Ciprofloxacin

These indications are based on manufacturer information for both originator and generic products. For product specific registered indications, please refer to product specific manufacturer information

Registered South African indications:

• Lower respiratory tract infections caused by Escherichia coli, Klebsiella pneumoniae, Enterobacter cloacae, Proteus mirabilis, Pseudomonas aeruginosa, Haemophilus influenzae and Haemophilus parainfluenzae 
• Urinary tract infections caused by Escherichia coli, Klebsiella pneumoniae, Enterobacter cloacae, Serratia marcescens, Proteus mirabilis, Providencia rettgeri, Morganella morganii, Citrobacter diversus, Citrobacter freundii, Pseudomonas aeruginosa, Staphylococcus epidermidis and Streptococcus faecalis 
• Skin and soft tissue infections caused by Escherichia coli, Klebsiella pneumoniae, Enterobacter cloacae, Proteus mirabilis, Proteus vulgaris, Providencia stuartii, Morganella morganii, Citrobacter freundii, Pseudomonas aeruginosa, Staphylococcus aureus, Staphylococcus epidermidis and Streptococcus pyogenes 
• Gastrointestinal infections: Infective diarrhoea caused by Escherichia coli, Campylobacter jejuni, Shigella flexneri and Shigella sonnei 
• Bone infections: Osteomyelitis due to susceptible Gram-negative organisms
• Prophylaxis of invasive infections due to Neisseria meningitidis (>18 years old)
• Gonorrhoea (except that is due to N. gonorrhoeae)

*Infections caused by Pseudomonas aeruginosa must be admin. with aminoglycoside

Ciprofloxacin should be used in caution with patients with a history of convulsive disorders. Crystalluria related to the use of ciprofloxacin has been observed. Patients receiving ciprofloxacin should be well hydrated and excessive alkalinity of the urine should be avoided Side effects that may be potentially life-threatening are pancytopenia and marrow depression Concurrent administration with methotrexate may increase the concentration of methotrexate to toxic levels Tendinitis may occur. It most frequently involves the Achilles tendon and may lead to tendon rupture. The risk of tendinitis and tendon rupture is increased in the elderly and in patients using corticosteroids and in patients with a kidney or lung transplant. Close monitoring of these patients is therefore necessary if ciprofloxacin is prescribed All patients should consult their medical practitioner if they experience symptoms of tendinitis. If tendinitis is suspected, treatment with ciprofloxacin must be discontinued immediately, and appropriate treatment (e.g., immobilisation) must be initiated for the affected tendon. Tendinitis and/or tendon rupture may still occur for several months after completion of treatment. The recovery process may be prolonged (weeks to months) and full recovery to the pre-treatment status may not occur

Registered South African contraindications

Film-coated tablets, Intravenous formulations, Suspension, XR tablets

• Hypersensitivity to the active ingredient or any of its excipients
• Hypersensitivity to other quinolones
• Concomitant use of ciprofloxacin with other medicines known to prolong the QT interval or in patients with disorders that prolong the QT interval to such an extent that it leads to prolonged QTcF interval known to be associated with serious and potentially fatal dysrhythmias, or if symptomatic dysrhythmias occur with concomitant use at time intervals shorter than QT intervals usually associated with dysrhythmias
• Myasthenia gravis where alternative appropriate antibiotic choices are available
• Coadministration with tizanidine
• A history of tendon, muscle, joint, central nervous system, epilepsy, or psychotic disorders, especially those related to previous quinolone/fluoroquinolone use where alternative, appropriate antibiotic choices are available for treatment
• Aortic aneurysm and/or dissection or in patients with risk factors or conditions predisposing for aortic aneurysm and/or dissection if alternative appropriate antibiotic choices are available
• Patients with confirmed mitral valve and/or aortic valve regurgitation unless no safer appropriate alternative antibiotic is available, has failed, or is not well tolerated
• Concomitant use of fluoroquinolones with ACE inhibitors/angiotensin-receptor blockers in patients with moderate to severe renal impairment (creatinine clearance ≤30ml/min) and in the elderly
• Children under 18 years, as there is evidence of damage to the cartilage of weight-bearing joints in immature animals
• Pregnancy
• Lactation

