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ciprofloxacin
generic
Black Box Warnings .
Disabling, Potentially Irreversible Serious Reactions
fluoroquinolones assoc. with tendinitis/tendon rupture, peripheral neuropathy, and CNS effects that may occur together; tendinitis/tendon rupture may occur during tx or months after tx D/C; incr. tendinitis/tendon rupture risk in all ages; risk further incr. in older pts >60 yo, pts taking corticosteroids, and pts w/ kidney, heart, or lung transplant; D/C immediately and avoid fluoroquinolone use in pts w/ these serious reactions
Avoid in Myasthenia Gravis
fluoroquinolones may exacerbate muscle weakness in pts w/ myasthenia gravis
Reserve Fluoroquinolone Use
for pts w/ no alternative tx options for acute bacterial sinusitis, acute bacterial exacerbation of chronic bronchitis, or uncomplicated UTI
Adult Dosing .
Dosage forms: TAB: 100 mg, 250 mg, 500 mg, 750 mg; ER TAB: 500 mg, 1000 mg; SUSP: 250 mg per 5 mL, 500 mg per 5 mL; INJ: various
infections, bacterial
- [PO route]
- Dose: 250-750 mg PO q12h; Info: dose, duration varies w/ infection type, severity
- [IV route]
- Dose: 200-400 mg IV q12h; Alt: 400 mg IV q8h for severe/complicated infection; Info: dose, duration varies w/ infection type, severity
UTI
- [uncomplicated cystitis]
- Dose: 500 mg ER PO q24h x3 days; Alt: 250 mg PO q12h x3 days; Info: for pts w/ no alternative tx options; refer to IDSA guidelines; do not cut/crush/chew ER tab
- [uncomplicated pyelonephritis]
- Dose: 1000 mg ER PO q24h x7 days; Alt: 500 mg PO q12h x7 days; 400 mg IV x1, then 500 mg PO q12h x7 days total; 400 mg IV q12h x7 days; Info: may give w/ ceftriaxone or gentamicin; refer to IDSA guidelines; do not cut/crush/chew ER tab
- [complicated]
- Dose: 1000 mg ER PO q24h x7-14 days; Alt: 500 mg PO q12h x7-14 days; 400 mg IV q12h x7-14 days; Info: do not cut/crush/chew ER tab
intra-abdominal infections, complicated
- [500 mg PO q12h x7-14 days]
- Alt: 400 mg IV q12h x7-14 days; Info: part of multi-drug regimen
bone/joint infections
- [500-750 mg PO q12h x4-8wk]
- Alt: 400 mg IV q8-12h x4-8wk
prostatitis, chronic bacterial
- [500 mg PO q12h x28 days]
pneumonia, hospital-acquired or ventilator-assoc.
- [400 mg IV q8h x7 days]
- Info: may extend duration based on clinical response; refer to IDSA guidelines
anthrax
- [systemic]
- Dose: 400 mg IV q8h for at least 2wk; Info: 1st-line agent; part of multi-drug regimen; may use as 1st-line agent in pregnant women; switch to PO abx for post-exposure prophylaxis if inhalational exposure
- [cutaneous]
- Dose: 500 mg PO q12h x7-10 days; Info: for non-systemic infection; 1st-line agent; may use as 1st-line agent in pregnant women; use extended duration for post-exposure prophylaxis if bioterrorism suspected
- [post-exposure prophylaxis]
- Dose: 500 mg PO q12h x60 days; Info: 1st-line agent; give in combo w/ anthrax vaccine; may use as 1st-line agent in pregnant women; may give x42 days or x14 days after last vaccine dose in immunocompetent pts 18-65 yo if anthrax vaccine regimen completed
typhoid fever
- [500 mg PO q12h x2wk]
plague
- [500-750 mg PO q12h x2wk]
- Info: for prophylaxis and tx
chancroid (off-label)
- [500 mg PO q12h x3 days]
salmonellosis, acute (off-label)
- [500-750 mg PO q12h x3-7 days]
