminoglycosides, AHA and IDSA suggest a fluoroquinolone replace gentamicin in these regimens, provided in vitro susceptibility tests indicate the organism is susceptible to the fluoroquinolone.768

Empiric treatment of culture-negative endocarditis.768 For empiric treatment of native valve culture-negative endocarditis, AHA and IDSA recommend a regimen of ampicillin-sulbactam with gentamicin or a regimen of vancomycin, gentamicin, and ciprofloxacin.768 Selection of the most appropriate anti-infective regimen is difficult and should be guided by epidemiologic features and clinical course of the infection.768 Consultation with an infectious diseases specialist is recommended.768

GI Infections

Treatment of infectious diarrhea caused by susceptible enterotoxigenic E. coli,1 293 297 474 477 Campylobacter fetus subsp. jejuni,1 293 297 350 412 474 538 Salmonella (see Typhoid Fever and other Salmonella Infections under Uses), Shigella297 412 477 538 612 flexneri,1 612 S. boydii, S. sonnei,1 474 or S. dysenteriae.1 612 Active in vitro against most pathogens associated with infectious diarrhea; may be a drug of choice for empiric treatment.296 305 328 350 378 412 493 522 610 611 Consider increasing emergence of fluoroquinolone-resistant Campylobacter secondary to widespread use of the drugs; use judiciously for treatment and prevention of enteropathogenic diarrhea.412 588 589

Alternative to co-trimoxazole for treatment of GI infections caused by Cyclospora cayetanensis (cyclosporiasis)477 533 557 or for treatment and chronic maintenance therapy (secondary prophylaxis) of infections caused by Cystoisospora belli (formerly Isospora belli) (cystoisosporiasis).292 412 477 533

Treatment of shigellosis caused by susceptible Shigella when anti-infectives indicated.412 477 Anti-infectives generally indicated in addition to fluid and electrolyte replacement for treatment of patients with severe shigellosis, dysentery, or underlying immunosuppression.412 292 Empiric treatment regimen can be used initially, but in vitro susceptibility testing indicated since resistance is common.292 Fluoroquinolones (e.g., ciprofloxacin, levofloxacin, moxifloxacin) are drugs of choice when susceptibility of isolate unknown or ampicillin- or co-trimoxazole-resistant strains involved.292 412 477 538

Treatment of GI infections caused by Yersinia enterocolitica or Y. pseudotuberculosis.681 These infections usually self-limited, but IDSA, AAP, and others recommend anti-infectives for severe infections or when septicemia or other invasive disease occurs.292 477 681 Some suggest that the role of anti-infectives in management of enterocolitis, pseudoappendicitis syndrome, or mesenteric adenitis caused by Yersinia needs further evaluation.677

Treatment of travelers’ diarrhea.305 378 399 412 525 650 651 677 679 If caused by bacteria, may be self-limited and resolve within 3–5 days without anti-infective treatment;305 525 if diarrhea is moderate or severe, persists for >3 days, or is associated with fever or bloody stools, short-term (1–3 days) anti-infective treatment recommended.305 525 Fluoroquinolones (ciprofloxacin, levofloxacin, norfloxacin, ofloxacin) usually drugs of choice when treatment, including self-treatment, indicated.305 412 525 594 611 612 650 677 679 Azithromycin is a treatment alternative if fluoroquinolones should not be used (e.g., children, pregnant women) and a drug of choice for travelers in areas with high prevalence of fluoroquinolone-resistant Campylobacter (e.g., South and Southeast Asia) or when there is no response after 48 hours of fluoroquinolone treatment.305 525 Rifaximin is another alternative for treatment of travelers’ diarrhea caused by noninvasive E. coli.305 525

Prevention of travelers’ diarrhea in individuals traveling for relatively short periods to areas where enterotoxigenic E. coli and other causative bacterial pathogens (e.g., Shigella) are known to be susceptible to the drug.305 412 525 610 611 677 679 CDC and others do not recommend anti-infective prophylaxis in most individuals traveling to areas of risk;305 412 525 677 679 the principal preventive measures are prudent dietary practices.412 525 650 651 If anti-infective prophylaxis is used (e.g., in immunocompromised individuals such as those with HIV infection), a fluoroquinolone (ciprofloxacin, levofloxacin, ofloxacin, norfloxacin) is recommended for nonpregnant adults;305 412 525 azithromycin and rifaximin are alternatives.305 412 Weigh use of anti-infective prophylaxis against use of prompt, early self-treatment with anti-infectives, a strategy that can limit duration of illness to 6–24 hours in most cases.525

Intra-abdominal Infections

Parenteral treatment of complicated intra-abdominal infections caused by E. coli, Ps. aeruginosa, P. mirabilis, K. pneumoniae, or Bacteroides fragilis; used in conjunction with oral metronidazole.1 579

For initial empiric treatment of mild to moderate community-acquired, extrabiliary, complicated intra-abdominal infections in adults (e.g., perforated or abscessed appendicitis), IDSA recommends either monotherapy with cefoxitin, ertapenem, moxifloxacin, tigecycline, or the fixed combination of ticarcillin and clavulanic acid, or a combination regimen that includes either a cephalosporin (cefazolin, ceftriaxone, cefotaxime, cefuroxime) or fluoroquinolone (ciprofloxacin, levofloxacin) in conjunction with metronidazole.773

For initial empiric treatment of high-risk or severe community-acquired, extrabiliary, complicated intra-abdominal infections in adults, IDSA recommends either monotherapy with a carbapenem (doripenem, imipenem, meropenem) or the fixed combination of piperacillin and tazobactam, or a combination regimen that includes either a cephalosporin (cefepime, ceftazidime) or fluoroquinolone (ciprofloxacin, levofloxacin) in conjunction with metronidazole.773

Consult current IDSA clinical practice guidelines at for additional information regarding management of intra-abdominal infections.773

Meningitis and CNS Infections

Has been used for treatment of meningitis and other CNS infections caused by susceptible gram-negative bacteria (e.g., Ps. aeruginosa, Salmonella) either alone or in conjunction with other drugs (e.g., aminoglycoside, ceftriaxone or cefotaxime).360 707 762 763 764 765 818

Safety and efficacy not established for CNS infections;293 481 only low ciprofloxacin concentrations attained in CSF.1 436 707 (See Distribution under Pharmacokinetics.) Fluoroquinolones (including ciprofloxacin) generally considered for treatment of meningitis only when the infection is caused by multidrug-resistant gram-negative bacilli or when the usually recommended anti-infectives cannot be used or have been ineffective.774

Otic Infections

Treatment of malignant otitis externa caused by Ps. aeruginosa.781 782 783 784 785 816 Treatment of choice usually is ciprofloxacin or an antipseudomonal β-lactam (e.g., ceftazidime, imipenem).781 782 783 784 Consider the possibility of ciprofloxacin-resistant strains if there is an inadequate response to treatment.783 784 785

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Respiratory Tract Infections

Treatment of respiratory tract infections (including bronchiectasis,333 474 479 596 bronchitis,205 297 301 333 335 345 346 347 356 435 466 474 479 lung abscess,474 596 pneumonia)205 326 333 346 347 356 357 435 466 474 479 491 596 caused by susceptible E. cloacae,1 333 474 579 E. coli,1 333 345 355 474 491 579 Haemophilus influenzae,1 297 301 324 333 346 351 380 427 474 491 596 579 H. parainfluenzae,1 297 474 579 K. pneumoniae,1 297 301 333 345 351 380 474 579 P. mirabilis,1 380 474 579 Ps. aeruginosa,1 300 301 324 333 346 359 380 427 433 474 579 or S. pneumoniae;1 324 326 333 345 346 355 356 357 425 427 474 491 also has been used for respiratory tract infections caused by susceptible E. aerogenes,474 K. oxytoca,474 or S. aureus.333 345 380 491

Treatment of acute sinusitis caused by susceptible H. influenzae, M. catarrhalis, or S. pneumoniae.1

Treatment of acute exacerbations of chronic bronchitis caused by susceptible Moraxella catarrhalis.1 324 333 346 356 395 427 474 491 579

Parenteral treatment of nosocomial pneumonia caused by susceptible H. influenzae or K. pneumoniae.579

Most effective in treatment of respiratory tract infections caused by H. influenzae or M. catarrhalis;178 296 298 479 596 treatment failures have occurred when used in infections caused by S. pneumoniae178 324 358 425 427 479 or Ps. aeruginosa.178 324 346 358 427 479 596

Not a drug of first choice for pneumonia caused by S. pneumoniae;1 generally should not be used for empiric treatment of community-acquired pneumonia (CAP) when S. pneumoniae is likely or suspected.5 178 296 356 427 479 522 621 IDSA and ATS state that other fluoroquinolones with enhanced activity against S. pneumoniae (gemifloxacin, levofloxacin, moxifloxacin) are drugs of choice for empiric treatment of CAP in outpatients at risk for infections caused by drug-resistant S. pneumoniae (DRSP) and also are drugs of choice for empiric treatment of CAP in inpatients.605

Treatment of acute exacerbations of bronchopulmonary Ps. aeruginosa infections in cystic fibrosis patients.178 205 289 296 299 301 302 304 307 308 309 310 311 359 424 474 479 As with other anti-infectives, Ps. aeruginosa may be cleared temporarily from the sputum, but a bacteriologic cure rarely is obtained and should not be expected in these patients.205 306 307 309 310 312 424 425 466 474 479

Probably should not be used for treatment of aspiration pneumonia since these infections generally involve anaerobic bacteria.293 296 621

Skin and Skin Structure Infections

Treatment of skin and skin structure infections (e.g., cellulitis, abscesses, folliculitis, furunculosis, pyoderma, postoperative wound infections, infected ulcers, burns, or wounds) caused by susceptible C. freundii,1 372 474 579 E. cloacae,1 362 474 579 E. coli,1 326 372 375 377 380 474 579 K. oxytoca,474 K. pneumoniae,1 362 372 377 380 474 579 M. morganii,1 474 579 P. mirabilis,1 362 364 372 377 380 474 579 P. vulgaris,1 372 474 579 P. stuartii,1 377 474 579 Ps. aeruginosa,1 280 300 326 359 362 372 375 377 382 433 474 579 S. marcescens,362 380 S. aureus (oxacillin-susceptible strains),1 326 362 364 372 373 375 377 382 466 474 579 S. epidermidis,1 364 372 375 377 382 474 579 or S. pyogenes (group A β-hemolytic streptococci).1 362 373 579

Urinary Tract Infections (UTIs) and Prostatitis

Treatment of complicated UTIs and pyelonephritis caused by susceptible E. coli in pediatric patients 1–17 years of age.1 579 Not a drug of first choice in pediatric patients because of increased risk of adverse events (e.g., events related to joints and/or surrounding tissues) in this age group.1 579 (See Musculoskeletal Effects under Cautions.)

Treatment of acute uncomplicated cystitis in adults caused by susceptible E. coli, P. mirabilis, S. saprophyticus, or E. faecalis.715

Treatment of complicated or uncomplicated UTIs in adults caused by susceptible gram-negative bacteria, including Citrobacter diversus,1 474 579 C. freundii,1 339 340 341 375 380 474 579 E. cloacae,1 327 332 380 474 579 E. coli,1 297 326 327 329 332 336 338 339 340 351 352 353 375 380 474 504 579 715 K. pneumoniae,1 297 327 329 336 338 340 341 353 375 474 504 579 715 M. morganii,1 340 341 474 579 P. mirabilis,1 327 332 336 340 352 353 474 504 579 715 Providencia rettgeri,1 474 579 Ps. aeruginosa,1 297 300 326 327 336 338 339 340 341 351 353 359 375 379 380 474 538 579 715 or S. marcescens;1 340 341 353 380 474 504 579 also has been used for UTIs caused by E. aerogenes,474 Klebsiella oxytoca,474 or P. stuartii.326 474

Treatment of UTIs in adults caused by susceptible gram-positive bacteria, including S. aureus,327 353 380 S. epidermidis,1 327 336 340 474 579 S. saprophyticus,1 332 579 or E. faecalis.1 327 336 339 340 341 353 474 538 579 715

Treatment of acute uncomplicated pyelonephritis in adults caused by E. coli.715

Treatment of recurrent UTIs and chronic prostatitis in adults caused by E. coli or P. mirabilis in men.1 180 294 296 339 343 379 466 579 May be a drug of choice because high concentrations are attained in prostatic tissue.180 293 338 339 343 466 479

Usually reserved for treatment of complicated UTIs, especially those caused by multidrug-resistant bacteria.299 336 379 425 481 551 Generally considered alternative for treatment of uncomplicated UTIs (e.g., acute cystitis) and used in these infections only when other urinary anti-infectives are likely to be ineffective or cannot be used.143 293 299 522 551 585

Anthrax

Postexposure prophylaxis to reduce the incidence or progression of disease following suspected or confirmed exposure to aerosolized Bacillus anthracis spores (inhalational anthrax).1 292 579 663 668 670 678 681 682 683 686 Initial drug of choice for such prophylaxis is ciprofloxacin or doxycycline.292 668 683 696 697 Based on in vitro data, other fluoroquinolones (e.g., moxifloxacin, ofloxacin, levofloxacin) are considered alternatives to ciprofloxacin when needed.292 668

Treatment of inhalational anthrax.292 668 670 678 683 686 Monotherapy may be effective for anthrax that occurs as the result of natural or endemic exposures, but a multiple-drug parenteral regimen (ciprofloxacin or doxycycline and 1 or 2 other anti-infectives predicted to be effective) is recommended for inhalational anthrax that occurs as the result of exposure to anthrax spores in the context of biologic warfare or bioterrorism.292 668 686 703 Other drugs suggested as possibilities to augment ciprofloxacin or doxycycline in such multiple-drug regimens include chloramphenicol, clindamycin, rifampin, vancomycin, macrolides (azithromycin, clarithromycin, erythromycin), imipenem, meropenem, penicillin, ampicillin, daptomycin, quinupristin and dalfopristin, linezolid, and aminoglycosides (gentamicin).292 668 683 686 If meningitis is established or suspected, some clinicians suggest a multiple-drug regimen that includes a fluoroquinolone (e.g., ciprofloxacin) and 1 or 2 additional agents with good CSF penetration (e.g., ampicillin or penicillin, meropenem, rifampin, vancomycin, chloramphenicol).668 683 770

Treatment of cutaneous anthrax, including that occurring following exposure to B. anthracis spores in the context of biologic warfare or bioterrorism.686 Parenteral multiple-drug regimen recommended for initial treatment when there are signs of systemic involvement, extensive edema, or lesions on the head and neck668 670 686 or when cutaneous anthrax occurs in children <2 years of age.703

Treatment of GI and oropharyngeal anthrax.681 If occurring in the context of biologic warfare or bioterrorism, use parenteral regimens recommended for inhalational anthrax.668 681 686 703

Prophylaxis following ingestion of B. anthracis spores in contaminated meat.662

Although ciprofloxacin not usually used in children <18 years of age or in pregnant women, CDC and others state ciprofloxacin can be used when necessary in these patients for postexposure prophylaxis or treatment of anthrax since the benefits of ciprofloxacin outweigh the risks.703

Bartonella Infections

Treatment of infections caused by Bartonella henselae (e.g., cat scratch disease, bacillary angiomatosis, peliosis hepatitis).292 733

