Ciprofloxacin

Ciprofloxacin

[1 vial $7.53; 1 tablet 16 cents]

ADMINISTRATION ROUTES:

  • IV, PO, NG

ALTERNATIVE NAMES:

  • Ciproxin

ICU INDICATIONS:

  1. treatment of infections caused by susceptible organisms

PRESENTATION AND ADMINISTRATION:

  • IV:
    200mg / 100ml (solution in normal saline)
    Store at room temperature
    Administer required dose over not less than 60 minutes. Solution is usually infused undiluted but can be mixed with other compatible IV fluids.
    Compatible with the following IV fluids:
    Normal saline, 5% dextrose, 10% dextrose, Hartman, Glucose and sodium chloride
    Do not mix with any infusion solution or medicines.
  • PO / NG:
    250mg, 500mg and 750mg tablets
    250mg/5ml and 500mg/100ml suspension
    Tablets can be crushed and dispersed in water for NG administration (check brand with pharmacist)

DOSAGE:

  • IV:
    400mg 8-12hrly
  • PO:
    500mg 12hrly

DOSAGE IN RENAL FAILURE AND RENAL REPLACEMENT THERAPY:

  • Dose in renal impairment [GFR (ml/min)]
    <10: 50% of normal dose
    10-20: 50% of normal dose
    >20-50: dose as in normal renal function
  • Dose in renal replacement therapy
    CAPD: Oral: 250mg-500mg every 12hrs; IV: 100mg every 12 hrs
    HD: Oral: 250mg-500mg every 12hrs; IV 100-200mg every 12 hrs
    CVVHDF: Oral: 500mg-750mg every 12hrs; IV 200-400mg every 12 hrs

DOSAGE IN PAEDIATRICS:

  • IV:
    4-7mg/kg 12 hourly
  • PO:
    5-10mg/kg 12 hourly

Note: Ciprofloxacin is indicated in paediatric patients for inhalational anthrax (postexposure). The risk-benefit assessment indicates that administration of ciprofloxacin to pediatric patients is appropriate in this setting. Although effective in clinical trials, ciprofloxacin is not a drug of first choice in the paediatric population for other indications due to an increased incidence of adverse events compared to other agents.

CLINICAL PHARMACOLOGY:

  • Ciprofloxacin is a quinolone antibiotic which has a bactericidal action through inhibition of the enzymes topoisomerase II (DNA gyrase) and topoisomerase IV, which are required for bacterial DNA replication, transcription, repair, and recombination.
  • Ciprofloxacin has in vitro activity against a wide range of gram-negative and gram- positive microorganisms and has been shown to be active against most strains of the following microorganisms, both in vitro and in clinical infections.
  • Aerobic Gram-Positive Microorganisms:
    Enterococcus faecalis (many strains are only moderately susceptible), Staphylococcus aureus (methicillin-susceptible strains only), Staphylococcus epidermidis (methicillin-susceptible strains only), Staphylococcus saprophyticus, Streptococcus pneumoniae (penicillin-susceptible strains only), Streptococcus pyogenes.
  • Aerobic Gram-Negative Microorganisms:
    Campylobacter jejuni, Citrobacter diversus, Citrobacter freundii, Enterobacter cloacae, Escherichia coli, Haemophilus influenzae, Haemophilus parainfluenzae, Klebsiella pneumoniae, Moraxella catarrhalis, Morganella morganii, Neisseria gonorrhoeae, Proteus mirabilis, Proteus vulgaris, Providencia rettgeri, Providencia stuartii, Pseudomonas aeruginosa, Salmonella typhi, Serratia marcescens, Shigella boydii, Shigella dysenteriae, Shigella flexneri, Shigella sonnei.
    Most strains of Burkholderia cepacia and some strains of Stenotrophomonas maltophilia are resistant to ciprofloxacin as are most anaerobic bacteria, including Bacteroides fragilis and Clostridium difficile.

CONTRAINDICATIONS:

1. hypersensitivity to ciprofloxacin or any member of the quinolone class of antimicrobials

WARNINGS

  • Central Nervous System Disorders
    Convulsions, increased intracranial pressure, and toxic psychosis have been reported in patients receiving quinolones, including ciprofloxacin.
  • Hypersensitivity Reactions
    Serious and occasionally fatal hypersensitivity (anaphylactic) reactions, some following the first dose, have been reported in patients receiving quinolone therapy. Severe hypersensitivity reactions characterized by rash, fever, eosinophilia, jaundice, and hepatic necrosis with fatal outcome have also been rarely reported in patients receiving ciprofloxacin along with other drugs.
  • Pseudomembranous Colitis
    Pseudomembranous colitis has been reported with nearly all antibacterial agents, including ciprofloxacin, and may range in severity from mild to life-threatening.
  • Peripheral Neuropathy
    Rare cases of sensory or sensorimotor axonal polyneuropathy affecting small and/or large axons resulting in paresthesias, hypoesthesias, dysesthesias and weakness have been reported in patients receiving quinolones, including ciprofloxacin.
  • Tendon Effects
    Ruptures of the shoulder, hand, achilles tendon or other tendons that required surgical repair or resulted in prolonged disability have been reported in patients receiving quinolones, including ciprofloxacin.