- Info: may extend tx x1wk if immunocompromised
salmonella, chronic carrier (off-label)
- [750 mg PO q12h x1mo]
shigellosis, severe (off-label)
- [500-750 mg PO q12h]
- Info: duration varies w/ infection severity; refer to CDC guidance
febrile neutropenia, chemo-induced (off-label)
- [500-750 mg PO q12h]
- Info: for empiric tx in low-risk pts not on fluoroquinolone prophylaxis; give w/ amoxicillin/clavulanate
meningococcal prophylaxis (off-label)
- [20 mg/kg/dose PO x1]
- Max: 500 mg; Info: for close contacts of pts w/ invasive meningococcal dz
infection prophylaxis, surgical (off-label)
- [400 mg IV x1]
- Start: w/in 120min preop
endocarditis (off-label)
- [400 mg IV q12h]
- Info: not 1st-line tx; dose, frequency, duration vary w/ pathogen susceptibility, infection severity, valve type; refer to AHA guidelines
renal dosing
- [PO route, IR form]
- CrCl 30-50: 250-500 mg PO q12h; CrCl <30: 250-500 mg PO q24h; Info: may give 750 mg/dose if serious infection w/ severe renal impairment
- HD: 250-500 mg PO q24h, on dialysis days admin. after dialysis; no supplement; PD: 250-500 mg PO q24h; no supplement; Info: may give 750 mg/dose if serious infection
- [PO route, ER form, uncomplicated cystitis]
- renal impairment: no adjustment
- HD/PD: no adjustment; no supplement
- [PO route, ER form, complicated UTI or uncomplicated pyelonephritis]
- CrCl <30: 500 mg PO q24h; Info: do not use 1000 mg ER tab for CrCl <30
- HD: max 500 mg PO q24h, on dialysis days admin. after dialysis; no supplement; PD: max 500 mg PO q24h; no supplement; Info: do not use 1000 mg ER tab
- [IV route]
- CrCl <30: 400 mg IV q24h
- HD: 200-400 mg IV q24h, on dialysis days admin. after dialysis; no supplement; PD: 200-400 mg IV q24h; no supplement
hepatic dosing
- [see below]
- hepatic impairment: not defined, caution advised
Peds Dosing .
- Dosage forms: TAB: 100 mg, 250 mg, 500 mg, 750 mg; SUSP: 250 mg per 5 mL, 500 mg per 5 mL; INJ: various
UTI
- [1-17 yo]
- Dose: 18-30 mg/kg/day IV divided q8h x10-21 days; Max: 400 mg/dose IV; 750 mg/dose PO; Alt: 20-40 mg/kg/day PO divided q12h; Info: for complicated UTI or pyelonephritis; not 1st-line agent
anthrax, systemic
- [neonates >32 wk gestation]
- Dose: 20-30 mg/kg/day IV divided q12h for at least 2wk; Info: 1st-line agent; part of multi-drug regimen; dose depends on gestational and post-natal age; switch to PO abx x60 days total if inhalational exposure
- [1 mo and older]
- Dose: 30 mg/kg/day IV divided q8h for at least 2wk; Max: 400 mg/dose; Info: 1st-line agent; part of multi-drug regimen; switch to PO abx x60 days total if inhalational exposure
anthrax, cutaneous
- [neonates >32 wk gestation]
- Dose: 20-30 mg/kg/day PO divided q12h x7-10 days; Info: for non-systemic infection; 1st-line agent; dose depends on gestational and post-natal age; give abx x60 days total if bioterrorism suspected
- [1 mo and older]
- Dose: 30 mg/kg/day PO divided q12h x7-10 days; Max: 500 mg/dose; Info: for non-systemic infection; 1st-line agent; give abx x60 days total if bioterrorism suspected
anthrax, post-exposure prophylaxis
- [neonates >32 wk gestation]
- Dose: 20-30 mg/kg/day PO divided q12h x60 days; Info: 1st-line agent; dose depends on gestational and post-natal age
- [1 mo and older]
- Dose: 30 mg/kg/day PO divided q12h x60 days; Max: 500 mg/dose; Info: 1st-line agent
