Ciprofloxacin (Monograph)

Brand name: Cipro
Drug 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

Medically reviewed by Drugs.com on Apr 10, 2024. Written by ASHP.

Warning

Fluoroquinolones, including ciprofloxacin, have been associated with disabling and potentially irreversible serious adverse reactions (e.g., tendinitis and tendon rupture, peripheral neuropathy, CNS effects) that have occurred together.¹ ⁵⁷⁹ ⁸⁵⁶ Discontinue immediately and avoid use of fluoroquinolones, including ciprofloxacin, in patients who have experienced any of these serious adverse reactions.¹ ⁵⁷⁹ ⁸⁵⁶ (See Warnings under Cautions.)
Fluoroquinolones, including ciprofloxacin, may exacerbate muscle weakness in patients with myasthenia gravis.¹ ⁵⁷⁹ ⁸⁵⁶ Avoid in patients with known history of myasthenia gravis.¹ ⁵⁷⁹ ⁸⁵⁶
Because of risk of serious adverse reactions, use ciprofloxacin for treatment of acute bacterial sinusitis, acute bacterial exacerbations of chronic bronchitis, or uncomplicated urinary tract infections (UTIs) only when no other treatment options available.¹ ⁵⁷⁹ ⁸⁵⁶

Introduction

Antibacterial; fluoroquinolone.¹ ¹⁸¹ ²⁰⁵ ²⁰⁶ ⁴⁷⁹ ⁴⁸¹ ⁵⁷⁹ ⁸⁵⁶

Uses for Ciprofloxacin

Bone and Joint Infections

Treatment of bone and joint infections (including osteomyelitis)²⁰⁵ ²⁹⁶ ³²⁶ ³⁶² ³⁶⁵ ³⁶⁷ ³⁶⁸ ³⁶⁹ ³⁷⁰ ³⁷¹ ³⁷⁵ ⁴⁷⁹ ⁵³⁵ ⁵⁹⁰ ⁵⁹¹ ⁷⁰⁶ caused by susceptible Pseudomonas aeruginosa,¹ ²⁰⁵ ²⁹⁶ ³⁰⁰ ³²⁶ ³⁵⁹ ³⁶² ³⁶⁸ ³⁶⁹ ³⁷⁰ ³⁷¹ ³⁸⁰ ⁴³³ ⁴⁷⁹ ⁵³⁵ ⁵⁷⁹ Enterobacter cloacae,¹ ³⁶² ³⁶⁹ ³⁷⁰ ³⁷⁵ ³⁸⁰ ⁵⁷⁹ ⁷⁰⁶ or Serratia marcescens;¹ ²⁹⁶ ³⁶² ³⁶⁸ ³⁶⁹ ³⁷⁰ ³⁸⁰ ⁵⁷⁹ also has been used in bone and joint infections caused by E. aerogenes^{† [off-label]},³⁶⁹ ³⁷⁰ ⁷⁰⁶ Escherichia coli^{† [off-label]},³⁶² ³⁶⁸ ³⁶⁹ ³⁷⁰ ⁴⁷⁴ ⁵³⁵ Klebsiella pneumoniae^{† [off-label]},³²⁶ ³⁶⁸ ³⁷¹ Morganella morganii^{† [off-label]},³⁶⁹ ³⁷⁰ or Proteus mirabilis^{† [off-label]}.³⁶⁸ ³⁶⁹ ³⁷¹ ³⁸⁰ ⁴⁷⁴ ⁷⁰⁶

IDSA recommends ciprofloxacin as a drug of choice or alternative for treatment of native vertebral osteomyelitis or prosthetic joint infections caused by Enterobacteriaceae or Ps. aeruginosa.⁵⁹⁰ ⁵⁹¹

Consult current IDSA clinical practice guidelines available at [Web] for additional information on management of bone and joint infections.⁵⁹⁰ ⁵⁹¹

Endocarditis

Alternative for treatment of endocarditis^† (native or prosthetic valve or other prosthetic material) caused by fastidious gram-negative bacilli known as the HACEK group (Haemophilus, Aggregatibacter, Cardiobacterium hominis, Eikenella corrodens, Kingella).⁴⁵⁰ AHA and IDSA recommend ceftriaxone (or other third or fourth generation cephalosporin),⁴⁵⁰ but state that a fluoroquinolone (ciprofloxacin, levofloxacin, moxifloxacin) may be considered in patients who cannot tolerate cephalosporins.⁴⁵⁰ Consultation with an infectious disease specialist recommended.⁴⁵⁰

GI Infections

Treatment of infectious diarrhea caused by susceptible enterotoxigenic E. coli,¹ ²¹¹ ²⁹⁷ Campylobacter,¹ ²¹¹ ²⁹⁷ ³⁵⁰ ⁴⁴⁰ ⁴⁷⁴ ⁴⁷⁷ Salmonella^†,⁴⁴⁰ ⁴⁷⁷ Shigella¹⁹⁷ ²⁹⁷ ⁴⁴⁰ ⁴⁷⁷ ⁶¹² flexneri,¹ ⁶¹² S. boydii, S. sonnei,¹ ⁴⁷⁴ or S. dysenteriae.¹ ⁶¹² Active in vitro against many pathogens associated with infectious diarrhea; may be a drug of choice for empiric treatment.²⁹⁶ ³⁰⁵ ³⁵⁰ ³⁷⁸ ⁴⁴⁰ ⁴⁹³ ⁵²² ⁶¹⁰ ⁶¹¹ Consider increasing emergence of fluoroquinolone-resistant enteric pathogens (e.g., Campylobacter, Salmonella, Shigella) secondary to widespread use of the drugs.⁴⁴⁰ ⁵⁸⁸ ⁵⁸⁹ Base decision to use a fluoroquinolone for empiric treatment of infectious diarrhea on local susceptibility patterns.⁴⁷⁷

Treatment of campylobacteriosis caused by susceptible Campylobacter.²⁹² ⁴⁴⁰ ⁴⁷⁷ Optimal treatment of campylobacteriosis in HIV-infected patients not identified.⁴⁴⁰ Some clinicians withhold anti-infective treatment in those with CD4⁺ T-cells >200 cells/mm³ if they have only mild campylobacteriosis, but initiate treatment if symptoms persist for more than several days.⁴⁴⁰ In those with mild to moderate campylobacteriosis, treatment with a fluoroquinolone (preferably ciprofloxacin or, alternatively, levofloxacin or moxifloxacin) or azithromycin is reasonable.⁴⁴⁰ Modify anti-infective therapy based on results of in vitro susceptibility testing;⁴⁴⁰ resistance to fluoroquinolones reported in 22% of C. jejuni and 35% of C. coli isolates tested in the US.⁴⁴⁰

Alternative to co-trimoxazole for treatment of cyclosporiasis^† caused by Cyclospora cayetanensis.¹³⁴

Treatment of cystoisosporiasis (formerly isosporiasis) caused by Cystoisospora belli^† (formerly Isospora belli).⁴⁴⁰ ⁴⁴¹ ⁴⁷⁷ ⁵³³ In HIV-infected individuals, recommended as an alternative to co-trimoxazole for treatment and chronic maintenance therapy (secondary prophylaxis) of cystoisosporiasis.⁴⁴⁰ ⁴⁴¹

Treatment of Salmonella gastroenteritis^†.⁴⁴⁰ ⁴⁷⁷ Anti-infective treatment indicated 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.¹⁹⁷ ²⁹² ⁴⁴⁰ ⁴⁷⁷ ⁶⁸¹ CDC, NIH, and HIV Medicine Association of IDSA recommend ciprofloxacin as initial drug of choice for treatment of Salmonella gastroenteritis (with or without bacteremia) in HIV-infected adults;⁴⁴⁰ other fluoroquinolones (levofloxacin, moxifloxacin) also likely to be effective, but data limited.⁴⁴⁰ Depending on in vitro susceptibility, alternatives are co-trimoxazole and third generation cephalosporins (ceftriaxone, cefotaxime).⁴⁴⁰ Role of long-term anti-infective treatment (secondary prophylaxis) against Salmonella in HIV-infected individuals with recurrent bacteremia not well established;⁴⁴⁰ weigh benefits of such prophylaxis against risks of long-term anti-infective therapy.⁴⁴⁰

Treatment of shigellosis caused by susceptible Shigella.⁴⁴⁰ ⁴⁷⁷ Anti-infectives may not be required for mild infections, but generally indicated in addition to fluid and electrolyte replacement for treatment of patients with severe shigellosis, dysentery, or underlying immunosuppression.²⁹² ⁴⁴⁰ Empiric treatment regimen can be used initially, but in vitro susceptibility testing indicated since resistance is common.²⁹² ⁴⁷⁷ Fluoroquinolones (preferably ciprofloxacin or, alternatively, levofloxacin or moxifloxacin) have been recommended for treatment of shigellosis in HIV-infected adults,⁴⁴⁰ ⁴⁷⁷ but consider that fluoroquinolone-resistant Shigella reported in the US, especially in international travelers, the homeless, and men who have sex with men (MSM).⁴⁴⁰ Depending on in vitro susceptibility, other drugs recommended for treatment of shigellosis include co-trimoxazole, ceftriaxone, azithromycin (not recommended in those with bacteremia), or ampicillin.¹⁹⁷ ²⁹² ⁴⁴⁰ ⁴⁷⁷

Treatment of GI infections caused by Yersinia enterocolitica^† or Y. pseudotuberculosis^†.⁶⁸¹ These infections usually self-limited, but some experts recommend anti-infectives for severe infections or when septicemia or other invasive disease occurs.²⁹² ⁶⁸¹ When treatment considered necessary, some clinicians recommend co-trimoxazole as drug of choice and cefotaxime and ciprofloxacin as alternatives.⁴⁷⁷

Treatment of travelers’ diarrhea^†.³⁰⁵ ³⁷⁸ ³⁹⁹ ⁴⁴⁰ ⁵²⁵ ⁶⁵⁰ ⁶⁵¹ ⁶⁷⁷ ⁶⁷⁹ If caused by bacteria, may be self-limited and resolve within 3–7 days without anti-infective treatment.³⁰⁵ ⁵²⁵ CDC states anti-infective treatment not recommended for mild travelers' diarrhea;⁵²⁵ CDC and others state empiric short-term anti-infective treatment (single dose or up to 3 days) may be used if diarrhea is moderate or severe, associated with fever or bloody stools, or extremely disruptive to travel plans.³⁰⁵ ⁵²⁵ ⁶⁵⁰ ⁶⁵¹ ⁶⁷⁷ ⁶⁷⁹ Fluoroquinolones (e.g., ciprofloxacin, levofloxacin) generally have been considered anti-infectives of choice for empiric treatment, including self-treatment;³⁰⁵ ⁴⁴⁰ ⁵²⁵ ⁶¹¹ ⁶¹² ⁶⁵⁰ ⁶⁷⁷ ⁶⁷⁹ alternatives include azithromycin and rifaximin.³⁰⁵ ⁵²⁵ Consider that increasing incidence of enteric bacteria resistant to fluoroquinolones and other anti-infectives may limit usefulness of empiric treatment in individuals traveling in certain geographic areas;⁵²⁵ also consider possible adverse effects of the anti-infective and adverse consequences of such treatment (e.g., development of resistance, effect on normal gut microflora).⁵²⁵

Prevention of travelers’ diarrhea^† in individuals traveling for relatively short periods to areas of risk.³⁰⁵ ⁴⁴⁰ ⁵²⁵ ⁶¹⁰ ⁶¹¹ ⁶⁷⁷ ⁶⁷⁹ CDC and others do not recommend anti-infective prophylaxis in most travelers.³⁰⁵ ⁴⁴⁰ ⁵²⁵ ⁶¹¹ ⁶⁷⁷ ⁶⁷⁹ May consider prophylaxis in short-term travelers who are high-risk individuals (e.g., HIV-infected or other immunocompromised individuals, travelers with poorly controlled diabetes mellitus or chronic renal failure) and those taking critical trips during which even a short episode of diarrhea could adversely affect purpose of trip.³⁰⁵ ⁵²⁵ If anti-infective prophylaxis used, fluoroquinolones (e.g., ciprofloxacin, levofloxacin) usually have been recommended;³⁰⁵ ⁴⁴⁰ ⁵²⁵ alternatives include azithromycin and rifaximin.³⁰⁵ ⁵²⁵ Weigh risks of use of anti-infective prophylaxis against use of prompt, early self-treatment with an empiric anti-infective if moderate to severe travelers' diarrhea occurs.⁵²⁵ Also consider increasing incidence of fluoroquinolone resistance in pathogens that cause travelers’ diarrhea (e.g., Campylobacter, Salmonella, Shigella).³⁰⁵ ⁵²⁵

Intra-abdominal Infections

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

Consult current IDSA clinical practice guidelines available at [Web] for additional information on management of intra-abdominal infections.⁷⁰⁸

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., an aminoglycoside, ceftriaxone, cefotaxime).³⁶⁶ ⁴¹⁸ ⁷⁰⁷ ⁷⁶² ⁷⁶³ ⁷⁶⁴ ⁷⁶⁵ ⁸¹⁸

Recommended as an alternative for treatment of healthcare-associated ventriculitis and meningitis^† caused by Enterobacteriaceae or Ps. aeruginosa when drugs of choice cannot be used.⁴¹⁶

Safety and efficacy not established for CNS infections;²¹¹ ⁴⁸¹ only low ciprofloxacin concentrations attained in CSF (see Distribution under Pharmacokinetics).¹ ⁴³⁶ ⁷⁰⁷ Fluoroquinolones (including ciprofloxacin) generally considered for treatment of meningitis only when the infection is caused by multidrug-resistant gram-negative bacilli or when usually recommended anti-infectives cannot be used or have been ineffective.⁴¹⁸ ⁷⁶² ⁸¹⁸

Consult current IDSA clinical practice guidelines available at [Web] for additional information on management of meningitis and other CNS infections.⁴¹⁶ ⁴¹⁸

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

Respiratory Tract Infections

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

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

Use for treatment of acute bacterial sinusitis or acute bacterial exacerbations of chronic bronchitis only when no other treatment options available.¹ ¹⁴⁰ ¹⁴⁵ ⁵⁷⁹ Because systemic fluoroquinolones, including ciprofloxacin, have been associated with disabling and potentially irreversible serious adverse reactions (e.g., tendinitis and tendon rupture, peripheral neuropathy, CNS effects) that can occur together in the same patient (see Cautions)¹ ¹⁴⁰ ¹⁴⁵ ⁵⁷⁹ and because acute bacterial sinusitis and acute bacterial exacerbations of chronic bronchitis may be self-limiting in some patients,¹ ⁵⁷⁹ risks of serious adverse reactions outweigh benefits of fluoroquinolones for patients with these infections.¹⁴⁰ ¹⁴⁵

Treatment of nosocomial pneumonia caused by susceptible H. influenzae or K. pneumoniae.⁵⁷⁹ Select regimen for empiric treatment of hospital-acquired pneumonia (HAP) not associated with mechanical ventilation or ventilator-associated pneumonia (VAP) based on local susceptibility data.³¹⁵ For initial empiric treatment of HAP, use in conjunction with an anti-infective active against methicillin-resistant S. aureus (MRSA; also known as oxacillin-resistant or ORSA) if likelihood of MRSA increased or patient is at high risk of mortality or has received IV anti-infectives during prior 90 days.³¹⁵ For initial empiric treatment of clinically suspected VAP, use in conjunction with an anti-infective active against MRSA plus an antipseudomonal β-lactam if likelihood of MRSA or multidrug-resistant gram-negative bacteria increased.³¹⁵

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

Consult current IDSA clinical practice guidelines available at [Web] for additional information on management of respiratory tract infections.³¹⁵ ⁵¹²

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,¹ ³⁷² ⁵⁷⁹ E. cloacae,¹ ³⁶² ⁵⁷⁹ E. coli,¹ ³²⁶ ³⁷² ³⁷⁵ ³⁷⁷ ³⁸⁰ ⁵⁷⁹ K. oxytoca^†,⁴⁷⁴ K. pneumoniae,¹ ³⁶² ³⁷² ³⁷⁷ ³⁸⁰ ⁵⁷⁹ M. morganii,¹ ⁵⁷⁹ P. mirabilis,¹ ³⁶² ³⁶⁴ ³⁷² ³⁷⁷ ³⁸⁰ ⁵⁷⁹ P. vulgaris,¹ ³⁷² ⁴⁷⁴ ⁵⁷⁹ P. stuartii,¹ ³⁷⁷ ⁵⁷⁹ Ps. aeruginosa,¹ ²⁸⁰ ³⁰⁰ ³²⁶ ³⁵⁹ ³⁶² ³⁷² ³⁷⁵ ³⁷⁷ ³⁸² ⁴³³ ⁵⁷⁹ S. marcescens^†,³⁶² ³⁸⁰ S. aureus (methicillin-susceptible strains),¹ ³²⁶ ³⁶² ³⁶⁴ ³⁷² ³⁷³ ³⁷⁵ ³⁷⁷ ³⁸² ⁴⁶⁶ ⁴⁷⁴ ⁵⁷⁹ S. epidermidis,¹ ³⁶⁴ ³⁷² ³⁷⁵ ³⁷⁷ ³⁸² ⁵⁷⁹ or S. pyogenes (group A β-hemolytic streptococci).¹ ³⁶² ³⁷³ ⁵⁷⁹

Consult current IDSA clinical practice guidelines available at [Web] for additional information on management of skin and skin structure infections.⁵⁴³

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 complicated or uncomplicated UTIs in adults caused by susceptible gram-negative bacteria, including Citrobacter koseri (formerly C. diversus),¹ ⁵⁷⁹ C. freundii,¹ ³³⁹ ³⁴⁰ ³⁴¹ ³⁷⁵ ³⁸⁰ ⁴⁷⁴ ⁵⁷⁹ E. cloacae,¹ ³²⁷ ³³² ³⁸⁰ ⁵⁷⁹ E. coli,¹ ²⁹⁷ ³²⁶ ³²⁷ ³²⁹ ³³² ³³⁶ ³³⁸ ³³⁹ ³⁴⁰ ³⁵¹ ³⁵² ³⁵³ ³⁷⁵ ³⁸⁰ ⁵⁰⁴ ⁵⁷⁹ ⁸⁵⁶ K. pneumoniae,¹ ²⁹⁷ ³²⁷ ³²⁹ ³³⁶ ³³⁸ ³⁴⁰ ³⁴¹ ³⁵³ ³⁷⁵ ⁵⁰⁴ ⁵⁷⁹ ⁸⁵⁶ M. morganii,¹ ³⁴⁰ ³⁴¹ ⁵⁷⁹ P. mirabilis,¹ ³²⁷ ³³² ³³⁶ ³⁴⁰ ³⁵² ³⁵³ ⁵⁰⁴ ⁵⁷⁹ ⁸⁵⁶ Providencia rettgeri,¹ ⁴⁷⁴ ⁵⁷⁹ Ps. aeruginosa,¹ ¹⁹⁷ ²⁹⁷ ³⁰⁰ ³²⁶ ³²⁷ ³³⁶ ³³⁸ ³³⁹ ³⁴⁰ ³⁴¹ ³⁵¹ ³⁵³ ³⁵⁹ ³⁷⁵ ³⁷⁹ ³⁸⁰ ⁵⁷⁹ ⁸⁵⁶ or S. marcescens;¹ ³⁴⁰ ³⁴¹ ³⁵³ ³⁸⁰ ⁵⁰⁴ ⁵⁷⁹ 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,¹ ³²⁷ ³³⁶ ³⁴⁰ ⁵⁷⁹ S. saprophyticus,¹ ³³² ⁵⁷⁹ or E. faecalis.¹ ¹⁹⁷ ³²⁷ ³³⁶ ³³⁹ ³⁴⁰ ³⁴¹ ³⁵³ ⁵⁷⁹ ⁸⁵⁶