PRECAUTIONS

  • General:
    Prescribing ciprofloxacin tablets and oral suspension in the absence of a proven or strongly suspected bacterial infection or a prophylactic indication is unlikely to provide benefit to the patient and increases the risk of the development of drug-resistant bacteria.
  • Laboratory Tests:
    No tests in addition to usual ICU tests are indicated
  • Drug/Laboratory Test Interactions:
    None of note

IMPORTANT DRUG INTERACTIONS FOR THE ICU

  • SERIOUS AND FATAL REACTIONS HAVE BEEN REPORTED IN PATIENTS RECEIVING CONCURRENT ADMINISTRATION OF CIPROFLOXACIN AND THEOPHYLLINE. These reactions have included cardiac arrest, seizure, status epilepticus, and respiratory failure. Although similar serious adverse effects have been reported in patients receiving theophylline alone, the possibility that these reactions may be potentiated by ciprofloxacin cannot be eliminated. If concomitant use cannot be avoided, serum levels of theophylline should be monitored and dosage adjustments made as appropriate.
  • Concurrent administration of a quinolone, including ciprofloxacin, with oral multivalent cation-containing products such as magnesium/aluminum antacids, sucralfate, didanosine chewable/buffered tablets or paediatric powder, other highly buffered drugs, or products containing calcium, iron, or zinc may substantially decrease its absorption, resulting in serum and urine levels considerably lower than desired.
  • Altered serum levels of phenytoin (increased and decreased) have been reported in patients receiving concomitant ciprofloxacin. The concomitant administration of ciprofloxacin with the sulfonylurea glyburide has, on rare occasions, resulted in severe hypoglycemia.
  • Some quinolones, including ciprofloxacin, have been associated with transient elevations in serum creatinine in patients receiving cyclosporine concomitantly. Quinolones, including ciprofloxacin, have been reported to enhance the effects of the oral anticoagulant warfarin or its derivatives.
  • Renal tubular transport of methotrexate may be inhibited by concomitant administration of ciprofloxacin potentially leading to increased plasma levels of methotrexate. This might increase risk of methotrexate associated toxic reactions. Therefore, patients under methotrexate therapy should be carefully monitored when concomitant ciprofloxacin therapy is indicated.
  • Non-steroidal antiinflammatory drugs (but not aspirin) in combination of very high doses of quinolones have been shown to provoke convulsions in preclinical studies.

ADVERSE REACTIONS

  • Body as a Whole:
    Headache, abdominal pain/discomfort, foot pain, pain, pain in extremities, injection site reaction
  • Cardiovascular System:
    Palpitation, atrial flutter, ventricular ectopy, syncope, hypertension, angina pectoris, myocardial infarction, cardiopulmonary arrest, cerebral thrombosis, phlebitis, tachycardia, migraine, hypotension.
  • Respiratory:
    Dyspnea, epistaxis, laryngeal or pulmonary edema, hiccough, hemoptysis, bronchospasm, pulmonary embolism.
  • Central Nervous System:
    Restlessness, dizziness, lightheadedness, insomnia, nightmares, hallucinations, manic reaction, irritability, tremor, ataxia, convulsive seizures, lethargy, drowsiness, weakness, malaise, anorexia, phobia, depersonalization, depression, paresthesia, abnormal gait, grand mal convulsion.
  • Digestive System:
    Painful oral mucosa, oral candidiasis, dysphagia, intestinal perforation, gastrointestinal bleeding, cholestatic jaundice, hepatitis. Haematological System: Lymphadenopathy, petechia.
  • Renal/Urogenital:
    Interstitial nephritis, nephritis, renal failure, polyuria, urinary retention, urethral bleeding, vaginitis, acidosis, breast pain. Skin: Allergic reaction, pruritus, urticaria, photosensitivity, flushing, fever, chills, angioedema, edema of the face, neck, lips, conjunctivae or hands, cutaneous candidiasis, hyperpigmentation, erythema nodosum, sweating.

Critical Care Drug Manual

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