Cat scratch disease generally self-limited in immunocompetent individuals and may resolve spontaneously in 2–4 months; some clinicians suggest that anti-infectives be considered for acutely or severely ill patients with systemic symptoms, particularly those with hepatosplenomegaly or painful lymphadenopathy, and probably is indicated in immunocompromised patients.292 729 730 731 732 Anti-infectives also indicated in patients with B. henselae infections who develop bacillary angiomatosis, neuroretinitis, or Parinaud’s oculoglandular syndrome.730 731 732 Optimum regimens have not been identified; some clinicians recommend azithromycin, ciprofloxacin, erythromycin, doxycycline, rifampin, co-trimoxazole, gentamicin, or third generation cephalosporins.292 538 729 730 731 732 733

Brucellosis

Treatment of brucellosis caused by Brucella melitensis.538 624 683 771 772 Ciprofloxacin used in conjunction with rifampin is an alternative to a regimen of a tetracycline and rifampin.538 683 771 772

Capnocytophaga Infections

Alternative to penicillin G for treatment of infections caused by Capnocytophaga canimorsus.538

Chancroid

Treatment of chancroid (genital ulcers caused by Haemophilus ducreyi).319 321 328 462 538

CDC and others recommend azithromycin, ceftriaxone, ciprofloxacin, or erythromycin as drugs of choice for treatment of chancroid.319 328 HIV-infected patients and uncircumcised patients may not respond to treatment as well as those who are HIV-negative or circumcised.319 328

Crohn’s Disease

Management of Crohn’s disease as an adjunct to conventional therapies.737 742 743 744 745 746 747 748

Has been used (with737 742 744 745 746 748 or without metronidazole743 747 ) for induction of remission of mildly to moderately active Crohn’s disease.737 742 743 744 745 746 747 748 May be more effective in patients with ileitis than in those with colitis.739 742

Has been used in the management of refractory perianal Crohn’s disease.737 739 750 751 Relapse usually occurs when the drug is discontinued.739 750

Gonorrhea and Associated Infections

Has been used for treatment of uncomplicated urethral, endocervical, rectal, or pharyngeal gonorrhea caused by susceptible Neisseria gonorrhoeae.1 314 317 322 428 619

Because quinolone-resistant N. gonorrhoeae (QRNG) is widely disseminated worldwide, including in the US319 328 754 835 837 839 (see Resistance in Neisseria gonorrhoeae under Cautions), CDC and others no longer recommend ciprofloxacin for treatment of gonorrhea or any associated infection that may involve N. gonorrhoeae (e.g., pelvic inflammatory disease [PID], epididymitis).319 328 837 839

Granuloma Inguinale (Donovanosis)

Alternative for treatment of granuloma inguinale (donovanosis) caused by Klebsiella granulomatis (formerly Calymmatobacterium granulomatis).319 538

CDC recommends doxycycline or co-trimoxazole as drugs of choice; ciprofloxacin, erythromycin, and azithromycin are alternatives.319

Legionnaires’ Disease

Treatment of Legionnaires’ Disease caused by Legionella pneumophila.734 A drug of choice, especially in immunocompromised patients (e.g., transplant recipients).538 605 622 704 734 735

Malaria

Although ciprofloxacin reportedly has in vitro activity against Plasmodium falciparum, it has been ineffective when used alone in the treatment of uncomplicated malaria caused by chloroquine-resistant P. falciparum.623

Mycobacterial Infections

Alternative for use in multiple-drug regimens for treatment of active tuberculosis.538 601 615 718 817

CDC, ATS, and IDSA state that use of fluoroquinolones can be considered in patients with relapse, treatment failure, or Mycobacterium tuberculosis resistant to isoniazid and/or rifampin or when first-line drugs cannot be tolerated.718 There have been recent reports of extensively drug-resistant tuberculosis (XDR tuberculosis).789 790 XDR tuberculosis is caused by M. tuberculosis resistant to rifampin and isoniazid (multiple-drug resistant strains) that also are resistant to a fluoroquinolone and at least one parenteral second-line antimycobacterial (capreomycin, kanamycin, amikacin).789 790

Although there is clinical experience with several fluoroquinolones in the treatment of tuberculosis (e.g., ciprofloxacin, levofloxacin, moxifloxacin, ofloxacin),799 802 804 805 806 807 levofloxacin and moxifloxacin are the fluoroquinolones recommended by CDC, ATS, and IDSA and levofloxacin may be preferred on the basis of cumulative experience.718 Consult the most recent CDC, ATS, and IDSA recommendations for treatment of tuberculosis for more specific information.718

Treatment of cutaneous infections caused by M. fortuitum; used alone or in conjunction with amikacin.607 817 671 ATS and IDSA recommend that M. fortuitum pulmonary infections be treated with a regimen consisting of at least 2 anti-infectives selected based on results of in vitro susceptibility testing and tolerability (e.g., amikacin, ciprofloxacin or ofloxacin, a sulfonamide, cefoxitin, imipenem, doxycycline).671

Has been used in multiple-drug regimens for treatment of pulmonary and extrapulmonary (localized or disseminated) M. avium complex (MAC) infections.412 538 602 607 614 616 617 817 819 Role of fluoroquinolones in treatment of MAC infections not been established.671 Moxifloxacin may be preferred if a fluoroquinolone is used in conjunction with other antimycobacterial anti-infectives for the treatment of MAC infections, but many strains are resistant in vitro.671 Treatment of MAC infections is complicated and should be directed by clinicians familiar with mycobacterial diseases; consultation with a specialist is particularly important when the patient cannot tolerate first-line drugs or when the infection has not responded to prior therapy or is caused by macrolide-resistant MAC.671

Based on results of in vitro susceptibility testing, ciprofloxacin may be considered for use in combination antimycobacterial regimens used for treatment of infections caused by M. chelonae, M. haemophilum, or M. terrae.671 Because of considerations related to resistance, not recommended for treatment of M. marinum infections.671

Nasal Carriage of Staphylococcus aureus

Has been used for temporary elimination of oxacillin-resistant (methicillin-resistant) S. aureus colonization in patients with serious diseases at risk for infection.410 479 Consider that management of oxacillin-resistant S. aureus colonization is controversial, permanent eradication of nasal carriage of staphylococci following topical or systemic anti-infectives is unlikely, ciprofloxacin resistance has been reported in some oxacillin-resistant S. aureus,140 144 362 410 479 548 549 and there is some evidence that ciprofloxacin may be an independent risk factor for colonization with oxacillin-resistant S. aureus in HIV-infected patients.727

Neisseria meningitidis Infections

Elimination of nasopharyngeal carriage of N. meningitidis in patients with invasive meningococcal disease who did not receive treatment with ceftriaxone or other third generation cephalosporin.292 374 376 406 409 411 544 545 569 CDC and AAP consider rifampin, ceftriaxone, or ciprofloxacin the drugs of choice for such carriers.292 374 409 411 522 569

Chemoprophylaxis to prevent meningococcal disease in household or other close contacts of patients with invasive meningococcal disease.292 374 376

Ceftriaxone, rifampin (not recommended in pregnant women), or ciprofloxacin (not recommended in those <18 years of age unless no other regimen can be used, not recommended in pregnant or lactating women) are the drugs of choice for elimination of N. meningitidis carriage and for chemoprophylaxis of meningococcal disease.292 374 376 All are 90–95% effective and any of these is an acceptable regimen;376 AAP suggests rifampin may be the drug of choice for most children.292

Consider that fluoroquinolone-resistant N. meningitidis has been reported rarely in the US and elsewhere (e.g., India).853 854 Do not use ciprofloxacin for prophylaxis in close contacts of individuals with meningococcal disease in areas where fluoroquinolone-resistant strains have been reported (e.g., selected counties of North Dakota and Minnesota).292 853

Plague

Alternative for treatment of plague caused by Yersinia pestis, including naturally occurring plague and plague that occurs following exposure to Y. pestis in the context of biologic warfare or bioterrorism.292 538 683 688 Regimen of choice is streptomycin (or gentamicin) with or without doxycycline;292 538 688 alternatives are tetracycline, doxycycline, chloramphenicol (a drug of choice for plague meningitis), fluoroquinolones (ciprofloxacin is a drug of choice for plague meningitis), or co-trimoxazole (may be less effective than other alternatives).292 538

Postexposure prophylaxis following a high-risk exposure to Y. pestis (e.g., household, hospital, or other close contact with an individual who has pneumonic plague; laboratory exposure to viable Y. pestis; confirmed exposure in the context of biologic warfare or bioterrorism).683 688 Drugs of choice for such prophylaxis are doxycycline (or tetracycline) or a fluoroquinolone (e.g., ciprofloxacin, levofloxacin, ofloxacin); co-trimoxazole and chloramphenicol are alternatives.683 688

Rickettsial Infections

Treatment of rickettsial infections.393 538 568 625 Has been effective for Q fever endocarditis caused by Coxiella burnetii625 and Mediterranean spotted fever caused by Rickettsia conorii.393 Tetracyclines (usually doxycycline) are drugs of choice for treatment of most rickettsial infections; fluoroquinolones are alternatives when tetracyclines cannot be used.538 683 808 Because of better CNS penetration, some experts suggest fluoroquinolones may be a better choice than tetracyclines for patients with meningoencephalitis.683 (See Distribution under Pharmacokinetics.)

Selective Decontamination of the GI Tract

Selective decontamination of the GI tract in granulocytopenic patients180 201 294 386 387 466 or other debilitated patients (e.g., those with cirrhosis).736

Tularemia

Treatment of tularemia caused by Francisella tularensis, including naturally occurring or endemic tularemia or tularemia that occurs following exposure to F. tularensis in the context of biologic warfare or bioterrorism.292 538 683 689 Considered an alternative to streptomycin (or gentamicin);292 538 683 689 risk of relapse may be higher than with aminoglycosides.689

Postexposure prophylaxis of tularemia following a high-risk laboratory exposure to F. tularensis (e.g., spill, centrifuge accident, needlestick injury) or in individuals exposed to the organism in the context of biologic warfare or bioterrorism.683 689 Postexposure prophylaxis usually not recommended after exposure to natural or endemic tularemia (e.g., tick bite, rabbit or other animal exposure) and is unnecessary in close contacts of tularemia patients since human-to-human transmission does not occur.683

Typhoid Fever and Other Salmonella Infections

Treatment of typhoid fever (enteric fever) caused by susceptible Salmonella typhi,1 326 396 408 441 479 493 494 538 603 654 655 656 657 658 659 660 including chloramphenicol-resistant strains.441 603 655 656 657 658 659 660

Treatment of chronic typhoid carriers.292 293 391 403 438 466 473 538 603 Considered a drug of choice by some clinicians,292 538 but manufacturer cautions that efficacy of ciprofloxacin in eradication of the chronic typhoid carrier state has not been demonstrated.1

Treatment of gastroenteritis caused by non-typhi Salmonella (e.g., S. enteritidis, S. typhimurium).292 412 477 538 681 Anti-infective treatment is indicated only in those with severe disease and in those at increased risk of invasive disease, including those <3–6 months of age or >50 years of age, those with hemoglobinopathies, severe atherosclerosis or valvular heart disease, prostheses, uremia, chronic GI disease, or severe colitis, and those immunocompromised because of malignancy, immunosuppressive therapy, HIV infection, or other immunosuppressive illness.292 412 477 538 681

Base choice of anti-infective on in vitro susceptibility.292 477 538 681 Consider that multidrug-resistant Salmonella serotypes typhi and paratyphi A and strains with decreased susceptibility to fluoroquinolones are common in Asia and found with increasing frequency in travelers to areas with endemic disease.292

Treatment of Salmonella gastroenteritis in HIV-infected adults to prevent extraintestinal spread of the infection.412 CDC, NIH, and IDSA recommend ciprofloxacin as drug of choice for treatment of Salmonella gastroenteritis (with or without bacteremia) in HIV-infected adults; other fluoroquinolones (levofloxacin, moxifloxacin) also may be effective.412 Depending on in vitro susceptibility, alternatives are co-trimoxazole and third generation cephalosporins (ceftriaxone, cefotaxime).412 Role of long-term anti-infective treatment (secondary prophylaxis) in HIV-infected individuals with recurrent bacteremia not well established; weigh benefits of such prophylaxis against risks of long-term anti-infective therapy.412

Has been used alone or in conjunction with a third generation cephalosporin (cefotaxime, ceftriaxone) for treatment of meningitis and other CNS infections caused by susceptible Salmonella.762 763 764 765 (See Meningitis and CNS Infections under Uses.)

Vibrio Infections

Treatment of cholera caused by Vibrio cholerae 01 or 0139.292 477 538 664 756 757 758 Tetracyclines generally drugs of choice when anti-infective indicated as an adjunct to fluid and electrolyte replacement; azithromycin also a recommended treatment.292 Alternatives for V. cholerae resistant to tetracyclines include co-trimoxazole, fluoroquinolones, or furazolidone.292 477 538 664 758

Alternative to tetracyclines for treatment of other Vibrio infections, including gastroenteritis or wound infections caused by V. parahaemolyticus or V. vulnificus.538 759

Treatment of infections caused by V. vulnificus.759 Optimum anti-infective therapy has not been identified; a tetracycline or third generation cephalosporin (e.g., cefotaxime, ceftazidime), a fluoroquinolone, or aminoglycoside has been recommended.759 Because the case fatality rate associated with V. vulnificus is high, initiate anti-infective therapy promptly if indicated.759

Perioperative Prophylaxis

Perioperative prophylaxis in high risk patients undergoing genitourinary surgery.787 Because of increasing resistance of E. coli to fluoroquinolones, consider local susceptibility patterns when selecting an anti-infective for prophylaxis.787

Perioperative prophylaxis using an appropriate anti-infective (e.g., ciprofloxacin) recommended in patients undergoing transurethral prostatectomy, transrectal prostatic biopsies, ureteroscopy, shock wave lithotripsy, or procedures that involve placement of a urologic prosthesis (e.g., penile transplant, artificial sphincter, synthetic pubovaginal sling, bone anchors for pelvic floor reconstruction).787

Perioperative prophylaxis not recommended for patients with sterile urine undergoing most urologic surgical procedures.787 Those who have positive (or unavailable) urine cultures and those with preoperative catheters should be treated to sterilize the urine before surgery or receive a single preoperative dose of an anti-infective (e.g., ciprofloxacin) active against the most likely urologic pathogens.787

Empiric Therapy in Febrile Neutropenic Patients

Empiric anti-infective therapy of presumed bacterial infections in febrile neutropenic patients;579 usually used in conjunction with another anti-infective.579 786

Regimen of oral ciprofloxacin and amoxicillin and clavulanate recommended for empiric therapy in selected low-risk adults (i.e., expected duration of neutropenia ≤7 days, clinically stable, no active medical comorbidities).786

Regimen of ciprofloxacin and clindamycin or vancomycin may be an alternative for empiric therapy in high-risk adults allergic to penicillin.786

IV ciprofloxacin has been used in conjunction with IV piperacillin (no longer commercially available in the US as a single-entity preparation) for empiric therapy in febrile neutropenic patients.579

Consult published protocols on treatment of infections in febrile neutropenic patients for specific recommendations regarding selection of initial empiric regimen, when to change initial regimen, possible subsequent regimens, and duration of therapy in these patients.786 Consultation with an infectious disease expert knowledgeable about infections in immunocompromised patients also advised.786

Ciprofloxacin Hydrochloride Dosage and Administration

Administration

Administer orally1 715 or by IV infusion.579

IV route generally reserved for patients who do not tolerate or are unable to take the drug orally and for other patients in whom IV route offers a clinical advantage.579 Patients receiving IV ciprofloxacin initially may be switched to oral ciprofloxacin when clinically appropriate.579

Patients receiving ciprofloxacin orally or IV should be well hydrated and should be instructed to drink fluids liberally.1 455 715

Oral Administration

Administer conventional tablets or oral suspension without regard to meals.1 715 (See Pharmacokinetics.)