Treatment of acute uncomplicated cystitis in adults caused by susceptible E. coli, P. mirabilis, S. saprophyticus, or E. faecalis.⁸⁵⁶

Treatment of acute uncomplicated pyelonephritis in adults caused by E. coli.⁸⁵⁶

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

Use for treatment of uncomplicated UTIs only when no other treatment options available.¹ ¹⁴⁰ ⁸⁵⁶ Because systemic fluoroquinolones, including ciprofloxacin, have been associated with disabling and potentially irreversible serious adverse reactions (e.g., tendinitis and tendon rupture, peripheral neuropathy, CNS effects) that can occur together in the same patient (see Cautions)¹ ¹⁴⁰ ¹⁴⁵ ⁸⁵⁶ and because uncomplicated UTIs may be self-limiting in some patients,¹ ⁸⁵⁶ risks of serious adverse reactions outweigh benefits of fluoroquinolones for patients with uncomplicated UTIs.¹⁴⁰ ¹⁴⁵

Usually reserved for treatment of complicated UTIs, especially those caused by multidrug-resistant bacteria.²⁹⁹ ³³⁶ ³⁷⁹ ⁴²⁵ ⁴⁸¹ ⁵⁵¹

Anthrax

Inhalational anthrax (postexposure) to reduce incidence or progression of disease following suspected or confirmed exposure to aerosolized Bacillus anthracis spores.¹ ⁵⁷⁹ ⁶⁶⁸ ⁶⁷¹ ⁶⁷² ⁶⁷³ ⁶⁸³ CDC, US Working Group on Civilian Biodefense, and US Army Medical Research Institute of Infectious Diseases (USAMRIID) recommend oral ciprofloxacin and oral doxycycline as initial drugs of choice for prophylaxis following such exposures that occur in the context of biologic warfare or bioterrorism.⁶⁶⁸ ⁶⁷² ⁶⁷³ ⁶⁸³ Other oral fluoroquinolones (levofloxacin, moxifloxacin, ofloxacin) are alternatives for postexposure prophylaxis when ciprofloxacin or doxycycline cannot be used.⁶⁶⁸ ⁶⁷¹ ⁶⁷² ⁶⁷³ AAP states that oral ciprofloxacin is the drug of choice for anthrax postexposure prophylaxis in neonates ≤4 weeks of age and oral ciprofloxacin or doxycycline are the drugs of choice for such prophylaxis in pediatric patients ≥1 month of age.⁶⁷¹

Treatment of systemic anthrax (inhalational, GI, meningitis, or cutaneous with systemic involvement, head or neck lesions, or extensive edema) that occurs in the context of biologic warfare or bioterrorism.⁶⁶⁸ ⁶⁷¹ ⁶⁷² ⁶⁷³ ⁶⁸³ CDC and AAP state that the preferred multiple-drug parenteral regimen for initial treatment of systemic anthrax with possible or confirmed meningitis in adults and pediatric patients (including neonates) is IV ciprofloxacin in conjunction with another IV bactericidal anti-infective (preferably meropenem) and an IV protein synthesis inhibitor (preferably linezolid).⁶⁷¹ ⁶⁷² ⁶⁷³ If meningitis excluded, these experts recommend an initial multiple-drug parenteral regimen of IV ciprofloxacin in conjunction with an IV protein synthesis inhibitor (preferably clindamycin or linezolid in adults or clindamycin in pediatric patients).⁶⁷¹ ⁶⁷² ⁶⁷³

Treatment of uncomplicated cutaneous anthrax^† (without systemic involvement) that occurs following exposure to B. anthracis spores in the context of biologic warfare or bioterrorism.⁶⁶⁸ ⁶⁷⁰ ⁶⁷¹ ⁶⁷² ⁶⁷³ ⁶⁸⁰ CDC states that oral ciprofloxacin, doxycycline, levofloxacin, and moxifloxacin are the preferred drugs in adults for treatment of uncomplicated cutaneous anthrax that occurs in the context of biologic warfare or bioterrorism.⁶⁷² ⁶⁷³ AAP states that oral ciprofloxacin is the preferred drug for treatment of such infections in pediatric patients (including neonates).⁶⁷¹

Oral ciprofloxacin has been suggested as possible alternative for treatment of inhalational anthrax^† when a parenteral regimen not available (e.g., supply or logistic problems because large numbers of individuals require treatment in a mass-casualty setting).⁶⁶⁸ ⁶⁸³ A multiple-drug parenteral regimen should be used for initial treatment of inhalational anthrax that occurs as the result of exposure to B. anthracis spores in the context of biologic warfare or bioterrorism;⁶⁶⁸ ⁶⁷¹ ⁶⁷² ⁶⁷³ ⁶⁸³ parenteral regimen may not be possible if large numbers of individuals require treatment in a mass casualty setting and it may be necessary to use an oral regimen.⁶⁶⁸ ⁶⁸³

Treatment of GI and oropharyngeal anthrax^†.⁶⁸¹ If occurring in the context of biologic warfare or bioterrorism, use parenteral regimens recommended for inhalational anthrax.⁶⁶⁸ ⁶⁸³ ⁶⁸⁶ ⁷⁰³

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

Consult CDC and AAP guidelines for additional information on management of anthrax, including postexposure prophylaxis of anthrax.⁶⁷¹ ⁶⁷² ⁶⁷³

Brucellosis

Treatment of brucellosis^† caused by Brucella melitensis;¹⁹⁷ ⁶²⁴ ⁶⁸³ ⁷⁷¹ ⁷⁷² used in conjunction with rifampin.¹⁹⁷ ⁶⁸³ ⁷⁷¹ ⁷⁷² Monotherapy with any drug usually associated with high relapse rate and not recommended.⁶⁸³ ⁷⁷²

Chancroid

Treatment of chancroid^† (genital ulcers caused by Haemophilus ducreyi).³⁴⁴ ³²¹ ⁴⁶²

CDC recommends azithromycin, ceftriaxone, ciprofloxacin, or erythromycin as drugs of choice for treatment of chancroid.³⁴⁴ HIV-infected patients and uncircumcised patients may not respond to treatment as well as those who are HIV-negative or circumcised.³⁴⁴

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

Was used in the past 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) widely disseminated worldwide, including in the US¹¹⁴ ³⁴⁴ ⁷⁵⁴ ⁸³⁵ ⁸³⁹ ⁸⁵⁷ (see Resistance in Neisseria gonorrhoeae under Cautions), CDC states fluoroquinolones no longer recommended for treatment of gonorrhea and should not be used routinely for any associated infection that may involve N. gonorrhoeae (e.g., pelvic inflammatory disease [PID], epididymitis).¹¹⁴ ³⁴⁴ ⁸³⁹

Granuloma Inguinale† (Donovanosis†)

Alternative for treatment of granuloma inguinale^† (donovanosis) caused by Klebsiella granulomatis (formerly Calymmatobacterium granulomatis).³⁴⁴

CDC recommends azithromycin;³⁴⁴ alternatives are doxycycline, ciprofloxacin, erythromycin, and co-trimoxazole.³⁴⁴

Legionnaires’ Disease†

Treatment of Legionnaires’ Disease^† caused by Legionella pneumophila,⁷³⁴ including in immunocompromised patients (e.g., transplant recipients).¹⁹⁷ ⁵¹² ⁶²² ⁷⁰⁴ ⁷³⁴ ⁷³⁵

Mycobacterial Infections

Has been used in multiple-drug regimens for treatment of active tuberculosis^† caused by Mycobacterium tuberculosis.⁶⁰¹ ⁶¹⁵ ⁸¹⁷

ATS, CDC, and IDSA state that use of fluoroquinolones as alternative (second-line) agents can be considered for treatment of active tuberculosis in patients intolerant of certain first-line agents and in those with relapse, treatment failure, or M. tuberculosis resistant to certain first-line agents.²¹⁸ ⁴⁴⁰ If a fluoroquinolone is used in multiple-drug regimens for treatment of active tuberculosis, levofloxacin or moxifloxacin is recommended;²¹⁸ ²³¹ ²⁷⁶ ⁴⁴⁰ some experts state ciprofloxacin is no longer recommended for treatment of tuberculosis.²³¹ ²⁷⁶

Treatment of cutaneous infections caused by M. fortuitum^†; used alone or in conjunction with amikacin.⁶⁰⁷ ⁸¹⁷ ⁶⁷⁵ 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).⁶⁷⁵

Has been used in multiple-drug regimens for treatment of pulmonary and extrapulmonary (localized or disseminated) M. avium complex^† (MAC) infections.¹⁹⁷ ⁶⁰² ⁶⁰⁷ ⁶¹⁴ ⁶¹⁶ ⁶¹⁷ ⁸¹⁷ ⁸¹⁹ Role of fluoroquinolones in treatment of MAC infections not been established.⁶⁷⁵ 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.⁶⁷⁵ 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.⁶⁷⁵

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^†.⁶⁷⁵ Because of considerations related to resistance, not recommended for treatment of M. marinum infections.⁶⁷⁵

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.²⁹² ³⁷⁴ ³⁷⁶ ⁴⁰⁶ ⁴⁰⁹ ⁴¹¹ ⁵³⁸ ⁵⁴⁵ ⁵⁶⁹ CDC and AAP consider rifampin, ceftriaxone, or ciprofloxacin the drugs of choice for such carriers.²⁹² ³⁷⁴ ³⁷⁶

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

Treatment of plague, including pneumonic and septicemic plague, caused by Yersinia pestis.¹ ²⁹² ⁵⁷⁹ ⁶⁸³ ⁶⁸⁸ Streptomycin (or gentamicin) historically has been considered regimen of choice for treatment of plague;¹⁹⁷ ²⁹² ⁶⁸³ ⁶⁸⁸ alternatives are doxycycline (or tetracycline), chloramphenicol (a drug of choice for plague meningitis), fluoroquinolones (ciprofloxacin [a drug of choice for plague meningitis], levofloxacin, moxifloxacin), or co-trimoxazole (may be less effective than other alternatives).¹⁹⁷ ²⁹² ⁶⁸³ ⁶⁸⁸ Regimens recommended for treatment of naturally occurring or endemic bubonic, septicemic, or pneumonic plague also recommended for plague that occurs following exposure to Y. pestis in the context of biologic warfare or bioterrorism.⁶⁸³ ⁶⁸⁸

Postexposure prophylaxis following 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).¹ ⁵⁷⁹ ⁶⁸³ ⁶⁸⁸ Drugs of choice for such prophylaxis are doxycycline (or tetracycline) or a fluoroquinolone (ciprofloxacin, levofloxacin, moxifloxacin, ofloxacin).⁶⁸³ ⁶⁸⁸

Rickettsial Infections

Has been used for treatment of some rickettsial infections^†,¹⁹⁷ ³⁹³ ⁵⁶⁸ ⁶²⁵ including Mediterranean spotted fever^† caused by Rickettsia conorii.³⁹³

Doxycycline is the drug of choice for treatment of all tickborne rickettsial diseases.⁵⁰⁰ Although some fluoroquinolones have in vitro activity against Rickettsiae,⁵⁰⁰ CDC states that fluoroquinolones are not recommended for treatment of Rocky Mountain spotted fever.⁵⁰⁰

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.¹⁹⁷ ²⁹² ⁶⁸³ ⁶⁸⁹ Considered an alternative to streptomycin (or gentamicin);¹⁹⁷ ²⁹² ⁶⁸³ ⁶⁸⁹ 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 Invasive Salmonella Infections

Treatment of typhoid fever (enteric fever) or paratyphoid fever^† caused by susceptible Salmonella enterica serovars Typhi or Paratyphi, respectively.¹ ¹⁹⁷ ³²⁶ ³⁹⁶ ⁴⁰⁸ ⁴⁴¹ ⁴⁷⁹ ⁴⁹³ ⁴⁹⁴ ⁵²⁵ ⁶⁰³ ⁶⁵⁴ ⁶⁵⁵ ⁶⁵⁶ ⁶⁵⁷ ⁶⁵⁸ ⁶⁵⁹ ⁶⁶⁰ Although fluoroquinolones have been recommended for empiric treatment of Salmonella enteric fever in adults, resistance to fluoroquinolones reported in >80% of such infections in travelers to South and Southeast Asia and treatment failures will occur.⁵²⁵

Has been used for treatment of chronic typhoid carriers^†;¹⁹⁷ ²¹¹ ²⁹² ³⁹¹ ⁴⁰³ ⁴³⁸ ⁴⁶⁶ ⁴⁷³ ⁶⁰³ however, manufacturer cautions that efficacy of ciprofloxacin in eradication of the chronic typhoid carrier state has not been demonstrated.¹

Recommended as a drug of choice for treatment of native vertebral osteomyelitis caused by Salmonella^†.⁵⁹⁰ (See Bone and Joint Infections under Uses.)

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 0139.¹⁹⁷ ²⁹² ⁴⁷⁷ ⁶⁶⁴ ⁷⁵⁶ ⁷⁵⁷ ⁷⁵⁸ Doxycycline generally considered drug of choice when an anti-infective indicated as an adjunct to fluid and electrolyte replacement; alternatives include azithromycin, co-trimoxazole, ciprofloxacin, or ceftriaxone.¹⁹⁷ ²⁹² ⁴⁷⁷ ⁶⁶⁴ ⁷⁵⁸

Alternative to tetracyclines for treatment of other Vibrio infections, including gastroenteritis or wound infections caused by V. parahaemolyticus^† or V. vulnificus^†.¹⁹⁷ ⁷⁵⁹ Optimum anti-infective therapy has not been identified for V. vulnificus^†; 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 patients undergoing certain GU surgery who are at high risk for postoperative infections.³⁶⁰ Because of increasing resistance of E. coli to fluoroquinolones, consider local susceptibility patterns when selecting an anti-infective for such prophylaxis.³⁶⁰

Perioperative prophylaxis not recommended for patients with sterile urine undergoing cystoscopy without manipulation.³⁶⁰ Some clinicians recommend that those with positive (or unavailable) urine cultures or preoperative indwelling urinary catheters and those undergoing cystoscopy with manipulation (dilation, biopsy, fulguration, resection, ureteral instrumentation) 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.³⁶⁰

Perioperative prophylaxis using an appropriate anti-infective (e.g., ciprofloxacin) recommended in patients undergoing transurethral prostatectomy, transrectal prostatic biopsies, ureteroscopy, shock wave lithotripsy, percutaneous renal surgery, open laparoscopic procedures, or procedures that involve placement of a urologic prosthesis (e.g., penile transplant, artificial sphincter, synthetic pubovaginal sling, bone anchors for pelvic floor reconstruction).³⁶⁰

Empiric Therapy in Febrile Neutropenic Patients

Empiric anti-infective therapy of presumed bacterial infections in febrile neutropenic patients.⁵⁷⁹ ⁷⁸⁶ ⁷⁸⁷

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

Some experts recommend fluoroquinolone prophylaxis during periods of expected neutropenia in patients at high risk for febrile neutropenia or profound, protracted neutropenia (e.g., most patients with acute myeloid leukemia/myelodysplastic syndromes [AML/MDS] or hematopoietic stem-cell transplantation [HSCT] treated with myeloablative conditioning regimens).⁷⁸⁶

Empiric regimen that includes a fluoroquinolone (ciprofloxacin or levofloxacin) in conjunction with the fixed combination of amoxicillin and clavulanate (or clindamycin) recommended for outpatient management of febrile neutropenic adults receiving treatment for malignancy.⁷⁸⁷ Use of a fluoroquinolone alone not recommended for initial empiric therapy in outpatients, but may be effective in low-risk outpatients.⁷⁸⁷

Consult published protocols on anti-infective prophylaxis in febrile neutropenic patients for specific recommendations when anti-infective prophylaxis is appropriate for immunosuppressed patients with cancer and options for such prophylaxis.⁷⁸⁶ ⁷⁸⁷

Ciprofloxacin Dosage and Administration

Administration

Administer orally¹ ⁸⁵⁶ or by IV infusion.⁵⁷⁹

Patients receiving IV ciprofloxacin initially may be switched to oral ciprofloxacin when clinically appropriate.⁵⁷⁹

Because of risk of crystalluria, instruct patients receiving oral or IV ciprofloxacin that they should be adequately hydrated and should drink fluids liberally.¹ ⁵⁷⁹ ⁸⁵⁶ (See Renal Effects under Cautions.)

Oral Administration

Administer conventional tablets, extended-release tablets, or oral suspension without regard to meals.¹ ⁸⁵⁶ (See Pharmacokinetics.)

Do not administer conventional 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.¹ ⁸⁵⁶ Doses should preferably be taken 2 hours before or after these calcium-fortified products or substantial calcium intake (>800 mg).¹ ⁸⁵⁶

Conventional or extended-release tablets: Swallow whole;¹ ⁸⁵⁶ do not split, crush, or chew.¹ ⁸⁵⁶

Oral suspension: Following reconstitution, administer using the graduated spoon provided by the manufacturer that has markings for 2.5 and 5 mL.¹ Swallow microcapsules contained in the reconstituted oral suspension;¹ do not chew.¹ May ingest water after the oral suspension is swallowed.¹

Reconstitution

Ciprofloxacin for oral suspension is provided in a kit containing a bottle of microcapsules, a bottle of oral suspension diluent, and a graduated dosing spoon.¹ At time of dispensing, add contents of bottle containing the microcapsules (either 5 or 10 g of ciprofloxacin) to the bottle of diluent according to manufacturer's directions and shake vigorously for about 15 seconds to provide a suspension containing either 250 mg/5 mL or 500 mg/5 mL, respectively.¹ Use only the diluent supplied in the kit;¹ do not add water.¹

Prior to administration of each dose, shake oral suspension vigorously for about 15 seconds.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 with compatible IV solution prior to IV infusion.⁵⁷⁹

Ciprofloxacin premixed 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 concentrate containing 10 mg/mL with compatible IV solution (e.g., 0.9% sodium chloride, 5 or 10% dextrose, 5% dextrose and 0.225 or 0.45% sodium chloride, lactated Ringer’s) to provide a solution containing 1–2 mg/mL.⁵⁷⁹ (See Compatibility under Stability.)

