Ciprofloxacin Dosing in ESRD
For patients with ESRD (creatinine clearance <10 mL/min), ciprofloxacin should be dosed at 250-500 mg every 24 hours, administered after dialysis on dialysis days. 1
FDA-Approved Dosing for Severe Renal Impairment
The FDA label provides clear guidance for ciprofloxacin dosing in renal failure 1:
- CrCl 30-50 mL/min: 250-500 mg every 12 hours
- CrCl 5-29 mL/min: 250-500 mg every 18 hours
- Hemodialysis or peritoneal dialysis: 250-500 mg every 24 hours (after dialysis)
For severe infections in patients with severe renal impairment, a unit dose of 750 mg may be administered at the intervals noted above, with careful monitoring 1.
Guideline Recommendations
The Infectious Diseases Society of America guidelines confirm dose adjustment is necessary for ciprofloxacin in patients with renal impairment 2, 3. The specific dosing table in the IDSA HIV/CKD guidelines begins to address ciprofloxacin dosing for CKD but the complete dosing information is cut off in the provided excerpt 2.
Pharmacokinetic Considerations in ESRD
Interval prolongation is superior to dose reduction for ciprofloxacin in renal failure 4:
- Ciprofloxacin elimination half-life increases from 4.4 hours in normal renal function to 8.7 hours in renal failure patients not on hemodialysis 5
- Urinary recovery drops dramatically from 37% to only 5.3% in renal failure 5
- Simulation studies demonstrate bacterial eradication occurs on day 3 with interval prolongation (500 mg every 24h) versus day 6 with dose reduction (250 mg every 12h) 4
Hemodialysis removes ciprofloxacin moderately 5, 6:
- Dialyzer extraction ratio is 23% with dialysis clearance of 40 mL/min 6
- Half-life during hemodialysis decreases to 3.2 hours compared to 5.8 hours on interdialysis days 5
- This supports post-dialysis dosing to replace removed drug 1
Practical Dosing Algorithm
For ESRD patients (CrCl <10 mL/min) 1:
- Standard infections: 250-500 mg every 24 hours
- Severe/complicated infections: 750 mg every 24 hours with close monitoring
- Hemodialysis patients: Administer dose after dialysis session
- Peritoneal dialysis: 250-500 mg every 24 hours
Critical Caveats
Target attainment concerns: Recent data show that even standard doses may be inadequate for less susceptible pathogens (MIC ≥0.5 mg/L), and paradoxically, reduced doses in renal impairment result in significantly lower drug exposure 7, 8. Only 13% of patients with impaired renal function achieved AUC/MIC ≥125 with guideline-recommended reduced doses 8.
Monitor renal function during treatment, as fluoroquinolones can occasionally cause acute renal failure 3.