Tablets

• Hypersensitivity to the active ingredient or any of its excipients
• Hypersensitivity to other quinolones
• Children below 18 years and growing adolescents, experimental evidence indicates lesions of the cartilage of weightbearing joints in immature members of certain animal species
• Pregnancy
• Lactation

Contraindications registered in other jurisdictions

• Hypersensitivity to the active ingredient or any of its excipients
• Hypersensitivity to other quinolones
• Coadministration with tizanidine

• Pregnancy (Recommendations in other jurisdictions)
• Breastfeeding (Recommendations in other jurisdictions)
• Renal impairment (CrCl ≤60ml/min) (inj, tab, sus)
• Renal impairment (XR tab)
• Hepatic impairment (XR tab)
• Elderly
• Patients who have experienced serious adverse reactions when using quinolone or fluoroquinolone-containing products
• Pre-existing risk factors for serious adverse reactions
• Monotherapy for the treatment of severe infections and infections that might be due to Gram-positive or anaerobic pathogens
• Streptococcal infections (including Streptococcus pneumoniae)
• Infections caused by Neisseria gonorrhoeae where resistance has not been excluded 
• Infections caused by Escherichia coli 
• Post-surgical intra-abdominal infections
• Travellers' diarrhoea
• Infections of the bones and joints
• Inhalational anthrax
• Children between 1-5 years (bronchopulmonary infections in cystic fibrosis) (Recommendations in other jurisdictions) 
• Children and adolescents aged 1-17 years (Complicated urinary tract infections and pyelonephritis) (Recommendations in other jurisdictions)
• Severe infections
• History of tendon disease/ disorder related to quinolone treatment
• Patients with solid organ transplants
• Myasthenia gravis
• Positive family history of aneurysm disease or congenital heart valve disease
• Pre-existing aortic aneurysm and/or dissection or heart valve disease
• Risk factors or conditions predisposing aortic aneurysm and dissection and heart valve regurgitation/ incompetence
• Connective tissue disorders
  - Marfan syndrome
  - Ehlers-Danlos syndrome
  - Turner syndrome
  - Behcet's disease
  - Hypertension
  - Rheumatoid arthritis
• Vascular disorders
  - Takayasu arteritis
  - Giant cell arteritis
  - Known atherosclerosis
  - Sjögren's syndrome
• Infective endocarditis
• Direct exposure to either extensive sunlight or UV irradiation
• Central nervous system disorders which predispose to seizures
• Known risk factors for prolongation of the QT interval
  - Congenital long QT syndrome
  - Coadministration with drugs that are known to prolong the QT interval (e.g. Class IA and III antiarrhythmics, tricyclic antidepressants, macrolides, antipsychotics)
  - Uncorrected electrolyte imbalance (e.g. hypokalaemia, hypomagnesaemia)
  - Cardiac disease (e.g. heart failure, myocardial infarction, bradycardia)
• Female patients
• Diabetes mellitus
• Dehydration
• Excessive alkalinity of urine
• Mitral valve and/or aortic valve regurgitation
• Patients with solid organ transplants
• Risk of fluoroquinolone-induced tendinitis and tendon rupture
• Risk of aortic aneurysm and dissection (particularly in the elderly)
• Uncontrolled hypertension
• Atherosclerosis
• Coadministration with methotrexate
• Coadministration with corticosteroids
• Glucose-6-phosphate dehydrogenase deficiency
• Fructose intolerance (sus)
• Glucose-galactose malabsorption (sus)
• Saccharose-isomaltase deficiency (sus)

Forms avail. in SA and covered in this monograph:  extended release tablet (XR tab), fct, inf, inj, sus, tab

Dosages below include:

• South African Standard Treatment Guidelines indications and dosages
• South African registered indications and dosages

