Alternative Antibiotics to Ciprofloxacin in Pediatric Patients
For most pediatric infections where ciprofloxacin might be considered, use cephalosporins (ceftriaxone or cefotaxime) as the primary alternative, with amoxicillin or amoxicillin-clavulanate for outpatient oral therapy. 1
Urinary Tract Infections
Standard empiric therapy for uncomplicated UTI in children should be a cephalosporin antibiotic, not ciprofloxacin. 2
First-Line Oral Options:
- Cephalosporins (cefixime, cefpodoxime, cefprozil, or cefuroxime) - preferred for uncomplicated UTI 1, 2
- Amoxicillin-clavulanate - effective alternative given increasing resistance to amoxicillin alone 1, 2
- Trimethoprim-sulfamethoxazole (TMP-SMX) - only if local resistance patterns permit 1, 2
- Nitrofurantoin - appropriate for cystitis but not pyelonephritis 2
Parenteral Options for Complicated UTI/Pyelonephritis:
- Ceftriaxone 50-80 mg/kg daily 1, 3
- Cefotaxime 50 mg/kg every 6 hours 1, 3
- Gentamicin 5-7.5 mg/kg daily (often combined with ampicillin) 1, 3
The American Academy of Pediatrics explicitly states that fluoroquinolones should only be considered for pyelonephritis or complicated UTI when first-line agents are inappropriate based on susceptibility data, allergy, or adverse-event history. 1, 2
Respiratory Tract Infections (Pneumonia)
Outpatient Treatment:
For children <5 years with presumed bacterial pneumonia:
- Amoxicillin 90 mg/kg/day divided twice daily (oral) 1
- Amoxicillin-clavulanate 90 mg/kg/day of amoxicillin component divided twice daily 1
For children ≥5 years:
- Amoxicillin 90 mg/kg/day (maximum 4 g/day) divided twice daily 1
- Add azithromycin (10 mg/kg day 1, then 5 mg/kg days 2-5) if atypical pneumonia cannot be excluded 1
Inpatient Treatment:
For fully immunized children with minimal local penicillin resistance:
For incompletely immunized or significant local resistance:
Gastrointestinal Infections
Dysentery:
- Ceftriaxone 50-80 mg/kg IV daily for 3 days (second-line after ciprofloxacin) 1
Typhoid Fever:
Skin and Soft Tissue Infections
Community-Acquired:
- Penicillin V 25-50 mg/kg/day oral in divided doses 1
- Amoxicillin 40 mg/kg oral every 8 hours for children <20 kg 1
- Erythromycin 40 mg/kg/day in divided doses 1
For Pseudomonas skin infections (hot tub folliculitis):
This represents one of the few scenarios where fluoroquinolones offer an oral option that may be preferred over parenteral non-fluoroquinolone therapy in children. 1 However, if avoiding ciprofloxacin, parenteral antipseudomonal therapy would be required.
Meningitis
For multidrug-resistant Gram-negative meningitis:
- Ceftriaxone 50 mg/kg twice daily for 7-10 days 1
- Cefotaxime 50 mg/kg every 6 hours for 7-10 days 1
- Chloramphenicol 25 mg/kg every 6 hours plus ampicillin 50 mg/kg every 6 hours (if no known local resistance) 1
Ciprofloxacin is only considered when multidrug-resistant Gram-negative bacteria are present and no other suitable agents exist. 1
Critical Considerations
Musculoskeletal adverse events occur in 9.3% of pediatric patients receiving ciprofloxacin versus 6.0% in controls, which is the primary reason to avoid fluoroquinolones when alternatives exist. 2
Inappropriate fluoroquinolone use drives bacterial resistance, making preservation of this class important for truly resistant infections. 2
For Pseudomonas aeruginosa or multidrug-resistant Gram-negative infections, ciprofloxacin remains appropriate when susceptibility data support its use and other options are limited. 1, 2 In these specific scenarios, the benefit outweighs the musculoskeletal risk.
Doxycycline (for children >7 years) can substitute for fluoroquinolones in atypical pneumonia and certain other infections, though it carries its own age-related restrictions. 1