Rate of Administration

Administer by IV infusion over 1 hour.⁵⁷⁹

Dosage

Available as ciprofloxacin (IV, oral suspension),¹ ⁵⁷⁹ ciprofloxacin hydrochloride (conventional tablets),¹ and a mixture of ciprofloxacin and ciprofloxacin hydrochloride (extended-release tablets);⁸⁵⁶ dosage expressed in terms of ciprofloxacin.¹ ⁵⁷⁹ ⁸⁵⁶

Unless otherwise specified, oral dosage is for conventional tablets or oral suspension.¹

Use extended-release tablets only for treatment of certain urinary tract infections (UTIs) in adults; do not use in pediatric patients.⁸⁵⁶ Extended-release tablets are not interchangeable with other oral ciprofloxacin preparations (conventional tablets, oral suspension).⁸⁵⁶

Dosage of oral and IV ciprofloxacin is not identical.¹ ⁵⁷⁹ Based on pharmacokinetic parameters (i.e., AUC), the following oral and IV regimens are considered equivalent: 250 mg orally every 12 hours (conventional tablets) is equivalent to 200 mg IV every 12 hours; 500 mg orally every 12 hours (conventional tablets) is equivalent to 400 mg IV every 12 hours; 750 mg orally every 12 hours (conventional tablets) is equivalent to 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

Children 1–17 years of age (oral suspension containing 250 mg/5 mL): 125 mg every 12 hours in those weighing 9–12 kg, 250 mg every 12 hours in those weighing 13–18 kg, 250–375 mg every 12 hours in those weighing 19–24 kg, 375–500 mg every 12 hours in those weighing 25–31 kg, 375–625 mg every 12 hours in those weighing 32–37 kg, and 500–750 mg every 12 hours in those weighing ≥38 kg.¹

Children 1–17 years of age (oral suspension containing 500 mg/5 mL): 250 mg every 12 hours in those weighing 13–24 kg, 250–500 mg every 12 hours in those weighing 25 kg, 500 mg every 12 hours in those weighing 26–37 kg, and 500–750 mg every 12 hours in those weighing ≥38 kg.¹

Children 1–17 years of age: 6–10 mg/kg (up to 400 mg) every 8 hours.⁵⁷⁹

Switch to oral route when clinically indicated; manufacturers recommend total treatment duration (IV and/or oral) of 10–21 days.¹ ⁵⁷⁹

Anthrax

Postexposure Prophylaxis of Anthrax (Biologic Warfare or Bioterrorism Exposure)

Oral

Neonates ≤4 weeks of age: AAP recommends 10 mg/kg every 12 hours in preterm neonates (gestational age 32–37 weeks) and 15 mg/kg every 12 hours in full-term neonates.⁶⁷¹

Pediatric patients ≥1 month of age: AAP recommends 15 mg/kg (up to 500 mg) every 12 hours.⁶⁷¹

Neonates, infants, and children ≤17 years of age: Manufacturer recommends 15 mg/kg (up to 500 mg) every 12 hours.¹

Neonates, infants, and children ≤17 years of age (oral suspension containing 250 mg/5 mL): Manufacturer recommends 125 mg every 12 hours in those weighing 9–12 kg, 250 mg every 12 hours in those weighing 13–18 kg, 250–375 mg every 12 hours in those weighing 19–24 kg, and 500 mg every 12 hours in those weighing ≥25 kg.¹

Neonates, infants, and children ≤17 years of age (oral suspension containing 500 mg/5 mL): Manufacturer recommends 250 mg every 12 hours in those weighing 13–24 kg and 500 mg every 12 hours in those weighing ≥25 kg.¹

Initiate prophylaxis as soon as possible following suspected or confirmed anthrax exposure.¹ ⁶⁶⁸ ⁶⁷³ ⁶⁸³

Because of possible persistence of B. anthracis spores in lung tissue following an aerosol exposure, CDC, AAP, and others recommend that anti-infective postexposure prophylaxis be continued for 60 days following a confirmed exposure.¹ ⁵⁷⁹ ⁶⁶⁸ ⁶⁷¹ ⁶⁷² ⁶⁷³ ⁶⁸³

Neonates, infants, and children ≤17 years of age: Manufacturer recommends 10 mg/kg (up to 400 mg) every 12 hours for 60 days.⁵⁷⁹

Treatment of Systemic Anthrax (Biologic Warfare or Bioterrorism Exposure)†

Neonates ≤4 weeks of age: AAP recommends 10 mg/kg every 12 hours in preterm neonates (gestational age 32–37 weeks) and 15 mg/kg every 12 hours in full-term neonates.⁶⁷¹

Pediatric patients ≥1 month of age: AAP recommends 10 mg/kg (up to 400 mg) every 8 hours.⁶⁷¹

Used in multiple-drug parenteral regimen for initial treatment of systemic anthrax (inhalational, GI, meningitis, or cutaneous with systemic involvement, lesions on the head or neck, or extensive edema).⁶⁷¹ Continue parenteral regimen for ≥2–3 weeks until patient is clinically stable and can be switched to appropriate oral anti-infective.⁶⁷¹

If systemic anthrax occurred after exposure to aerosolized B. anthracis spores in the context of biologic warfare or bioterrorism, continue oral follow-up regimen until 60 days after illness onset.⁶⁷¹

Oral

Neonates ≤4 weeks of age (follow-up after initial multiple-drug parenteral regimen): AAP recommends 10 mg/kg every 12 hours in preterm neonates (gestational age 32–37 weeks) and 15 mg/kg every 12 hours in full-term neonates.⁶⁷¹

Pediatric patients ≥1 month of age (follow-up after initial multiple-drug parenteral regimen): AAP recommends 15 mg/kg (up to 500 mg) every 12 hours.⁶⁷¹

Initial multiple-drug parenteral treatment regimen recommended;⁶⁶⁸ ⁶⁷¹ ⁶⁸³ use oral regimen after clinical improvement occurs or when a parenteral regimen not available (e.g., mass casualty setting).⁶⁶⁸ ⁶⁷¹ ⁶⁸³

Treatment of Uncomplicated Cutaneous Anthrax (Biologic Warfare or Bioterrorism Exposure)†

Oral

Neonates ≤1 month of age: AAP recommends 10 mg/kg every 12 hours in preterm neonates (gestational age 32–37 weeks) and 15 mg/kg every 12 hours in full-term neonates.⁶⁷¹

Pediatric patients ≥1 month of age: AAP recommends 15 mg/kg (up to 500 mg) every 12 hours.⁶⁷¹

Recommended duration is 60 days after illness onset if cutaneous anthrax occurred after exposure to aerosolized B. anthracis spores in the context of biologic warfare or bioterrorism.⁶⁷¹ Duration of 7–10 days may be sufficient if uncomplicated cutaneous anthrax occurred as the result of naturally occurring or endemic exposure.⁶⁷¹

Neisseria meningitidis Infections†

Elimination of Pharyngeal Carrier State†

Oral

20 mg/kg (up to 500 mg) as a single dose.²⁹²

Chemoprophylaxis in Household or Other Close Contacts†

Oral

20 mg/kg (up to 500 mg) as a single dose.²⁹²

Plague

Treatment of Plague

Oral

Neonates, infants, and children ≤17 years of age: Manufacturer recommends 15 mg/kg (up to 500 mg) every 8 or 12 hours for 10–21 days.¹

Neonates, infants, and children ≤17 years of age (oral suspension containing 250 mg/5 mL): Manufacturer recommends 125 mg every 12 hours in those weighing 9–12 kg, 250 mg every 12 hours in those weighing 13–18 kg, 250–375 mg every 12 hours in those weighing 19–24 kg, 375–500 mg every 12 hours in those weighing 25–31 kg, 375–625 mg every 12 hours in those weighing 32–37 kg, and 500–750 mg every 12 hours in those weighing ≥38 kg.¹

Neonates, infants, and children ≤17 years of age (oral suspension containing 500 mg/5 mL): Manufacturer recommends 250 mg every 12 hours in those weighing 13–24 kg, 250–500 mg every 12 hours in those weighing 25 kg, 500 mg every 12 hours in those weighing 26–37 kg, and 500–750 mg every 12 hours in those weighing ≥38 kg.¹

Some experts (e.g., US Working Group on Civilian Biodefense, USAMRIID) recommend 20 mg/kg twice daily (up to 1 g daily) for treatment of plague that occurs as the result of exposure to Y. pestis in the context of biologic warfare or bioterrorism.⁶⁸³ ⁶⁸⁸

Initial parenteral regimen preferred;⁶⁸³ ⁶⁸⁸ use oral regimen after clinical improvement occurs or when a parenteral regimen not available (e.g., mass casualty setting).⁶⁸³ ⁶⁸⁸

Manufacturer recommends total treatment duration (IV and oral) of 10–21 days in pediatric patients;⁵⁷⁹ some experts state total treatment duration should be at least 10–14 days.⁶⁸³ ⁶⁸⁸

Neonates, infants, and children ≤17 years of age: Manufacturer recommends 10 mg/kg (up to 400 mg) IV every 8 or 12 hours for 10–21 days.⁵⁷⁹

Some experts (e.g., US Working Group on Civilian Biodefense, USAMRIID) recommend 15 mg/kg IV every 12 hours (up to 1 g daily) for treatment of plague that occurs as the result of exposure to Y. pestis in the context of biologic warfare or bioterrorism.⁶⁸³ ⁶⁸⁸

When clinical improvement occurs, may switch to oral regimen.⁶⁸³ ⁶⁸⁸

Postexposure Prophylaxis of Plague

Oral

Neonates, infants, and children ≤17 years of age: Manufacturer recommends 15 mg/kg (up to 500 mg) every 8 or 12 hours for 10–21 days.¹

Neonates, infants, and children ≤17 years of age (oral suspension containing 250 mg/5 mL): Manufacturer recommends 125 mg every 12 hours in those weighing 9–12 kg, 250 mg every 12 hours in those weighing 13–18 kg, 250–375 mg every 12 hours in those weighing 19–24 kg, 375–500 mg every 12 hours in those weighing 25–31 kg, 375–625 mg every 12 hours in those weighing 32–37 kg, and 500–750 mg every 12 hours in those weighing ≥38 kg.¹

Some experts (e.g., US Working Group on Civilian Biodefense, USAMRIID) recommend 20 mg/kg twice daily (up to 1 g daily) following exposures that occur in the context of biologic warfare or bioterrorism.⁶⁸³ ⁶⁸⁸

Initiate prophylaxis as soon as possible after suspected or confirmed exposure.¹

Close contacts of patients with pneumonic plague or individuals exposed to plague aerosol (e.g., in the context of biologic warfare or bioterrorism): Continue prophylaxis for 7 days or for duration of risk of exposure plus 7 days.⁶⁸³ ⁶⁸⁸ If fever or cough develops during prophylaxis, switch to regimen recommended for treatment of plague.⁶⁸³ ⁶⁸⁸

Neonates, infants, and children ≤17 years of age: Manufacturer recommends 10 mg/kg (up to 400 mg) IV every 8 or 12 hours for 10–21 days.⁵⁷⁹

Tularemia†

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

Oral

15 mg/kg twice daily (up to 1 g daily).⁶⁸³ ⁶⁸⁹

Initial parenteral regimen preferred; use oral regimen after improvement occurs or when a parenteral regimen not available (e.g., mass casualty setting).⁶⁸³ ⁶⁸⁹

Total treatment duration (IV and oral) of at least 10–14 days.⁶⁸³ ⁶⁸⁹

IV, then Oral

15 mg/kg IV every 12 hours (up to 1 g daily).⁶⁸³ ⁶⁸⁹

When clinical improvement occurs, may switch to oral regimen.⁶⁸³ ⁶⁸⁹

Total treatment duration (IV and oral) of at least 10–14 days.⁶⁸³ ⁶⁸⁹

Postexposure Prophylaxis Following High-risk Exposure to Tularemia†

Oral

15 mg/kg every 12 hours (up to 1 g daily).⁶⁸³ ⁶⁸⁹

Initiate prophylaxis within 24 hours of exposure and continue for at least 14 days.⁶⁸³ ⁶⁸⁹

Cystoisospora Infections

Oral

HIV-infected: 10–20 mg/kg (up to 500 mg) twice daily for 7 days.⁴⁴¹

Chronic maintenance therapy (secondary prophylaxis) in HIV-infected: 10–20 mg/kg (up to 500 mg) 3 times weekly.⁴⁴¹ Consider discontinuing if no evidence of active Cystoisospora infection and there has been sustained improvement in immunologic status (CDC immunologic category 1 or 2) for >6 months in response to antiretroviral therapy.⁴⁴¹

Meningitis and Other CNS Infections†

IV

Healthcare-associated ventriculitis and meningitis caused by susceptible gram-negative bacteria: IDSA recommends 30 mg/kg daily in divided doses every 8–12 hours.⁴¹⁶

Neisseria meningitidis Infections†

Elimination of Nasopharyngeal Carrier State†

Oral

AAP recommends single dose of 20 mg/kg.²⁹² Do not use if fluoroquinolone-resistant N. meningitis identified in the community.²⁹²

Chemoprophylaxis in Household or Other Close Contacts†

Oral

AAP recommends single dose of 20 mg/kg.²⁹² Do not use if fluoroquinolone-resistant N. meningitis identified in the community.²⁹²

Vibrio Infections†

Cholera†

Oral

15 mg/kg (up to 500 mg) twice daily for 3 days.²⁹²

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

Oral

Manufacturer recommends 500–750 mg every 12 hours for 4–8 weeks.¹

Native vertebral osteomyelitis: IDSA recommends 750 mg every 12 hours for 6 weeks for Ps. aeruginosa, 500 mg every 12 hours for 6–8 weeks for Salmonella, and 500–750 mg every 12 hours for 6 weeks for other Enterobacteriaceae.⁵⁹⁰

Prosthetic joint infections: IDSA recommends 750 mg twice daily for 4–6 weeks for Ps. aeruginosa and for Enterobacter or other Enterobacteriaceae.⁵⁹¹

IV

Manufacturer recommends 400 mg every 8 to 12 hours for 4–8 weeks.⁵⁷⁹

Native vertebral osteomyelitis: IDSA recommends 400 mg every 8 hours for 6 weeks for Ps. aeruginosa and 400 mg every 12 hours for 6 weeks for Enterobacteriaceae.⁵⁹⁰

Prosthetic joint infections: IDSA recommends 400 mg every 12 hours for 4–6 weeks for Ps. aeruginosa or Enterobacter.⁵⁹¹

Endocarditis†

Endocarditis Caused by the HACEK Group†

Oral

1 g daily given in 2 equally divided doses recommended by AHA and IDSA.⁴⁵⁰ Duration of treatment is 4 weeks for native valve endocarditis or 6 weeks for endocarditis involving prosthetic cardiac valves or other prosthetic cardiac material.⁴⁵⁰

800 mg daily given in 2 equally divided doses recommended by AHA and IDSA.⁴⁵⁰ Duration of treatment is 4 weeks for native valve endocarditis or 6 weeks for endocarditis involving prosthetic cardiac valves or other prosthetic cardiac material.⁴⁵⁰

GI Infections

Infectious Diarrhea

Oral

Manufacturer recommends 500 mg every 12 hours for 5–7 days.¹ ³⁵⁰ ³⁷⁸ ⁶¹²

Campylobacter Infections†

Oral

HIV-infected: 500–750 mg every 12 hours.⁴⁴⁰

Recommended treatment duration is 7–10 days for gastroenteritis or ≥14 days for bacteremic infections.⁴⁴⁰ Duration of 2–6 weeks recommended for recurrent infections.⁴⁴⁰

HIV-infected: 400 mg every 12 hours.⁴⁴⁰

Recommended treatment duration is 7–10 days for gastroenteritis or ≥14 days for bacteremic infections.⁴⁴⁰ Duration of 2–6 weeks recommended for recurrent infections.⁴⁴⁰

Cyclospora Infections†

Oral

500 mg twice daily for 7 days.¹³⁴

Cystoisospora Infections†

Oral

HIV-infected: 500 mg twice daily for 7 days.⁴⁴⁰

Chronic maintenance therapy (secondary prophylaxis) if CD4⁺ T-cells <200 cells/mm³: 500 mg 3 times weekly.⁴⁴⁰ Consider discontinuing if CD4⁺ T-cells remain >200 cells/mm³ for >6 months in response to antiretroviral therapy.⁴⁴⁰

Salmonella Gastroenteritis in HIV-infected Patients

Oral

500–750 mg every 12 hours.⁴⁴⁰

Recommended treatment 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/mm³.⁴⁴⁰

Consider secondary prophylaxis in those with recurrent bacteremia;⁴⁴⁰ also may consider in those with recurrent gastroenteritis (with or without bacteremia) or with CD4⁺ T-cells <200 cells/mm³ and severe diarrhea.⁴⁴⁰ Discontinue secondary prophylaxis if Salmonella infection resolves and there has been a sustained response to antiretroviral therapy with CD4⁺ T-cells >200 cells/mm³.⁴⁴⁰

400 mg every 12 hours.⁴⁴⁰

Recommended treatment 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/mm³.⁴⁴⁰

Shigella Infections

Oral

HIV-infected: 500–750 mg every 12 hours.⁴⁴⁰

Recommended treatment duration is 7–10 days for gastroenteritis or ≥14 days for bacteremic infections.⁴⁴⁰ Up to 6 weeks may be required for recurrent infections, especially if CD4⁺ T-cells <200 cells/mm³.⁴⁴⁰

HIV infected: 400 mg every 12 hours.⁴⁴⁰

Treatment of Travelers’ Diarrhea†

Oral

Conventional tablets or oral suspension: 500 once or twice daily for 1–3 days or 750 mg once daily for 1–3 days.³⁰⁵

Extended-release tablets: 500 mg or 1 g once daily for 1–3 days.³⁰⁵

HIV-infected (conventional tablets or oral suspension): 500–750 mg every 12 hours.⁴⁴⁰ If no clinical response after 3–4 days, consider stool culture and in vitro susceptibility testing.⁴⁴⁰

HIV-infected: 400 mg every 12 hours.⁴⁴⁰

If no clinical response after 3–4 days, consider stool culture and in vitro susceptibility testing.⁴⁴⁰

Prevention of Travelers’ Diarrhea†

Oral

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

Anti-infective prophylaxis generally discouraged (see GI Infections under Uses);³⁰⁵ ⁵²⁵ if such prophylaxis used, give during period of risk (not exceeding 2–3 weeks) beginning day of travel and continuing for 1 or 2 days after leaving area of risk.³⁰⁵ ⁶⁵⁰ ⁶⁵¹ ⁶⁷⁷

Intra-abdominal Infections

Complicated Infections

Oral

500 mg every 12 hours given in conjunction with metronidazole.¹

Manufacturers recommend total treatment duration of 7–14 days.¹ IDSA recommends treatment duration of 4–7 days;⁷⁷³ longer duration not associated with improved outcome and not recommended unless adequate source control difficult to achieve.⁷⁷³

400 mg IV every 12 hours given in conjunction with metronidazole.⁵⁷⁹

Manufacturers recommends total treatment duration 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†

400 mg every 8 hours has been used alone or in conjunction with an aminoglycoside.⁷⁶⁶ Alternatively, 800–1200 mg daily has been recommended.⁴¹⁸

Healthcare-associated ventriculitis and meningitis: IDSA recommends 800–1200 mg daily given in divided doses every 8–12 hours.⁴¹⁶

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 Ps. 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 Bacterial Sinusitis

Oral

500 mg every 12 hours for 10 days.¹ (See Respiratory Tract Infections under Uses.)