Administer extended-release tablets containing the hydrochloride and base (e.g., Cipro XR) without regard to meals.715 (See Pharmacokinetics.)

Do not administer tablets, extended-release tablets, or oral suspension concurrently with dairy products (e.g., milk, yogurt) or calcium-fortified products (e.g., juices) alone (without a meal) since absorption of the drug may be substantially reduced.1 715 Doses should preferably be taken 2 hours before or after these calcium-fortified products or substantial calcium intake (>800 mg).1 715

Extended-release tablets should not be split, crushed, or chewed.715

The microcapsules are used to prepare oral suspensions and should not be chewed.1 The oral suspension should not be administered through feeding tubes.1

Reconstitution

Prepare oral suspensions by mixing the microcapsules for suspension with the diluent provided by the manufacturer.1 Shake vigorously for approximately 15 seconds prior to administration of each dose.1

IV Infusion

IV infusions should be given into a large vein to minimize discomfort and reduce the risk of venous irritation.579 If a Y-type administration set is used, the other IV solution flowing through the tubing should be discontinued while ciprofloxacin is being infused.579

Ciprofloxacin concentrate containing 10 mg/mL must be diluted prior to IV infusion.579

Ciprofloxacin solution for IV infusion containing 2 mg/mL in 5% dextrose injection may be administered without further dilution.579

For solution and drug compatibility information, see Compatibility under Stability.

Ciprofloxacin preparations for IV administration contain lactic acid as a solubilizing agent.579

Dilution

Dilute ciprofloxacin containing 10 mg/mL in 0.9% sodium chloride injection or 5% dextrose injection to provide a solution containing 1–2 mg/mL.579

Rate of Administration

Administer by IV infusion over 1 hour.579

Dosage

Available as ciprofloxacin,1 579 ciprofloxacin hydrochloride,1 and a mixture of ciprofloxacin and ciprofloxacin hydrochloride;715 dosage expressed in terms of ciprofloxacin.1 579 715

Extended-release tablet preparations (e.g., Cipro XR) are used only for treatment of certain urinary tract infections (UTIs).715 These extended-release preparations are not interchangeable with other oral ciprofloxacin preparations (conventional tablets, oral suspension).715

Based on pharmacokinetic parameters (i.e., AUC), the following regimens are considered equivalent: ciprofloxacin conventional tablets 250 mg every 12 hours—ciprofloxacin 200 mg IV every 12 hours; ciprofloxacin conventional tablets 500 mg every 12 hours—ciprofloxacin 400 mg IV every 12 hours; ciprofloxacin conventional tablets 750 mg every 12 hours—ciprofloxacin 400 mg IV every 8 hours.1 579

Pediatric Patients

Urinary Tract Infections (UTIs)
Complicated UTIs and Pyelonephritis
Oral

Children 1–17 years of age: 10–20 mg/kg (up to 750 mg) every 12 hours for 10–21 days.1 579

IV

Children 1–17 years of age: 6–10 mg/kg (up to 400 mg) every 8 hours.1 579 Switch to oral route when clinically indicated; total duration of IV and oral therapy 10–21 days.1 579

Endocarditis
Endocarditis Caused by the HACEK Group
Oral

20–30 mg/kg daily given in 2 equally divided doses recommended by AHA and IDSA.768 Duration of treatment is 4 weeks for native valve endocarditis or 6 weeks for endocarditis involving prosthetic cardiac valves or other prosthetic cardiac material.768

IV

20–30 mg/kg daily given in 2 equally divided doses recommended by AHA and IDSA.768 Duration of treatment is 4 weeks for native valve endocarditis or 6 weeks for endocarditis involving prosthetic cardiac valves or other prosthetic cardiac material.768

Culture-negative Endocarditis
Oral

20–30 mg/kg daily given in 2 equally divided doses in conjunction with vancomycin (40 mg/kg daily given IV in 2 equally divided doses) and gentamicin (3 mg/kg daily given IM or IV in 3 equally divided doses) recommended by AHA and IDSA.768 All 3 drugs should be given for 4–6 weeks.768

IV

20–30 mg/kg daily given in 2 equally divided doses in conjunction with vancomycin (40 mg/kg daily given IV in 2 equally divided doses) and gentamicin (3 mg/kg daily given IM or IV in 3 equally divided doses) recommended by AHA and IDSA.768 All 3 drugs should be given for 4–6 weeks.768

Meningitis and CNS Infections
Salmonella Meningitis
IV

10–30 mg/kg daily has been given alone or in conjunction with cefotaxime.762

Anthrax
Postexposure Prophylaxis Following Exposure in the Context of Biologic Warfare or Bioterrorism
Oral

15 mg/kg (up to 500 mg) every 12 hours ≥60 days.1 668 682 683 767 Because of concerns regarding long-term use of ciprofloxacin in infants and children, consider changing (after 10–14 days) to amoxicillin to complete the full duration of postexposure prophylaxis if the strain is found to be susceptible to penicillin.668 703

Optimum duration of postexposure prophylaxis after an inhalation exposure to B. anthracis spores is unclear,683 767 but prolonged postexposure prophylaxis usually required.668 682 683 A duration of 60 days may be adequate for a low-dose exposure, but a duration >4 months may be necessary to reduce the risk following a high-dose exposure.767 CDC, US Working Group on Civilian Biodefense, and US Army Medical Research Institute of Infectious Diseases (USAMRIID) recommend that postexposure prophylaxis in unvaccinated individuals be continued for ≥60 days following a confirmed exposure (including in laboratory workers with confirmed exposures to B. anthracis cultures).599 600 668 682 683 The USPHS Advisory Committee on Immunization Practices (ACIP) and USAMRIID recommend that individuals who are partially or fully vaccinated against anthrax receive postexposure prophylaxis for ≥30 days;600 683 if given in conjunction with anthrax vaccine, continue prophylaxis for at least 7–14 days after the third vaccine dose.600 683

IV

10 mg/kg (up to 400 mg) every 12 hours for ≥60 days.579

Treatment of Inhalational, GI, or Oropharyngeal Anthrax
Oral

15 mg/kg (up to 500 mg) every 12 hours given for ≥60 days.668

Initial parenteral regimen preferred; use oral regimen for initial treatment only when a parenteral regimen is not available (e.g., supply or logistic problems because large numbers of individuals require treatment in a mass casualty setting).668 Continue for total duration of ≥60 days if inhalational anthrax occurred as the result of exposure to anthrax spores in the context of biologic warfare or bioterrorism.668 Because of concerns regarding long-term use of ciprofloxacin in infants and children, consider changing (after 10–14 days) to amoxicillin to complete the treatment regimen if penicillin susceptibility is confirmed.668 703

IV, then Oral

10 mg/kg (up to 400 mg) IV every 12 hours.668 686

Used in conjunction with 1 or 2 other anti-infectives predicted to be effective.668 686 When clinical improvement occurs, switch IV ciprofloxacin to oral ciprofloxacin in a dosage of 15 mg/kg (up to 500 mg) twice daily and continue for a total duration of ≥60 days.668 686 Because of concerns regarding long-term use of ciprofloxacin in infants and children, consider changing (after 10–14 days) to amoxicillin to complete the treatment regimen if penicillin susceptibility is confirmed.668 703

Treatment of Cutaneous Anthrax
Oral

15 mg/kg (up to 500 mg) every 12 hour.668 686

For mild, uncomplicated cutaneous anthrax that occurs following natural or endemic exposure (e.g., known exposure to infected livestock or their products), 5–10 days of treatment may be sufficient.668 670 680

For cutaneous anthrax that occurs following exposure in the context of biologic warfare or bioterrorism, duration of treatment is ≥60 days.668 683 686 Because of concerns regarding long-term use of ciprofloxacin in infants and children, consider changing (after 10–14 days) to amoxicillin to complete the treatment regimen if penicillin susceptibility is confirmed.668 703

Oral regimen should not be used for initial treatment of cutaneous anthrax if there are signs of systemic involvement, extensive edema, or head and neck lesions or in infants <2 years of age.668 686 703

IV, then Oral

10 mg/kg (up to 400 mg) IV every 12 hours.668 686

Used in conjunction with 1 or 2 other anti-infectives predicted to be effective.668 686 When clinical improvement occurs, switch IV ciprofloxacin to oral ciprofloxacin in a dosage of 500 mg twice daily and continue for a total duration of ≥60 days.668 686 Because of concerns regarding long-term use of ciprofloxacin in infants and children, consider changing (after 10–14 days) to amoxicillin to complete the treatment regimen if penicillin susceptibility is confirmed.668 703

Neisseria meningitidis Infections
Elimination of Pharyngeal Carrier State
Oral

Conventional tablets or oral suspension: 20 mg/kg (up to 500 mg) as a single dose.292

Chemoprophylaxis in Household or Other Close Contacts
Oral

Conventional tablets or oral suspension: 20 mg/kg (up to 500 mg) as a single dose.292

Plague
Treatment of Pneumonic Plague Occurring in Context of Biologic Warfare or Bioterrorism
Oral

Conventional tablets or oral suspension: 20 mg/kg twice daily.688 Usual duration of treatment is 10 days;688 some experts recommend a duration of at least 10–14 days.683

Initial parenteral regimen preferred; use oral regimen for initial treatment only when a parenteral regimen is not available (e.g., supply or logistic problems because large numbers of individuals require treatment in a mass casualty setting).688

IV, then Oral

15 mg/kg IV twice daily.688 When clinical improvement occurs, IV ciprofloxacin may be switched to oral ciprofloxacin in a dosage of 20 mg/kg twice daily.688

Usual duration of treatment is 10 days;688 some experts recommend a duration of at least 10–14 days.683

Postexposure Prophylaxis Following High-risk Exposure
Oral

Conventional tablets or oral suspension: 20 mg/kg twice daily for 7 days.683 688

Tularemia
Treatment of Tularemia Occurring in the Context of Biologic Warfare or Bioterrorism
Oral

Conventional tablets or oral suspension: 15 mg/kg twice daily.689 Usual duration of treatment is 10 days;689 some experts recommend a duration of at least 10–14 days.683

Initial parenteral regimen preferred; use oral regimen for initial treatment only when a parenteral regimen is not available (e.g., supply or logistic problems because large numbers of individuals require treatment in a mass casualty setting).689

IV, then Oral

15 mg/kg IV twice daily.689

When clinical improvement occurs, switch IV ciprofloxacin to oral ciprofloxacin in a dosage of 15 mg/kg twice daily.689 Usual total duration of treatment is 10 days;689 some experts recommend a duration of at least 10–14 days.683

Postexposure Prophylaxis Following High-risk Exposure
Oral

Conventional tablets or oral suspension: 15 mg/kg twice daily for 14 days.683 689

Vibrio Infections
Cholera
Oral

Children 2–12 years of age: A single dose of 20 mg/kg (up to 750 mg) has been used for treatment of cholera caused by V. cholerae 01 or 0139.758

Adults

Bone and Joint Infections
Mild to Moderate Infections
Oral

Conventional tablets or oral suspension: 500 mg every 12 hours for at least 4–6 weeks.1

IV

400 mg every 12 hours for ≥4–6 weeks.579

Severe or Complicated Infections
Oral

Conventional tablets or oral suspension: 750 mg every 12 hours for at least 4–6 weeks.1

IV

400 mg every 8 hours for ≥4–6 weeks.579

Endocarditis
Endocarditis Caused by the HACEK Group
Oral

1 g daily given in 2 equally divided doses recommended by AHA and IDSA.768 Duration of treatment is 4 weeks for native valve endocarditis or 6 weeks for endocarditis involving prosthetic cardiac valves or other prosthetic cardiac material.768

IV

800 mg daily given in 2 equally divided doses recommended by AHA and IDSA.768 Duration of treatment is 4 weeks for native valve endocarditis or 6 weeks for endocarditis involving prosthetic cardiac valves or other prosthetic cardiac material.768

Staphylococcal Endocarditis in the Absence of Prosthetic Materials
Oral

750 mg twice daily in conjunction with rifampin (300 mg orally twice daily) given for 28 days has been used for uncomplicated right-sided S. aureus endocarditis in IV drug abusers who will not comply with usually recommended parenteral regimens.768

Culture-negative Endocarditis
Oral

1 g daily given in 2 equally divided doses in conjunction with vancomycin (30 mg/kg daily given IV in 2 equally divided doses) and gentamicin (3 mg/kg daily given IM or IV in 3 equally divided doses) recommended by AHA and IDSA.768 All 3 drugs should be given for 4–6 weeks.768

IV

800 mg daily given in 2 equally divided doses in conjunction with vancomycin (30 mg/kg daily given IV in 2 equally divided doses) and gentamicin (3 mg/kg daily given IM or IV in 3 equally divided doses) recommended by AHA and IDSA.768 All 3 drugs should be given for 4–6 weeks.768

GI Infections
Infectious Diarrhea
Oral

Conventional tablets or oral suspension: 500 mg every 12 hours for 5–7 days.1 305 350 378 474 612

HIV-infected: 500–750 mg every 12 hours.412 If no clinical response after 5–7 days, consider stool culture and in vitro susceptibility testing.412

IV

HIV-infected: 400 mg every 12 hours.412 If no clinical response after 5–7 days, consider stool culture and in vitro susceptibility testing.412

Cyclospora Infections
Oral

Conventional tablets or oral suspension: 500 mg twice daily for 7 days.557

Cystoisospora Infections
Oral

HIV-infected: 500 mg twice daily for 7 days.412

Chronic maintenance therapy (secondary prophylaxis) if CD4+ T-cells <200 cells/mm3: 500 mg 3 times weekly.412 Consider discontinuing if CD4+ T-cells remain >200 cells/mm3 for >6 months in response to antiretroviral therapy.412

Shigella Infections
Oral

HIV-infected: 500–750 mg every 12 hours.412

Recommended duration of treatment is 7–10 days for gastroenteritis or ≥14 days for bacteremic infections.412 Up to 6 weeks may be required for recurrent infections, especially if CD4+ T-cells <200 cells/mm3.412

IV

HIV infected: 400 mg every 12 hours.412

Treatment of Travelers’ Diarrhea
Oral

Conventional tablets or oral suspension: 500 mg every 12 hours for 1–3 days.305 412 679

Extended-release tablets containing the hydrochloride and the base (e.g., Cipro XR): 1 g once daily for 1–3 days.305

HIV-infected: 500–750 mg every 12 hours.412 If no clinical response after 5–7 days, consider stool culture and in vitro susceptibility testing.412

IV

HIV-infected: 400 mg every 12 hours.412 If no clinical response after 5–7 days, consider stool culture and in vitro susceptibility testing.412

