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 Guide Editors
 Editor In Chief
    Joel E. Gallant, MD, MPH

Pharmacology Editor
    Paul Pham, PharmD, BCPS

Zambia Guideline Team
   Peter Mwaba MMed PhD FRCP
   Alywn Mwinga MMed
   Isaac Zulu MMed MPH
   Velepie Mtonga MMed
   Albert Mwango MBChB
   Jabbin Mulwanda MMed FCS
 

 

 

Drugs>Antimicrobial Agents>
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Ciprofloxacin

Paul A. Pham, Pharm.D. and John G. Bartlett, M.D.
12-02-2010

Zambia Specific Information

  • Available formulation in Zambia: Tablet: 250 mg (as hydrochloride).
  • Uncomplicated UTI: ciprofloxacin 500 mg x 1 is preferred.
  • Recurrent UTI in women or UTI in males: 250 mg q12h x 7d.
  • Acute pyelonephritis: gentamicin 5mg/kg/day then switch to ciprofloxacin 500 mg PO q12h x 7 days when pt can tolerate oral fluids.
  • Acute bacterial prostatitis (<35 years): ciprofloxacin 500 mg x 1, followed by doxycycline 100 mg q12h x 7 days.
  • Acute bacterial prostatitis (>35 years): ciprofloxacin 500 mg q12h x 14 days. Treat for 28 days if chronic, relapse, or persistent infection.
  • Typhoid fever (S. typhi or S. paratyphi): ciprofloxacin 500 mg PO q12h x 10 days. Check stool culture weekly x 2 to exclude carrier state. If chronic carrier, treat with ciprofloxacin 750 mg PO q12h x 6 weeks.
  • Cholera (V. cholerae): ciprofloxacin 1gm PO x1
  • Acute inflammatory diarrhea (severe dysentery due to Shigella, Salmonella, and Campylobacter): ciprofloxacin 500 mg PO twice-daily x 3-7 d.
  • STDs in men and non-pregnant women: ciprofloxacin 500 mg x1 plus doxycycline 100 mg twice-daily x 7 days for pt and female partner. Metronidazole 2000 mg x1 should also be given to female partner.
  • Meningococcal meningitis prophylaxis in adults: 500 mg x1.
  • GC arthritis in PCN allergic pts: ciprofloxacin 500 mg PO q12h
  • Necrotizing otitis externa: ciprofloxacin 500 mg PO q12h x 4-6 weeks.
  • Chancroid: ciprofloxacin 500 mg PO twice-daily x 3d.

REFERENCES

Zambia Information Author: Paul A. Pham, Pharm. D.

INDICATIONS

FDA

  • Uncomplicated UTI (ciprofloxacin XR and ciprofloxacin), complicated UTI (ciprofloxacin).
  • Post-exposure prophylaxis for inhalation anthrax. CDC recommends as first line agent + 1-2 additional agent(s) with in vitro activity (for inhalation anthrax, see "biodefense-anthrax" module).
  • Complicated intra-abdominal infections (in combination with metronidazole)
  • Infectious diarrhea
  • Endocervical and urethral infections caused N. gonorrhoeae (high resistance rates reported in Hawaii and California).
  • Empiric therapy for neutropenic fever (in combination with piperacillin); typhoid fever
  • Nosocomial pneumonia
  • Prostatitis
  • Acute sinusitis
  • Skin and soft tissue infections; bone and joint infections 11) bacterial conjunctivitis (ophthalmic ointment) 12) bacterial conjuctivitis and corneal ulcers (ophthalmic solution) 13) Acute otitis externa (otic suspension)
NON-FDA APPROVED USES

  • Tuberculosis, MAC and other atypical mycobacterial infections (2nd or 3rd line)

FORMS

brand 
name
 
generic 
Mfg 
brand 
forms
 
cost* 
Cipro and genericsCiprofloxacin Bayer and generics (Barr, Eon)Oral
Tablet
250 mg; 500 mg; 750 mg
$4.59; $5.37; $5.62
      IV
Vial
200 mg
$14.40
      IV
Vial
400 mg
$28.80
      Oral
Tablet
100 mg (6 pack)
na 
      Oral
XR tablet
500 mg; 1000 mg
$10.46; $11.91
Ciprodex Ciprofloxacin 0.3%/dexamethasone 0.1%Alcon LabsOtic
Suspension
Ciprofloxacin 0.3%/dexamethasone 0.1% (7.5 ml)
$126.48
Cipro HC Otic Ciprofloxacin 0.2%/hydrocortisone 1%Alcon LabsOtic
Suspension
Ciprofloxacin 0.2%/hydroxortisone 1% (10 ml)
$126.48
Ciloxan CiprofloxacinAlcon LabsTopical
Ophthalmic solution
0.3% (2.5 ml; 5 ml; 10 ml)
$66.66 per 5 ml
      Topical
Ophthalmic ointment
0.3% (3.5 g)
$86.52

*Prices represent cost per unit specified and are representative of "Average Wholesale Price" (AWP). AWP Prices were obtained and gathered by Lakshmi Vasist Pharm D using the Red Book, manufacturer's information, and the McKesson database.

^Dosage is indicated in mg unless otherwise noted.

