From the Guidelines
For patients with end-stage renal disease (ESRD), the recommended dosing of ciprofloxacin (Cipro) is 250-500 mg every 24 hours, which is a 50% reduction from the standard dosing, as indicated in the clinical practice guideline for the management of chronic kidney disease 1.
Key Considerations
- The dosage adjustment is necessary because ciprofloxacin is primarily eliminated by the kidneys, and patients with ESRD have significantly reduced renal clearance, which can lead to drug accumulation and increased risk of adverse effects such as tendon damage, CNS effects, and QT prolongation if standard doses are used.
- For patients on hemodialysis, the dose should be administered after the dialysis session as ciprofloxacin is partially removed during dialysis, with a recommended dose of 250-500 mg every 24 hours or 200-400 mg IV every 24 hours, dosing post-hemodialysis 1.
- In severe infections, such as complicated urinary tract infections or respiratory infections, the higher end of the dosing range (500 mg daily) may be used, while for less severe infections, 250 mg daily is often sufficient.
- The duration of therapy typically ranges from 7-14 days depending on the type and severity of infection.
Important Interactions and Precautions
- It's also important to monitor for drug interactions, as ciprofloxacin can interact with medications commonly used in ESRD patients, such as phosphate binders and antacids, which can reduce ciprofloxacin absorption.
- Patients with ESRD should be closely monitored for signs of ciprofloxacin toxicity, including tendonitis, CNS effects, and QT prolongation, and the dose should be adjusted accordingly.
Dosing Summary
- CrCl <30 mL/min: 250-500 mg q18-24h OR 400 IV q24h
- Receiving hemodialysis: 250-500 mg q24h OR 200-400 IV q24h (days of HD dose post-HD) 1
From the FDA Drug Label
Adults with Impaired Renal Function: ... The following table provides dosage guidelines for use in patients with renal impairment: RECOMMENDED STARTING AND MAINTENANCE DOSES FOR PATIENTS WITH IMPAIRED RENAL FUNCTION Creatinine Clearance (mL/min)Dose ... Patients on hemodialysis or Peritoneal dialysis 250-500 mg q 24 h (after dialysis)
The recommended dosing of ciprofloxacin (Cipro) for patients with end-stage renal disease (ESRD) is 250-500 mg every 24 hours after dialysis for patients on hemodialysis or peritoneal dialysis 2.
From the Research
Ciprofloxacin Dosing in End-Stage Renal Disease (ESRD)
- The dosing of ciprofloxacin in patients with ESRD requires careful consideration due to the impaired renal excretion of the drug 3.
- In patients with ESRD, the normal dosage regimen of ciprofloxacin may need to be adjusted based on the remaining kidney function, estimated by the glomerular filtration rate (GFR) 3.
- A study found that a daily dose of 400 mg of ciprofloxacin may not be sufficient for patients with ESRD and less susceptible pathogens, and higher doses may be necessary 4.
- Another study suggested that prolonging the administration interval may be a preferable dose adjustment method in renal failure with ciprofloxacin, rather than reducing the dose 5.
- The pharmacokinetics of ciprofloxacin have been studied in patients with renal failure, and the results show that the drug is partly removed by hemodialysis 6.
Dosage Adjustment
- The dosage adjustment of ciprofloxacin in patients with ESRD should be based on the patient's renal function and the minimum inhibitory concentration (MIC) of the causative pathogen 4.
- A dosing algorithm for ciprofloxacin in critically ill patients has been developed, which takes into account both renal function and pathogen susceptibility 4.
- The algorithm suggests that higher doses of ciprofloxacin may be necessary for patients with ESRD and less susceptible pathogens, and that the dosing should be individualized based on the patient's renal function and the MIC of the pathogen 4.