Prevention of Travelers’ Diarrhea
Oral

Conventional tablets or oral suspension: 500 mg once daily.305 650 651 677

Although anti-infective prophylaxis generally discouraged,305 525 some clinicians state it can be given during period of risk (for ≤3 weeks) beginning day of travel and continuing for 1 or 2 days after leaving area of risk.650 651 677

Intra-abdominal Infections
Complicated Infections
IV, then Oral

Initiate therapy with 400 mg IV every 12 hours given in conjunction with IV metronidazole.579 When appropriate, switch to oral ciprofloxacin in a dosage of 500 mg every 12 hours in conjunction with oral metronidazole.579

Manufacturer recommends total duration of therapy of 7–14 days.579 IDSA recommends treatment duration of 4–7 days; longer duration not associated with improved outcome and not recommended unless adequate source control difficult to achieve.773

Meningitis and CNS Infections
Gram-negative Meningitis
IV

400 mg every 8 hours has been used alone or in conjunction with an aminoglycoside.766 Alternatively, 800–1200 mg daily has been recommended.774

Otic Infections
Malignant Otitis Externa
Oral

750 mg twice daily has been used.784 816 Although rapid relief of symptoms (pain, otorrhea) may occur, continue treatment for 6–8 weeks.784 816

Because ciprofloxacin-resistant Pseudomonas aeruginosa have been isolated from patients with malignant otitis externa with increasing frequency,783 784 785 in vitro susceptibility testing is indicated, especially if there is an inadequate response to treatment.785

Respiratory Tract Infections
Acute Sinusitis
Oral

Conventional tablets or oral suspension: 500 mg every 12 hours for 10 days.1

IV

400 mg every 12 hours for 10 days.579

Mild to Moderate Infections
Oral

Conventional tablets or oral suspension: 500 mg every 12 hours for 7–14 days.1

IV

400 mg every 12 hours for 7–14 days.579

Severe or Complicated Infections
Oral

Conventional tablets or oral suspension: 750 mg every 12 hours for 7–14 days.1

IV

400 mg every 8 hours for 7–14 days.579

Mild, Moderate, or Severe Nosocomial Pneumonia
IV

400 mg every 8 hours for 10–14 days.579

Skin and Skin Structure Infections
Mild to Moderate Infections
Oral

Conventional tablets or oral suspension: 500 mg every 12 hours for 7–14 days.1

IV

400 mg every 12 hours for 7–14 days.579

Severe or Complicated Infections
Oral

Conventional tablets or oral suspension: 750 mg every 12 hours for 7–14 days.1

IV

400 mg every 8 hours for 7–14 days.579

Urinary Tract Infections (UTIs) and Prostatitis
Uncomplicated UTIs (Acute Cystitis)
Oral

Conventional tablets or oral suspension: 250 mg every 12 hours for 3 days.1

Extended-release tablets containing the hydrochloride and base (e.g., Cipro XR): 1 tablet (500 mg) once daily for 3 days, preferably given with the evening meal.715

Mild to Moderate UTIs
Oral

Conventional tablets or oral suspension: 250 mg every 12 hours for 7–14 days.1

IV

200 mg every 12 hours for 7–14 days.579

Complicated UTIs
Oral

Conventional tablets or oral suspension: 500 mg every 12 hours for 7–14 days.1

Extended-release tablets containing the hydrochloride and base (e.g., Cipro XR): 1 tablet (1 g) once every 24 hours for 7–14 days.715

IV

400 mg every 12 hours for 7–14 days.579

Acute Uncomplicated Pyelonephritis
Oral

Extended-release tablets containing the hydrochloride and base (e.g., Cipro XR): 1 g once every 24 hours for 7–14 days.715

Mild to Moderate Chronic Prostatitis
Oral

Conventional tablets or oral suspension: 500 mg every 12 hours for 28 days.1

IV

400 mg every 12 hours for 28 days.579

Anthrax
Postexposure Prophylaxis Following Exposure in the Context of Biologic Warfare or Bioterrorism
Oral

Conventional tablets or oral suspension: 500 mg every 12 hours for ≥60 days.1 663 668 682 683

Optimum duration of postexposure prophylaxis after an inhalation exposure to B. anthracis spores is unclear,683 767 but prolonged postexposure prophylaxis usually required.668 682 683 A duration of 60 days may be adequate for a low-dose exposure, but a duration >4 months may be necessary to reduce the risk following a high-dose exposure.767 CDC, US Working Group on Civilian Biodefense, and US Army Medical Research Institute of Infectious Diseases (USAMRIID) recommend that postexposure prophylaxis in unvaccinated individuals be continued for ≥60 days following a confirmed exposure (including in laboratory workers with confirmed exposures to B. anthracis cultures).599 600 668 682 683 The USPHS Advisory Committee on Immunization Practices (ACIP) and USAMRIID recommend that individuals who are partially or fully vaccinated against anthrax receive postexposure prophylaxis for ≥30 days;600 683 if given in conjunction with anthrax vaccine, continue prophylaxis for at least 7–14 days after the third vaccine dose.600 683

IV

400 mg every 12 hours for ≥60 days.579 778

Postexposure Prophylaxis Following Ingestion of Bacillus anthracis Spores in Contaminated Meat
Oral

Conventional tablets or oral suspension: 500 mg every 12 hours has been recommended.662

Treatment of Inhalational, GI, or Oropharyngeal Anthrax
Oral

Conventional tablets or oral suspension: 500 mg every 12 hours given for ≥60 days.668

Initial parenteral regimen preferred; use oral regimen for initial treatment only when a parenteral regimen is not available (e.g., supply or logistic problems because large numbers of individuals require treatment in a mass casualty setting).668 Continue for total duration of ≥60 days if inhalational anthrax occurred as the result of exposure to anthrax spores in the context of biologic warfare or bioterrorism.668

IV, then Oral

400 mg IV every 12 hours.668 686

Used in conjunction with 1 or 2 other anti-infectives predicted to be effective.668 686 When clinical improvement occurs, switch IV ciprofloxacin to oral ciprofloxacin in a dosage of 500 mg twice daily and continue for a total duration of ≥60 days.668 686

Treatment of Cutaneous Anthrax
Oral

Conventional tablets or oral suspension: 500 mg every 12 hour.668 686

For mild, uncomplicated cutaneous anthrax that occurs following natural or endemic exposure, 5–10 days of treatment has been recommended.668 670 680

For cutaneous anthrax that occurs following exposure in the context of biologic warfare or bioterrorism, duration of treatment is ≥60 days.668 683 686

Oral regimen should not be used for initial treatment of cutaneous anthrax if there are signs of systemic involvement, extensive edema, or head and neck lesions.668 686 703

IV, then Oral

400 mg IV every 12 hours.668 686

Used in conjunction with 1 or 2 other anti-infectives predicted to be effective.668 686 When clinical improvement occurs, switch IV ciprofloxacin to oral ciprofloxacin in a dosage of 500 mg twice daily and continue for a total duration of ≥60 days.668 683 686

Bartonella Infections
Cat Scratch Disease Caused by Bartonella henselae
Oral

Conventional tablets or oral suspension: 500 mg twice daily for 10–16 days has been used.733

Brucella Infections
Oral

Conventional tablets or oral suspension: 500 mg twice daily in conjunction with oral rifampin (600 mg once daily).771 772 Alternatively, 500 mg 2 or 3 times daily for 6–12 weeks or 750 mg 3 times daily for 6–8 weeks has been used for brucellosis or acute brucella arthritis-diskitis.624 Monotherapy or treatment regimens <4–6 weeks not recommended.683 772

Chancroid
Oral

Conventional tablets or oral suspension: 500 mg twice daily for 3 days recommended by CDC and others.319 328

Crohn’s Disease
Oral

Conventional tablets or oral suspension: 500 mg twice daily (with or without metronidazole) has been used as an adjunct to conventional therapies for induction of remission of mildly to moderately active disease.742 744 745 746 749

Gonorrhea and Associated Infections
Uncomplicated Urethral, Endocervical, Rectal, or Pharyngeal Gonorrhea
Oral

Conventional tablets or oral suspension: 250 mg as a single dose recommended by manufacturer.1

Not recommended by CDC or others for treatment of gonorrhea or any associated infections that may involve N. gonorrhoeae (e.g., PID, epididymitis).319 328 837 839 (See Gonorrhea and Associated Infections under Uses.)

Granuloma Inguinale (Donovanosis)
Oral

Conventional tablets or oral suspension: 750 mg twice daily for ≥3 weeks and until all lesions have healed completely;319 consider adding IV aminoglycoside (e.g., gentamicin) if improvement is not evident within the first few days of therapy and in HIV-infected patients.319

Relapse can occur 6–18 months after apparently effective treatment.319

Legionnaires’ Disease
Oral

Conventional tablets or oral suspension: 500 mg every 12 hours for 2–3 weeks.622

IV

400 mg every 12 hours for 2–3 weeks.622

Mycobacterial Infections
Oral

Conventional tablets or oral suspension: 750 mg twice daily has been used in treatment of active tuberculosis caused by M. tuberculosis or treatment of infections caused by M. avium complex.615 616 617 671

Neisseria meningitidis Infections
Elimination of Pharyngeal Carrier State
Oral

Conventional tablets or oral suspension: 500 mg as a single dose.376

Chemoprophylaxis in Household or Other Close Contacts
Oral

Conventional tablets or oral suspension: 500 mg as a single dose.376

Plague
Treatment of Pneumonic Plague Occurring in Context of Biologic Warfare or Bioterrorism
Oral

Conventional tablets or oral suspension: 500 mg twice daily.688 Usual duration of treatment is 10 days;688 some experts recommend a duration of at least 10–14 days.683

Initial parenteral regimen preferred; use oral regimen for initial treatment only when a parenteral regimen is not available (e.g., supply or logistic problems because large numbers of individuals require treatment in a mass casualty setting).688

IV, then Oral

400 mg twice daily.688 When clinical improvement occurs, IV ciprofloxacin may be switched to oral ciprofloxacin in a dosage of 500 mg twice daily.688

Usual duration of treatment is 10 days;688 some experts recommend a duration of at least 10–14 days.683

Postexposure Prophylaxis Following High-risk Exposure
Oral

Conventional tablets or oral suspension: 500 mg twice daily for 7 days.683 688

Tularemia
Treatment of Tularemia Occurring in the Context of Biologic Warfare or Bioterrorism
Oral

Conventional tablets or oral suspension: 500 mg twice daily.689 Usual duration of treatment is 10 days;689 some experts recommend a duration of at least 10–14 days.683

Initial parenteral regimen preferred; use oral regimen for initial treatment only when a parenteral regimen is not available (e.g., supply or logistic problems because large numbers of individuals require treatment in a mass casualty setting).689

IV, then Oral

400 mg IV twice daily.689

When clinical improvement occurs, switch IV ciprofloxacin to oral ciprofloxacin in a dosage of 500 mg twice daily.689 Usual total duration of treatment is 10 days;689 some experts recommend a duration of at least 10–14 days.683

Postexposure Prophylaxis Following High-risk Exposure
Oral

Conventional tablets or oral suspension: 500 mg twice daily for 14 days.683 689

Typhoid Fever and Other Salmonella Infections
Mild to Moderate Typhoid Fever
Oral

Conventional tablets or oral suspension: 500 mg every 12 hours for 10 days.1

Chronic Typhoid Carriers
Oral

Conventional tablets or oral suspension: 750 mg every 12 hours for 28 days.391 403 438 466 473

Salmonella Gastroenteritis in HIV-infected Patients
Oral

Conventional tablets or oral suspension: 500–750 mg every 12 hours.412

Recommended duration is 7–14 days if CD4+ T-cells ≥200 cells/mm3 (≥14 days if bacteremic or infection is complicated) or 2–6 weeks if CD4+ T-cells <200 cells/mm3.412

Role of long-term treatment (secondary prophylaxis) in those with recurrent bacteremia not well established; weigh benefits against risks of long-term anti-infective exposure.412 Consider secondary prophylaxis in those with CD4+ T-cells <200 cells/mm3 and severe diarrhea.412

IV

400 mg every 12 hours.412

Vibrio Infections
Cholera
Oral

1 g given as a single dose or in 2 divided doses 12 hours apart has been used for treatment of cholera caused by V. cholerae 01 or 0139.664 757

Perioperative Prophylaxis
Oral

Single 500-mg dose given prior to the procedure.787

IV

Single 400-mg dose given within 1–2 hours prior to the procedure or initial incision.787

Empiric Therapy in Febrile Neutropenic Patients
IV

400 mg every 8 hours;579 has been used in conjunction with IV piperacillin (50 mg/kg every 4 hours, not to exceed 24 g/daily or 300 mg/kg daily).579

Usual duration of treatment is 7–14 days.579

Prescribing Limits

Pediatric Patients

Urinary Tract Infections (UTIs)
Complicated UTIs and Pyelonephritis
Oral

Children 1–17 years of age: Maximum 750 mg every 12 hours, even in those weighing >51 kg.1 579

IV

Children 1–17 years of age: Maximum 400 mg every 8 hours, even in those weighing >51 kg.1 579

Anthrax
Postexposure Prophylaxis Following Exposure in the Context of Biologic Warfare or Bioterrorism
Oral

Maximum 500 mg every 12 hours.1 579

IV

Maximum 400 mg every 12 hours.1 579

Adults

Do not exceed usual dosage because of risk of crystalluria.1 (See Renal Effects under Cautions.)

Special Populations

Hepatic Impairment

Dosage adjustments not required in patients with stable chronic cirrhosis;715 pharmacokinetics not fully studied in those with acute hepatic insufficiency.1 579 715

Carefully monitor patients who have both hepatic and renal impairment.579 (See Renal Impairment under Dosage and Administration.)

Renal Impairment

Dosage adjustments may be necessary in adults with renal impairment, especially those with severe impairment.1 579 715 Dosage recommendations not available for pediatric patients with moderate to severe renal impairment (Clcr <50 mL/minute per 1.73 m2).1 579

Conventional tablets or oral suspension: Decrease dosage in adults with Clcr ≤50 mL/minute.1 (See Table 1.) Manufacturer states a dosage of 750 mg given at the intervals noted in Table 1 may be used with close monitoring in adults with severe infections and severe renal impairment.1

Table 1. Dosage of Conventional Tablets or Oral Suspension in Adults with Renal Impairment1

Clcr (mL/minute)

Dosage

30–50

250–500 mg every 12 hours

5–29

250–500 mg every 18 hours

Hemodialysis or peritoneal dialysis patients

250–500 mg once every 24 hours; give dose after dialysis

Extended-release tablets containing the hydrochloride and base (e.g., Cipro XR): Dosage adjustment not needed when 500-mg extended-release tablet used for uncomplicated UTIs (acute cystitis) in adults with renal impairment.715 Decrease dosage when used for complicated UTIs or acute uncomplicated pyelonephritis in adults with Clcr ≤30 mL/minute.715 (See Table 2.) Do not use 1-g extended-release tablet in patients who have Clcr ≤30 mL/minute or are undergoing hemodialysis or peritoneal dialysis.715

Table 2. Dosage of Extended-release Tablets Containing the Hydrochloride and Base (e.g., Cipro XR) in Adults with Renal Impairment715

Clcr (mL/minute)

Dosage

<30 (uncomplicated UTI; acute cystitis)

No dosage adjustment needed

<30 (complicated UTI or acute uncomplicated pyelonephritis)

500 mg once daily

Hemodialysis or peritoneal dialysis patients

Give dose after dialysis period (maximum 500 mg once daily)

CAPD

Maximum 500 mg once daily

IV ciprofloxacin: Decrease dosage in those with Clcr <30 mL/minute.579 (See Table 3.)