400 mg every 12 hours for 10 days.⁵⁷⁹ (See Respiratory Tract Infections under Uses.)

Lower Respiratory Tract Infections

Oral

500–750 mg every 12 hours for 7–14 days.¹

400 mg every 8 to 12 hours;⁵⁷⁹ use 400 mg IV every 8 hours for severe or complicated infections. Usual treatment duration is 7–14 days.⁵⁷⁹

Nosocomial Pneumonia

400 mg every 8 hours for HAP and VAP.³¹⁵ ⁵⁷⁹

Manufacturer recommends a treatment duration of 10–14 days.⁵⁷⁹ IDSA recommends treatment duration of 7 days, but longer or shorter duration may be indicated depending on clinical response.³¹⁵

Skin and Skin Structure Infections

Oral

500–750 mg every 12 hours for 7–14 days.¹

IV

400 mg every 8 to 12 hours for 7–14 days.⁵⁷⁹

Urinary Tract Infections (UTIs) and Prostatitis

Acute, Uncomplicated Cystitis

Oral

Conventional tablets or oral suspension: 250 mg every 12 hours for 3 days.¹ (See Urinary Tract Infections [UTIs] and Prostatitis under Uses.)

Extended-release tablets: 500 mg once every 24 hours for 3 days.⁸⁵⁶ (See Urinary Tract Infections [UTIs] and Prostatitis under Uses.)

Complicated UTIs and Pyelonephritis

Oral

Conventional tablets or oral suspension: 250–500 mg every 12 hours for 7–14 days.¹

Extended-release tablets: 1 g once every 24 hours for 7–14 days.⁸⁵⁶

200–400 mg every 8 or 12 hours for 7–14 days.⁵⁷⁹

Chronic Bacterial Prostatitis

Oral

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

400 mg every 12 hours for 28 days.⁵⁷⁹

Anthrax

Postexposure Prophylaxis of Anthrax (Biologic Warfare or Bioterrorism Exposure)

Oral

500 mg every 12 hours.¹ ⁶⁶⁸ ⁶⁷² ⁶⁷³ ⁶⁸³

Initiate prophylaxis as soon as possible following suspected or confirmed exposure.¹ ⁶⁶⁸ ⁶⁷³ ⁶⁸³

Because of possible persistence of B. anthracis spores in lung tissue following an aerosol exposure, CDC and others recommend that postexposure prophylaxis be continued for 60 days following a confirmed exposure (including in laboratory workers with confirmed exposures to B. anthracis cultures).⁶⁶⁸ ⁶⁷² ⁶⁷³ ⁶⁸³

400 mg every 12 hours for 60 days.⁵⁷⁹

Treatment of Systemic Anthrax (Biologic Warfare or Bioterrorism Exposure)†

400 mg IV every 8 hours.⁶⁷² ⁶⁷³

Used in multiple-drug parenteral regimen for initial treatment of systemic anthrax (inhalational, GI, meningitis, or cutaneous with systemic involvement, lesions on the head or neck, or extensive edema).⁶⁷² ⁶⁷³ Continue parenteral regimen for ≥2–3 weeks until patient is clinically stable and can be switched to appropriate oral anti-infective.⁶⁷² ⁶⁷³

If systemic anthrax occurred after exposure to B. anthracis spores in the context of biologic warfare or bioterrorism, continue oral follow-up regimen until 60 days after illness onset.⁶⁷² ⁶⁷³

Oral

500 mg every 12 hours given for ≥60 days.⁶⁶⁸

Initial multiple-drug parenteral regimen recommended;⁶⁶⁸ ⁶⁷² ⁶⁷³ ⁶⁸³ use oral regimen after clinical improvement occurs or when a parenteral regimen not available (e.g., mass casualty setting).⁶⁶⁸ ⁶⁷² ⁶⁷³ ⁶⁸³

Treatment of Uncomplicated Cutaneous Anthrax (Biologic Warfare or Bioterrorism Exposure)†

Oral

500 mg every 12 hours.⁶⁷² ⁶⁷³

Recommended duration is 60 days if cutaneous anthrax occurred after exposure to aerosolized B. anthracis spores in the context of biologic warfare or bioterrorism.⁶⁶⁸ ⁶⁷² ⁶⁷³ ⁶⁸³

Treatment of Uncomplicated Cutaneous Anthrax (Naturally Occurring or Endemic Exposure)†

Oral

500 mg every 12 hours.⁶⁸⁰

Duration of 3–10 days may be sufficient if uncomplicated cutaneous anthrax occurred as the result of naturally occurring or endemic exposure (e.g., known exposure to infected livestock or their products).⁶⁶⁸ ⁶⁷² ⁶⁷³ ⁶⁸⁰ ⁶⁸³

400 mg every 12 hours.⁶⁸⁰

Postexposure Prophylaxis Following Ingestion of B. anthracis Spores in Contaminated Meat†

Oral

500 mg every 12 hours has been recommended.⁶⁶²

Duration of 7–14 days can be considered for prophylaxis following a naturally occurring GI exposure (e.g., ingestion of meat from undercooked carcass of an anthrax-infected animal).⁶⁶³

Brucella Infections†

Oral

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

500 mg twice daily for 3 days recommended by CDC.³⁴⁴

Crohn’s Disease†

Oral

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

250 mg as a single dose recommended by manufacturer.¹

No longer recommended by CDC for treatment of gonorrhea.¹¹⁴ ³⁴⁴ ⁸³⁹ (See Gonorrhea and Associated Infections under Uses.)

Granuloma Inguinale (Donovanosis)†

Oral

750 mg twice daily for ≥3 weeks and until all lesions have healed completely;³⁴⁴ consider adding IV aminoglycoside (gentamicin 1 mg/kg IV every 8 hours) if improvement not evident within first few days of treatment.³⁴⁴

Relapse can occur 6–18 months after apparently effective treatment.³⁴⁴

Legionnaires’ Disease†

Oral

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

IV

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

Mycobacterial Infections†

Oral

750 mg twice daily has been used in multiple-drug regimens for treatment of infections caused by M. avium complex (MAC).⁶¹⁶ ⁶¹⁷ ⁶⁷⁵

Neisseria meningitidis Infections†

Elimination of Pharyngeal Carrier State†

Oral

500 mg as a single dose.³⁷⁶

Chemoprophylaxis in Household or Other Close Contacts†

Oral

500 mg as a single dose.³⁷⁶

Plague

Treatment of Plague

Oral

500–750 mg every 12 hours for 14 days.¹

Some experts (e.g., US Working Group on Civilian Biodefense, USAMRIID) recommend 500–750 mg twice daily for treatment of plague that occurs as the result of exposure to Y. pestis in the context of biologic warfare or bioterrorism.⁶⁸³ ⁶⁸⁸

Initial parenteral regimen preferred;⁶⁸³ ⁶⁸⁸ use oral regimen after clinical improvement occurs or when a parenteral regimen not available (e.g., mass casualty setting).⁶⁸³ ⁶⁸⁸ Total treatment duration should be at least 10–14 days.⁶⁸³ ⁶⁸⁸

IV, then Oral

400 mg IV every 8 to 12 hours for 14 days.⁵⁷⁹

Some experts (e.g., US Working Group on Civilian Biodefense, USAMRIID) recommend 400 mg IV every 12 hours for treatment of plague that occurs as the result of exposure to Y. pestis in the context of biologic warfare or bioterrorism.⁶⁸³ ⁶⁸⁸

When clinical improvement occurs, IV ciprofloxacin may be switched to oral ciprofloxacin.⁶⁸³ ⁶⁸⁸ Total treatment duration should be at least 10–14 days.⁶⁸³ ⁶⁸⁸

Postexposure Prophylaxis of Plague

Oral

500–750 mg every 12 hours for 14 days.¹

Some experts (e.g., US Working Group on Civilian Biodefense, USAMRIID) recommend 500 mg twice daily following exposures that occur in the context of biologic warfare or bioterrorism.⁶⁸³ ⁶⁸⁸

Initiate prophylaxis as soon as possible after suspected or confirmed exposure.¹

400 mg every 8 to 12 hours for 14 days.⁵⁷⁹

Tularemia†

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

Oral

500 mg twice daily.⁶⁸³ ⁶⁸⁹

Initial parenteral regimen preferred; use oral regimen after improvement occurs or when a parenteral regimen not available (e.g., mass casualty setting).⁶⁸³ ⁶⁸⁹ Total treatment duration should be at least 10–14 days.⁶⁸³ ⁶⁸⁹

IV, then Oral

400 mg IV every 12 hours.⁶⁸³ ⁶⁸⁹

When clinical improvement occurs, switch IV ciprofloxacin to oral ciprofloxacin.⁶⁸³ ⁶⁸⁹ Total treatment duration should be at least 10–14 days.⁶⁸³ ⁶⁸⁹

Postexposure Prophylaxis Following High-risk Exposure†

Oral

500 mg every 12 hours.⁶⁸³ ⁶⁸⁹

Initiate prophylaxis within 24 hours of exposure and continue for at least 14 days.⁶⁸³ ⁶⁸⁹

Typhoid Fever and Other Invasive Salmonella Infections

Mild to Moderate Typhoid Fever

Oral

500 mg every 12 hours for 10 days.¹

Chronic Typhoid Carriers†

Oral

750 mg every 12 hours for 28 days.³⁹¹ ⁴⁰³ ⁴³⁸ ⁴⁶⁶ ⁴⁷³

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.³⁶⁰ (See Perioperative Prophylaxis under Uses.)

IV

Single 400-mg dose given within 1–2 hours prior to the procedure or initial incision.³⁶⁰ (See Perioperative Prophylaxis under Uses.)

Empiric Therapy in Febrile Neutropenic Patients

IV

400 mg every 8 hours for 7–14 days;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

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

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

Treatment or Postexposure Prophylaxis of Anthrax or Plague

Oral

Neonates, infants, and children ≤17 years of age: Maximum 500 mg per dose.¹ ⁶⁶⁸ ⁶⁷¹

IV

Neonates, infants, and children ≤17 years of age: Maximum 400 mg per dose.⁵⁷⁹ ⁶⁶⁸ ⁶⁷¹

Special Populations

Hepatic Impairment

Manufacturers make no specific dosage recommendations for patients with impaired hepatic function.¹ ⁵⁷⁹ Carefully monitor patients who have both hepatic and renal impairment.⁵⁷⁹ (See Renal Impairment under Dosage and Administration.)

No clinically important pharmacokinetic changes in patients with stable chronic cirrhosis;¹ ⁵⁷⁹ ⁸⁵⁶ pharmacokinetics not fully studied in those with acute hepatic insufficiency.¹ ⁵⁷⁹ ⁸⁵⁶

Renal Impairment

Dosage adjustments may be necessary in adults with renal impairment, especially those with severe impairment.¹ ⁵⁷⁹ ⁸⁵⁶ Dosage recommendations not available for pediatric patients with moderate to severe renal impairment (Cl_cr <50 mL/minute per 1.73 m²).¹ ⁵⁷⁹

Conventional tablets or oral suspension: Decrease dosage in adults with Cl_cr ≤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 Ciprofloxacin Conventional Tablets or Oral Suspension in Adults with Renal Impairment1
Cl_cr (mL/minute)	Dosage
>50	No dosage adjustment
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: Dosage adjustments not needed when 500-mg extended-release tablet used for treatment of uncomplicated UTIs (acute cystitis) in adults with renal impairment.⁸⁵⁶ Decreased dosage recommended when used for treatment of complicated UTIs or acute uncomplicated pyelonephritis in adults with Cl_cr ≤30 mL/minute.⁸⁵⁶ (See Table 2.) Do not use 1-g extended-release tablets in adults who have Cl_cr ≤30 mL/minute or are undergoing hemodialysis or peritoneal dialysis.⁸⁵⁶

Table 2. Dosage of Ciprofloxacin Extended-release Tablets in Adults with Renal Impairment856
Cl_cr (mL/minute)	Dosage

≤30 (complicated UTIs 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 Cl_cr <30 mL/minute.⁵⁷⁹ (See Table 3.)

Table 3. Dosage of IV Ciprofloxacin in Adults with Renal Impairment579
Cl_cr (mL/min)	Dosage
>30	No dosage adjustment
5–29	200–400 mg every 18–24 hours

Geriatric Patients

No dosage adjustments except those related to renal impairment.¹ ⁵⁷⁹ ⁸⁵⁶ (See Renal Impairment under Dosage and Administration.)

Select dosage with caution because of possible age-related decreases in renal impairment.¹ ⁵⁷⁹ ⁸⁵⁶

Cautions for Ciprofloxacin

Contraindications

Known hypersensitivity to ciprofloxacin, any quinolone, or any ingredient in the formulation.¹ ⁵⁷⁹ ⁸⁵⁶
Concomitant use with tizanidine.¹ ⁵⁷⁹ ⁸⁵⁶ (See Interactions.)

Warnings/Precautions

Warnings

Disabling and Potentially Irreversible Serious Adverse Reactions

Systemic fluoroquinolones, including ciprofloxacin, associated with disabling and potentially irreversible serious adverse reactions (e.g., tendinitis and tendon rupture, peripheral neuropathy, CNS effects) that can occur together in the same patient.¹ ¹⁴⁰ ¹⁴⁵ ⁵⁷⁹ ⁸⁵⁶ May occur within hours to weeks after systemic fluoroquinolone initiated;¹ ⁵⁷⁹ ⁸⁵⁶ have occurred in all age groups and in patients without preexisting risk factors for such adverse reactions.¹ ⁵⁷⁹ ⁸⁵⁶

Immediately discontinue ciprofloxacin at first signs or symptoms of any serious adverse reactions.¹ ¹⁴⁰ ¹⁴⁵ ⁵⁷⁹ ⁸⁵⁶

Avoid systemic fluoroquinolones, including ciprofloxacin, in patients who have experienced any of the serious adverse reactions associated with fluoroquinolones.¹ ¹⁴⁰ ¹⁴⁵ ⁵⁷⁹ ⁸⁵⁶

Tendinitis and Tendon Rupture

Systemic fluoroquinolones, including ciprofloxacin, are associated with an increased risk of tendinitis and tendon rupture in all age groups.¹ ⁵⁷⁹ ⁸⁵⁶

Risk of fluoroquinolone-associated tendinitis and tendon rupture is increased in older adults (usually those >60 years of age), individuals receiving concomitant corticosteroids, and kidney, heart, or lung transplant recipients.¹ ⁵⁷⁹ ⁸⁵⁶ (See Geriatric Use under Cautions.)

Other factors that may independently increase the risk of tendon rupture include strenuous physical activity, renal failure, and previous tendon disorders such as rheumatoid arthritis.¹ ⁵⁷⁹ ⁸⁵⁶ Tendinitis and tendon rupture have been reported in patients receiving fluoroquinolones who did not have any risk factors for such adverse reactions.¹ ⁵⁷⁹ ⁸⁵⁶

Fluoroquinolone-associated tendinitis and tendon rupture most frequently involve the Achilles tendon;¹ ⁵⁷⁹ ⁸⁵⁶ also reported in rotator cuff (shoulder), hand, biceps, thumb, and other tendon sites.¹ ⁵⁷⁹ ⁸⁵⁶

Tendinitis or tendon rupture can occur within hours or days after ciprofloxacin initiated or as long as several months after completion of therapy and can occur bilaterally.¹ ⁵⁷⁹ ⁸⁵⁶

Immediately discontinue ciprofloxacin if pain, swelling, inflammation, or rupture of a tendon occurs.¹ ⁵⁷⁹ ⁸⁵¹ ⁸⁵² ⁸⁵⁶ (See Advice to Patients.)

Avoid systemic fluoroquinolones, including ciprofloxacin, in patients who have a history of tendon disorders or have experienced tendinitis or tendon rupture.¹ ⁵⁷⁹ ⁸⁵⁶

Peripheral Neuropathy

Systemic fluoroquinolones, including ciprofloxacin, are associated with an increased risk of peripheral neuropathy.¹ ⁵⁷⁹ ⁸⁵⁶

Sensory or sensorimotor axonal polyneuropathy affecting small and/or large axons resulting in paresthesias, hypoesthesias, dysesthesias, and weakness reported with systemic fluoroquinolones, including ciprofloxacin.¹ ¹³⁰ ⁵⁷⁹ ⁸⁵⁶ Symptoms may occur soon after initiation of the drug and, in some patients, may be irreversible.¹ ¹³⁰ ⁵⁷⁹ ⁸⁵⁶

Immediately discontinue ciprofloxacin if symptoms of peripheral neuropathy (e.g., pain, burning, tingling, numbness, and/or weakness) occur or if there are other alterations in sensations (e.g., light touch, pain, temperature, position sense, vibratory sensation) and/or motor strength.¹ ¹³⁰ ⁵⁷⁹ ⁸⁵⁶ (See Advice to Patients.)

Avoid systemic fluoroquinolones, including ciprofloxacin, in patients who have experienced peripheral neuropathy.¹ ⁵⁷⁹ ⁸⁵⁶

CNS Effects

Systemic fluoroquinolones, including ciprofloxacin, are associated with increased risk of adverse psychiatric effects, including toxic psychosis,¹ ⁵⁷⁹ psychotic reactions progressing to suicidal ideations/thoughts,¹ ⁵⁷⁹ hallucinations,¹ ⁵⁷⁹ paranoia,¹ ⁵⁷⁹ depression,¹ ⁵⁷⁹ self-injurious behavior such as attempted or completed suicide,¹ ⁵⁷⁹ anxiety,¹ ⁵⁷⁹ agitation,¹ ¹⁷¹ ⁵⁷⁹ delirium,¹ ¹⁷¹ ⁵⁷⁹ confusion,¹ ⁵⁷⁹ disorientation,¹ ¹⁷¹ ⁵⁷⁹ disturbances in attention,¹ ¹⁷¹ ⁵⁷⁹ nervousness,¹ ¹⁷¹ ⁵⁷⁹ insomnia,¹ ⁵⁷⁹ nightmares,¹ ⁵⁷⁹ and memory impairment.¹ ¹⁷¹ ⁵⁷⁹ These adverse effects may occur after first dose.¹ ⁵⁷⁹

Systemic fluoroquinolones, including ciprofloxacin, are associated with increased risk of seizures (convulsions), increased intracranial pressure (including pseudotumor cerebri), dizziness, and tremors.¹ ⁵⁷⁹ ⁸⁵⁶ Ciprofloxacin, like other fluoroquinolones, is known to trigger seizures or lower the seizure threshold.¹ ⁵⁷⁹ ⁸⁵⁶ Status epilepticus reported.¹ ⁵⁷⁹ ⁸⁵⁶

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 convulsions, reduced cerebral blood flow, altered brain structure, stroke) or other risk factors that may predispose to seizures or lower seizure threshold (e.g., certain drug therapy, renal dysfunction).¹ ⁵⁷⁹ ⁸⁵⁶

If psychiatric or other CNS effects occur, immediately discontinue ciprofloxacin and institute appropriate measures.¹ ⁵⁷⁹ ⁸⁵⁶ (See Advice to Patients.)

