Antimicrobials

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Ciprofloxacin

Guidelines for use

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1. Spectrum of Activity

Active against:

  • Most aerobic Gram-negative rods, including influenzae, E. coli (25% resistance), K. pneumoniae, P. mirabilis, Enterobacter, Serratia, Citrobacter
  • Most strains of Pseudomonas aeruginosa (30 – 40% resistance)

Not active against:

  • Anaerobes
  • Streptococci
  • Staphylococci (may have some activity; however, ciprofloxacin is not a recommended treatment)

2. Clinical Use

Appropriate Uses:

  • Treatment of serious Gram-negative infections (e.g., nosocomial pneumonia, osteomyelitis, intra-abdominal sepsis) when other antibiotics are not suitable due to resistance or patient history of drug intolerance
  • Urinary Tract Infections with confirmed susceptibility

Inappropriate Uses:

  • Treatment of community-acquired respiratory tract infections
  • As empiric therapy for urinary tract infection or intra-abdominal infection, due to elevated risk of gram-negative resistance
  • IV treatment of infections for which a less costly agent would be appropriate

3. Precautions

4. Adverse Effects

  • CNS (< 1%): confusion, dizziness, headaches, tremor, restlessness, seizures
  • Dermatological (<1%): skin rash, pruritus
  • Cardiac (<1%): QTc prolongation with risk for progression to Torsades de Pointes. Caution in patients with risk factors (concurrent QT-prolonging medications, cardiac comorbidities, advanced age, etc)
  • Hepatic (<1%): elevations in in ALT, AST, ALP and total bilirubin levels have been reported. Liver enzyme abnormalities are usually mild and reversible upon fluoroquinolone discontinuation but there have been reports of serious hepatic failure.
  • Collagen-mediated toxicities (<1%): such as tendonpathies/tendon rupture, retinal detachment, aortopathy (aortic dissection or aneurysm rupture)
    • Consider alternative therapy in those at highest risk of aortopathy: pre-existing aneurysms or those with cartilage disorders (e.g., Marfan and Ehlers-Danlos syndromes)

5. Drug Interactions

  • Ciprofloxacin may reduce the hepatic metabolism and elimination of theophylline, warfarin and possibly phenytoin
  • Enteral feeds may reduce the absorption of oral ciprofloxacin by 25 – 75%. Ciprofloxacin absorption is highly variable and unpredictable when enteral feeds are held prior to ciprofloxacin dosing. If ciprofloxacin is the best option for the patient, suggest switching to IV therapy until enteral feeds are discontinued.
  • Oral ciprofloxacin absorption may be reduced by as much as 50 – 75% when administered with aluminum, magnesium, iron, or zinc salts. Products containing these salts include sucralfate, some antacids, some laxatives, and multivitamins with minerals. It is recommended that ciprofloxacin be ingested either 2 hours before or 2 hours after any interacting products.
  • Concurrent administration with tizanidine is contraindicated.

    6. Dosage

    » Creatinine Clearance ≥ 30 mL/min

    Usual Dose:
    • Oral: 500 mg PO q12h
    • IV: 400 mg IV q12h

    High-Dose Therapy (i.e., for Pseudomonas or bone and joint infections):

    • Oral: 750 mg PO q12h
    • IV: 400 mg IV q8h

    » Creatinine Clearance < 30 mL/min

    Usual Dose:
    • Oral: 500 mg PO q24h
    • IV: 400 mg IV q 24h*

    *In critical illness use 400mg IV q12h1,2

    High-Dose Therapy (i.e., for Pseudomonas or bone and joint infections):

    • Oral: 750 mg PO q24h
    • IV: 400 mg IV q12h*

    *In critical illness use 400mg IV q8h1,2

    Automatic Substitution Policy:
    • Orders for 200 mg IV q12h will be converted to 400 mg IV q24h

    » Peritoneal Dialysis (PD)

    Usual Dose:
    • Oral: 500 mg PO q24h*
    • IV: 400 mg IV q24h*

    *In peritoneal dialysis related peritonitis higher doses of 500mg PO q12h or 400mg IV q12h can be considered3,4

    High-Dose Therapy (i.e., for Pseudomonas or bone and joint infections):

    • Oral: 750 mg PO q24h*
    • IV: 400 mg IV q12h*

    *In peritoneal dialysis related peritonitis higher doses of 750mg PO q12h or 400mg IV q8h should be considered3,4

    » Hemodialysis (HD)

    Usual Dose:
    • Oral: 500 mg PO q24h
    • IV: 400 mg IV q24h
    • Schedule without regard to time of HD, since only about 10% is removed with HD

    High-Dose Therapy (i.e., for Pseudomonas or bone and joint infections):

    • Oral: 750 mg PO q24h
    • IV: 400 mg IV 12h
    • Schedule without regard to time of HD

    » Continuous Renal Replacement Therapy (CRRT)

    Usual Dose:
    • Oral: 500 mg PO q12h
    • IV: 400 mg IV q12h

    High-Dose Therapy (i.e., for Pseudomonas or bone and joint infections):

    • Oral: 750 mg PO q12h
    • IV: 400 mg IV q8h

    7. Administration

    8. References

    1. de Vroom SL, et al. Pharmacokinetic/pharmacodynamic target attainment of ciprofloxacin in adult patients on general wards with adequate and impaired renal function. Int J Antimicrob Agents. 2020 Nov;56(5):106166
    2. Gieling EM, et al. Higher Dosage of Ciprofloxacin Necessary in Critically Ill Patients: A New Dosing Algorithm Based on Renal Function and Pathogen Susceptibility. Clin Pharmacol Ther. 2020 Oct;108(4):770-774.
    3. Yeung SM, et al. Pharmacokinetics of oral ciprofloxacin in continuous cycling peritoneal dialysis. Perit Dial Int. 2004 Sep-Oct;24(5):447-53.
    4. Lee C, et al. Steady-State Pharmacokinetics of Oral Ciprofloxacin in Continuous Cycling Peritoneal Dialysis Patients: Brief Report. Perit Dial Int. 2018 Jan-Feb;38(1):73-76
    5. Brown P, et al. Principles of Drug Dosing in Sustained Low Efficiency Dialysis (SLED) and Review of Antimicrobial Dosing Literature. Pharmacy (Basel). 2020 Mar 9;8(1):33

    Last updated: November 30, 2021