What are the indications and dosing guidelines for Ciprofloxacin (ciprofloxacin) use?

Ciprofloxacin: Indications and Dosing Guidelines

Ciprofloxacin is FDA-approved for a broad range of bacterial infections, but should be reserved as an alternative agent for uncomplicated urinary tract infections due to resistance concerns, while remaining a preferred option for complicated UTIs, pyelonephritis, and various systemic infections when local resistance patterns permit. 1

FDA-Approved Indications in Adults

Urinary Tract Infections

• Acute uncomplicated cystitis (females): 250 mg orally twice daily for 3 days 1
• Complicated UTIs: 500 mg orally every 12 hours for 7-14 days 1
• Chronic bacterial prostatitis: 500 mg orally every 12 hours for 28 days 1
• Pyelonephritis: 500-750 mg orally twice daily for 7 days, or 1000 mg extended-release once daily for 7 days 2, 3

Respiratory Tract Infections

• Mild/moderate lower respiratory tract infections: 500 mg orally every 12 hours for 7-14 days 1
• Severe/complicated infections: 750 mg orally every 12 hours for 7-14 days 1
• Acute sinusitis: 500 mg orally every 12 hours for 10 days 1

Important caveat: Ciprofloxacin is not first-choice for pneumococcal pneumonia despite clinical efficacy 1

Skin and Soft Tissue Infections

• Mild/moderate: 500 mg orally every 12 hours for 7-14 days 1
• Severe/complicated: 750 mg orally every 12 hours for 7-14 days 1
• Necrotizing infections (Aeromonas hydrophila): 500 mg IV every 12 hours combined with doxycycline 2

Bone and Joint Infections

• Mild/moderate: 500 mg orally every 12 hours for ≥4-6 weeks 1
• Severe/complicated: 750 mg orally every 12 hours for ≥4-6 weeks 1

Gastrointestinal Infections

• Infectious diarrhea: 500 mg orally every 12 hours for 5-7 days 1
• Typhoid fever: 500 mg orally every 12 hours for 10 days 1
• Complicated intra-abdominal infections: 500 mg orally every 12 hours for 7-14 days (combined with metronidazole) 1

Sexually Transmitted Infections

• Uncomplicated gonorrhea: 500 mg orally as a single dose 2

Critical resistance warning: This indication is now obsolete in most regions due to widespread fluoroquinolone resistance in Neisseria gonorrhoeae 2

Bioterrorism

• Inhalational anthrax (post-exposure): 500 mg orally every 12 hours for 60 days 1
• Cutaneous anthrax: Ciprofloxacin 500 mg orally twice daily or levofloxacin 500 mg IV/orally every 24 hours for 60 days 2

Pediatric Dosing (Ages 1-17 Years)

Ciprofloxacin is not first-choice in pediatrics due to increased joint-related adverse events, but is FDA-approved for specific indications. 1

Approved Pediatric Indications

• Complicated UTI/pyelonephritis (oral): 10-20 mg/kg every 12 hours (maximum 750 mg/dose) for 10-21 days 1
• Complicated UTI/pyelonephritis (IV): 6-10 mg/kg every 8 hours (maximum 400 mg/dose) for 10-21 days 1
• Inhalational anthrax (oral): 15 mg/kg every 12 hours (maximum 500 mg/dose) for 60 days 1
• Inhalational anthrax (IV): 10 mg/kg every 12 hours (maximum 400 mg/dose) for 60 days 1

Multidrug-resistant organisms (off-label): 10-20 mg/kg/dose orally every 12 hours (maximum 750 mg/dose) or 10 mg/kg/dose IV every 8-12 hours (maximum 400 mg/dose) 2

Critical Resistance Thresholds

Fluoroquinolone resistance must be <10% in the local community for empirical use in pyelonephritis. 2, 3

• When local resistance exceeds 10%, administer an initial IV dose of ceftriaxone 1g before starting ciprofloxacin 2, 3
• For uncomplicated cystitis, reserve ciprofloxacin only when first-line agents (nitrofurantoin, trimethoprim-sulfamethoxazole) cannot be used 3
• The major concern is promoting resistance in more serious pathogens, including MRSA 3

Renal Dose Adjustments

Dosing modifications are required for creatinine clearance <50 mL/min: 1

• CrCl >50 mL/min: Standard dosing
• CrCl 30-50 mL/min: 250-500 mg every 12 hours
• CrCl 5-29 mL/min: 250-500 mg every 18 hours
• Hemodialysis/peritoneal dialysis: 250-500 mg every 24 hours (after dialysis)

IV to Oral Conversion

Patients may switch from IV to oral when clinically stable using equivalent dosing: 1

• 200 mg IV every 12 hours = 250 mg orally every 12 hours
• 400 mg IV every 12 hours = 500 mg orally every 12 hours
• 400 mg IV every 8 hours = 750 mg orally every 12 hours

Important Clinical Caveats

• Administer at least 2 hours before or 6 hours after antacids containing magnesium/aluminum, sucralfate, or products containing calcium, iron, or zinc 1
• Extended-release formulations (500 mg once daily) are equivalent to immediate-release (250 mg twice daily) for uncomplicated cystitis with improved convenience 3
• Duration principle: Continue for at least 2 days after signs/symptoms resolve, except for anthrax prophylaxis 1
• Longer durations (7 days vs 3 days) increase adverse events without improving efficacy for uncomplicated UTI 3