Infections caused by: Enterobacter cloacae, Escherichia coli, Haemophilus influenzae, Haemophilus parainfluenzae, Klebsiella pneumoniae, Proteus mirabilis, Pseudomonas aeruginosa; Citrobacter diversus, Citrobacter freundii, Morganella morganii, Providencia rettgeri, Serratia marcescens, Staphylococcus epidermidis, Streptococcus faecalis; Proteus vulgaris, Providencia stuartii, Staphylococcus aureus, Streptococcus pyogenes; Campylobacter jejuni, Shigella flexneri and Shigella sonnei; Sensitive Gram-negative organisms

Specific doses based on individual indications

Please note that the dosages below should be used in combination with regional guidelines, taking into account local antibiotic sensitivities

South African Standard Treatment Guidelines indications and dosages

Complicated community acquired cystitis
Acute pyelonephritis
- As an oral switch option from IV gentamicin

• Oral (sus, tab, fct): 500mg, 12hrly; Treatment duration: 7-10 days
  (STG, Adult 2019; PHC 2020)

- As an oral switch option from IV ceftriaxone in those with impaired renal function
Complicated cystitis

• Oral (sus, tab, fct): 500mg, 12hrly; Treatment duration: 7 days
  (STG, PHC 2020)

Catheter associated urinary tract infection
- If local resistance patterns show low level resistance to ciprofloxacin or culture shows sensitivity

• Oral (sus, tab, fct): 500mg, 12hrly; Treatment duration: 7-14 days
  (STG, Adult 2019)

Spontaneous bacterial peritonitis
- As an oral switch option from IV ceftriaxone when clinically appropriate
Acute bacterial prostatitis
- If there are no features of associated urethritis
- In men >35 years of age or if there is associated cystitis

• Oral (sus, tab, fct): 500mg, 12hrly; Treatment duration: 14 days
  (STG, Adult 2019; PHC 2020)

Chronic, relapsed or persistent prostatitis infection

• Oral (sus, tab, fct): 500mg, 12hrly; Treatment duration: 28 days
  (STG, Adult 2019)

Cholera
Bacillary dysentery
Acute inflammatory diarrhoea (Dysentery)
- Uncomplicated dysentery in patients with no co-morbidity
- As an oral switch option from IV ceftriaxone

• Oral (sus, tab, fct): 500mg, 12hrly; Treatment duration: 3 days
  (STG, Adult 2019; PHC 2020)

- Uncomplicated dysentery in patients with significant co-morbidity e.g., immunocompromised patients

• Oral (sus, tab, fct): 500mg, 12hrly; Treatment duration: 7 days
  (STG, Adult 2019)

Pelvic inflammatory disease - stage II-IV (Additional agents required)
- As an oral switch option when there is definite clinical improvement

• Oral (sus, tab, fct): 500mg, 12hrly; Treatment duration: 10 days (includes initial IV antibiotic therapy)
  (STG, Adult 2019)

Enteric fever (Typhoid fever)
- As a follow on with oral therapy as soon as patient can swallow and the temperature is <37.8^oC for 24hrs, based on culture sensitivity results
Cystoisosporiasis
- In those allergic to cotrimoxazole

• Oral (sus, tab, fct): 500mg, 12hrly; Treatment duration: 10 days
  (STG, Adult 2019, 2023)

Chronic carriers of enteric fever

• Oral (sus, tab, fct): 500mg, 12hrly; Treatment duration: 6 weeks
  (STG, Adult 2019)

Tick bite fever
- For the rare patient unable to take oral therapy

• IV: 400mg, 8hrly; Treatment duration: 7 days
  (STG, Adult 2019)

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Note: Tick bitter fever: This is inferior to doxycycline and oral doxycycline should be commenced as soon as possible

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Septic miscarriage (Additional agent required)
- As an oral switch option in those with a severe penicillin allergy after clinical improvement

• Oral (sus, tab, fct): 500mg, 12hrly; Treatment duration: 5 days
  (STG, Adult 2019)

Prophylaxis of meningococcal meningitis
- For close household contacts
- For healthcare workers who resuscitate patients before they received appropriate treatment
Eradication of nasopharyngeal carriage of meningococcal meningitis
- After treatment with benzylpenicillin if the patient did not receive an initial, pre-referral dose of ceftriaxone