Table 3. IV Dosage in Adults with Renal Impairment579

Clcr (mL/min)

Dosage

5–29

200–400 mg every 18–24 hours

Geriatric Patients

No dosage adjustments except those related to renal impairment.1 579 715 (See Renal Impairment under Dosage and Administration.)

Select dosage with caution because of possible age-related decreases in renal impairment.1 579 715

Cautions for Ciprofloxacin Hydrochloride

Contraindications

  • Known hypersensitivity to ciprofloxacin or any quinolone.1 579 715

  • Concomitant use with tizanidine.1 579 715 (See Interactions.)

Warnings/Precautions

Warnings

Tendinopathy and Tendon Rupture

Systemic fluoroquinolones, including ciprofloxacin, are associated with increased risk of tendinitis and tendon rupture in all age groups.1 579 715 851 852 This risk is further increased in older adults (usually those >60 years of age), individuals receiving concomitant corticosteroids, and kidney, heart, or lung transplant recipients.1 579 715 851 852

Other factors that may independently increase risk of tendon rupture include strenuous physical activity, renal failure, and previous tendon disorders such as rheumatoid arthritis.1 579 715 851 852 Tendinitis and tendon rupture have been reported in patients receiving fluoroquinolones who did not have any of these risk factors.1 579 715

Fluoroquinolone-associated tendinitis and tendon rupture most frequently involve the Achilles tendon and may require surgical repair.1 579 715 Tendinitis and tendon rupture in the rotator cuff (shoulder), hand, biceps, thumb, and other tendon sites also reported.1 579 715

Tendon rupture can occur during or following fluoroquinolone therapy and has been reported up to several months after completion of therapy.1 579 715

Discontinue if pain, swelling, inflammation, or rupture of a tendon occurs.1 579 715 851 852 Advise patients to rest and refrain from exercise and contact a clinician at the first sign of tendinitis or tendon rupture (e.g., pain, swelling, or inflammation of a tendon or weakness or inability to use a joint).1 579 715 851 852 (See Advice to Patients.)

Myasthenia Gravis Patients

May exacerbate muscle weakness in myasthenia gravis patients;1 579 715 need for ventilatory support and death reported.1 579 715

Avoid use in patients with known history of myasthenia gravis.1 579 715

Hepatobiliary Effects

Severe hepatotoxicity, including hepatic necrosis, life-threatening hepatic failure, and fatal events, reported.1 579 715 Most fatalities have occurred in adults >55 years of age.1 579 715

Acute liver injury has rapid onset (range 1–39 days) and is often associated with hypersensitivity.1 579 715 Pattern of injury can be hepatocellular, cholestatic, or mixed.1 579 715

Temporary increase in aminotransferase or alkaline phosphatase concentrations or cholestatic jaundice may occur, especially in patients with previous liver damage.1 579 715

Immediately discontinue ciprofloxacin if any sign or symptom of hepatitis (e.g., anorexia, jaundice, dark urine, pruritus, tender abdomen) occurs.1 579 715

Musculoskeletal Effects

Increased incidence of musculoskeletal disorders related to joints and/or surrounding tissues (e.g., arthralgia, abnormal gait, abnormal joint exam, joint sprains, leg pain, back pain, arthrosis, bone pain, myalgia, arm pain, decreased range of motion in a joint) reported in pediatric patients receiving ciprofloxacin.1 579 Use in pediatric patients <18 years of age only for certain indications.1 579 (See Pediatric Use under Cautions.)

Fluoroquinolones, including ciprofloxacin, cause arthropathy and osteochondrosis in immature animals of various species.1 183 186 213 455 479 579 715 841 842 843 844 845 846 847 848 849 850 Permanent lesions of the cartilage and lameness reported in ciprofloxacin studies in immature dogs.1 579 715 Relevance of these adverse effects in immature animals to use in humans unknown.840 846 847 848 850 Safety and efficacy not established in pregnant or lactating women (see Pregnancy and see Lactation under Cautions)1 579 715 and safety and efficacy for any indication other than complicated UTIs and pyelonephritis caused by susceptible E. coli or inhalational anthrax (postexposure) not established in children and adolescents <18 years of age (see Pediatric Use under Cautions).1 579

CNS Effects

Possibility of CNS effects, including seizures, increased intracranial pressure, toxic psychoses, and CNS stimulation leading to dizziness, confusion, tremors, hallucinations, depression, and, rarely, suicidal thoughts or acts.1 579 715 These may occur following first dose.1 579 715 Status epilepticus reported.1 579 715

Use with caution in epileptic patients and patients with known or suspected CNS disorders that may predispose to seizures or lower seizure threshold (e.g., severe cerebral arteriosclerosis, history of seizures, reduced cerebral blood flow, altered brain structure, stroke) or other risk factors that may predispose to seizures (e.g., certain drug therapy, renal dysfunction).1 579 715

Use in patients with risk factors that predispose to seizures only if benefits outweigh risks.1 579 715

Discontinue ciprofloxacin and institute appropriate measures if seizures or other CNS effects occur.1 579 715

Peripheral Neuropathy

Sensory or sensorimotor axonal polyneuropathy affecting small and/or large axons resulting in paresthesias, hypoesthesias, dysesthesias, and weakness reported with fluoroquinolones, including ciprofloxacin.1 579 715 Symptoms may occur soon after initiation of the drug and may be irreversible.1 579 715

Immediately discontinue ciprofloxacin if symptoms of peripheral neuropathy (e.g., pain, burning, tingling, numbness, weakness) occur or if there are alterations in sensations (e.g., light touch, pain, temperature, position sense, vibratory sensation).1 579 715

Prolongation of QT Interval

Prolonged QT interval reported; rare reports of arrhythmia and torsades de pointes.1 579 715

Avoid use in patients with known prolonged QT interval or with risk factors for QT interval prolongation or torsades de pointes (e.g., congenital long QT syndrome, uncorrected electrolyte imbalance such as hypokalemia or hypomagnesemia, cardiac disease such as heart failure, MI, or bradycardia).1 579 715

Also avoid in patients receiving class IA or III antiarrhythmic agents or other drugs known to prolong QT interval;1 579 715 if necessary, use concomitantly with caution.1 579 715 (See Drugs that Prolong QT Interval under Interactions.)

Superinfection/Clostridium difficile-associated Diarrhea and Colitis (CDAD)

Possible emergence and overgrowth of nonsusceptible bacteria or fungi.1 297 300 338 346 348 390 426 466 479 579 715 Institute appropriate therapy if superinfection occurs.1 579 715

Treatment with anti-infectives alters normal colon flora and may permit overgrowth of Clostridium difficile.1 348 579 672 674 675 715 796 C. difficile infection (CDI) and C. difficile-associated diarrhea and colitis (CDAD; also known as antibiotic-associated diarrhea and colitis or pseudomembranous colitis) reported with nearly all anti-infectives, including ciprofloxacin, and may range in severity from mild diarrhea to fatal colitis.1 579 672 674 675 715 792 793 797 798 C. difficile produces toxins A and B which contribute to development of CDAD; hypertoxin-producing strains of C. difficile are associated with increased morbidity and mortality since they may be refractory to anti-infectives and colectomy may be required.1 579 715

Outbreaks of severe CDAD caused by fluoroquinolone-resistant C. difficile have been reported with increasing frequency over the last several years.792 793 794 795 797

Consider CDAD if diarrhea develops during or after therapy and manage accordingly.1 579 672 674 675 715 Obtain careful medical history since CDAD may occur as late as 2 months or longer after anti-infective therapy is discontinued.1 579 672 674 675 715

If CDAD is suspected or confirmed, discontinue anti-infectives not directed against C. difficile whenever possible.1 579 672 674 675 715 Initiate appropriate supportive therapy (e.g., fluid and electrolyte management, protein supplementation), anti-infective therapy directed against C. difficile (e.g., metronidazole, vancomycin), and surgical evaluation as clinically indicated.1 579 672 674 675 579 715

Interactions

Pharmacokinetic interaction with CYP1A2 substrates (e.g., clozapine, methylxanthines [e.g., caffeine, theophylline], olanzapine, ropinirole, tizanidine).1 579 715

Concomitant use with tizanidine contraindicated.1 579 715 Concomitant use with other CYP1A2 substrates should be avoided or requires particular caution.1 579 715 (See Specific Drugs under Interactions.)

Sensitivity Reactions

Hypersensitivity Reactions

Serious and occasionally fatal (anaphylactic) hypersensitivity reactions, which may occur following first dose, reported with some quinolones.1 579 715

Some reactions have been accompanied by cardiovascular collapse, loss of consciousness, tingling, pharyngeal or facial edema, dyspnea, urticaria, and itching.1 579 715

If a hypersensitivity reaction occurs, discontinue ciprofloxacin and institute appropriate therapy as indicated (e.g., epinephrine, corticosteroids, and maintenance of an adequate airway and oxygen).1 579 715

Photosensitivity Reactions

Moderate to severe photosensitivity/phototoxicity reactions reported with fluoroquinolones, including ciprofloxacin.1 579 715

Phototoxicity may manifest as exaggerated sunburn reactions (e.g., burning, erythema, exudation, vesicles, blistering, edema) on areas exposed to sun or artificial ultraviolet (UV) light (usually the face, neck, extensor surfaces of forearms, dorsa of hands).1 579

Avoid unnecessary or excessive exposure to sunlight or artificial UV light (sunlamps, tanning beds, UVA/UVB treatment) while receiving ciprofloxacin.1 579 715 If patient needs to be in sunlight, they should use sunscreen and wear a hat and clothing that protects skin from sun exposure.1 579 715

Discontinue ciprofloxacin if photosensitivity or phototoxicity (sunburn-like reaction, skin eruption) occurs.1 579 715

General Precautions

Renal Effects

Possible crystalluria;1 234 339 355 373 426 466 479 579 715 generally associated with alkaline urine and high dosage.1 183 188 455 479 579 715

Adequate fluid intake necessary to ensure proper hydration and adequate urinary output;1 455 579 715 avoid alkaline urine and do not exceed usual dosage.1 455 579 715

Selection and Use of Anti-infectives

When prescribing a fluoroquinolone, consider potential benefits and risks for the individual patient.851 852 Most patients tolerate the drugs, but serious adverse reactions (e.g., CNS effects, QT prolongation, C. difficile-associated diarrhea and colitis, damage to liver, kidneys, or bone marrow, alterations in glucose homeostasis) may occur rarely.851 852

To reduce development of drug-resistant bacteria and maintain effectiveness of ciprofloxacin and other antibacterials, use only for treatment or prevention of infections proven or strongly suspected to be caused by susceptible bacteria.1 579 715

When selecting or modifying anti-infective therapy, use results of culture and in vitro susceptibility testing.1 579 715 In the absence of such data, consider local epidemiology and susceptibility patterns when selecting anti-infectives for empiric therapy.1 579 715

Resistance in Neisseria gonorrhoeae

N. gonorrhoeae with decreased susceptibility to ciprofloxacin and other fluoroquinolones (quinolone-resistant N. gonorrhoeae; QRNG) has been reported with increasing frequency over the past several years.319 328 632 634 635 637 638 639 669 754 837

US data indicate that QRNG has continued to increase among men who have sex with men and among heterosexual males and is now present in all regions of the country.837

CDC and others state that fluoroquinolones, including ciprofloxacin, should not be used to treat gonorrhea or any associated infections that may involve N. gonorrhoeae (e.g., PID, epididymitis).319 328 837 839

Laboratory Monitoring

Periodically assess organ system function, including renal, hepatic, and hematopoietic, during prolonged therapy.1 579 715

Specific Populations

Pregnancy

Category C.1 579 715

Lactation

Distributed into milk;1 567 579 715 830 discontinue nursing or the drug.1 579 715

AAP states maternal use of ciprofloxacin usually is compatible with breast-feeding since absorption of the drug by nursing infants would be negligible and adverse effects in infants have not been reported to date following such exposures.703 705

Pediatric Use

Ciprofloxacin causes arthropathy and histologic changes in weight-bearing joints of juvenile animals.1 579 715 An increased incidence of musculoskeletal disorders related to joints and/or surrounding tissues reported in pediatric patients.1 579 (See Musculoskeletal Effects under Cautions.)

Conventional tablets or oral suspension (Cipro) or parenteral ciprofloxacin (Cipro I.V.) are labeled by FDA for treatment of complicated UTIs and pyelonephritis caused by susceptible E. coli or for inhalational anthrax (postexposure) in children and adolescents <18 years of age.1 579 Safety and efficacy not established for any other indication in this age group.1 579

Safety and efficacy of extended-release tablets containing the hydrochloride and base (e.g., Cipro XR) not established for any indication in children and adolescents <18 years of age.715

AAP states use of fluoroquinolones may be justified in children <18 years of age in special circumstances after careful assessment of the risks and benefits for the individual patient and after these benefits and risks have been explained to the parents and/or caregivers.110 292 Some clinicians suggest that the potential benefits of ciprofloxacin may outweigh the possible risks in certain children 9–18 years of age with serious infections (e.g., cystic fibrosis, typhoid fever) when the causative organism is resistant to other available anti-infectives.522 654

Geriatric Use

Retrospective analysis of controlled clinical trials indicates no substantial differences in safety and efficacy relative to younger adults, but increased sensitivity cannot be ruled out.1 579 715

Risk of severe tendon disorders, including tendon rupture, is increased in geriatric adults >60 years of age.1 579 715 851 852 This risk is further increased in those receiving concomitant corticosteroids.1 579 715 851 852 (See Tendinopathy and Tendon Rupture under Cautions.) Use caution in geriatric adults, especially those receiving concomitant corticosteroids.1 579 715

Risk of prolonged QT interval leading to ventricular arrhythmias may be increased in geriatric patients.1 579 715 Use with caution in those receiving concurrent therapy with drugs that can prolong QT interval (e.g., class IA or III antiarrhythmic agents) or those with risk factors for torsades de pointes (e.g., known QT prolongation, uncorrected hypokalemia).1 579 715

Age-related decline in renal function may increase risk of adverse reactions.1 579 715

Hepatic Impairment

Possible increased half-life.479 532

Use with caution and monitor serum ciprofloxacin concentrations in patients with both hepatic and renal impairment.1 579 715

Renal Impairment

Increased ciprofloxacin concentrations and prolonged half-life;1 180 205 214 237 254 255 256 257 260 474 479 524 534 possible increased risk of adverse reactions.1 474 524

Dosage adjustments necessary in patients with renal impairment.1 579 715 (See Renal Impairment under Dosage and Administration.)

Use with caution and monitor serum ciprofloxacin concentrations in patients with changing renal function or with both hepatic and renal impairment.1 579 715

Common Adverse Effects

GI effects (nausea, diarrhea, vomiting, abdominal pain/discomfort); headache; restlessness; rash.1 178 183 289 237 297 301 307 308 317 329 336 363 424 425 426 428 462 466 473 474 478 479 579 715

Interactions for Ciprofloxacin Hydrochloride

Inhibits CYP1A2.1 579 715

Drugs Metabolized by Hepatic Microsomal Enzymes

Potential pharmacokinetic interaction with CYP1A2 substrates (increased concentrations and increased pharmacologic or adverse effects of CYP1A2 substrate).1 579 715

Drugs that Prolong QT Interval

Potential pharmacologic interactions (additive effect on QT interval prolongation).1 579 715 Avoid use in patients receiving drugs known to prolong QT interval.1 579 715 If concomitant use necessary, use with caution.1 579 715 (See Prolongation of QT Interval under Cautions.)