Exacerbation of Myasthenia Gravis

Fluoroquinolones, including ciprofloxacin, have neuromuscular blocking activity and may exacerbate muscle weakness in myasthenia gravis patients;¹ ⁵⁷⁹ ⁸⁵⁶ death or need for ventilatory support reported.¹ ⁵⁷⁹ ⁸⁵⁶

Avoid use in patients with known history of myasthenia gravis.¹ ⁵⁷⁹ ⁸⁵⁶ (See Advice to Patients.)

Sensitivity Reactions

Hypersensitivity Reactions

Serious and occasionally fatal hypersensitivity (anaphylactic) reactions reported in patients receiving fluoroquinolones, including ciprofloxacin.¹ ⁵⁷⁹ ⁸⁵⁶ These reactions may occur with first dose.¹ ⁵⁷⁹ ⁸⁵⁶

Some hypersensitivity reactions have been accompanied by cardiovascular collapse, loss of consciousness, tingling, pharyngeal or facial edema, dyspnea, urticaria, and itching.¹ ⁵⁷⁹ ⁸⁵⁶

Other serious and sometimes fatal adverse reactions reported with fluoroquinolones, including ciprofloxacin, that may or may not be related to hypersensitivity reactions include one or more of the following: fever, rash or other severe dermatologic reactions (e.g., toxic epidermal necrolysis, Stevens-Johnson syndrome); vasculitis, arthralgia, myalgia, serum sickness; allergic pneumonitis; interstitial nephritis, acute renal insufficiency or failure; hepatitis, jaundice, acute hepatic necrosis or failure; anemia (including hemolytic and aplastic), thrombocytopenia (including thrombotic thrombocytopenic purpura), leukopenia, agranulocytosis, pancytopenia, and/or other hematologic effects.¹ ⁵⁷⁹ ⁸⁵⁶

Immediately discontinue ciprofloxacin at first appearance of rash, jaundice, or any other sign of hypersensitivity.¹ ⁵⁷⁹ ⁸⁵⁶ Initiate appropriate therapy (e.g., epinephrine, corticosteroids, maintenance of an adequate airway and oxygen) as indicated.¹ ⁵⁷⁹ ⁸⁵⁶

Photosensitivity Reactions

Moderate to severe photosensitivity/phototoxicity reactions reported with fluoroquinolones, including ciprofloxacin.¹ ⁵⁷⁹ ⁸⁵⁶

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).¹ ⁵⁷⁹ ⁸⁵⁶

Avoid unnecessary or excessive exposure to sunlight or artificial UV light (sunlamps, tanning beds, UVA/UVB treatment) while receiving ciprofloxacin.¹ ⁵⁷⁹ ⁸⁵⁶ If patient needs to be in sunlight, they should use sunscreen and wear a hat and clothing that protects skin from sun exposure.¹ ⁵⁷⁹ ⁸⁵⁶ (See Advice to Patients.)

Discontinue ciprofloxacin if photosensitivity or phototoxicity (sunburn-like reaction, skin eruption) occurs.¹ ⁵⁷⁹ ⁸⁵⁶

Other Warnings/Precautions

Hepatotoxicity

Severe hepatotoxicity, including hepatic necrosis, life-threatening hepatic failure, and fatal events, reported.¹ ⁵⁷⁹ ⁸⁵⁶ Most fatalities have occurred in adults >55 years of age.¹ ⁵⁷⁹ ⁸⁵⁶

Acute liver injury has rapid onset (range 1–39 days) and is often associated with hypersensitivity.¹ ⁵⁷⁹ ⁸⁵⁶ Pattern of injury can be hepatocellular, cholestatic, or mixed.¹ ⁵⁷⁹ ⁸⁵⁶

Temporary increases in aminotransferase or alkaline phosphatase concentrations or cholestatic jaundice may occur, especially in patients with previous liver damage.¹ ⁵⁷⁹ ⁸⁵⁶

Immediately discontinue ciprofloxacin if any signs or symptoms of hepatitis (e.g., anorexia, jaundice, dark urine, pruritus, tender abdomen) occur.¹ ⁵⁷⁹ ⁸⁵⁶ (See Advice to Patients.)

Risk of Aortic Aneurysm and Dissection

Rupture or dissection of aortic aneurysms reported in patients receiving systemic fluoroquinolones.¹⁷² Epidemiologic studies indicate an increased risk of aortic aneurysm and dissection within 2 months following use of systemic fluoroquinolones, particularly in elderly patients.¹ ⁵⁷⁹ Cause for this increased risk not identified.¹ ¹⁷² ⁵⁷⁹

Unless there are no other treatment options, do not use systemic fluoroquinolones, including ciprofloxacin, in patients who have an aortic aneurysm or are at increased risk for an aortic aneurysm.¹ ¹⁷² ⁵⁷⁹ This includes elderly patients and patients with peripheral atherosclerotic vascular disease, hypertension, or certain genetic conditions (e.g., Marfan syndrome, Ehlers-Danlos syndrome).¹⁷²

If patient reports adverse effects suggestive of aortic aneurysm or dissection, immediately discontinue the fluoroquinolone.¹⁷² (See Advice to Patients.)

Prolongation of QT Interval

Prolonged QT interval leading to ventricular arrhythmia, including torsades de pointes, reported with fluoroquinolones, including ciprofloxacin.¹ ⁵⁷⁹ ⁸⁵⁶

Avoid use in patients with history of 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).¹ ⁵⁷⁹ ⁸⁵⁶

Avoid in patients receiving class IA (e.g., quinidine, procainamide) or III (e.g., amiodarone, sotalol) antiarrhythmic agents or other drugs known to prolong QT interval (e.g., macrolides, antipsychotic agents, tricyclic antidepressants).¹ ⁵⁷⁹ ⁸⁵⁶

Risk of prolonged QT interval may be increased in geriatric patients.¹ ⁵⁷⁹ ⁸⁵⁶ (See Geriatric Use under Cautions.)

Hypoglycemia or Hyperglycemia

Systemic fluoroquinolones are associated with alterations in blood glucose concentrations, including symptomatic hypoglycemia and hyperglycemia.¹ ¹⁷¹ ⁵⁷⁹ Blood glucose disturbances during fluoroquinolone therapy usually have occurred in patients with diabetes mellitus receiving an oral antidiabetic agent (e.g., glyburide) or insulin.¹ ¹⁷¹ ⁵⁷⁹

Severe cases of hypoglycemia resulting in coma or death reported with some systemic fluoroquinolones.¹ ¹⁷¹ ⁵⁷⁹ Although most reported cases of hypoglycemic coma involved patients with risk factors for hypoglycemia (e.g., older age, diabetes mellitus, renal insufficiency, concomitant use of antidiabetic agents [especially sulfonylureas]), some involved patients receiving a fluoroquinolone who were not diabetic and not receiving an oral antidiabetic agent or insulin.¹⁷¹

Carefully monitor blood glucose concentrations when ciprofloxacin used in diabetic patients receiving antidiabetic agents.¹ ¹⁷¹ ⁵⁷⁹

If hypoglycemic reaction occurs, discontinue ciprofloxacin and immediately initiate appropriate therapy.¹ ⁵⁷⁹ (See Advice to Patients.)

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.¹ ⁵⁷⁹ ⁸⁵⁶ Usually mild to moderate in intensity; events occurring within first 6 weeks of ciprofloxacin treatment usually resolve (clinical resolution of signs and symptoms) within 30 days after treatment ends.¹ ⁵⁷⁹ Use ciprofloxacin 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.¹ ¹⁸³ ¹⁸⁶ ²¹³ ⁴⁵⁵ ⁴⁷⁹ ⁵⁷⁹ ⁸⁴¹ ⁸⁴² ⁸⁴³ ⁸⁴⁴ ⁸⁴⁵ ⁸⁴⁶ ⁸⁴⁷ ⁸⁴⁸ ⁸⁴⁹ ⁸⁵⁰ ⁸⁵⁶ Permanent lesions of the cartilage and lameness reported in ciprofloxacin studies in immature dogs.¹ ⁵⁷⁹ ⁸⁵⁶

Superinfection/C. difficile-associated Diarrhea and Colitis

Possible emergence and overgrowth of nonsusceptible bacteria or fungi.²⁹⁷ ³⁰⁰ ³³⁸ ³⁴⁶ ³⁴⁸ ³⁹⁰ ⁴²⁶ ⁴⁶⁶ ⁴⁷⁹ ⁸⁵⁶

Treatment with anti-infectives alters normal colon flora and may permit overgrowth of Clostridioides difficile (formerly known as Clostridium difficile).¹ ³⁰² ³⁰³ ³⁰⁴ ³⁴⁸ ⁵⁷⁹ ⁷⁹⁶ ⁸⁵⁶ 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.¹ ³⁰² ³⁰³ ³⁰⁴ ⁵⁷⁹ ⁷⁹² ⁷⁹³ ⁷⁹⁷ ⁷⁹⁸ ⁸⁵⁶ 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.¹ ⁵⁷⁹ ⁸⁵⁶

Consider CDAD if diarrhea develops during or after therapy and manage accordingly.¹ ³⁰² ³⁰³ ³⁰⁴ ⁵⁷⁹ ⁸⁵⁶ Obtain careful medical history since CDAD may occur as late as 2 months or longer after anti-infective therapy is discontinued.¹ ³⁰² ³⁰³ ³⁰⁴ ⁵⁷⁹ ⁸⁵⁶

If CDAD suspected or confirmed, discontinue anti-infectives not directed against C. difficile as soon as possible.³⁰² Manage using appropriate anti-infective therapy directed against C. difficile (e.g., vancomycin, fidaxomicin, metronidazole), supportive therapy (e.g., fluid and electrolyte management, protein supplementation), and surgical evaluation as clinically indicated.¹ ³⁰² ³⁰³ ³⁰⁴ ⁵⁷⁹ ⁵⁷⁹ ⁸⁵⁶

Interactions

Pharmacokinetic interaction with CYP1A2 substrates (e.g., clozapine, methylxanthines [e.g., caffeine, theophylline], olanzapine, ropinirole, tizanidine).¹ ⁵⁷⁹ ⁸⁵⁶

Concomitant use with tizanidine contraindicated.¹ ⁵⁷⁹ ⁸⁵⁶ Avoid concomitant use with theophylline since serious and sometimes fatal reactions (e.g., cardiac arrest, seizure, status epilepticus, respiratory failure) reported.¹ ¹⁹⁵ ²⁹⁷ ⁵⁵² ⁵⁷⁹ ⁸⁵⁶ In addition, concomitant use with other CYP1A2 substrates should be avoided or requires particular caution.¹ ⁵⁷⁹ ⁸⁵⁶ (See Specific Drugs under Interactions.)

Renal Effects

Possible crystalluria;¹ ²³⁴ ³³⁹ ³⁵⁵ ³⁷³ ⁴²⁶ ⁴⁶⁶ ⁴⁷⁹ ⁵⁷⁹ ⁸⁵⁶ generally associated with alkaline urine and high dosage.¹ ¹⁸³ ¹⁸⁸ ⁴⁵⁵ ⁴⁷⁹ ⁵⁷⁹ ⁸⁵⁶

Adequate fluid intake necessary to ensure proper hydration and adequate urinary output;¹ ⁴⁵⁵ ⁵⁷⁹ ⁸⁵⁶ avoid alkaline urine.¹ ⁴⁵⁵ ⁵⁷⁹ ⁸⁵⁶

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.¹¹⁴ ³⁴⁴ ⁶³² ⁶³⁴ ⁶³⁵ ⁶³⁷ ⁶³⁸ ⁶³⁹ ⁶⁶⁹ ⁷⁵⁴ ⁸⁵⁷

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.¹¹⁴ ⁸⁵⁷

CDC states that fluoroquinolones, including ciprofloxacin, are no longer recommended for treatment of gonorrhea and should not be used routinely for any associated infections that may involve N. gonorrhoeae (e.g., PID, epididymitis).¹¹⁴ ³⁴⁴ ⁸³⁹

Selection and Use of Anti-infectives

Use for treatment of acute bacterial sinusitis, acute bacterial exacerbations of chronic bronchitis, or uncomplicated UTIs only when no other treatment options available.¹ ¹⁴⁰ ¹⁴⁵ ⁵⁷⁹ ⁸⁵⁶ Because ciprofloxacin, like other systemic fluoroquinolones, has been associated with disabling and potentially irreversible serious adverse reactions (e.g., tendinitis and tendon rupture, peripheral neuropathy, CNS effects) that can occur together in the same patient, risks of serious adverse reactions outweigh benefits for patients with these infections.¹⁴⁰ ¹⁴⁵

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.¹ ⁵⁷⁹ ⁸⁵⁶

When selecting or modifying anti-infective therapy, use results of culture and in vitro susceptibility testing.¹ ⁵⁷⁹ ⁸⁵⁶ In the absence of such data, consider local epidemiology and susceptibility patterns when selecting anti-infectives for empiric therapy.¹ ⁵⁷⁹ ⁸⁵⁶

Information on test methods and quality control standards for in vitro susceptibility testing of antibacterial agents and specific interpretive criteria for such testing recognized by FDA is available at [Web].¹

Specific Populations

Pregnancy

No adequate and controlled studies in pregnant women;¹ ⁵⁷⁹ ⁸⁵⁶ expert review of published data concluded that therapeutic doses of ciprofloxacin during pregnancy unlikely to pose a substantial teratogenic risk, but data insufficient to state that there is no risk.¹ ⁵⁷⁹ ⁸⁵⁶

Use during pregnancy only if potential benefits justify potential risks to fetus and mother.¹ ⁵⁷⁹ ⁸⁵⁶

CDC states oral ciprofloxacin is preferred drug for initial anti-infective postexposure prophylaxis in pregnant and postpartum women exposed to B. anthracis spores in the context of biologic warfare or bioterrorism.⁶⁷² CDC also states oral ciprofloxacin is preferred drug for treatment of uncomplicated cutaneous anthrax and IV ciprofloxacin is preferred bactericidal component of multiple-drug regimens for treatment of systemic anthrax in pregnant and postpartum women.⁶⁷²

Animal studies (rats and mice) using oral ciprofloxacin did not reveal evidence of harm to the fetus.¹ ⁵⁷⁹ ⁸⁵⁶ In rabbits, oral ciprofloxacin caused GI toxicity resulting in maternal weight loss and increased incidence of abortion, but no evidence of teratogenicity;¹ ⁵⁷⁹ ⁸⁵⁶ IV ciprofloxacin did not result in maternal toxicity, embryotoxicity, or teratogenicity.¹ ⁵⁷⁹

Lactation

Distributed into milk;¹ ⁵⁶⁷ ⁵⁷⁹ ⁸³⁰ ⁸⁵⁶ discontinue nursing or the drug.¹ ⁵⁷⁹ ⁸⁵⁶

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

CDC states recommendations for use of ciprofloxacin in breast-feeding women for postexposure prophylaxis following a suspected or confirmed exposure to aerosolized B. anthracis spores in the context of biologic warfare or bioterrorism and treatment of uncomplicated cutaneous anthrax or systemic anthrax in such situations are the same as those for other adults.⁶⁷²

Pediatric Use

Ciprofloxacin causes arthropathy and histologic changes in weight-bearing joints of juvenile animals.¹ ⁵⁷⁹ ⁸⁵⁶ An increased incidence of musculoskeletal disorders related to joints and/or surrounding tissues reported in pediatric patients.¹ ⁵⁷⁹ (See Musculoskeletal Effects under Cautions.)

IV, conventional tablets, oral suspension: Labeled by FDA for treatment of complicated UTIs and pyelonephritis caused by susceptible E. coli in pediatric patients 1–17 years of age, inhalational anthrax (postexposure) in infants and children ≤17 years of age, and treatment or prophylaxis of plague in infants and children ≤17 years of age.¹ ⁵⁷⁹ Safety and efficacy not established for any other indication in pediatric patients.¹ ⁵⁷⁹

AAP and other experts (e.g., AHA, IDSA) state that use of ciprofloxacin (IV, conventional tablets, oral suspension) may also be justified in children <18 years of age in certain specific circumstances when there are no safe and effective alternatives (e.g., endocarditis, typhoid fever, multidrug-resistant gram-negative infections) and after careful assessment of the risks and benefits for the individual patient.²⁹² ²⁹³ ⁴⁵⁰ ⁵²² ⁶⁵⁴

Extended-release tablets: Safety and efficacy not established for any indication in children and adolescents <18 years of age;⁸⁵⁶ do not use for any indication in pediatric patients.⁸⁵⁶

Geriatric Use

Retrospective analysis of controlled clinical trials and results of a prospective, randomized study indicate no substantial differences in safety and efficacy relative to younger adults, but increased sensitivity cannot be ruled out.¹ ⁵⁷⁹ ⁸⁵⁶

Risk of fluoroquinolone-associated disorders, including tendon rupture, is increased in geriatric adults >60 years of age.¹ ⁵⁷⁹ ⁸⁵¹ ⁸⁵² ⁸⁵⁶ This risk is further increased in those receiving concomitant corticosteroids.¹ ⁵⁷⁹ ⁸⁵¹ ⁸⁵² ⁸⁵⁶ (See Tendinitis and Tendon Rupture under Cautions.) Use caution in geriatric adults, especially those receiving concomitant corticosteroids.¹ ⁵⁷⁹ ⁸⁵⁶

Risk of prolonged QT interval leading to ventricular arrhythmias may be increased in geriatric patients.¹ ⁵⁷⁹ ⁸⁵⁶ 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).¹ ⁵⁷⁹ ⁸⁵⁶

Risk of fluoroquinolone-associated aortic aneurysm and dissection may be increased in geriatric patients.¹ (See Risk of Aortic Aneurysm and Dissection under Cautions.)

Age-related decline in renal function may increase risk of adverse reactions.¹ ⁵⁷⁹ ⁸⁵⁶

Hepatic Impairment

Carefully monitor patients with both hepatic and renal impairment.⁵⁷⁹

Renal Impairment

Increased ciprofloxacin concentrations and prolonged half-life;¹ ¹⁸⁰ ²⁰⁵ ²¹⁴ ²³⁷ ²⁵⁴ ²⁵⁵ ²⁵⁶ ²⁵⁷ ²⁶⁰ ⁴⁷⁹ ⁵²⁴ ⁵³⁴ ⁸⁵⁶ possible increased risk of adverse reactions.¹ ⁵²⁴

Dosage adjustments necessary in patients with renal impairment.¹ ⁵⁷⁹ ⁸⁵⁶ (See Renal Impairment under Dosage and Administration.)

