Ciprofloxacin is NOT Appropriate as First-Line Treatment for Uncomplicated UTIs
Ciprofloxacin should not be used as first-line therapy for uncomplicated urinary tract infections due to FDA warnings about serious adverse effects, high resistance rates, and unfavorable risk-benefit ratio. 1
FDA Warning and Guideline Recommendations
In July 2016, the FDA issued an advisory warning that fluoroquinolones, including ciprofloxacin, should not be used to treat uncomplicated UTIs because the disabling and serious adverse effects result in an unfavorable risk-benefit ratio 1
Since 2011, the Infectious Diseases Society of America guidelines have not recommended fluoroquinolones as first-line therapy for uncomplicated UTI, and the FDA advisory calls into question their use even as second-line agents 1
Fluoroquinolones are more likely than other antibiotic classes to alter fecal microbiota, cause Clostridium difficile infection, and produce long-term adverse effects in individual patients and society 1
High Resistance Rates
In a cohort from Ireland examining E. coli UTI, there was an 83.8% likelihood of persistent resistance to ciprofloxacin 1
Ciprofloxacin is no longer an appropriate choice as first-line treatment in many geographic regions because of the prevalence of fluoroquinolone resistance 1
Contemporary Escherichia coli resistance rates in most geographical regions limit utility as first-line treatment 1
Recommended First-Line Agents
For uncomplicated cystitis, use nitrofurantoin (NF), trimethoprim-sulfamethoxazole (TMP-SMX), or fosfomycin as first-line therapy. 1
Antibiotic stewardship in patients with recurrent UTI starts with treating all acute UTIs according to clinical practice guidelines using short duration NF, TMP-SMX, or fosfomycin as first-line therapy 1
The likelihood of persistent resistance to nitrofurantoin was only 20.2% at 3 months and 5.7% at 9 months, with only a 2.6% prevalence of resistance with initial infection 1
When Ciprofloxacin May Be Considered
Ciprofloxacin should be reserved as an alternative agent only when other recommended antimicrobials cannot be used for uncomplicated cystitis. 2
Appropriate Uses:
Acute pyelonephritis: 500 mg orally twice daily for 7 days (or 1000 mg extended-release once daily for 7 days) 2
Complicated UTIs: When Pseudomonas is confirmed or suspected, standard oral dosing of 500 mg twice daily for 7 days 2
High local resistance to first-line agents: If local fluoroquinolone resistance exceeds 10%, an initial one-time intravenous dose of a long-acting parenteral antimicrobial should be administered before starting oral ciprofloxacin 2
Critical Caveats
Beta-lactam antibiotics are also not considered first-line therapy because of collateral damage effects and their propensity to promote more rapid recurrence of UTI 1
Urine culture and susceptibility testing should be obtained before initiating therapy for pyelonephritis 2
The choice between available agents should be based on local resistance patterns 2
In pediatric patients, ciprofloxacin is not a drug of first choice due to an increased incidence of adverse events compared to controls, including events related to joints and surrounding tissues 3