• Oral (sus, tab, fct): 500mg, immediately as a single dose
  (STG, Adult 2019; PHC 2020)

Bacterial endophthalmitis with soft tissue involvement or as prophylaxis after a penetrating eye injury
Bronchiectasis with confirmed pseudomonas infection on culture (Additional agent required)

• Oral (sus, tab, fct): 750mg, 12hrly; Treatment duration: 7 days
  (STG, Adult 2019)

Necrotising otitis externa

• Oral (sus, tab, fct): 750mg, 12hrly (and refer)
  (STG, Adult 2019)

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There is increasing resistance to ciprofloxacin in South Africa and it is important to send specimens for culture and sensitivity prior to commencing antibiotic therapy

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South African registered indications and dosages

General dose range

• Oral (sus, tab, fct): 250-750mg, twice daily
• IV: 100-200mg, every 12hrs

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Ciprofloxacin is not indicated/ approved for the initiation of treatment (first line treatment) of infections described as mild/ moderate/ acute and uncomplicated, caused by bacteria sensitive to ciprofloxacin, unless treatment with other appropriate antimicrobials, approved for a similar indication and to which the causative bacteria are sensitive, have failed, are contraindicated or not tolerated

Ciprofloxacin is indicated for the treatment of severe and/ or complicated infections caused by ciprofloxacin-sensitive bacteria where other antimicrobials, approved for a similar indication and to which the causative bacteria are sensitive, were considered not to be an appropriate treatment option, have failed, are contraindicated or not tolerated

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The duration of treatment to contain and eradicate an infection depends upon the type and severity of the infection, immunological status, clinical response and bacteriological findings. Use the lowest effective dose for the shortest time to contain and eradicate infection

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Suspension, film coated tablet treatment duration: For infections of the kidneys, urinary tract and abdominal cavity the treatment period is up to 7 days. In all other infections the treatment period is 7-14 days. In streptococcal infections, the treatment must last at least 10 days, because of the risk of late complications

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Tablet treatment duration: For acute infections the usual treatment period is 5-10 days with ciprofloxacin. For severe and complicated infections more prolonged therapy may be required. In streptococcal infections the treatment must last at least 10 days. Generally, treatment should be continued for at least 3 days after the signs and symptoms of the infection have disappeared

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XR tablets treatment duration: Depends on the severity of the illness and on the clinical bacteriological course. It is essential to continue therapy for at least 3 days after disappearance of the fever or of the clinical symptoms

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Severe and/or complicated infections of the lower respiratory tract
- Caused by Escherichia coli, Klebsiella pneumoniae, Enterobacter cloacae, Proteus mirabilis, Pseudomonas aeruginosa, Haemophilus influenzae and Haemophilus parainfluenzae

• Oral (fct, sus, tab): 750mg, twice daily
• IV: 400mg, every 12hrs; Treatment duration: Up to 7 days; Discontinue IV therapy as soon as oral therapy can be substituted

- In cystic fibrosis

• Oral (fct, sus, tab): 750mg, twice daily; The low body mass of these patients should, however, be taken into consideration when determining dosage (7.5-15mg/kg/day)
• IV: 200mg, every 12hrs; The low body mass of these patients should, however, be taken into consideration when determining dosage (5-10mg/kg/day)

Severe and/or complicated urinary tract infections
- Caused by Escherichia coli, Klebsiella pneumoniae, Enterobacter cloacae, Serratia marcescens, Proteus mirabilis, Providencia rettgeri, Morganella morganii, Citrobacter diversus, Citrobacter freundii, Pseudomonas aeruginosa, Staphylococcus epidermidis and Streptococcus faecalis

• Oral (fct, sus, tab): 500mg, twice daily 
• Oral (XR tab): 1000mg, once daily; Treatment duration: 7-14 days
• IV: 400mg, every 12hrs; Treatment duration: Up to 7 days; Discontinue IV therapy as soon as oral therapy can be substituted