Carefully monitor patients with both hepatic and renal impairment.⁵⁷⁹

Common Adverse Effects

GI effects (nausea, diarrhea, vomiting, abdominal pain/discomfort), headache, dizziness, restlessness, rash.¹ ¹⁷⁸ ¹⁸³ ²⁸⁹ ²³⁷ ²⁹⁷ ³⁰¹ ³⁰⁷ ³⁰⁸ ³¹⁷ ³²⁹ ³³⁶ ³⁶³ ⁴²⁴ ⁴²⁵ ⁴²⁶ ⁴²⁸ ⁴⁶² ⁴⁶⁶ ⁴⁷³ ⁴⁷⁸ ⁴⁷⁹ ⁵⁷⁹ ⁸⁵⁶

Drug Interactions

Inhibits CYP1A2.¹ ⁵⁷⁹ ⁸⁵⁶

Drugs Metabolized by Hepatic Microsomal Enzymes

Potential pharmacokinetic interaction with CYP1A2 substrates (increased concentrations and increased pharmacologic or adverse effects of CYP1A2 substrate).¹ ⁵⁷⁹ ⁸⁵⁶

Drugs that Prolong QT Interval

Potential pharmacologic interactions (additive effect on QT interval prolongation).¹ ⁵⁷⁹ ⁸⁵⁶ Avoid use in patients receiving drugs known to prolong QT interval.¹ ⁵⁷⁹ ⁸⁵⁶ If concomitant use necessary, use with caution.¹ ⁵⁷⁹ ⁸⁵⁶ (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;¹¹⁶ ¹²⁹ ⁴⁷⁹ synergism unpredictable⁸⁵ ¹²⁶ ¹²⁹ ¹³⁵ ²⁰⁵ ⁴⁷⁹
Antacids (aluminum-, magnesium-, or calcium-containing)	Decreased absorption of oral ciprofloxacin¹ ⁸¹ ¹⁹⁰ ¹⁹⁶ ²⁰² ²⁰³ ²⁰⁸ ⁵³⁶ ⁵⁴⁰ ⁵⁹⁷ ⁵⁹⁸ ⁸²⁴ ⁸⁵⁶	Administer ciprofloxacin tablets, extended-release tablets, or oral suspension at least 2 hours before or 6 hours after such antacids¹ ⁸⁵⁶
Antiarrhythmic agents (class IA [e.g., quinidine, procainamide], class III [e.g., amiodarone, sotalol])	Possible additive effect on QT interval prolongation¹ ⁵⁷⁹ ⁸⁵⁶	Avoid concomitant use¹ ⁵⁷⁹ ⁸⁵⁶
Anticoagulants, oral (warfarin)	Potential for enhanced warfarin effects¹ ⁵⁵⁸ ⁸²³ ⁸⁵⁶	Use concomitantly with caution;¹ ⁵⁵⁸ ⁵⁷⁹ ⁸²³ ⁸⁵⁶ monitor PT and INR frequently during and shortly after concomitant therapy¹ ⁵⁵⁸ ⁵⁷⁹ ⁸²³ ⁸⁵⁶
Antidepressants, tricyclic	Agents that prolong QT interval: Possible additive effect on QT interval prolongation¹ ⁵⁷⁹ ⁸⁵⁶	Avoid concomitant use¹ ⁵⁷⁹ ⁸⁵⁶
Antidiabetic agents, sulfonylureas (glimepiride, glyburide)	Severe hypoglycemia, including some fatalities, reported¹ ⁵⁷⁹ ⁸⁵⁶	Use concomitantly with caution;¹ ⁵⁷⁹ ⁸⁵⁶ monitor blood glucose concentrations¹ ⁵⁷⁹ ⁸⁵⁶
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 ⁵⁷⁹ ⁸⁵⁶	Avoid concomitant use¹ ⁵⁷⁹ ⁸⁵⁶
β-lactam antibiotics	In vitro evidence of additive or synergistic antibacterial effects against Ps aeruginosa;¹¹⁶ ¹¹⁷ ¹¹⁸ ¹¹⁹ ¹²⁴ ¹³² ⁴³⁰ ⁴³⁴ ⁴⁷⁹ 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 ¹⁸⁵ ¹⁹⁴ ⁴⁷⁹ ⁵¹³ ⁵¹⁴ ⁵¹⁵ ⁵²⁸ ⁵⁴¹ ⁵⁷⁷ ⁵⁷⁹ ⁸⁵⁶	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 ⁵¹³ ⁵²⁸ ⁵⁷⁷ ⁵⁷⁹ ⁸⁵⁶ 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;¹ ⁵⁷⁹ ⁷⁷⁵ ⁸²² ⁸⁵⁶ possible increased adverse effects⁷⁷⁵ ⁸²²	Use concomitantly with caution;¹ ⁵⁷⁹ ⁸⁵⁶ carefully monitor for clozapine adverse effects and make appropriate clozapine dosage adjustments during and shortly after concomitant therapy¹ ⁵⁷⁹ ⁸⁵⁶
Corticosteroids	Increased risk of tendinitis or tendon rupture, especially in patients >60 years of age¹ ⁵⁷⁹ ⁸⁵¹ ⁸⁵² ⁸⁵⁶
Cyclosporine	Possible additive nephrotoxic effects or interference with metabolism of cyclosporine;⁵³⁹ transiently increased S_cr reported¹ ⁵⁷⁹ ⁸⁵⁶	Use concomitantly with caution;¹ ⁵⁷⁹ ⁸⁵⁶ monitor renal function (especially S_cr)¹ ⁵⁷⁹ ⁸⁵⁶
Didanosine	Decreased absorption of oral ciprofloxacin with buffered didanosine preparations¹ ⁸⁵⁶	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)¹ ⁸⁵⁶
Duloxetine	Possible increased concentrations and AUC of duloxetine¹ ⁵⁷⁹ ⁸⁵⁶	Avoid concomitant use;¹ ⁵⁷⁹ ⁸⁵⁶ if concomitant use cannot be avoided, monitor for duloxetine toxicity¹ ⁵⁷⁹ ⁸⁵⁶
Histamine H₂-receptor antagonists (cimetidine, ranitidine)	No evidence of pharmacokinetic interaction³³⁹ ⁴⁷⁴ ⁸²⁴
Iron preparations	Decreased absorption of oral ciprofloxacin¹ ⁸⁵⁶	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 ⁸⁵⁶
Lanthanum	Possible decreased GI absorption and substantially decreased serum and urine concentrations of ciprofloxacin¹ ⁸⁵⁶	Administer ciprofloxacin tablets, extended-release tablets, or oral suspension at least 2 hours before or 6 hours after lanthanum¹ ⁸⁵⁶
Lidocaine (systemic)	Increased concentrations and AUC of lidocaine;¹ ⁵⁷⁹ ⁸⁵⁶ possible increased lidocaine adverse effects¹ ⁵⁷⁹ ⁸⁵⁶
Macrolides	Agents that prolong QT interval: Possible additive effect on QT interval prolongation¹ ⁵⁷⁹ ⁸⁵⁶	Avoid concomitant use¹ ⁵⁷⁹ ⁸⁵⁶
Methotrexate	Possible increased methotrexate concentrations and increased risk of methotrexate-associated toxic reactions¹ ⁵⁷⁹ ⁸⁵⁶	Use concomitantly with caution;¹ ⁵⁷⁹ ⁸⁵⁶ monitor closely¹ ⁵⁷⁹ ⁸⁵⁶
Metoclopramide	Increased rate of absorption of oral ciprofloxacin;¹ ⁸¹ ⁴⁷⁴ ⁴⁷⁹ ⁵⁷⁹ ⁸⁵⁶ effect on ciprofloxacin bioavailability not clinically important¹ ⁵⁷⁹ ⁸⁵⁶
Metronidazole	No effect on concentrations of either drug¹ ⁵⁷⁹ ⁸⁵⁶
Multivitamins and mineral supplements	Decreased absorption of oral ciprofloxacin¹ ⁸⁵⁶	Administer ciprofloxacin tablets, extended-release tablets, or oral suspension at least 2 hours before or 6 hours after supplements containing calcium, zinc, or iron¹ ⁸⁵⁶
NSAIAs	Possible increased risk of seizures;¹ ⁵⁷⁹ ⁸¹⁵ ⁸⁵⁶ animal studies suggest risk may vary depending on the specific NSAIA⁸¹⁵	Use concomitantly with caution¹ ⁵⁷⁹ ⁸⁵⁶
Olanzapine	Possible increased olanzapine concentrations and increased pharmacologic or adverse effects¹ ⁵⁷⁹ ⁸⁵⁶
Omeprazole	Decreased concentrations and AUC of ciprofloxacin¹ ⁸⁵⁶	Clinical importance unknown¹ ⁸⁵⁶
Pentoxifylline	Increased pentoxifylline concentrations; possible increased pharmacologic or adverse effects¹ ⁵⁷⁹ ⁸⁵⁶
Phenytoin	Possible altered (increased or decreased) phenytoin concentrations¹ ⁵⁷⁹ ⁸⁵⁶	Use concomitantly with caution;¹ ⁵⁷⁹ ⁸⁵⁶ monitor phenytoin concentrations during and shortly after concomitant therapy¹ ⁵⁷⁹ ⁸⁵⁶
Probenecid	Decreased clearance of ciprofloxacin and increased ciprofloxacin concentrations;¹ ⁸¹ ⁸⁵⁶ may potentiate ciprofloxacin toxicity¹ ⁵⁷⁹ ⁸⁵⁶	Use concomitantly with caution¹ ⁵⁷⁹ ⁸⁵⁶
Rifampin	Does not appear to affect pharmacokinetics of either drug⁸³² In vitro evidence of indifferent against S. aureus; antagonism reported rarely.¹¹⁵ ⁴⁷⁹ ⁵⁵⁷
Ropinirole	Increased ropinirole concentrations and AUC¹ ⁵⁷⁹ ⁸³⁶ ⁸⁵⁶	Use concomitantly with caution;¹ ⁵⁷⁹ ⁸⁵⁶ monitor for ropinirole adverse effects and adjust ropinirole dosage as needed during and shortly after concomitant therapy¹ ⁵⁷⁹ ⁸⁵⁶
Sevelamer	Possible decreased GI absorption and substantially decreased serum and urine concentrations of ciprofloxacin¹ ⁸⁵⁶	Administer ciprofloxacin tablets, extended-release tablets, or oral suspension at least 2 hours before or 6 hours after sevelamer¹ ⁸⁵⁶
Sildenafil	Increased peak concentration and AUC of sildenafil¹ ⁵⁷⁹ ⁸⁵⁶	Use concomitantly with caution;¹ ⁵⁷⁹ ⁸⁵⁶ monitor for sildenafil toxicity¹ ⁵⁷⁹ ⁸⁵⁶
Sucralfate	Possible decreased GI absorption and decreased concentrations of ciprofloxacin ¹ ⁸²⁵ ⁸⁵⁶	Administer ciprofloxacin tablets, extended-release tablets, or oral suspension at least 2 hours before or 6 hours after sucralfate¹ ⁸⁵⁶
Tizanidine	Increased peak concentration and AUC of tizanidine; hypotensive and sedative effects of tizanidine potentiated¹ ⁵⁷⁹ ⁸⁵⁶	Concomitant use contraindicated¹ ⁵⁷⁹ ⁸⁵⁶
Theophylline	Possible increased theophylline concentrations and increased risk of theophylline-related adverse effects;¹ ¹⁹³ ¹⁹⁸ ²⁰⁰ ²⁰⁴ ²¹⁶ ⁴²¹ ⁵⁰⁶ ⁵⁰⁷ ⁵⁰⁸ ⁵⁰⁹ ⁵¹⁰ ⁵¹¹ ⁵⁵² ⁵⁷⁹ ⁸⁵⁶ serious and fatal reactions reported¹ ¹⁹⁵ ²⁹⁷ ⁵⁵² ⁵⁷⁹ ⁸⁵⁶	Avoid concomitant use¹ ¹⁸⁰ ⁵⁰⁹ ⁵⁵² ⁵⁷⁹ ⁸⁵⁶ If used concomitantly, closely monitor patient and theophylline concentrations and make appropriate theophylline dosage adjustments as needed, especially in geriatric patients¹ ¹⁸⁵ ¹⁹³ ¹⁹⁹ ²⁰⁰ ²⁰⁴ ²¹⁶ ³⁵⁵ ⁴⁶⁶ ⁵⁰⁶ ⁵⁰⁷ ⁵⁰⁸ ⁵⁰⁹ ⁵¹⁰ ⁵¹¹ ⁵²⁷ ⁵²⁸ ⁵⁵² ⁵⁷⁹ ⁸⁵⁶
Zolpidem	Possible increased zolpidem concentrations¹	Concomitant use not recommended¹

Ciprofloxacin Pharmacokinetics

Absorption

Bioavailability

Rapidly and well absorbed from GI tract;¹ ¹⁷⁷ ¹⁷⁸ ¹⁸⁰ ¹⁸² ²¹² ²¹⁴ ²²⁶ ²²⁹ ²⁷² ²⁸¹ ²⁸⁶ ⁴⁷⁹ undergoes minimal first-pass metabolism.¹ ¹⁸² ²⁰⁵ ²¹⁴ ⁴¹² ⁴⁷⁹ ⁵³⁴

Oral bioavailability of conventional tablets is 50–85% in healthy, fasting adults;¹ ¹⁷⁷ ¹⁷⁸ ¹⁸⁰ ²¹² ²¹⁴ ²³⁵ ²³⁶ ²³⁸ ²⁸¹ ⁴¹² ⁴⁷⁴ ⁴⁷⁹ peak serum concentrations attained within 0.5–2.3 hours.¹ ¹⁷⁸ ¹⁸⁰ ¹⁸² ²¹² ²¹⁴ ²¹⁵ ²¹⁹ ²²⁰ ²²¹ ²²³ ²²⁴ ²²⁹ ²³⁰ ²³³ ²³⁴ ²³⁵ ²³⁷ ²³⁸ ²³⁹ ²⁶² ²⁸¹ ⁴⁷⁴ ⁴⁷⁹ ⁵³¹

A 500-mg dose given as the oral suspension containing 250 mg/5 mL is bioequivalent to a 500-mg conventional tablet.¹ A 500-mg dose given as 10 mL of the oral suspension containing 250 mg/5 mL is bioequivalent to 500-mg dose given as 5 mL of the oral suspension containing 500 mg/5 mL.¹

Extended-release tablets: Peak plasma concentrations attained within 1–4 hours.⁸⁵⁶ Extended-release tablets contain approximately 35% of the dose within an immediate-release component; the remaining 65% is contained in a slow-release matrix.⁸⁵⁶

Extended-release tablets are not bioequivalent to conventional tablets.⁸⁵⁶

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 ⁸¹ ¹⁷⁷ ¹⁷⁸ ¹⁸⁰ ¹⁸² ²¹⁴ ²¹⁹ ²⁴⁰ ⁴¹² ⁴⁷⁴ ⁴⁷⁹ ⁷⁹¹ ⁸¹⁰

Administration of ciprofloxacin conventional tablets with food results in a delay in absorption of the drug, but overall absorption not substantially affected.¹ ⁸¹ ¹⁷⁷ ¹⁷⁸ ¹⁸⁰ ¹⁸² ²¹⁴ ²¹⁹ ²⁴⁰ ⁴¹² ⁴⁷⁴ ⁴⁷⁹

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

Manufacturers state that, based on pharmacokinetic studies, extended-release tablets can be administered with or without food (e.g., with a high- or low-fat meal or under fasting conditions).⁸⁵⁶

Concomitant administration with dairy products (e.g., milk, yogurt) or calcium-fortified juices alone (i.e., without a meal) or with substantial calcium intake (>800 mg) may affect absorption.¹ ⁸⁵⁶ Manufacturers state oral ciprofloxacin can be taken with dairy products or calcium-fortified juices that are part of a meal.¹ ⁸⁵⁶

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.¹ ²⁴⁸ ²⁵⁰ ²⁵¹ ⁴⁴² ⁵³¹ ⁵⁷⁹ ⁸⁵⁶ Not considered clinically important.¹ ⁵⁷⁹ ⁸⁵⁶

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;¹ ¹⁷⁸ ²¹⁴ ²⁸¹ ⁴¹² ⁴³⁶ ⁷⁶⁶ 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%.¹ ¹⁷⁹ ¹⁸⁰ ²⁰⁵ ²¹⁴ ²²³ ⁴⁷⁴ ⁴⁷⁹

Elimination

Metabolism

Partially metabolized¹ ¹⁸⁰ ²⁰⁹ ²¹⁴ ²⁷¹ ²⁷² ⁴¹² ⁴⁷⁴ ⁴⁹⁰ ⁵³⁰ in liver⁵³⁰ to at least 4 metabolites.¹ ¹⁸⁰ ²⁰⁹ ²¹⁴ ²⁷¹ ⁴¹² ⁴⁷⁴ ⁴⁷⁹ ⁴⁸⁸ ⁵³⁴ Metabolites have microbiologic activity less than that of the parent drug,¹ ²⁰⁵ ²¹⁴ ²³⁸ ²⁷² ⁴¹² ⁴⁷⁴ ⁴⁸⁸ ⁵³⁰ but some have activity similar to or greater than that of some other quinolones.²⁷² ⁴⁸⁸

Elimination Route

Eliminated by renal and nonrenal mechanisms.¹⁸⁰ ¹⁸² ²¹⁴ ²⁴⁵ ²⁵⁹ ²⁶⁰ ⁴¹² ⁴⁷⁴ ⁴⁷⁹ ⁴⁹⁰

Excreted in urine by both glomerular filtration and tubular secretion (15–50% of dose is unchanged drug and 10–15% is metabolites).¹ ¹⁷⁷ ¹⁷⁸ ¹⁸⁰ ²⁰⁵ ²⁰⁹ ²¹⁴ ²¹⁵ ²¹⁹ ²²¹ ²²⁴ ²³⁰ ²³⁴ ²³⁵ ²³⁷ ²³⁸ ²³⁹ ²⁴⁰ ²⁵⁸ ²⁵⁹ ²⁷¹ ²⁸⁶ ⁴¹² ⁴⁷⁴ ⁴⁷⁹ ⁴⁹⁰ ⁵³⁰ ⁵³⁴ 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 ¹⁸⁰ ²¹⁴ ²⁵⁴ ²⁵⁶ ⁴¹² ⁴⁷⁴ ⁴⁷⁹ or peritoneal dialysis.²¹⁴ ²⁵²

Half-life

Adults with normal renal function: 3–7 hours.¹ ¹⁷⁸ ¹⁸² ²¹² ²¹⁴ ²¹⁹ ²²⁰ ²²⁴ ²²⁹ ²³⁰ ²³⁵ ²³⁸ ²³⁹ ²⁴⁰ ⁴¹² ⁴⁷⁴ ⁴⁷⁹ ⁵³⁰ ⁵³⁴ ⁵⁷⁹ ⁸⁵⁶

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.¹ ¹⁷⁸ ²¹⁵ ²¹⁴ ²⁴⁸ ²⁴⁹ ²⁵⁰ ²⁵¹ ⁵⁷⁹ ⁸⁵⁶ 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.¹ ¹⁸⁰ ²⁰⁵ ²¹⁴ ²³⁷ ²⁵⁴ ²⁵⁵ ²⁵⁶ ²⁵⁷ ²⁶⁰ ⁴⁷⁴ ⁴⁷⁹ ⁵²⁴ ⁵³⁴ ⁵⁷⁹ ⁸⁵⁶ Half-life is 4.4–12.6 hours in adults with Cl_cr ≤30 mL/minute.¹⁸⁰ ²⁵⁶ ⁵²⁴

Stability

Storage

Oral

Tablets

Conventional tablets: 20–25°C (may be exposed to 15–30°C).¹

Extended-release tablets: 20–25°C in tight, light-resistant container.⁸⁵⁶

For Suspension

<25°C (may be exposed to 15–30°C).¹ Following reconstitution, stable at 25°C (may be exposed to 15–30°C) for 14 days.¹ Do not freeze.¹

Parenteral

Concentrate for IV Infusion

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

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.