plague
- [15 mg/kg/dose PO q8-12h x10-21 days]
- Max: 500 mg/dose; Info: for prophylaxis and tx
infections, bacterial (off-label)
- [20-30 mg/kg/day PO divided q12h]
- Alt: 15-30 mg/kg/day IV divided q8-12h; Max: 750 mg/dose PO; 400 mg/dose IV
resp. infections, cystic fibrosis pts (off-label)
- [40 mg/kg/day PO divided q12h]
- Alt: 30 mg/kg/day IV divided q8h; Max: 750 mg/dose PO; 400 mg/dose IV
community-acquired pneumonia, mod-severe bacterial (off-label)
- [>3 mo]
- Dose: 30 mg/kg/day IV divided q12h x10 days; Info: may switch to PO regimen when possible to complete course
salmonellosis, acute (off-label)
- [20-30 mg/kg/day PO divided q12h x3-7 days]
- Max: 750 mg/dose; Info: may extend tx x1wk if immunocompromised
salmonella, chronic carrier (off-label)
- [20-30 mg/kg/day PO divided q12h x1mo]
- Max: 750 mg/dose
shigellosis, severe (off-label)
- [1 mo and older]
- Dose: 30 mg/kg/day PO divided q12h; Max: 500 mg/dose; Info: duration varies w/ infection severity; refer to CDC guidance
typhoid fever (off-label)
- [30 mg/kg/day PO/IV divided q12h x1-2wk]
- Max: 500 mg/dose
chancroid (off-label)
- [preadolescents >45 kg and adolescents]
- Dose: 500 mg PO q12h x3 days
febrile neutropenia, chemo-induced (off-label)
- [20-40 mg/kg/day PO divided q12h]
- Max: 750 mg/dose; Info: for empiric tx in low-risk pts not on fluoroquinolone prophylaxis; give w/ amoxicillin/clavulanate
meningococcal prophylaxis (off-label)
- [1 mo and older]
- Dose: 20 mg/kg/dose PO x1; Max: 500 mg; Info: for close contacts of pts w/ invasive meningococcal dz
infection prophylaxis, surgical (off-label)
- [1 yo and older]
- Dose: 10 mg/kg/dose IV x1; Start: w/in 120min preop; Max: 400 mg/dose
renal dosing
- [adjust dose frequency]
- CrCl 10-29: give usual divided dose q18h; CrCl <10: give usual divided dose q24h
- HD: give usual divided dose q24h, on dialysis days admin. after dialysis; no supplement; PD: give usual divided dose q24h; no supplement
hepatic dosing
- [see below]
- hepatic impairment: not defined, caution advised
Contraindications / Cautions .
- hypersensitivity to drug or ingredient
- pregnancy (meningococcal prophylaxis use)
- pts >60 yo
- myasthenia gravis
- aortic aneurysm hx
- aortic aneurysm risk
- Marfan syndrome
- Ehlers-Danlos syndrome
- avoid: breastfeeding x3-4h after dose (anthrax use)
- avoid: breastfeeding during tx and x2 days after D/C (except anthrax use)
- avoid: sun exposure
- avoid: UV light exposure, artificial
- caution: QT prolongation
- caution: long QT syndrome, congenital
- caution: QT prolongation family hx
- caution: torsades de pointes hx
- caution: ventricular arrhythmia
- caution: bradycardia
- caution: MI, recent
- caution: CHF
- caution: electrolyte abnormalities
- caution: G6PD deficiency
- caution: tendon disorder hx
- caution: kidney transplant
- caution: heart transplant
- caution: lung transplant
- caution: peripheral neuropathy
- caution: peripheral neuropathy hx
- caution: renal impairment
- caution: hepatic impairment
- caution: seizure disorder
- caution: seizure threshold, lowered
- caution: CNS disorder
- caution: dehydration
- caution: diabetes mellitus
- caution: abx-associated colitis hx, recent
- caution: depression
- caution: depression hx
Drug Interactions .