- Acute uncomplicated pyelonephritis caused by Escherichia coli where treatment with other appropriate antimicrobials approved for a similar indication and to which the causative bacteria are sensitive, have failed, are contraindicated, or not tolerated

• Oral (XR tab): 1000mg, once daily; Treatment duration: 7-14 days

Severe and/or complicated infection of the skin
- Caused by Escherichia coli, Klebsiella pneumoniae, Enterobacter cloacae, Proteus mirabilis, Proteus vulgaris, Providencia stuartii, Morganella morganii, Citrobacter freundii, Pseudomonas aeruginosa, Staphylococcus aureus, Staphylococcus epidermidis and Streptococcus pyogenes

• Oral (fct, sus, tab): 750mg, twice daily 
• IV: 400mg, every 12hrs; Treatment duration: Up to 7 days; Discontinue IV therapy as soon as oral therapy can be substituted

Severe and/or complicated infectious diarrhoea caused by Escherichia coli, Campylobacter jejuni, Shigella flexneri and Shigella sonnei

• Oral (fct, sus, tab): 500mg, twice daily
• IV: 400mg, every 12hrs; Treatment duration: Up to 7 days; Discontinue IV therapy as soon as oral therapy can be substituted

- In severe and/or complicated bacterial diarrhoea where other appropriate antimicrobials approved for a similar indication and to which the causative bacteria are sensitive, have failed, are contraindicated, or not tolerated

• Oral (XR tab): 1000mg, once daily; Treatment duration: Up to 7 days

Severe and/or complicated bone infections

• Oral (fct, sus, tab): 750mg, twice daily; Treatment duration: 4-6 weeks or longer
• IV: 400mg, every 12hrs; Treatment duration: Up to 7 days; Discontinue IV therapy as soon as oral therapy can be substituted

Prophylaxis of invasive infections due to Neisseria meningitidis 

• Oral (fct, sus): 500mg, as a single dose

Mild to moderate acute and uncomplicated infections 
- Lower respiratory tract infections

• Oral (fct, sus): 250mg, twice daily
• Oral (tab): 250-500mg, twice daily

- Urinary tract infections

• Oral (fct, sus, tab): 250mg, twice daily 

- Acute cystitis caused by Escherichia coli where treatment with other appropriate antimicrobials approved for a similar indication and to which the causative bacteria are sensitive, have failed, are contraindicated, or not tolerated

• Oral (XR tab): 500mg, once daily; Treatment duration: 3 days

- Skin infections
- Bone infections
- Infectious diarrhoea

• Oral (fct, sus, tab): 500mg, twice daily 

Acute uncomplicated cystitis in women

• Oral (tab): 250mg, twice daily; Treatment duration: 3 days; Generally, treatment should be continued for at least 3 days after the signs and symptoms of the infection have disappeared

Gonorrhoea (except that is due to N. gonorrhoeae)

• Oral (tab): 250mg, as a single dose

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If the patient is unable to take XR tablets, film-coated tablets or suspension, because of the severity of the illness or for other reasons (e.g. patients on parenteral nutrition), therapy should be commenced with IV ciprofloxacin. After intravenous administration treatment may be continued orally

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Film coated tablets: If a dose is missed, it should be taken anytime but not later than 6 hours prior to the next scheduled dose. If less than 6 hours remains before the next dose, the missed dose should not be taken, and treatment should be continued as prescribed with the next scheduled dose. Double doses should not be taken to compensate for a missed dose

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XR tablets should not be crushed or divided for intake and should be swallowed whole with plenty of liquid with or without meals. XR tablets can be taken independently of mealtimes 

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XR tablets: If they are taken on an empty stomach, the active substance is absorbed more rapidly. In this case, ciprofloxacin XR tablets should not be taken concurrently with dairy products or with mineral-fortified drinks alone (e.g. milk, yoghurt, calcium-fortified orange juice). However, dietary calcium as part of a meal does not significantly affect ciprofloxacin absorption