Premixed Injection in 5% Dextrose

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

Compatibility

Parenteral

Solution CompatibilityHID

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 CompatibilityHID
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
Amoxicillin sodium
Amoxicillin sodium and clavulanate potassium
Amphotericin B
Ampicillin sodium and sulbactam sodium
Azithromycin
Cefuroxime sodium
Clindamycin phosphate
Fluorouracil
Heparin sodium
Meropenem
Potassium phosphates
Sodium bicarbonate
Variable
Ceftazidime

Y-Site CompatibilityHID
Compatible
Amifostine
Amino acids, dextrose
Amiodarone HCl
Anidulafungin
Aztreonam
Bivalirudin
Calcium gluconate
Caspofungin acetate
Ceftaroline fosamil
Ceftazidime
Ceftolozane sulfate-tazobactam
Cisatracurium besylate
Clarithromycin
Defibrotide sodium
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
Hydroxyethyl starch 130/0.4 in sodium chloride 0.9%
Hydroxyzine HCl
Isavuconazonium sulfate
Lidocaine HCl
Linezolid
Lorazepam
Metoclopramide HCl
Midazolam HCl
Milrinone lactate
Oritavancin diphosphate
Posaconazole
Potassium acetate
Potassium chloride
Promethazine HCl
Quinupristin-dalfopristin
Ranitidine HCl
Remifentanil HCl
Sodium chloride
Tacrolimus
Tedizolid phosphate
Telavancin HCl
Teniposide
Thiotepa
Tigecycline
Tobramycin sulfate
Vasopressin
Verapamil HCl
Incompatible
Aminophylline
Ampicillin sodium and sulbactam sodium
Azithromycin
Blinatumomab
Cangrelor tetrasodium
Cloxacillin sodium
Dexamethasone sodium phosphate
Furosemide
Heparin sodium
Hydrocortisone sodium succinate
Letermovir
Meropenem-vaborbactam
Methylprednisolone sodium succinate
Pemetrexed disodium
Phenytoin sodium
Sodium phosphates

Variable
Magnesium sulfate
Sodium bicarbonate

Actions and Spectrum

Usually bactericidal.¹ ¹⁵ ⁵⁷ ¹⁴⁸ ¹⁵¹ ¹⁷⁶ ¹⁷⁹ ¹⁸⁰ ¹⁸¹ ⁴⁷⁹ ⁴⁸¹ ⁸⁵⁶
Like other fluoroquinolones, ciprofloxacin inhibits bacterial DNA gyrase and topoisomerase IV.¹ ⁴⁷ ¹⁴⁷ ¹⁴⁸ ¹⁴⁹ ¹⁵⁴ ¹⁶⁷ ¹⁸⁰ ¹⁸¹ ⁴⁶⁷ ⁴⁷⁹ ⁴⁸¹ ⁴⁹⁷ ⁵¹⁹ ⁷²² ⁷²³ ⁷²⁴ ⁷²⁵ ⁷²⁶ ⁸³⁵ ⁸⁵⁶
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 ⁵⁸ ¹⁰⁰ ¹⁷⁸ ¹⁸⁰ ¹⁸¹ ¹⁸⁹ ²⁰⁵ ²⁰⁷ ²⁹⁵ ⁴⁵⁹ ⁴⁶⁰ ⁴⁶⁷ ⁴⁷⁹ ⁴⁸¹ 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 (methicillin-susceptible [oxacillin-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 ³⁸ ⁴¹ ⁴⁵ ⁵⁶ ⁵⁷ ⁵⁸ ⁶⁰ ⁸⁴ ⁹⁰ ¹⁰⁰ ¹⁸⁷ ¹⁸⁹ ²⁰⁵ ⁴⁴⁷ ⁴⁵⁹ ⁴⁶⁰ 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 ³⁸ 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 ³³ ³⁴ ³⁷ ³⁸ ⁴⁵ ⁴⁶ ⁵⁶ ⁵⁸ ⁶⁴ ¹⁰⁰ ¹⁰⁴ ¹⁸⁷ ¹⁸⁹ ²⁰⁵ ²¹³ ⁴⁴⁷ ⁴⁵⁹ ⁴⁶⁰ ⁶²⁰ Also active in vitro against Acinetobacter,¹ Aeromonas,¹ Brucella,¹ Francisella tularensis,¹ Legionella pneumophila,¹ Vibrio,¹ 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) widely disseminated worldwide, including in the US.¹¹⁴ ³⁴⁴ ⁶³² ⁶³⁴ ⁶³⁵ ⁶³⁷ ⁶³⁸ ⁶³⁹ ⁷⁵⁴
Resistance to fluoroquinolones, including ciprofloxacin, can occur as the result of mutations in the target DNA type II topoisomerase enzymes and mutations that result in alterations in membrane permeability and/or efflux pumps.¹⁴¹ ¹⁵¹ ¹⁸¹ ⁴⁵⁸ ⁴⁶⁹ ⁴⁷⁹ ⁵⁰³ ⁵⁰⁵ ⁵¹⁹ ⁵⁶⁴ ⁵⁶⁵ ⁷²² ⁷²⁴ ⁷²⁵ ⁷²⁶ ⁸³³ ⁸³⁴
Some cross-resistance occurs between ciprofloxacin and other fluoroquinolones.⁷⁷ ⁸⁶ ¹⁴⁸ ¹⁶¹ ¹⁸¹ ²⁰⁵ ²¹⁴ ²⁹⁵ ⁴⁷⁹ ⁵²¹ ⁵⁶⁴ ⁶³² ⁶³⁵ ⁶³⁸

Advice to Patients

Advise patients to read manufacturer’s patient information (medication guide) prior to initiating ciprofloxacin therapy and each time prescription refilled.¹ ⁵⁷⁹
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).¹ ⁵⁷⁹ ⁸⁵⁶
Importance of completing full course of therapy, even if feeling better after a few days.¹ ⁵⁷⁹ ⁸⁵⁶
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.¹ ⁵⁷⁹ ⁸⁵⁶
May be taken without regard to meals, but do not take with dairy products (e.g., milk, yogurt) or calcium-fortified juices alone (without a meal) since absorption of the drug may be decreased.¹ ⁸⁵⁶
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 buffered didanosine (pediatric oral suspension admixed with antacids).¹ ⁸⁵⁶
Importance of drinking fluids liberally during therapy to avoid formation of highly concentrated urine and crystal formation in urine.¹ ⁵⁷⁹ ⁸⁵⁶
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.¹ ⁵¹³ ⁵⁷⁹ ⁸⁵⁶
Inform patients that systemic fluoroquinolones, including ciprofloxacin, have been associated with disabling and potentially irreversible serious adverse reactions (e.g., tendinitis and tendon rupture, peripheral neuropathy, CNS effects) that may occur together in same patient.¹ ¹⁴⁰ ¹⁴⁵ ⁵⁷⁹ ⁸⁵⁶ Advise patients to immediately discontinue ciprofloxacin and contact a clinician if they experience any signs or symptoms of serious adverse effects (e.g., unusual joint or tendon pain, muscle weakness, a “pins and needles” tingling or pricking sensation, numbness of the arms or legs, confusion, hallucinations) while taking the drug.¹ ¹⁴⁰ ¹⁴⁵ ⁵⁷⁹ Advise patients to talk with clinician if they have any questions or concerns.¹ ¹⁴⁰ ¹⁴⁵ ⁵⁷⁹ ⁸⁵⁶
Inform patients that systemic fluoroquinolones, including ciprofloxacin, are associated with an increased risk of tendinitis and tendon rupture in all age groups and this risk is increased risk in adults >60 years of age, individuals receiving corticosteroids, and kidney, heart, or lung transplant recipients.¹ ⁵⁷⁹ ⁸⁵¹ ⁸⁵² ⁸⁵⁶ Symptoms may be irreversible.¹ ⁵⁷⁹ ⁸⁵⁶ 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 or weakness or inability to use a joint) and importance of immediately discontinuing the drug and contacting a clinician.¹ ⁵⁷⁹ ⁸⁵⁶ (See Tendinitis and Tendon Rupture under Cautions.)
Inform patients that peripheral neuropathies have been reported with systemic fluoroquinolones, including ciprofloxacin, and that symptoms may occur soon after initiation of the drug and may be irreversible.¹ ¹³⁰ ⁵⁷⁹ ⁸⁵⁶ Importance of immediately discontinuing ciprofloxacin and contacting a clinician if symptoms of peripheral neuropathy (e.g., pain, burning, tingling, numbness, and/or weakness) occur.¹ ¹³⁰ ⁵⁷⁹ ⁸⁵⁶
Inform patients that systemic fluoroquinolones, including ciprofloxacin, have been associated with CNS effects (e.g., convulsions, dizziness, lightheadedness, increased intracranial pressure).¹ ⁵⁷⁹ ⁸⁵⁶ Importance of informing clinician about any history of convulsions before initiating therapy with the drug.¹ ⁵⁷⁹ ⁸⁵⁶ Importance of contacting a clinician if persistent headache with or without blurred vision occurs.¹ ⁵⁷⁹ ⁸⁵⁶
Advise patients that ciprofloxacin may cause dizziness and lightheadedness;¹ ⁵⁷⁹ ⁸⁵⁶ caution patients not to engage in activities requiring mental alertness and motor coordination (e.g., driving a vehicle, operating machinery) until effects of the drug on the individual are known.¹ ⁵⁷⁹ ⁸⁵⁶
Advise patients that systemic fluoroquinolones, including ciprofloxacin, may worsen myasthenia gravis symptoms;¹ ⁵⁷⁹ ⁸⁵⁶ importance of informing clinician of any history of myasthenia gravis.¹ ⁵⁷⁹ ⁸⁵⁶ Importance of immediately contacting a clinician if any symptoms of muscle weakness, including respiratory difficulties, occur.¹ ⁵⁷⁹ ⁸⁵⁶
Inform patients that ciprofloxacin may be associated with hypersensitivity reactions (including anaphylactic reactions), even after first dose.¹ ⁵⁷⁹ ⁸⁵⁶ Importance of immediately discontinuing ciprofloxacin and informing a clinician at first sign of rash, hives, other skin reaction, jaundice, rapid heartbeat, difficulty swallowing or breathing, any swelling suggesting angioedema (e.g., swelling of lips, tongue, or face; tightness of throat; hoarseness), or any other sign of hypersensitivity.¹ ⁵⁷⁹ ⁸⁵⁶
Inform patients that photosensitivity/phototoxicity reactions reported following exposure to sun or UV light in patients receiving fluoroquinolones.¹ ⁵⁷⁹ ⁸⁵⁶ 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.¹ ⁵⁷⁹ ⁸⁵⁶ Importance of discontinuing ciprofloxacin and contacting a clinician if a sunburn-like reaction or skin eruption occurs.¹ ⁵⁷⁹ ⁸⁵⁶
Inform patients that systemic fluoroquinolones may increase risk of aortic aneurysm and dissection;¹⁷² importance of informing clinician of any history of aneurysms, blockages or hardening of the arteries, high blood pressure, or genetic conditions such as Marfan syndrome or Ehlers-Danlos syndrome.¹⁷² Advise patients to seek immediate medical treatment if they experience sudden, severe, and constant pain in the stomach, chest, or back.¹ ¹⁷² ⁵⁷⁹
Advise patients that hypoglycemia has been reported in patients receiving ciprofloxacin and oral antidiabetic agents.¹ ⁵⁷⁹ ⁸⁵⁶ If low blood glucose occurs, importance of contacting clinician to determine whether the anti-infective should be changed.¹ ⁵⁷⁹ ⁸⁵⁶
Inform patients that severe hepatotoxicity, including acute hepatitis and some fatalities, reported.¹ ⁵⁷⁹ ⁸⁵⁶ Importance of immediately discontinuing ciprofloxacin and contacting a clinician if any signs or symptoms of hepatotoxicity (e.g., loss of appetite, nausea, vomiting, fever, weakness, tiredness, right upper quadrant tenderness, itching, yellowing of skin or eyes, light colored bowel movements, dark colored urine) occur.¹ ⁵⁷⁹ ⁸⁵⁶
Importance of informing clinician of personal or family history of QT interval prolongation or proarrhythmic conditions (e.g., hypokalemia, bradycardia, recent myocardial ischemia) or current therapy with any class IA (e.g., quinidine, procainamide) or class III (amiodarone, sotalol) antiarrhythmic agents.¹ ⁵⁷⁹ ⁸⁵⁶ Importance of contacting clinician if any symptoms of prolongation of QT interval (e.g., prolonged heart palpitations, loss of consciousness) occur.¹ ⁵⁷⁹ ⁸⁵⁶
Advise patients that diarrhea is a common problem caused by anti-infectives and usually ends when the drug is discontinued.¹ ⁵⁷⁹ ⁸⁵⁶ 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.¹ ⁵⁷⁹ ⁸⁵⁶
If considering ciprofloxacin for a pediatric patient (see Pediatric Use under Cautions), importance of parent informing clinician if the child has a history of joint-related problems.¹ ⁵⁷⁹ ⁸⁵⁶ Importance of parent contacting a clinician if the child develops any joint-related problems during or following ciprofloxacin therapy.¹ ⁵⁷⁹ ⁸⁵⁶
Importance of informing clinician of existing or contemplated concomitant therapy, including prescription and OTC drugs (e.g., drugs that may affect QT interval, tizanidine, theophylline, antidiabetic agent, warfarin), as well as any concomitant illnesses.¹ ⁵⁷⁹ ⁸⁵⁶
Importance of women informing clinicians if they are or plan to become pregnant or plan to breast-feed.¹ ⁵⁷⁹ ⁸⁵⁶
Importance of advising patients of other important precautionary information.¹ ⁵⁷⁹ ⁸⁵⁶ (See Cautions.)

Preparations

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

Please refer to the ASHP Drug Shortages Resource Center for information on shortages of one or more of these preparations.

* 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
			Ciprofloxacin for Oral Suspension
		500 mg/5 mL*	Cipro	Bayer
			Ciprofloxacin for Oral Suspension
Parenteral	For injection concentrate, for IV infusion	10 mg (of ciprofloxacin) per mL (200 or 400 mg)*	Ciprofloxacin for Injection Concentrate

* 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])*	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])*	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*	Ciprofloxacin in 5% Dextrose

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

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765. Ragunathan PL, Potkins DV, Watson JG et al. Neonatal meningitis due to Salmonella typhimurium treated with ciprofloxacin. J Antimicrob Chemother. 1990; 26:727-8. http://www.ncbi.nlm.nih.gov/pubmed/2079456?dopt=AbstractPlus

766. Lipman J, Allworth A, Wallis SC. Cerebrospinal fluid penetration at high doses of intravenous ciprofloxacin in meningitis. Clin Infect Dis. 2000; 31:1131-3. http://www.ncbi.nlm.nih.gov/pubmed/11073740?dopt=AbstractPlus

767. Brookmeyer R, Johnson E, Bollinger R. Modeling the optimum duration of antibiotic prophyalxis in an anthrax outbreak. Proc Natl Acad Sci. 2003; 100:10129-32. http://www.pubmedcentral.nih.gov/picrender.fcgi?tool=pmcentrez&artid=187789&blobtype=pdf http://www.ncbi.nlm.nih.gov/pubmed/12890865?dopt=AbstractPlus

769. Heldman AW, Hartert TV, Ray SC et al. Oral antibiotic treatment of right-sided staphylocccal endocarditis in injection drug users: prospective randomized comparison with parenteral therapy. Am J Med. 1996; 101:68-76. http://www.ncbi.nlm.nih.gov/pubmed/8686718?dopt=AbstractPlus

770. Sejvar JJ, Tenover FC, Stephens DS. Management of anthrax meningitis. Lancet Infect Dis. 2005; 5:287-95. http://www.ncbi.nlm.nih.gov/pubmed/15854884?dopt=AbstractPlus

771. Agalar C, Usubutun S, Turkyilmaz R. Ciprofloxacin and rifampicin versus doxycycline and rifampicin in the treatment of brucellosis. Eur J Clin Microbiol Infect Dis. 1999; 18:535-8. http://www.ncbi.nlm.nih.gov/pubmed/10517189?dopt=AbstractPlus

772. Pappas G, Akritidis N, Bosilkovski M et al. Brucellosis. N Engl J Med. 2005; 352:2325-36. http://www.ncbi.nlm.nih.gov/pubmed/15930423?dopt=AbstractPlus

773. Centers for Disease Control and Prevention. Update: investigation of bioterrorism-related anthrax—Connecticut, 2001. MMWR Morb Mortal Wkly Rep. 2001; 50:1049-51. http://www.ncbi.nlm.nih.gov/pubmed/11808925?dopt=AbstractPlus

775. Novartis Pharmaceuticals. Clozaril (clozapine) prescribing information. East Hanover, NJ; 2005 May.

781. Johnson MP, Ramphal R. Malignant external otitis: report on therapy with ceftazidime and review of therapy and prognosis. Clin Infect Dis. 1990; 12:173-80.

782. Hern JD, Ghufoor K, Jayaraj SM et al. ENT manifestations of Pseudomonas aeruginosa infection in HIV and AIDS. Int J Clin Pract. 1998; 52:141-4. http://www.ncbi.nlm.nih.gov/pubmed/9684426?dopt=AbstractPlus

783. Berenholz L, Katzenell U, Harell M. Evolving resistant pseudomonas to ciprofloxacin in malignant otitis externa. Laryngoscope. 2002; 112:1619-22. http://www.ncbi.nlm.nih.gov/pubmed/12352675?dopt=AbstractPlus

784. Grandis R, Branstetter BF, Yu VL. The changing face of malignant (necrotising) external otitis: clinical, radiological, and anatomic correlations. Lancet Infect Dis. 2004; 4:34-9. http://www.ncbi.nlm.nih.gov/pubmed/14720566?dopt=AbstractPlus

785. Bernstein JM, Holland NJ, Porter GC et al. Resistance of Pseudomonas to ciprofloxacin: implications for the treatment of malignant otitis externa. J Laryngol Otol. 2006; Sep 25:1-6.