Specific Drugs

Drug

Interaction

Comments

Aminoglycosides

In vitro evidence of additive or synergistic antibacterial effects against Enterobacteriaceae and Ps. aeruginosa;114 129 479 synergism unpredictable85 126 129 135 205 479

Antacids (aluminum-, magnesium-, or calcium-containing)

Decreased absorption of oral ciprofloxacin1 81 196 197 202 203 208 536 540 597 598 715 824

Administer ciprofloxacin tablets, extended-release tablets, or oral suspension at least 2 hours before or 6 hours after such antacids1 715

Antiarrhythmic agents (class IA [e.g., quinidine, procainamide], class III [e.g., amiodarone, sotalol])

Possible additive effect on QT interval prolongation1 579 715

Avoid concomitant use; if concomitant use necessary, use with caution1 579 715

Anticoagulants, oral (warfarin)

Potential for enhanced warfarin effects1 558 579 823 715

Use with caution;558 823 monitor PT and INR frequently during and shortly after concomitant therapy1 558 579 715 823 715

Antidepressants, tricyclic

Agents that prolong QT interval: Possible additive effect on QT interval prolongation1 579 715

Avoid concomitant use; if concomitant use necessary, use with caution1 579 715

Antimuscarinics (scopolamine, pirenzepine)

Possible delayed absorption of oral ciprofloxacin81 474 479

Antipsychotic agents

Agents that prolong QT interval: Possible additive effect on QT interval prolongation1 579 715

Avoid concomitant use; if concomitant use necessary, use with caution1 579 715

β-lactam antibiotics

In vitro evidence of additive or synergistic antibacterial effects against Ps aeruginosa;114 117 118 119 124 132 430 434 479 indifference against Enterobacteriaceae132 205 434

Bismuth subsalicylate

Slight decrease in peak plasma concentrations and AUC of ciprofloxacin821

Not considered clinically important821

Caffeine

Prolonged half-life and increased concentrations of caffeine1 185 194 479 513 514 515 528 541 577 579 715

Advise patients receiving ciprofloxacin that regular consumption of large quantities of coffee, tea, or caffeine-containing soft drinks or drugs during treatment may result in exaggerated or prolonged caffeine effects1 513 528 577 579 715

If excessive cardiac or CNS stimulation occurs, restrict caffeine intake513

Restrict caffeine intake in those receiving ciprofloxacin at risk for adverse effects from CNS or cardiac stimulation514 528 577

Clozapine

Increased clozapine concentrations;1 579 715 775 822 possible increased adverse effects775 822

Carefully monitor for clozapine adverse effects and make appropriate clozapine dosage adjustments during and shortly after concomitant therapy1 579 715

Corticosteroids

Increased risk of tendinitis or tendon rupture, especially in patients >60 years of age1 579 715 851 852

Cyclosporine

Possible additive nephrotoxic effects or interference with metabolism of cyclosporine;539 transiently increased Scr reported1 579 715

Didanosine

Decreased absorption of oral ciprofloxacin with buffered didanosine preparations1 715

Administer ciprofloxacin tablets, extended-release tablets, or oral suspension at least 2 hours before or 6 hours after buffered didanosine (pediatric oral suspension admixed with antacids)1 715

Duloxetine

Possible increased concentrations and AUC of duloxetine1 579 715

Glyburide

Severe hypoglycemia reported1 579 715

Histamine H2-receptor antagonists (cimetidine, ranitidine)

No evidence of pharmacokinetic interaction339 474 824

Iron preparations

Decreased absorption of oral ciprofloxacin1 715

Administer ciprofloxacin tablets, extended-release tablets, or oral suspension at least 2 hours before or 6 hours after ferrous sulfate and dietary supplements containing iron1 715

Lanthanum

Possible decreased GI absorption and substantially decreased serum and urine concentrations of ciprofloxacin1 715

Administer ciprofloxacin tablets, extended-release tablets, or oral suspension at least 2 hours before or 6 hours after lanthanum1 715

Lidocaine (systemic)

Increased concentrations and AUC of lidocaine;1 579 715 possible increased lidocaine adverse effects1 579 715

Macrolides

Agents that prolong QT interval: Possible additive effect on QT interval prolongation1 579 715

Avoid concomitant use; if concomitant use necessary, use with caution1 579 715

Methotrexate

Possible increased methotrexate concentrations and increased risk of toxic effects1 579 715

Monitor closely1 579 715

Metoclopramide

Increased rate of absorption of oral ciprofloxacin;1 81 474 479 579 715 effect on ciprofloxacin bioavailability not clinically important1 579 715

Metronidazole

No effect on concentrations of either drug1 579 715

Multivitamins and mineral supplements

Decreased absorption of oral ciprofloxacin1 715

Administer ciprofloxacin tablets, extended-release tablets, or oral suspension at least 2 hours before or 6 hours after supplements containing calcium, zinc, or iron1 715

NSAIAs

Possible increased risk of seizures;1 579 715 815 animal studies suggest risk may vary depending on the specific NSAIA815

Olanzapine

Possible increased olanzapine concentrations and increased pharmacologic or adverse effects1 579 715

Omeprazole

Decreased concentrations and AUC of ciprofloxacin1 715

Clinical importance unknown715

Pentoxifylline

Increased pentoxifylline concentrations; possible increased pharmacologic or adverse effects1 579 715

Phenytoin

Possible altered (increased or decreased) phenytoin concentrations1 579 715

Monitor phenytoin concentrations during and shortly after concomitant therapy1 579 715

Probenecid

Decreased clearance of ciprofloxacin1 715

Rifampin

Does not appear to affect pharmacokinetics of either drug832

In vitro evidence of indifferent against S. aureus; antagonism reported rarely.130 134 479

Ropinirole

Increased ropinirole concentrations and AUC1 579 715 836

Monitor for ropinirole adverse effects and adjust ropinirole dosage as needed during and shortly after concomitant therapy1 579 715

Sevelamer

Possible decreased GI absorption and substantially decreased serum and urine concentrations of ciprofloxacin1 715

Administer ciprofloxacin tablets, extended-release tablets, or oral suspension at least 2 hours before or 6 hours after sevelamer1 715

Sildenafil

Increased peak concentration and AUC of sildenafil1 579 715

Use concomitantly with caution1 579 715

Sucralfate

Possible decreased GI absorption and decreased concentrations of ciprofloxacin 1 715 825

Administer ciprofloxacin tablets, extended-release tablets, or oral suspension at least 2 hours before or 6 hours after sucralfate1 715

Tizanidine

Increased peak concentration and AUC of tizanidine; increased risk of adverse effects1 579 715

Concomitant use contraindicated1 579 715

Theophylline

Possible increased theophylline concentrations and increased risk of theophylline-related adverse effects;1 193 198 200 204 216 421 506 507 508 509 510 511 552 579 715 serious and fatal reactions reported1 195 297 552

Avoid concomitant use1 180 474 509 552 715

If used concomitantly, closely monitor patient and theophylline concentrations and make appropriate theophylline dosage adjustments as needed, especially in geriatric patients1 185 193 199 200 204 216 355 466 474 506 507 508 509 510 511 512 528 552 579 715

Ciprofloxacin Hydrochloride Pharmacokinetics

Absorption

Bioavailability

Rapidly and well absorbed from GI tract;1 177 178 180 182 214 218 226 229 272 281 286 474 479 undergoes minimal first-pass metabolism.1 182 205 214 418 479 534

Oral bioavailability of conventional tablets is 50–85% in healthy, fasting adults;1 177 178 180 214 218 235 236 238 281 418 474 479 peak serum concentrations attained within 0.5–2.3 hours.1 178 180 182 214 215 218 219 220 221 223 224 229 230 233 234 235 237 238 239 262 281 474 479 531

500-mg dose of oral suspension containing 250 mg/5 mL is bioequivalent to a 500-mg conventional tablet.1

Conventional tablets are not bioequivalent to extended-release tablets.715

Peak plasma concentrations are attained within 1–4 hours following oral administration of extended-release tablets.715 Extended-release tablets contain approximately 35% of the dose within an immediate-release component; the remaining 65% is contained in a slow-release matrix.715

Food or Milk

Effect of food and/or milk on GI absorption of ciprofloxacin varies depending on the specific preparation (conventional tablets, extended-release tablets, oral solution) and situation.1 81 177 178 180 182 214 219 240 418 474 479 791 810

Administration of ciprofloxacin conventional tablets with food results in a delay in absorption of the drug, but overall absorption not substantially affected.1 81 177 178 180 182 214 219 240 418 474 479

Manufacturer states food does not affect pharmacokinetics of ciprofloxacin oral suspension.1

Manufacturer of extended-release tablets containing ciprofloxacin hydrochloride and base (e.g., Cipro XR) states that administration with a high- or low-fat meal does not substantially affect pharmacokinetics.715

Concomitant administration with dairy products or calcium-fortified juices alone (i.e., without a meal) or with substantial calcium intake (>800 mg) may affect absorption.1 715 Manufacturer states that absorption may not be affected substantially by dietary calcium that is part of a meal.1 715

Concomitant administration of conventional ciprofloxacin tablets with a nutritional supplement may decrease peak plasma concentrations and/or AUC of the drug.791 820

Special Populations

Bioavailability of oral suspension is approximately 60% in pediatric patients.1 579

Peak serum concentrations and AUCs are slightly higher in geriatric patients than in younger adults; this may occur because of increased bioavailability, reduced volume of distribution, and/or reduced renal clearance.248 250 251 442 531 Not considered clinically important.1 579 715

Distribution

Extent

Widely distributed into body tissues and fluids following oral or IV administration.1 180 205 214 281 474 479 Highest concentrations205 474 479 attained in bile,1 178 214 272 277 474 479 530 lungs,205 265 445 474 479 kidney,205 479 liver,479 gallbladder,205 277 479 530 uterus,205 214 282 474 seminal fluid,474 prostatic tissue and fluid,1 177 178 180 205 264 267 269 270 275 281 283 437 474 479 tonsils,273 281 474 479 endometrium,282 446 474 fallopian tubes,282 446 474 and ovaries.282 446 474 Concentrations achieved in most of these tissues and fluids substantially exceed those in serum.1 177 180 205 277 437 474 479 530

Also distributed into bone,1 178 214 261 281 474 479 aqueous humor,214 278 431 479 sputum,1 178 241 242 244 245 246 281 439 saliva,1 214 221 226 263 442 nasal secretions,1 829 skin,1 268 muscle,1 232 261 268 274 281 479 adipose tissue,1 232 268 274 281 cartilage,1 heart tissue (heart valves, myocardia),831 and pleural,281 826 827 peritoneal,1 178 252 253 281 479 ascitic,479 828 blister,1 224 230 239 262 266 269 281 479 lymphatic,1 214 266 479 and renal cyst fluid.470

Low concentrations distributed into CSF;1 178 214 279 281 418 436 766 peak CSF concentrations may be 6–10% of peak serum concentrations.1 436

Crosses the placenta and is distributed into amniotic fluid.567

Distributed into milk.567 830

Plasma Protein Binding

16–43%.1 179 180 205 214 223 276 474 479

Elimination

Metabolism

Partially metabolized1 180 214 231 271 272 418 474 490 530 in liver530 to at least 4 metabolites.1 180 214 231 271 418 474 479 488 534 Metabolites have microbiologic activity less than that of the parent drug,1 205 214 238 272 418 474 488 530 but some have activity similar to or greater than that of some other quinolones.272 488

Elimination Route

Eliminated by renal and nonrenal mechanisms.180 182 214 245 259 260 418 474 479 490

Excreted in urine by both glomerular filtration and tubular secretion (15–50% of dose is unchanged drug and 10–15% is metabolites).1 177 178 180 205 214 215 219 221 224 230 231 234 235 237 238 239 240 258 259 271 286 418 474 479 490 530 534 Approximately 20–40% of dose is excreted in feces as unchanged drug and metabolites;1 479 490 most of unchanged ciprofloxacin in feces results from biliary excretion.530 534

Only small amounts removed by hemodialysis178 180 214 254 256 418 474 479 or peritoneal dialysis.214 252

Half-life

Adults with normal renal function: 3–7 hours.1 178 182 214 218 219 220 224 229 230 235 238 239 240 418 474 479 530 534 579 715

Special Populations

Pediatric patients: Predicted mean half-life is 4–5 hours.1 579

Geriatric patients: Elimination half-life is slightly longer compared with younger adults.178 215 214 248 249 250 251 Half-life is 3.3–6.8 hours in adults 60–91 years of age with renal function normal for their age.248 249 250 251 531 596

Adults with hepatic impairment: Half-life may be slightly prolonged.479 532

Patients with impaired renal function: Serum concentrations are higher and half-life prolonged.1 180 205 214 237 254 255 256 257 260 474 479 524 534 Half-life is 4.4–12.6 hours in adults with Clcr ≤30 mL/minute.180 256 524

Stability

Storage

Oral

Tablets

Conventional tablets: <30°C.1

Extended-release tablets: 25°C (may be exposed to 15–30°C).715

For Suspension

<25°C.1 Following reconstitution, <30°C for 14 days.1 Do not freeze.1

Parenteral

Concentrate for Infusion

5–30°C.579 Protect from light and excessive heat; do not freeze.579

IV infusions containing 0.5–2 mg/mL prepared using sterile water, 0.9% sodium chloride, 5 or 10% dextrose, 5% dextrose and 0.225 or 0.45% sodium chloride, or lactated Ringer’s are stable for up to 14 days refrigerated or at room temperature.579

Injection

5–25°C.579 Protect from light and excessive heat; do not freeze.579

Compatibility

For information on systemic interactions resulting from concomitant use, see Interactions.