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Appropriate culture and susceptibility tests should be performed before treatment in order to isolate and identify organisms causing infection and to determine their susceptibility to ciprofloxacin. Therapy with ciprofloxacin may be initiated in severe and/or complicated infections before results of these tests are known; once results become available, appropriate therapy should be continued

Paed. forms avail. in SA and covered in this monograph: fct, inf, inj, sus, tab

Paed. dosages below include:

• South African Standard Treatment Guideline indications and dosages
• South African registered indications and dosages

Infections caused by: Enterobacter cloacae, Escherichia coli, Haemophilus influenzae, Haemophilus parainfluenzae, Klebsiella pneumoniae, Proteus mirabilis, Pseudomonas aeruginosa; Citrobacter diversus, Citrobacter freundii, Morganella morganii, Providencia rettgeri, Serratia marcescens, Staphylococcus epidermidis, Streptococcus faecalis; Proteus vulgaris, Providencia stuartii, Staphylococcus aureus, Streptococcus pyogenes; Campylobacter jejuni, Shigella flexneri and Shigella sonnei; Sensitive Gram-negative organisms

Specific doses based on individual indications

Please note that the dosages below should be used in combination with regional guidelines, taking into account local antibiotic sensitivities

South African Standard Treatment Guidelines indications and dosages

Cholera (Additional agent may be required)
- Severe dehydration
Dysentery
- Treat initially as Shigella dysentery

• Oral (sus, tab, fct): 15mg/kg/dose, 12hrly; Treatment duration: 3 days
  (STG, Paed 2023; PHC 2020)

Chemoprophylaxis for close contacts of N. meningitidis (Meningococcal meningitis)
- A close contact is defined as someone living in the same household, dormitory, institution, children in the same crèche, or any other ‘kissing’ contact
- Health care workers who have intimate contact should receive prophylaxis

• Younger than 12 years: Oral (sus, tab, fct): 10mg/kg, as a single dose OR Oral (fct, tab): 250mg, as a single dose in those able to swallow tablets
  (STG, Paed. 2023)
  OR
• Between 6-12 years: Oral (sus, tab, fct): 250mg, as a single dose
  (STG, PHC 2020)
• Older than 12 years: Oral (sus, tab, fct): 500mg, as a single dose
  (STG, Paed. 2023; PHC 2020)

Typhoid
- As an oral switch option once patient is stable based on clinical response and susceptibility testing results

• Oral (sus, tab, fct): 15mg/kg/dose, 12hrly; Treatment duration: 7-10 days
  (STG, Paed. 2023)

- Treat for carriage in those with positive cultures of S. Typhi in 3 follow-up stool samples

• Oral (sus, tab, fct): 15mg/kg/dose, 12hrly; Treatment duration: 4-6 weeks
  (STG, Paed. 2023)

Urinary tract infections with penicillin allergy 

Neonates

• Oral (sus, tab, fct): 6mg/kg/dose, 12hrly

Infants

• Oral (sus, tab, fct): 6mg/kg/dose, 8hrly

Older than 1 year

• Oral (sus, tab, fct): 10mg/kg/dose, 12hrly
  (STG, Paed. 2023)

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South African registered indications and dosages

• Contraindicated in children under 18 years

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NOTE:

This contraindication is aligned with the official South African Health Products Regulatory Authority (SAHPRA) Professional Information (PI). However, ciprofloxacin is still included in the South African Standard Treatment Guidelines (STG) for specific indications, as the clinical benefits in these situations are considered to outweigh the risks. Prescribers should always use their clinical judgment, considering both the registered PI and the relevant STG.