Overview
ciprofloxacin
fluoroquinolone
- OAT1 substrate
- OAT3 substrate
- CYP1A2 inhibitor, strong
- CYP3A4 inhibitor, moderate
- affected by altered gastrointestinal motility
- alters GI flora
- binds to anion exchange resin/polymer
- binds to cation exchange resin/polymer
- binds to polyvalent cations
- hyperglycemic effects
- hypoglycemic effects
- impairs immunomodulatory bacterial infective agent
- lowers seizure threshold
- peripheral neuropathy
- photosensitivity
- prolongs QT interval (conditional)
- pseudotumor cerebri
- urine pH sensitive
Contraindicated
- cisapride
- eliglustat
- fezolinetant
- flibanserin
- lomitapide
- pimozide
- thioridazine
- tizanidine
Avoid/Use Alternative
- aldesleukin
- alfentanil
- alosetron
- alprazolam
- amifampridine
- aminolevulinic acid topical
- aminophylline
- amiodarone
- aprepitant
- arsenic trioxide
- artemether/lumefantrine
- asenapine
- avapritinib
- azithromycin
- BCG live intravesical
- bedaquiline
- bendamustine
- bosentan
- bosutinib
- bremelanotide
- brigatinib
- buspirone
- cholera vaccine, live
- clarithromycin
- cobimetinib
- codeine
- colchicine
- conivaptan
- crizotinib
- dihydrocodeine
- dihydroergotamine
- disopyramide
- dofetilide
- domperidone
- doxorubicin
- dronedarone
- duloxetine
- elacestrant
- encorafenib
- entrectinib
- ephedra
- ergotamine
- erlotinib
- erythromycin
- etrasimod
- fecal microbiota, live
- fentanyl
- fexinidazole
- fosaprepitant
- haloperidol
- hydrocodone
- hydroxychloroquine
- ibutilide
- infigratinib
- iohexol
- ivabradine
- ivosidenib
- ixabepilone
- lefamulin
- lemborexant
- levoketoconazole
- lonafarnib
- lovastatin
- lurbinectedin
- macitentan
- meperidine
- methadone
- methotrexate
- methylergonovine
- midazolam
- mobocertinib
- naloxegol
- neratinib
- nilotinib
- nirogacestat
- nisoldipine
- olaparib
- oliceridine
- omaveloxolone
- oxycodone
- pacritinib
- paliperidone
- palovarotene
- pemigatinib
- pexidartinib
- pirfenidone
- pomalidomide
- porfimer
- pralsetinib
- procainamide
- propafenone
- quinidine (antiarrhythmic)
- quizartinib
- repotrectinib
- rifabutin
- rivaroxaban
- selpercatinib
- selumetinib
- simvastatin
- siponimod
- sonidegib
- sotalol
- sufentanil
- tasimelteon
- tazemetostat
- theophylline
- tolvaptan
- toremifene
- tramadol
- triazolam
- typhoid vaccine, live
- vandetanib
- vardenafil
- venetoclax
- ziprasidone
- zolpidem
Monitor/Modify Tx
- abemaciclib
- acalabrutinib
- acarbose
- adagrasib
- alfuzosin
- alogliptin
- aluminum hydroxide
- anagrelide
- apalutamide
- apixaban
- apomorphine
- aripiprazole
- aripiprazole bimonthly injection
- atorvastatin
- avanafil
- avatrombopag
- axitinib
- bempedoic acid
- bexagliflozin
- brexpiprazole
- bromocriptine
- budesonide
- bupropion
- butorphanol
- cabotegravir
- cabozantinib
- caffeine citrate
- calcium acetate
- calcium carbonate
- calcium citrate
- calcium gluconate
- canagliflozin
- capivasertib
- carbamazepine
- ceritinib
- chloroquine
- chlorpromazine
- chromium
- cilostazol
- citalopram
- clofazimine
- clomipramine
- clonazepam
- clozapine
- colesevelam
- cyclosporine
- dapagliflozin
- daridorexant
- dasatinib
- deflazacort
- degarelix
- demeclocycline
- desflurane
- desipramine
- dexmedetomidine
- dexmedetomidine injection
- dichlorphenamide
- docetaxel
- donepezil
- doxycycline
- droperidol
- dulaglutide
- empagliflozin
- epirubicin
- eplerenone
- eravacycline
- erdafitinib
- eribulin
- ertugliflozin
- estazolam
- everolimus
- exenatide
- fedratinib
- felodipine
- fenfluramine
- ferric citrate
- ferric maltol
- ferrous fumarate
- ferrous gluconate
- ferrous sulfate
- finerenone