Parenteral

Solution Compatibility755

Compatible

Dextrose 5% in sodium chloride 0.225 or 0.45%

Dextrose 5 or 10% in water

Ringer’s injection

Ringer’s injection, lactated

Sodium chloride 0.9%

Drug Compatibility
Admixture Compatibility755

Compatible

Amikacin sulfate

Atracurium besylate

Aztreonam

Cyclosporine

Dobutamine HCl

Dopamine HCl

Fluconazole

Gentamicin sulfate

Lidocaine HCl

Linezolid

Metronidazole

Midazolam HCl

Norepinephrine bitartrate

Pancuronium bromide

Potassium chloride

Ranitidine HCl

Tobramycin sulfate

Vecuronium bromide

Incompatible

Aminophylline

Amphotericin B

Ampicillin sodium and sulbactam sodium

Azithromycin

Cefuroxime sodium

Clindamycin phosphate

Fluorouracil

Heparin sodium

Potassium phosphates

Sodium bicarbonate

Variable

Ceftazidime

Ticarcillin disodium-clavulanate potassium

Y-Site Compatibility755

Compatible

Amifostine

Amino acids, dextrose

Amiodarone HCl

Anidulafungin

Aztreonam

Bivalirudin

Calcium gluconate

Caspofungin acetate

Ceftaroline fosamil

Ceftazidime

Cisatracurium besylate

Dexmedetomidine HCl

Digoxin

Diltiazem HCl

Dimenhydrinate

Diphenhydramine HCl

Dobutamine HCl

Docetaxel

Dopamine HCl

Doripenem

Doxorubicin HCl liposome injection

Etoposide phosphate

Fenoldopam mesylate

Gallium nitrate

Gemcitabine HCl

Gentamicin sulfate

Granisetron HCl

Hetastarch in lactated electrolyte injection (Hextend)

Hydroxyethyl starch 130/0.4 in sodium chloride 0.9%

Hydroxyzine HCl

Lidocaine HCl

Linezolid

Lorazepam

Metoclopramide HCl

Midazolam HCl

Potassium acetate

Potassium chloride

Promethazine HCl

Quinupristin-dalfopristin

Ranitidine HCl

Remifentanil HCl

Tacrolimus

Telavancin HCl

Teniposide

Thiotepa

Tigecycline

Tobramycin sulfate

Vasopressin

Verapamil HCl

Incompatible

Aminophylline

Ampicillin sodium and sulbactam sodium

Azithromycin

Dexamethasone sodium phosphate

Furosemide

Heparin sodium

Hydrocortisone sodium succinate

Methylprednisolone sodium succinate

Pemetrexed disodium

Phenytoin sodium

Sodium phosphates

Warfarin sodium

Variable

Magnesium sulfate

Sodium bicarbonate

Actions and Spectrum

  • Usually bactericidal.15 57 145 151 176 179 180 181 479 481 715

  • Like other fluoroquinolones, ciprofloxacin inhibits bacterial DNA gyrase and topoisomerase IV.47 145 147 149 154 167 180 181 467 479 481 497 519 722 723 724 725 726 715 835

  • Spectrum of activity includes many gram-positive aerobic bacteria, many gram-negative aerobic bacteria, a few anaerobic bacteria, and some other organisms (e.g., Chlamydia, Mycoplasma, Mycobacterium, Rickettsia).1 3 4 5 7 8 9 10 33 34 56 57 58 100 178 180 181 189 205 207 295 459 460 467 474 479 481 715 Inactive against fungi and viruses.153

  • Generally less active against gram-positive than gram-negative bacteria.56 57 58 178 180 181 189 207 479 481

  • Gram-positive aerobic cocci: Active in vitro and in clinical infections against S. aureus (oxacillin-susceptible [methicillin-susceptible] strains only),1 S. epidermidis (oxacillin-susceptible strains only), S. pneumoniae (penicillin-susceptible strains),1 S. pyogenes (group A β-hemolytic streptococci), S. saprophyticus, and Enterococcus faecalis.1 4 5 7 8 9 10 13 20 21 33 34 36 39 41 45 56 57 58 60 84 90 100 187 189 205 447 459 460 715 Also active in vitro against some other staphylococci (e.g., S. haemolyticus, S. hominis), some penicillin-resistant S. pneumoniae, viridans streptococci, groups C, F, and G streptococci, and nonenterococcal group D streptococci.1 3 4 5 7 8 9 10 13 18 20 33 34 39 41 45 46 57 58 60 80 84 90 94 96 100 187 189 205 447 459 460 563

  • Gram-positive aerobic bacilli: Active against Bacillus anthracis,1 686 692 712 Corynebacterium,9 10 33 36 74 102 213 460 and Listeria monocytogenes.5 9 10 33 34 41 56 60 100 213 447 459 460 Nocardia asteroides are resistant.10 108 213 447

  • Gram-negative aerobes: Active in vitro and in clinical infections against Campylobacter jejuni, H. influenzae, H. parainfluenzae, M. catarrhalis, Ps. aeruginosa, and most Enterobacteriaceae (including Citrobacter, Edwardsiella, Enterobacter, E. coli, Klebsiella, M. morganii, P. mirabilis, P. vulgaris, Providencia, Salmonella, Shigella, Serratia, Yersinia enterocolitica).1 4 8 19 20 21 26 33 34 37 39 45 46 56 58 64 100 104 187 189 205 213 447 459 460 620 715 Also active in vitro against Acinetobacter, Aeromonas, Brucella, Francisella tularensis, Legionella pneumophila, Vibrio, and Yersinia pestis.1 However, Burkholderia cepacia and Stenotrophomonas maltophilia are resistant.1

  • Other organisms: Active in vitro and in clinical infections against by C. pneumoniae,37 52 64 67 70 78 413 M. pneumoniae,78 M. tuberculosis,28 32 812 68 and other mycobacteria.1 2 28 32 68 106 180 181 205 518 554 607

  • N. gonorrhoeae with decreased susceptibility to ciprofloxacin and other fluoroquinolones (quinolone-resistant N. gonorrhoeae; QRNG) are widely disseminated worldwide, including in the US.319 632 634 635 637 638 639 754 837

  • Some cross-resistance occurs between ciprofloxacin and other fluoroquinolones.77 86 145 161 181 205 214 295 479 521 564 632 635 638

Advice to Patients

  • Advise patients that antibacterials (including ciprofloxacin) should only be used to treat bacterial infections and not used to treat viral infections (e.g., the common cold).1 579 715

  • Importance of completing full course of therapy, even if feeling better after a few days.1 579 715

  • Advise patients that skipping doses or not completing the full course of therapy may decrease effectiveness and increase the likelihood that bacteria will develop resistance and will not be treatable with ciprofloxacin or other antibacterials in the future.1 579 715

  • Importance of taking ciprofloxacin at least 2 hours before or 6 hours after multivitamins containing calcium, magnesium, or zinc; aluminum- or magnesium-containing antacids; or didanosine chewable/dispersible buffered tablets, buffered powder for oral solution, or pediatric powder for oral solution prepared as an admixture with antacid.1 579 715

  • May be taken without regard to meals, but do not take alone with dairy products (e.g., milk, yogurt) or calcium-fortified juices since absorption of the drug may be decreased.1 715

  • Importance of drinking sufficient quantities of fluids during therapy.1 579 715

  • Increased risk of tendinitis and tendon rupture in all age groups and further increased risk in adults >60 years of age, individuals receiving corticosteroids, and kidney, heart, or lung transplant recipients.1 579 715 851 852 Importance of resting and refraining from exercise at the first sign of tendinitis or tendon rupture (e.g., pain, swelling, or inflammation of a tendon, weakness or inability to use a joint) and discontinuing the drug and contacting a clinician regarding changing to an anti-infective that is not a fluoroquinolone.1 579 715 851 852 (See Tendinopathy and Tendon Rupture under Cautions.)

  • Advise patients that ciprofloxacin may worsen myasthenia gravis symptoms; importance of immediately contacting clinician if any worsening muscle weakness or breathing problems occur.1 579 715

  • Advise patients that seizures have been reported and to contact clinicians before taking ciprofloxacin if they have a history of seizures.1 579 715

  • Potential for ciprofloxacin to cause dizziness and lightheadedness; need for caution when operating machinery or driving a motor vehicle until effects of drug on individual are known.1 579 715

  • May be associated with hypersensitivity reactions (including anaphylactic reactions), even after a single dose.1 579 715 Importance of immediately discontinuing ciprofloxacin and informing clinician at first sign of rash, jaundice, or any other sign of hypersensitivity.1 579 715

  • Risk of photosensitivity/phototoxicity reactions following exposure to sun or UV light while receiving fluoroquinolones.1 579 715 Importance of avoiding or minimizing exposure to sunlight or artificial UV light (e.g., sunlamps, tanning beds, UVA/UVB treatment) and using protective measures (e.g., sunscreen, wearing a hat and clothing that covers the skin) if in sunlight during ciprofloxacin therapy.1 579 715 Discontinue ciprofloxacin and inform a clinician if a sunburn-like reaction or skin eruption occurs.1 579 715

  • Advise patients that peripheral neuropathies have been reported with ciprofloxacin and that symptoms may occur soon after initiation of the drug and may be irreversible.1 579 715 Importance of immediately discontinuing the drug and contacting clinician if symptoms of peripheral neuropathy (e.g., pain, burning, tingling, numbness, weakness) occur.1 579 715

  • Advise patients that diarrhea is a common problem caused by anti-infectives and usually ends when the drug is discontinued.1 579 715 Importance of contacting a clinician if watery and bloody stools (with or without stomach cramps and fever) occur during or as late as 2 months or longer after the last dose.1 579 715

  • Advise patients that regular consumption of large quantities of coffee, tea, or caffeine-containing soft drinks or drugs during treatment may result in exaggerated or prolonged caffeine effects.1 513 579 715

  • Importance of informing clinician of existing or contemplated concomitant therapy, including prescription and OTC drugs, and concomitant illnesses.1 579 715

  • If use in a pediatric patient <18 years of age is being considered, advise parents and caregivers that ciprofloxacin may be associated with an increased rate of adverse events involving joints and surrounding tissue structures (like tendons) in this age group.1 579 715 Importance of informing clinician prior to use of ciprofloxacin if the child has a history of joint-related problems and importance of notifying clinician if any joint-related problems occur during or following treatment with the drug.1 579 715

  • Importance of women informing clinicians if they are or plan to become pregnant or plan to breast-feed.1 579 715

  • Importance of advising patients of other important precautionary information.1 579 715 (See Cautions.)

Preparations

Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.

* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name

Ciprofloxacin

Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Oral

For suspension

250 mg/5 mL

Cipro

Bayer

500 mg/5 mL

Cipro

Bayer

Parenteral

For injection concentrate, for IV infusion

10 mg (of ciprofloxacin) per mL (200 or 400 mg)*

Cipro I.V.

Bayer

Ciprofloxacin I.V.

* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name

Ciprofloxacin and Ciprofloxacin Hydrochloride

Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Oral

Tablets, extended-release, film-coated

500 mg total ciprofloxacin (with ciprofloxacin 212.6 mg [of anhydrous ciprofloxacin] and ciprofloxacin hydrochloride 287.5 mg [of anhydrous ciprofloxacin])*

Cipro XR

Bayer

Ciprofloxacin Extended-release Tablets

1 g total ciprofloxacin (with ciprofloxacin 425.2 mg [of anhydrous ciprofloxacin] and ciprofloxacin hydrochloride 574.9 mg [of anhydrous ciprofloxacin])*

Cipro XR

Bayer

Ciprofloxacin Extended-release Tablets

* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name

Ciprofloxacin Hydrochloride

Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Oral

Tablets, film-coated

100 mg (of ciprofloxacin)*

Ciprofloxacin Tablets

250 mg (of ciprofloxacin)*

Cipro

Bayer

Ciprofloxacin Tablets

500 mg (of ciprofloxacin)*

Cipro

Bayer

Ciprofloxacin Tablets

750 mg (of ciprofloxacin)*

Ciprofloxacin Tablets

* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name

Ciprofloxacin in Dextrose

Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Parenteral

Injection, for IV infusion

2 mg (of ciprofloxacin) per mL (200 or 400 mg) in 5% dextrose*

Cipro I.V. in 5% Dextrose Injection (in flexible container)

Bayer

Ciprofloxacin Injection, for IV Infusion

Comparative Pricing

This pricing information is subject to change at the sole discretion of DS Pharmacy. This pricing information was updated 02/2014. Actual costs to patients will vary depending on the use of specific retail or mail-order locations and health insurance copays.

Cipro 500MG Tablets (BAYER HEALTHCARE PHARMA): 30/$177.09 or 90/$497.73

Ciprofloxacin HCl 500MG Tablets (WATSON LABS): 100/$39.00 or 300/$97.20

Ciprofloxacin HCl 750MG Tablets (DR.REDDY'S LABORATORIES): 30/$135.99 or 90/$395.97

Ciprofloxacin-Ciproflox HCl 1000MG 24-hr Tablets (MYLAN): 50/$465.99 or 150/$1,385.98

AHFS DI Essentials. © Copyright, 2004-2014, Selected Revisions January 7, 2014. American Society of Health-System Pharmacists, Inc., 7272 Wisconsin Avenue, Bethesda, Maryland 20814.

† Use is not currently included in the labeling approved by the US Food and Drug Administration.

References

1. Bayer HealthCare Pharmaceuticals Inc. Cipro (ciprofloxacin hydrochloride) tablets and Cipro (ciprofloxacin) oral suspension prescribing information. Wayne, NJ; 2013 Jul.

2. Young LS, Berlin OG, Inderlied CB. Activity of ciprofloxacin and other fluorinated quinolones against mycobacteria. Am J Med. 1987; 82(Suppl 4A):23-6. [IDIS 230493] [PubMed 3107379]

3. Van Caekenberghe DL, Pattyn SR. In vitro activity of ciprofloxacin compared with those of other new fluorinated piperazinyl-substituted quinoline derivatives. Antimicrob Agents Chemother. 1984; 25:518-21. [IDIS 223928] [PubMed 6732221]

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6. Stobberingh EE, Houben AW, Van Boven CP. In vitro evaluation of Ro 23-6240, a new fluorinated 4-quinolone. Chemotherapy. 1987; 33:197-203. [IDIS 230084] [PubMed 3109817]

7. Ligtvoet EE, Wickerhoff-Minoggio T. In-vitro activity of pefloxacin compared with six other quinolones. J Antimicrob Chemother. 1985; 16:485-90. [PubMed 3864776]

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9. Hirschhorn L, Neu HC. In vitro activity of two new aryl-fluoroquinolone antimicrobial agents, difloxacin (A-56619) and A-56620 compared to that of other antimicrobial agents. Chemotherapy. 1987; 33:28-39. [IDIS 226233] [PubMed 3549179]

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12. Hoepelman IM, Steyger G, Rozenberg-Arska M et al. Comparative in vitro antimicrobial activity of carumonam (Ro 17-2301) and its influence on the activity of other antibiotics. Chemotherapy. 1987; 33:103-9. [IDIS 227275] [PubMed 3568798]

13. Turgeon PL, Desrochers C, Mantha R. Comparative in vitro activity of fluoroquinolones and other parenteral antimicrobial agents against urinary bacterial isolates and oxacillin-resistant Staphylococcus aureus. Curr Ther Res Clin Exp. 1987; 41:670-8.