USUAL ADULT DOSING

  • Uncomplicated UTI: 250 mg PO twice-daily or ciprofloxacin XR 500 mg once daily PO x 3 d.
  • Complicated UTI: 500 mg PO twice-daily x 7-10 d.
  • Nosocomial pneumonia (P. aeruginosa): 400 mg IV q8h, then 750mg PO twice-daily x 10-14 d.
  • Endocervical and urethral infections caused N. gonorrhoeae: 500mg PO x1. Due to reports of fluoroquinolone resistance, rifampin, ceftriaxone, and azithromycin recommended in selected counties in North Dakota and Minnesota (MMWR 2008; 57:173)
  • Salmonellosis: 500-750 mg PO twice-daily or 400 mg IV twice-daily x 7-14 d for mild disease or 4-6 wks for CD4 <200 and/or bacteremia.
  • Traveler's diarrhea: 500 mg PO twice-daily x 3 d.
  • Tuberculosis, MAC, and other atypical mycobacteria: 750 mg PO twice-daily .
  • Milk or dairy products decreases GI absorption of ciprofloxacin by 36-47%. Administer ciprofloxacin 2 hrs before dairy products.

RENAL DOSING

DOSING FOR GLOMERULAR FILTRATION OF 50-80

Usual dose.

DOSING FOR GLOMERULAR FILTRATION OF 10-50

GFR >30 ml/min: 0.4Gm IV q12h (0.25Gm-0.5Gm PO q12h). GFR <30 ml/min: 0.4Gm IV q24h (0.25Gm-0.5Gm PO q12h)

DOSING FOR GLOMERULAR FILTRATION OF <10 ML/MIN

0.4Gm IV q24h (0.25Gm-0.5Gm PO q24h)

DOSING IN HEMODIALYSIS

0.2-0.4 Gm IV q24h (0.25-0.5 Gm PO q24h). Give post-HD on days of dialysis.

DOSING IN PERITONEAL DIALYSIS

0.2-0.4 Gm IV q24h (0.25Gm-0.5Gm po q24h).

DOSING IN HEMOFILTRATION

CVVH: 200mg IV q12h. CVVHD: 400 mg q12h.

ADVERSE DRUG REACTIONS

Generally well tolerated.

OCCASIONAL

  • GI intolerance: nausea and diarrhea
  • CNS: headache, malaise, insomnia, restlessness and dizziness
  • Candida vaginitis
  • C. difficile-associated colitis.
RARE

  • Tendon rupture (Increased incidence especially seen in older patients over age 60, concurrent use of corticosteroids, kidney, heart, and lung transplant recipients.)
  • Photosensitivity/phototoxicity reaction (can be severe)
  • Allergic reactions (fever and rash)
  • QTc prolongation
  • Transaminases elevation and rare cases of hepatic failure.
  • Peripheral neuropathy
  • Crystalluria
  • Photosensitivity
  • Seizure
  • Severe allergic reactions (TEN, Stevens-Johnsons syndrome, allergic pneumonitis, hepatitis, and bone marrow suppression)
  • Interstitial nephritis

DRUG INTERACTIONS

Drug-to-Drug Interactions

Drug-to-Drug Interaction

DrugEffect of InteractionRecommendations/Comments
Antacids (magnesium, aluminum, calcium, Al-Mg contained in buffered ddI), vitamins, and minerals Cations bind to ciprofloxacin resulting in decreased absorption and loss therapeutic efficacy. Avoid co-administration. Administer ciprfloxacin at least 2 hrs before cations.
Didanosine (buffered suspension) Antacid buffer bind to ciprofloxacin resulting in decreased absorption and loss therapeutic efficacy. Avoid co-administration. Administer ciprfloxacin at least 2 hrs before cations. No interaction with ddI EC.
Glyburide May cause hyper-or hypo-glycemia. Monitor glucose levels closely.
Methotrexate May increase methotrexate serum concentrations. Monitor for methotrexate toxicity.
Mexiletine Ciprofloxacin may inhibit CYP1A2 resulting in increased mexiletine concentrations. Monitor mexiletine serum concentrations with co-administration.
NSAIDs May increase risk of seizure. Avoid co-administration in pts with seizure history.
Probenecid Probenecid interferes with renal tubular secretion of ciprofloxacin, this may result in 50% increase in serum levels of ciprofloxacin. No dose adjustment.
Sevelamer Ciprofloxacin absorption significantly decreased. Avoid co-administration. Administer ciprofloxacin 2 hrs before sevelamer.
Sucralfate Decreased absorption of ciprofloxacin. Do not co-administer. Administer ciprofloxacin at least 2 hrs before sucralfate.
Theophylline Increases theophylline concentrations by 17-257%. Monitor theophylline serum concentrations with co-administration.
Warfarin Ciprofloxacin inhibit R-warfarin metabolism. Case reports of ciprofloxacin enhancing anti-coagulation effect of warfarin. Monitor INR closely.

SPECTRUM

Detailed Spectrum of Activity

PHARMACOLOGY

Pharmacology

COMMENTS

Oral and parenteral fluoroquinolone with best clinical and in vitro data for activity against P. aeruginosa, but resistance rates have increased over the years. Experience is favorable and extensive for nosocomial pneumonia, osteomyelitis, neutropenic fever, travelers diarrhea, chronic prostatitis and UTIs. Other fluoroquinolones (e.g.,levofloxacin and moxifloxacin) preferred for infections due to S. pneumoniae. Ciprofloxacin may be used as 3rd or 4th line agent for MDR TB and MAC infections in HIV+ pts. Like other fluoroquinolones, ciprofloxacin may result in false positive opiate screen (JAMA 2001;286:3115-9).

REFERENCES

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