From the Guidelines
Ciprofloxacin should be used with caution in patients with acute kidney injury (AKI) and dose adjustment is necessary to prevent toxicity while maintaining efficacy. The most recent and highest quality study 1 suggests that each nephrotoxin administration presents a 53% greater odds of developing AKI, and combining nephrotoxins can result in pharmacodynamic drug interactions.
Key Considerations
- For mild to moderate AKI (creatinine clearance 30-50 mL/min), reduce the dose to 250-500 mg every 12 hours.
- For severe AKI (creatinine clearance 5-29 mL/min), administer 250-500 mg every 18-24 hours.
- In patients on hemodialysis, give 250-500 mg every 24 hours after dialysis.
- Monitor renal function regularly during treatment and adjust dosing accordingly.
Rationale
Ciprofloxacin is primarily eliminated by the kidneys, with approximately 40-50% excreted unchanged in urine, making dose adjustment essential in kidney dysfunction. Without proper adjustment, the drug can accumulate, increasing the risk of adverse effects including seizures, tendon rupture, and QT prolongation. Additionally, ciprofloxacin may worsen kidney function in some patients with AKI, so careful monitoring is necessary. Consider alternative antibiotics if the patient has severely impaired renal function or if the infection can be treated with antibiotics less dependent on renal clearance, as suggested by 1.
Nephrotoxin Management
The evaluation of nephrotoxins as a plausible cause of AKI is the first consideration in the management of medications for patients with AKI, as stated in 1. Determining nephrotoxic causality involves assessment of the temporal sequence between administration and the onset of injury, other possible causes, response to the removal of a drug, and in some cases the effects of restarting the drug.
Clinical Implications
In clinical practice, it is essential to weigh the benefits and risks of using ciprofloxacin in patients with AKI, considering the potential for nephrotoxicity and the availability of alternative antibiotics. Regular monitoring of renal function and adjustment of dosing as needed can help minimize the risks associated with ciprofloxacin use in AKI patients.
From the FDA Drug Label
Ciprofloxacin is known to be substantially excreted by the kidney, and the risk of adverse reactions may be greater in patients with impaired renal function. The FDA drug label does not provide specific guidance on the use of ciprofloxacin in Acute Kidney Injury (AKI).
- Dose adjustment may be necessary in patients with impaired renal function, but the label does not provide explicit recommendations for AKI.
- Renal function monitoring may be useful in patients with AKI, but the label does not provide specific guidance on this topic.
- The label recommends caution when using ciprofloxacin in patients with impaired renal function, but does not provide specific guidance on the use of ciprofloxacin in AKI 2.
From the Research
Ciprofloxacin and Acute Kidney Injury (AKI)
- Ciprofloxacin is a type of antibiotic that can potentially cause nephrotoxicity, leading to AKI 3.
- AKI is a clinical syndrome characterized by a rapid decline in glomerular filtration rate and resultant accumulation of metabolic waste products 4.
- The use of ciprofloxacin and other antimicrobials can increase the risk of AKI, especially in patients with pre-existing chronic kidney disease or those taking concomitant nephrotoxic medications 3, 5.
Risk Factors for Ciprofloxacin-Induced AKI
- Pre-existing chronic kidney disease is a significant risk factor for ciprofloxacin-induced AKI 3, 5.
- Concomitant use of other nephrotoxic medications, such as amphotericin B or piperacillin-tazobactam, can increase the risk of AKI 6.
- Elevated serum creatinine and chloride concentrations, as well as decreased serum albumin concentration, can also increase the risk of AKI 6.
Management and Prevention of Ciprofloxacin-Induced AKI
- Discontinuation of ciprofloxacin and other nephrotoxic medications is essential in managing AKI 4.
- Fluid and electrolyte management, as well as adjustment of prescribed drugs according to renal function, are crucial in preventing and managing AKI 4, 5.
- Pharmacist-led quality-improvement programs and antimicrobial stewardship can help reduce the incidence of AKI in hospitalized patients 4, 5.