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17. Smith SM, Eng RH, Berman E. The effect of ciprofloxacin on methicillin-resistant Staphylococcus aureus. J Antimicrob Chemother. 1986; 17:287-95. [PubMed 2939049]

18. Kim MJ, Weiser M, Gottschall S et al. Identification of Streptococcus faecalis and Streptococcus faecium and susceptibility studies with newly developed antimicrobial agents. J Clin Microbiol. 1987; 25:787-90. [PubMed 3108309]

19. Kaukoranta-Tolvanen SS, Renkonen OV. In vitro susceptibility of Neisseria gonorrhoeae to RO 23-6240 and ciprofloxacin. Eur J Clin Microbiol. 1987; 6:315-7. [PubMed 3113941]

20. Weber AH, Scribner RK, Marks MI. In vitro activity of ciprofloxacin against pediatric pathogens. Chemotherapy. 1985; 31:456-65. [IDIS 211005] [PubMed 2934233]

21. Chau PY, Leung YK, NG WW. Comparative in vitro antibacterial activity of ofloxacin and ciprofloxacin against some selected gram-positive and gram-negative isolates. Infection. 1986; 14(Suppl 4):S237-9. [PubMed 3469153]

22. Smith SM, Eng RH. Activity of ciprofloxacin against methicillin-resistant Staphylococcus aureus. Antimicrob Agents Chemother. 1985; 688-91. (IDIS 200502)

23. Gombert ME, Aulicino TM. Susceptibility of multiply antibiotic-resistant pneumococci to the new quinoline antibiotics, nalidixic acid, coumermycin, and novobiocin. Antimicrob Agents Chemother. 1984; 26:933-4. [IDIS 223941] [PubMed 6570085]

25. Foster JK, Lentino JR, Strodtman R et al. Comparison of in vitro activity of quinolone antibiotics and vancomycin against gentamicin-and methicillin-resistant Staphylococcus aureus by time-kill kinetic studies. Antimicrob Agents Chemother. 1986; 30:823-7. [IDIS 224003] [PubMed 3643771]

26. Peeters M, Van Dyck E, Piot P. In vitro activities of the spectinomycin analog U-63366 and four quinolone derivatives against Neisseria gonorrhoeae. Antimicrob Agents Chemother. 1984; 26:608-9. [IDIS 193544] [PubMed 6240224]

27. Van der Auwera P, Klastersky J. Bactericidal activity and killing rate of serum in volunteers receiving ciprofloxacin alone or in combination with vancomycin. Antimicrob Agents Chemother. 1986; 30:892-5. [IDIS 224006] [PubMed 3813515]

28. Gay JD, DeYoung DR, Roberts GD. In vitro activities of norfloxacin and ciprofloxacin against Mycobacterium tuberculosis, M. avium complex, M. chelonei, M. fortuitum, and M. kansasii. Antimicrob Agents Chemother. 1984; 26:94-6. [IDIS 187632] [PubMed 6236748]

29. Goodman LJ, Fliegelman RM, Trenholme GM et al. Comparative in vitro activity of ciprofloxacin against Campylobacter spp. and other bacterial enteric pathogens. Antimicrob Agents Chemother. 1984; 25:504-6. [IDIS 184287] [PubMed 6732220]

31. Reinhardt JF, George WL. Comparative in vitro activities of selected antimicrobial agents against Aeromonas species and Plesiomonas shigelloides. Antimicrob Agents Chemother. 1985; 27:643-5. [IDIS 198591] [PubMed 4004196]

32. Fenlon CH, Cynamon MH. Comparative in vitro activities of ciprofloxacin and other 4-quinolones against Mycobacterium tuberculosis and Mycobacterium intracellulare. Antimicrob Agents Chemother. 1986; 29:386-8. [IDIS 211610] [PubMed 2940969]

33. Mandell W, Neu HC. In vitro activity of CI-934, a new quinolone, compared with that of other quinolones and other antimicrobial agents. Antimicrob Agents Chemother. 1986; 29:852-7. [PubMed 3729343]

34. Chin NX, Brittain DC, Neu HC. In vitro activity of Ro 23-6240, a new fluorinated 4-quinolone. Antimicrob Agents Chemother. 1986; 29:675-80. [IDIS 215029] [PubMed 3085584]

35. Hooper DC, Wolfson JS, Souza KS et al. Genetic and biochemical characterization of norfloxacin resistance in Escherichia coli. Antimicrob Agents Chemother. 1986; 29:639-44. [IDIS 215024] [PubMed 3010850]

36. Venezio FR, Tatarowicz W, DiVincenzo CA et al. Activity of ciprofloxacin against multiply resistant strains of Pseudomonas aeruginosa, Staphylococcus epidermidis, and group JK corynebacteria. Antimicrob Agents Chemother. 1986; 30:940-1. [IDIS 224011] [PubMed 3101589]

37. Liebowitz LD, Saunders J, Fehler G et al. In vitro activity of A-56619 (difloxacin), A-56620, and other new quinolone antimicrobial agents against genital pathogens. Antimicrob Agents Chemother. 1986; 30:948-50. [IDIS 224012] [PubMed 3101590]

39. Wise R, Andrews JM, Edwards LJ. In vitro activity of Bay 09867, a new quinoline derivative, compared with those of other antimicrobial agents. Antimicrob Agents Chemother. 1983; 23:559-64. [IDIS 170010] [PubMed 6222695]

40. Prabhala RH, Rao B, Marshall R et al. In vitro susceptibility of anaerobic bacteria to ciprofloxacin (Bay o 9867). Antimicrob Agents Chemother. 1984; 26:785-6. [IDIS 194091] [PubMed 6517561]

41. Fass RJ. In vitro activity of ciprofloxacin (Bay o 9867). Antimicrob Agents Chemother. 1983; 24:568-74. [IDIS 177504] [PubMed 6228192]

42. Van der Auwera P, Scorneaux B. In vitro susceptibility of Campylobacter jejuni to 27 antimicrobial agents and various combinations of β-lactams with clavulanic acid or sulbactam. Antimicrob Agents Chemother. 1985; 28:37-40. [IDIS 203395] [PubMed 2994557]

43. Fliegelman RM, Petrak RM, Goodman LJ et al. Comparative in vitro activities of twelve antimicrobial agents against Campylobacter species. Antimicrob Agents Chemother. 1985; 27:429-30. [IDIS 197551] [PubMed 3873216]

44. Sutter VL, Kwok YY, Bulkacz J. Comparative activity of ciprofloxacin against anaerobic bacteria. Antimicrob Agents Chemother. 1985; 27:427-8. [IDIS 197550] [PubMed 3158278]

45. Hirai K, Aoyama H, Hosaka M et al. In vitro and in vivo antibacterial activity of AM-833, a new quinolone derivative. Antimicrob Agents Chemother. 1986; 29:1059-66. [PubMed 2942103]

46. Barry AL, Thornsberry C, Jones RN. In vitro evaluation of A-56619 and A-56620, two new quinolones. Antimicrob Agents Chemother. 1986; 29:40-3. [IDIS 223866] [PubMed 2942099]

47. Benbrook DM, Miller RV. Effects of norfloxacin on DNA metabolism in Pseudomonas aeruginosa. Antimicrob Agents Chemother. 1986; 29:1-6. [IDIS 212932] [PubMed 3015000]

48. Bansal MB, Thadepalli H. Activity of difloxacin (A-56619) and A-56620 against clinical anaerobic bacteria in vitro. Antimicrob Agents Chemother. 1987; 31:619-21. [PubMed 3606066]

49. Delmee M, Avesani V. Comparative in vitro activity of seven quinolones against 100 clinical isolates of Clostridium difficile. Antimicrob Agents Chemother. 1986; 29:374-5. [IDIS 212800] [PubMed 2940968]

50. Smith SM. In vitro comparison of A-56619, A-56620, amifloxacin, ciprofloxacin, enoxacin, norfloxacin, and ofloxacin against methicillin-resistant Staphylococcus aureus. Antimicrob Agents Chemother. 1986; 29:325-6. [IDIS 212794] [PubMed 2940966]

51. Whiting JL, Cheng N, Chow AW. Interactions of ciprofloxacin with clindamycin, metronidazole, cefoxitin, cefotaxime, and mezlocillin against gram-positive and gram-negative anaerobic bacteria. Antimicrob Agents Chemother. 1987; 31:1379-82. [IDIS 236952] [PubMed 3674848]

52. Aznar J, Caballero MC, Loxano MC et al. Activities of new quinoline derivatives against genital pathogens. Antimicrob Agents Chemother. 1985; 27:76-8. [IDIS 195272] [PubMed 3920959]

53. Goossens H, De Mol P, Coignau H et al. Comparative in vitro activities of aztreonam, ciprofloxacin, norfloxacin, ofloxacin, HR 810 (a new cephalosporin), RU28965 (a new macrolide), and other agents against enteropathogens. Antimicrob Agents Chemother. 1985; 27:388-92. [PubMed 3158276]

54. Goldstein EJ, Citron DM. Comparative activity of the quinolones against anaerobic bacteria isolated at community hospitals. Antimicrob Agents Chemother. 1985; 27:657-9. [IDIS 198595] [PubMed 3847273]

55. Reinhardt JF, Fowlston S, Jones J et al. Comparative in vitro activities of selected antimicrobial agents against Edwardsiella tarda. Antimicrob Agents Chemother. 1985; 27:966-7. [IDIS 201053] [PubMed 4026271]

56. Chin NX, Neu HC. Ciprofloxacin, a quinolone carboxylic acid compound active against aerobic and anaerobic bacteria. Antimicrob Agents Chemother. 1984; 25:319-26. [IDIS 183087] [PubMed 6232895]

57. Eliopoulos GM, Gardella A, Moellering RC. In vitro activity of ciprofloxacin, a new carboxyquinoline antimicrobial agent. Antimicrob Agents Chemother. 1984; 25:331-5. [IDIS 183089] [PubMed 6721464]

58. Barry AL, Jones RN, Thornsberry C et al. Antibacterial activities of ciprofloxacin, norfloxacin, oxolinic acid, cinoxacin, and nalidixic acid. Antimicrob Agents Chemother. 1984; 25:633-7. [IDIS 185381] [PubMed 6233935]

59. Zeiler HJ. Evaluation of the in vitro bactericidal action of ciprofloxacin on cells of Escherichia coli in the logarithmic and stationary phases of growth. Antimicrob Agents Chemother. 1985; 28:524-7. [IDIS 207609] [PubMed 2934022]

60. Eliopoulos GM, Moellering AE, Reiszner E et al. In vitro activities of the quinolone antimicrobial agents A-56629 and A-56620. Antimicrob Agents Chemother. 1985; 28:514-20. [IDIS 207607] [PubMed 3935046]

61. Sanders CC, Sanders WE, Goering RV et al. Selection of multiple antibiotic resistance by quinolones, β-lactams, and aminoglycosides with special reference to cross-resistance between unrelated drug classes. Antimicrob Agents Chemother. 1984; 26:797-801. [IDIS 194031] [PubMed 6098219]

62. Stamm JM, Hanson CW, Chu DT et al. In vitro evaluation of A-56619 (difloxacin) and A-56620: new aryl-fluoroquinolones. Antimicrob Agents Chemother. 1986; 29:193-200. [IDIS 223871] [PubMed 3087274]

63. Gaya H, Chadwick MV. In vitro activity of ciprofloxacin against mycobacteria. Eur J Clin Microbiol. 1985; 4:345-7. [PubMed 3160585]

64. Tjiam KH, Wagenvoort JH, van Klingeren B et al. In vitro activity of the two new 4-quinolones A56619 and A56620 against Neisseria gonorrhoeae, Chlamydia trachomatis, Mycoplasma hominis, Ureaplasma urealyticum and Gardnerella vaginalis. Eur J Clin Microbiol. 1986; 5:498-501. [PubMed 3096726]

66. Clabots CR, Shanholtzer CJ, Peterson LR et al. In vitro activity of efrotomycin, ciprofloxacin, and six other antimicrobials against Clostridium difficile. Diagn Microbiol Infect Dis. 1987; 6:49-52. [PubMed 3802745]

67. How SJ, Hobson D, Hart A et al. An in-vitro investigation of synergy and antagonism between antimicrobials against Chlamydia trachomatis. J Antimicrob Chemother. 1985; 15:533-8. [PubMed 4008386]

68. Marinis E, Legakis NJ. In-vitro activity of ciprofloxacin against clinical isolates of mycobacteria resistant to antimycobacterial drugs. J Antimicrob Chemother. 1985; 16:527-30. [PubMed 2933382]

69. Rosenfeld M, Spannuth G, Wempe E et al. In vitro activity of the new quinoline derivative ciprofloxacin alone and in combination against various Mycobacterium, Salmonella and Escherichia coli strains. Arzneimittelforschung. 1986; 36:904-12. [PubMed 2943293]

70. Meier-Ewert H, Wil G, Millott G. In vitro activity of ciprofloxacin against clinical isolates of Chlamydia trachomatis. Eur J Clin Microbiol. 1984; 3:372. [PubMed 6593220]

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333. Koboyashi H. Clinical efficacy of ciprofloxacin in the treatment of patients with respiratory tract infections in Japan. Am J Med. 1987; 82(Suppl 4A):169-73.

334. Ramirez-Ronda CH, Saavedra S, Rivera-Vazquez CR. Comparative, double-blind study of oral ciprofloxacin and intravenous cefotaxime in skin and skin structure infections. Am J Med. 1987; 82(Suppl 4A):220-3. [IDIS 230523] [PubMed 3555040]

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338. Ryan JL, Berenson CS, Greco TP et al. Oral ciprofloxacin in resistant urinary tract infections. Am J Med. 1987; 82(Suppl 4A):303-6. [IDIS 230544] [PubMed 3555052]

339. Preheim LC, Cuevas TA, Roccaforte JS et al. Oral ciprofloxacin in the treatment of elderly patients with complicated urinary tract infections due to trimethoprim/sulfamethoxazole-resistant bacteria. Am J Med. 1987; 82(Suppl 4A):295-300. [IDIS 230542] [PubMed 3555051]

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341. Cox C. Brief report: ciprofloxacin in the treatment of urinary tract infections caused by Pseudomonas species and organisms resistant to trimethoprim/sulfamethoxazole. Am J Med. 1987; 82(Suppl 4A):288-9.

342. Goldstein EJ, Kahn RM, Alpert ML et al. Ciprofloxacin versus cinoxacin in therapy of urinary tract infections: a randomized, double-blind trial. Am J Med. 1987; 82(Suppl 4A):284-7. [IDIS 230539] [PubMed 3555049]

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344. Gasser TC, Graversen PH, Madsen PO. Treatment of complicated urinary tract infections with ciprofloxacin. Am J Med. 1987; 82(Suppl 4A):278-9.

345. Esposito S, Galante D, Bianchi W et al. Efficacy and safety of oral ciprofloxacin in the treatment of respiratory tract infections associated with chronic hepatitis. Am J Med. 1987; 82(Suppl 4A):211-4. [IDIS 230521] [PubMed 3555038]

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347. Bantz PM, Grote J, Peters-Haertel W et al. Low-dose ciprofloxacin in respiratory tract infections: a randomized comparison with doxycycline in general practice. Am J Med. 1987; 82(Suppl 4A):208-10.

348. Scully BE, Jules K, Chin N et al. Effect of ciprofloxacin on fecal flora of patients with cystic fibrosis and other patients treated with oral ciprofloxacin. Am J Med. 1987; 82(Suppl 4A):336-8. [IDIS 230551] [PubMed 3578324]

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358. Davies BI, Maesen FP. Quinolones in chest infections. J Antimicrob Chemother. 1986; 18:296-9. [PubMed 3533884]

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360. Miller MR, Bransby-Zachary MA, Tompkins DS et al. Ciprofloxacin for Pseudomonas aeruginosa meningitis. Lancet. 1986; 1:1325. [IDIS 216933] [PubMed 2872448]

361. Lode H, Wiley R, Hoffken G et al. Prospective randomized controlled study of ciprofloxacin versus imipenem-cilastatin in severe clinical infections. Antimicrob Agents Chemother. 1987; 31:1491-6. [IDIS 234997] [PubMed 3324956]

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365. Nix DE, Cumbo TJ, Kuritzky P et al. Oral ciprofloxacin in the treatment of serious soft tissue and bone infections: efficacy, safety, and pharmacokinetics. Am J Med. 1987; 82(Suppl 4A):146-53. [IDIS 230510] [PubMed 3555029]

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