- flecainide
- fluorouracil
- fosphenytoin
- futibatinib
- gemfibrozil
- gepirone
- gilteritinib
- glasdegib
- glimepiride
- glipizide
- glyburide
- goserelin
- guanfacine
- histrelin
- hydrocortisone
- hydroxyzine
- ibrutinib
- iloperidone
- imipramine
- inotuzumab ozogamicin
- insulin
- iopamidol
- irinotecan
- isoflurane
- itraconazole
- lanthanum
- lapatinib
- leflunomide
- leuprolide
- lidocaine
- linagliptin
- liraglutide
- lofexidine
- lorlatinib
- lumateperone
- lurasidone
- macimorelin
- magnesium carbonate
- magnesium citrate
- magnesium hydroxide
- magnesium oxide
- magnesium supplement
- mavacamten
- mavorixafor
- mefloquine
- meropenem
- metformin
- mexiletine
- midostaurin
- minocycline
- mirtazapine
- mitapivat
- molindone
- nateglinide
- nifedipine
- nimodipine
- nitisinone
- nortriptyline
- olanzapine
- omadacycline
- ondansetron
- osilodrostat
- osimertinib
- palbociclib
- palonosetron
- panobinostat
- pasireotide
- patiromer
- pazopanib
- pentamidine
- phenytoin
- pimavanserin
- pioglitazone
- pirtobrutinib
- ponatinib
- pramlintide
- pretomanid
- probenecid
- propranolol
- quetiapine
- quinapril
- quinidine (CYP2D6 inhibitor)
- quinine
- ranolazine
- rasagiline
- red yeast rice
- repaglinide
- ribociclib
- rimegepant
- riociguat
- romidepsin
- ropinirole
- rosiglitazone
- rucaparib
- ruxolitinib
- ruxolitinib topical
- saquinavir
- sarecycline
- saxagliptin
- semaglutide
- sertraline
- sevelamer
- sevoflurane
- sirolimus
- sirolimus albumin-bound
- sitagliptin
- sodium phenylbutyrate/taurursodiol
- sparsentan
- sucralfate
- sulfate bowel prep
- sunitinib
- suvorexant
- tacrolimus
- tadalafil
- telavancin
- temsirolimus
- teriflunomide
- tetrabenazine
- tetracycline
- tigecycline
- tirzepatide
- tofacitinib
- trabectedin
- trazodone
- triclabendazole
- trifluridine
- trimethoprim
- triptorelin
- ubrogepant
- vaborbactam
- vemurafenib
- vinblastine
- vincristine
- vinorelbine
- voclosporin
- warfarin
- zanubrutinib
- zinc oral
Caution Advised
- acetazolamide
- acitretin
- aliskiren
- avacopan
- betamethasone
- brivaracetam
- budesonide rectal
- busulfan
- caffeine
- cannabidiol
- cenobamate
- chlorambucil
- clobazam
- clorazepate
- copanlisib
- cortisone
- cyclophosphamide
- darifenacin
- dexamethasone
- diazepam
- diclofenac
- diclofenac topical
- diflunisal
- duvelisib
- eletriptan
- eslicarbazepine acetate
- ethosuximide
- etodolac
- felbamate
- fenoprofen
- flurbiprofen
- gabapentin
- ganaxolone
- grazoprevir
- ibuprofen
- ibuprofen lysine
- ifosfamide
- indomethacin
- isavuconazonium
- istradefylline
- ketoprofen
- ketorolac
- lacosamide
- lactulose
- lamotrigine
- larotrectinib
- levetiracetam
- lindane topical
- lorazepam
- maraviroc
- meclofenamate
- mefenamic acid
- melatonin
- meloxicam
- methazolamide
- methoxsalen
- methsuximide
- methylprednisolone
- mifepristone
- mycophenolate mofetil
- mycophenolic acid
- nabumetone
- naldemedine
- naproxen
- oxaprozin
- oxcarbazepine
- pentoxifylline
- perampanel
- phenobarbital
- piroxicam
- polyethylene glycol
- polyethylene glycol/electrolytes
- potassium citrate
- prednisolone
- prednisone
- pregabalin
- primidone
- promethazine
- ramelteon
- riluzole
- roflumilast
- roflumilast topical
- ropivacaine
- rufinamide
- sildenafil
- silodosin
- sirolimus topical
- sodium bicarbonate
- sodium citrate
- sodium phosphate (bowel prep)
- sodium picosulfate
- stiripentol
- sulindac
- tamsulosin
- tiagabine
- ticagrelor
- tolmetin
- topiramate
- tretinoin
- triamcinolone
- valproic acid
- verapamil
- verteporfin
- vigabatrin
- vilazodone
- zolmitriptan
- zonisamide
Adverse Reactions .