786. Taplitz RA, Kennedy EB, Bow EJ et al. Antimicrobial Prophylaxis for Adult Patients With Cancer-Related Immunosuppression: ASCO and IDSA Clinical Practice Guideline Update. J Clin Oncol. 2018; :JCO1800374. http://www.ncbi.nlm.nih.gov/pubmed/30179565?dopt=AbstractPlus

787. Taplitz RA, Kennedy EB, Bow EJ et al. Outpatient Management of Fever and Neutropenia in Adults Treated for Malignancy: American Society of Clinical Oncology and Infectious Diseases Society of America Clinical Practice Guideline Update. J Clin Oncol. 2018; 36:1443-1453. http://www.ncbi.nlm.nih.gov/pubmed/29461916?dopt=AbstractPlus

788. Huang TS, Kunin CM, Lee SS et al. Trends in fluoroquinolone resistance of Mycobacterium tuberculosis complex in Taiwanese medical centre: 1995-2003. J Antimicrob Chemother. 2005; 56:1058-62. http://www.ncbi.nlm.nih.gov/pubmed/16204341?dopt=AbstractPlus

789. World Health Organization. Extensively drug-resistant tuberculosis (XDR-TB): recommendations for prevention and control. Wkly Epidemiol Rec. 2006; 45:430-2.

790. Gandhi NR, Moll A, Sturm AW et al. Extensively drug-resistant tuberculosis as a cause of death in patients co-infected with tuberculosis and HIV in a rural area of South Africa. Lancet. 2006; 368:1575-80. http://www.ncbi.nlm.nih.gov/pubmed/17084757?dopt=AbstractPlus

791. Mueller BA, Brierton DG, Abel SR et al. Effect of enteral feeding with ensure on oral bioavailabilities of ofloxacin and ciprofloxacin. Antimicrob Agents Chemother. 1994; 38:2101-5. http://www.pubmedcentral.nih.gov/picrender.fcgi?tool=pmcentrez&artid=284691&blobtype=pdf http://www.ncbi.nlm.nih.gov/pubmed/7811026?dopt=AbstractPlus

792. McDonald LC, Killgore GE, Thompson A et al. An epidemic, toxin gene-variant strain of Clostridium difficile. N Engl J Med. 2005; 353:2433-41. http://www.ncbi.nlm.nih.gov/pubmed/16322603?dopt=AbstractPlus

793. Loo VG, Poirier L, Miller MA et al. A predominantly clonal multi-institutional outbreak of Clostridium difficile-associated diarrhea with high morbidity and mortality. N Engl J Med. 2005; 353:2442-9. http://www.ncbi.nlm.nih.gov/pubmed/16322602?dopt=AbstractPlus

794. McDonald LC, Owings M, Jernigan DB. Clostridium difficile infection in patients discharged from US short-stay hospitals, 1996-2003. Emerg Infect Dis. 2006; 12:409-15. http://www.pubmedcentral.nih.gov/picrender.fcgi?tool=pmcentrez&artid=3291455&blobtype=pdf http://www.ncbi.nlm.nih.gov/pubmed/16704777?dopt=AbstractPlus

795. Bartlett JG, Peri TM. The new Clostridium difficile–what does it mean? N Engl J Med. 2005; 353:2503-5.

796. Centers for Disease Control and Prevention. Severe Clostridium difficile-associated disease in populations previously at low risk–four states, 2005. MMWR Morb Mortal Wkly Rep. 2005; 54:1201-5. http://www.ncbi.nlm.nih.gov/pubmed/16319813?dopt=AbstractPlus

797. Kazakova SV, Ware K, Baughman B et al. A hospital outbreak of diarrhea due to an emerging epidemic strains of Clostridium difficile. Arch Intern Med. 2006; 166:2518-24. http://www.ncbi.nlm.nih.gov/pubmed/17159019?dopt=AbstractPlus

798. Dhalla IA, Mamdani MM, Simor AE et al. Are broad-spectrum fluoroquinolones more likely to cause Clostridium difficile-associated disease? Antimicrob Agents Chemother. 2006; 50:3216-9.

799. Chiang CY, Enarson DA, Yu MC et al. Outcome of pulmonary multidrug-resistant tuberculosis: a 6-yr follow-up study. Eur Respir J. 2006; 28:980-5. http://www.ncbi.nlm.nih.gov/pubmed/16837502?dopt=AbstractPlus

800. Shi R, Zhang J, Li C et al. Emergence of ofloxacin resistance in Mycobacterium tuberculosis clinical isolates from China as determined by gyrA mutation analysis using denaturing high-pressure liquid chromatography and DNA sequencing. J Clin Microbiol. 2006; 44:4566-8. http://www.pubmedcentral.nih.gov/picrender.fcgi?tool=pmcentrez&artid=1698392&blobtype=pdf http://www.ncbi.nlm.nih.gov/pubmed/17035499?dopt=AbstractPlus

801. Granich RM, Oh P, Lewis B et al. Multidrug resistance among persons with tuberculosis in California, 1994-2003. JAMA. 2005; 293:2732-9. http://www.ncbi.nlm.nih.gov/pubmed/15941802?dopt=AbstractPlus

802. Johnson JL, Hadad DJ, Boom WH et al. Early and extended early bactericidal activity of levofloxacin, gatifloxacin and moxifloxacin in pulmonary tuberculosis. Int J Tuberc Lung Dis. 2006; 10:605-12. http://www.ncbi.nlm.nih.gov/pubmed/16776446?dopt=AbstractPlus

803. Aubry A, Veziris N, Cambau E et al. Novel gyrase mutations in quinolone-resistant and -hypersusceptible clinical isolates of Mycobacterium tuberculosis: functional analysis of mutant enzymes. Antimicrob Agents Chemother. 2006; 50:104-12. http://www.pubmedcentral.nih.gov/picrender.fcgi?tool=pmcentrez&artid=1346799&blobtype=pdf http://www.ncbi.nlm.nih.gov/pubmed/16377674?dopt=AbstractPlus

804. Yew WW, Chan CK, Leung CC et al. Comparative roles of levofloxacin and ofloxacin in the treatment of multidrug-resistant tuberculosis. Chest. 2003; 124:1476-81. http://www.ncbi.nlm.nih.gov/pubmed/14555582?dopt=AbstractPlus

805. Marra F, Marra CA, Moadebi S et al. Levofloxacin treatment of active tuberculosis and the risk of adverse events. Chest. 2005; 128:1406-13. http://www.ncbi.nlm.nih.gov/pubmed/16162736?dopt=AbstractPlus

806. Ziganshina LE, Vizel AA, Squire SB. Fluoroquinolones for treating tuberculosis. Cochrane Database Syst Rev. 2005; Jul 20:CD004795.

807. El-Sadr WM, Perlman DC, Matts JP et al. Evaluation of an intensive intermittent-induction regimen and duration of short-course treatment for human immunodeficiency virus-related pulmonary tuberculosis. Clin Infect Dis. 1998; 26:1148-58.

809. Flanagan MC, Mitchell ES, Haigney MC. Ciprofloxacin-induced torsade de pointes. Int J Cardiol. 2006; 113:239-41. http://www.ncbi.nlm.nih.gov/pubmed/16386810?dopt=AbstractPlus

810. Neuvonen PJ, Kivisto KT, Lehto P. Interference of dairy products with the absorption of ciprofloxacin. Clin Pharmacol Ther. 1991; 50:498-502. http://www.ncbi.nlm.nih.gov/pubmed/1934862?dopt=AbstractPlus

811. Shitrit D, Baum GL, Priess R et al. Pulmonary Mycobacterium kansasii infection in Israel, 1999-2004: clinical features, drug susceptibility, and outcome. Chest. 2006; 129:771-6. http://www.ncbi.nlm.nih.gov/pubmed/16537880?dopt=AbstractPlus

812. Ruiz-Serrano MJ, Alcala L, Martinez L et al. In vitro activities of six fluoroquinolones against 250 clinical isolates of Mycobacterium tuberculosis susceptible or resistant to first-line antituberculosis drugs. Antimicrob Agents Chemother. 2000; 44:2567-8.

813. Kam KM, Yip CW, Cheung TL et al. Stepwise decrease in moxifloxacin susceptibility amongst clinical isolates of multidrug-resistant Mycobacterium tuberculosis: correlation with ofloxacin susceptibility. Microb Drug Resist. 2006; 12:7-11. http://www.ncbi.nlm.nih.gov/pubmed/16584301?dopt=AbstractPlus

814. Shandil RK, Jayaram R, Kaur P et al. Moxifloxacin, ofloxacin, sparfloxacin, and ciprofloxacin against Mycobacterium tuberculosis: evaluation of in vitro and pharmacodynamic indices that best predict in vivo efficacy. Antimicrob Agents Chemother. 2007; 51:576-82. http://www.ncbi.nlm.nih.gov/pubmed/17145798?dopt=AbstractPlus

815. Hori S, Kizu J, Kawamura M. Effects of anti-inflammatory drugs on convulsant activity of quinolones: a comparative study of drug interactions between quinolones and anti-inflammatory drugs. J Infect Chemother. 2003; 9:314-20. http://www.ncbi.nlm.nih.gov/pubmed/14691652?dopt=AbstractPlus

816. Lang R, Goshen S, Kitzes-Cohen R et al. Successful treatment of malignant external otitis with oral ciprofloxacin: report of experience with 23 patients. J Infect Dis. 1990; 161:537-40. http://www.ncbi.nlm.nih.gov/pubmed/2313132?dopt=AbstractPlus

817. Alangaden GJ, Lerner SA. The clinical use of fluoroquinolones for the treatment of mycobacterial diseases. Clin Infect Dis. 1997; 25:1213-21. http://www.ncbi.nlm.nih.gov/pubmed/9402384?dopt=AbstractPlus

818. Wong-Beringer A, Beringer P, Lovett MA. Successful treatment of multidrug-resistant Pseudomonoas aeruginosa meningitis with high-dose ciprofloxacin. Clin Infect Dis. 1997; 25:936-7.

819. Shafran SD, Singer J, Zarowny DP et al. A comparison of two regimens for the treatment of Mycobacterium avium complex bacteremia in AIDS: rifabutin, ethambutol, and clarithromycin versus rifampin, ethambutol, clofazimine, and ciprofloxacin. N Engl J Med. 1996; 335:377-83. http://www.ncbi.nlm.nih.gov/pubmed/8676931?dopt=AbstractPlus

820. Piccolo JL, Toossi Z, Goldman M. Effect of coadministration of a nutritional supplement on ciprofloxacin absorption. Am J Hosp Pharm. 1994; 51:2697-9. http://www.ncbi.nlm.nih.gov/pubmed/7856583?dopt=AbstractPlus

821. Rambout L, Sahai J, Gallicano K et al. Effect of bismuth subsalicylate on ciprofloxacin bioavailability. Antimicrob Agents Chemother. 1994; 38:2187-90. http://www.pubmedcentral.nih.gov/picrender.fcgi?tool=pmcentrez&artid=284708&blobtype=pdf http://www.ncbi.nlm.nih.gov/pubmed/7811043?dopt=AbstractPlus

822. Markowitz JS, Gill HS, Devane CL et al. Fluoroquinolone inhibition of clozapine metabolism. Am J Psychiatry. 1997; 153:881.

823. Dugoni-Kramer BM. Ciprofloxacin-warfarin interaction. Ann Pharmacother. 1991; 25:1397.

824. Nix DE, Watson WA, Lener ME et al. Effects of aluminum and magnesium antacids and ranitidine on the absorption of ciprofloxacin. Clin Pharmacol Ther. 1989; 46:700-5. http://www.ncbi.nlm.nih.gov/pubmed/2598571?dopt=AbstractPlus

825. Garrelts JC, Godley PJ, Peterie JD et al. Sucralfate significantly reduces ciprofloxacin concentrations in serum. Antmicrob Agents Chemother. 1990; 34:931-3.

826. Joseph J, Vaughan LM, Basran GS. Penetration of intravenous and oral ciprofloxacin into sterile and empyemic human pleural fluid. Ann Pharmacother. 1994; 28:313-5. http://www.ncbi.nlm.nih.gov/pubmed/8193415?dopt=AbstractPlus

827. Jacobs F, Marchal M, Francquen P et al. Penetration of ciprofloxacin into human pleural fluid. Antimicrob Agents Chemother. 1990; 34:934-6. http://www.pubmedcentral.nih.gov/picrender.fcgi?tool=pmcentrez&artid=171726&blobtype=pdf http://www.ncbi.nlm.nih.gov/pubmed/2360834?dopt=AbstractPlus

828. Dan M, Zuabi T, Quassem C et al. Distribution of ciprofloxacin in ascitic fluid following administration of a single oral dose of 750 milligrams. Antimicrob Agents Chemother. 1992; 36:677-8. http://www.pubmedcentral.nih.gov/picrender.fcgi?tool=pmcentrez&artid=190579&blobtype=pdf http://www.ncbi.nlm.nih.gov/pubmed/1622184?dopt=AbstractPlus

829. Darouiche R, Perkins B, Musher D et al. Levels of rifampin and ciprofloxacin in nasal secretions: correlation with MIC₉₀ and eradication of nasopharyngeal carriage of bacteria. J Infect Dis. 1990; 162:1124-7. http://www.ncbi.nlm.nih.gov/pubmed/2121836?dopt=AbstractPlus

830. Cover DL, Mueller BA. Ciprofloxacin penetration into human breast milk: a case report. Ann Pharmacother. 1990; 24:703-4.

831. Mertes PM, Voiriot P, Dopff C et al. Penetration of ciprofloxacin into heart valves, myocardium, mediastinal fat, and sternal bone marrow in humans. Antimicrob Agents Chemother. 1990; 34:398-401. http://www.pubmedcentral.nih.gov/picrender.fcgi?tool=pmcentrez&artid=171604&blobtype=pdf http://www.ncbi.nlm.nih.gov/pubmed/2185690?dopt=AbstractPlus

832. Chandler MHH, Toler SM, Rapp RP et al. Multiple-dose pharmacokinetics of concurrent oral ciprofloxacin and rifampin therapy in elderly patients. Antimicrob Agents Chemother. 1990; 34:442-7. http://www.pubmedcentral.nih.gov/picrender.fcgi?tool=pmcentrez&artid=171612&blobtype=pdf http://www.ncbi.nlm.nih.gov/pubmed/2185691?dopt=AbstractPlus

833. Zeller V, Janoir C, Kitzis MD et al. Active efflux as a mechanism of resistance to ciprofloxacin in Streptococcus pneumoniae. Antimicrob Agents Chemother. 1997; 41:1973-8. http://www.pubmedcentral.nih.gov/picrender.fcgi?tool=pmcentrez&artid=164047&blobtype=pdf http://www.ncbi.nlm.nih.gov/pubmed/9303396?dopt=AbstractPlus

834. Ng EY, Trucksis M, Hooper DC. Quinolone resistance mutations in topoisomerase IV: relationship to the flqA locus and genetic evidence that topoisomerase IV is the primary target and DNA gyrase is the secondary target of fluoroquinolones in Staphylococcus aureus. Antimicrob Agents and Chemother. 1996; 40:1881-8.

835. Gordon SM, Carlyn CJ, Doyle LJ et al. The emergence of Neisseria gonorrhoeae with decreased susceptibility to ciprofloxacin in Cleveland, Ohio: epidemiology and risk factors. Ann Intern Med. 1996; 125:465-70. http://www.ncbi.nlm.nih.gov/pubmed/8779458?dopt=AbstractPlus

836. GlaxoSmithKline. Requip (ropinirole hydrochloride) tablets prescribing information. Research Triangle Park, NC; 2006 Oct.

839. Douglas JM Jr. Dear colleague letter: Fluoroquinolones are no longer recommended for the treatment of gonorrhea in the United States. Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention, Department of Health & Human Services; 2007 April 12.

840. Ball P. Long-term use of quinolones and their safety. Rev Infect Dis. 1989; 11(Suppl 5):S1365-9. http://www.ncbi.nlm.nih.gov/pubmed/2672258?dopt=AbstractPlus

841. Davis GJ, McKenzie ME. Toxicologic evaluation of ofloxacin. Am J Med. 1989; 87(Suppl 6C):43S-46S. http://www.ncbi.nlm.nih.gov/pubmed/2690619?dopt=AbstractPlus

842. Mayer DG. Overview of toxicological studies. Drugs. 1987; 34(Suppl 1):150-3. http://www.ncbi.nlm.nih.gov/pubmed/3325258?dopt=AbstractPlus

843. Kato M, Onodera T. Morphological investigation of cavity formation in articular cartilage induced by ofloxacin in rats. Fund Appl Toxicol. 1988; 11:110-9.

844. Hooper DC, Wolfson JS. Fluoroquinolone antimicrobial agents. N Engl J Med. 1991; 324:384-94. http://www.ncbi.nlm.nih.gov/pubmed/1987461?dopt=AbstractPlus

845. Paton JH, Reeves DS. Fluoroquinolone antibiotics: microbiology, pharmacokinetics and clinical uses. Drugs. 1988; 36:193-228. http://www.ncbi.nlm.nih.gov/pubmed/3053126?dopt=AbstractPlus

846. Maggiolo F, Caprioli S, Suter F. Risk/benefit analysis of quinolone use in children: the effect on diarthrodial joints. J Antimicrob Chemother. 1990; 26:469-71. http://www.ncbi.nlm.nih.gov/pubmed/2254219?dopt=AbstractPlus

847. Pfister K, Mazur D, Vormann J et al. Diminished ciprofloxacin-induced chondrotoxicity by supplementation with magnesium and vitamin E in immature rats. Antimicrob Agents Chemother. 2007; 51:1022-7. http://www.pubmedcentral.nih.gov/picrender.fcgi?tool=pmcentrez&artid=1803142&blobtype=pdf http://www.ncbi.nlm.nih.gov/pubmed/17210779?dopt=AbstractPlus

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851. Food and Drug Administration. FDA news. FDA requests boxed warnings on fluoroquinolone antimicrobial drugs. 2008 Jul 8. From FDA website. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/2008/ucm116919.htm

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856. Mylan Pharmaceuticals Inc. Ciprofloxacin tablet, film coated, extended realease prescribing information. Morgantown, WV; 2013 Dec.

857. Kirkcaldy RD, Harvey A, Papp JR et al. Neisseria gonorrhoeae Antimicrobial Susceptibility Surveillance - The Gonococcal Isolate Surveillance Project, 27 Sites, United States, 2014. MMWR Surveill Summ. 2016; 65:1-19. http://www.ncbi.nlm.nih.gov/pubmed/27414503?dopt=AbstractPlus

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