Serious Reactions
- hypersensitivity rxn
- anaphylaxis
- skin rxn, severe
- vasculitis
- pneumonitis, hypersensitivity
- serum sickness
- phototoxicity
- C. difficile-assoc. diarrhea
- superinfection
- seizures
- ICP incr.
- toxic psychosis
- depression
- suicidality
- QT prolongation
- torsades de pointes
- nephrotoxicity
- crystalluria
- hepatotoxicity
- myelosuppression
- blood dyscrasias
- peripheral neuropathy
- tendon rupture
- arthropathy (animal studies)
- myasthenia gravis exacerbation
- hypoglycemia, severe
- aortic aneurysm
- aortic dissection
Common Reactions
- nausea
- diarrhea
- vomiting
- abdominal pain
- headache
- dyspepsia
- dizziness
- restlessness
- lightheadedness
- vaginitis
- insomnia
- photosensitivity
- pruritus
- rash
- anxiety
- agitation
- confusion
- tendinitis
- arthralgia
- LFTs elevated
- myalgia
- disorientation
- attention disturbance
- nervousness
- impaired memory
- delirium
- paranoia
- hallucinations
- nightmares
- tremor
- hyperglycemia
Safety/Monitoring .
Monitoring Parameters
Cr at baseline, then if elderly or prolonged tx cont. periodically; CBC, LFTs if prolonged tx
Look/Sound-Alike Drug Names
ciprofloxacin confused with: cephalexin; gatifloxacin; levoFLOXacin; moxifloxacin; ofloxacin
Pregnancy/Lactation .
Pregnancy
Clinical Summary
avoid use during pregnancy if meningococcal prophylaxis use, otherwise weigh risk/benefit; no known risk of teratogenicity based on human and animal data; possible risk of spontaneous abortion based on conflicting human data; risk of bone/cartilage damage based on animal data
Lactation
Clinical Summary
avoid breastfeeding x3-4h after dose if anthrax use, otherwise avoid breastfeeding during tx and x2 days after D/C; inadequate human data available, though possible risk of infant C. difficile-assoc. diarrhea; no human data available to assess effects on milk production
Pharmacology .
Metabolism: liver partially; CYP450: 1A2 (strong), 3A4 (moderate) inhibitor; Info: active metabolites
Excretion: urine (40-50% unchanged), feces 20-35%; Half-life: 4h
Subclass: Anthrax ; Fluoroquinolones
Mechanism of Action
inhibits DNA gyrase and topoisomerase IV
Formulary .
No Formulary Selected
Manufacturer/Pricing .
Manufacturer: generic
DEA/FDA: Rx
Approximate Retail Price
from http://www.goodrx.com/ciprofloxacin
oral tablet:
- 250 mg (14 ea): $10.00
- 500 mg (14 ea): $8.00
- 750 mg (20 ea): $17.00
oral tablet:
- 100 mg (1 dose pack, 6 tablets): $65.00
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