Pregnancy

South African recommendations

• Contraindicated
• The safety of ciprofloxacin in pregnant women has not been established
• Ciprofloxacin must not be prescribed to pregnant women. Animal studies have demonstrated that ciprofloxacin may damage the articular cartilage in the foetus. It has also been reported to cause teratogenic effects in animals

Recommendations in other jurisdictions

• Caution; not recommended
• The data that are available on administration of ciprofloxacin to pregnant women indicates no malformative or feto/ neonatal toxicity of ciprofloxacin. Animal studies do not indicate direct or indirect harmful effects with respect to reproductive toxicity. In juvenile and prenatal animals exposed to quinolones, effects on immature cartilage have been observed, thus, it cannot be excluded that the drug could cause damage to articular cartilage in the human immature organism/ foetus
• As a precautionary measure, it is preferable to avoid the use of ciprofloxacin during pregnancy

Breastfeeding

South African recommendations

• Contraindicated
• Safety during lactation has not been established
• Ciprofloxacin is excreted in breast milk
• Due to the potential risk of articular damage, mothers on ciprofloxacin should not breastfeed their infants

Recommendations in other jurisdictions

• Caution; not recommended 
• Ciprofloxacin is excreted in breast milk. Due to the potential risk of articular damage, ciprofloxacin should not be used during breastfeeding

Fertility

Recommendations below are applicable to South Africa and other jurisdictions

• No information available

• IV/Oral (tab, sus): CrCl>60ml/min/1.73m²: No dose adjustment recommended
• IV/Oral (tab, sus): CrCl≤60ml/min/1.73m²: Caution; dose adjustment recommended 
  Dosing in children with impaired renal function has not been studied
• XR tab (500mg): Caution; dose adjustment recommended 
  The half-life of ciprofloxacin is prolonged and the dosage needs to be adjusted. For patients with changing renal function or patients with renal impairment, monitoring of drug serum levels provides the most reliable basis for dose adjustment
• XR tab (1000mg): CrCl>30ml/min/1.73m²: Caution; no dose adjustment recommended
• XR tab (1000mg): CrCl≤30ml/min/1.73m²: Caution; not recommended
  Serum creatinine concentration ≥2,0mg/100ml: Caution not recommended
  Haemodialysis or CAPD: Caution; not recommended

CrCl (ml/min/1.73m2)	Dose
30-60	Oral (tab, sus): 250-500mg, 12hrly IV: 200-400mg, 12hrly
<30	Oral (tab, sus): 250-500mg, 24hrly Oral (XR tab): Use of 1000mg tab not recommended IV: 200-400mg, 24hrly
Haemodialysis	Oral (tab, sus): 250-500mg, 24hrly; after dialysis Oral (XR tab): Use of 1000mg tab not recommended IV: 200-400mg, 24hrly; after dialysis
Peritoneal dialysis	Oral (tab, sus): 250-500mg, 24hrly Oral (XR tab): Use of 1000mg tab not recommended IV: 200-400mg, 24hrly

• IV/Oral (tab, sus): No dose adjustment recommended 
  Dosing in children with impaired hepatic function has not been studied 
• Oral (XR tab): Caution; dose adjustment recommended 
  For patients with hepatic impairment, monitoring of drug serum levels provides the most reliable basis for dose adjustment

• Caution; no dose adjustment recommended 
  Elderly patients should receive a dose selected according to the severity of the infection and the patient's creatinine clearance 

Central Nervous System Disorders

• Psychomotor hyperactivity
• Agitation
• Confusion
• Disorientation
• Anxiety reaction
• Abnormal dreams
• Depression (potentially culminating in suicidal ideations/ thoughts or suicide attempts and completed suicide)
• Psychotic reactions (potentially culminating in suicidal ideations/thoughts or suicide attempts and completed suicide)
• Hallucinations
• Mania, including hypomania
• Headache
• Dizziness
• Sleep disorders
• Paraesthesia
• Dysaesthesia
• Hypoaesthesia
• Tremor
• Seizures (including status epilepticus)
• Migraine
• Disturbed coordination
• Gait disturbance
• Intracranial hypertension and pseudotumor cerebri
• Peripheral neuropathy and polyneuropathy
• Neuropathies associated with paraesthesia
• Asthenia
• Memory impairment

Cardiovascular Disorders

• Tachycardia
• Ventricular arrhythmia
• Torsades de pointes
• QT prolongation
• Vasodilatation
• Hypotension
• Syncope
• Vasculitis
• Oedema
• Mitral valve and/or aortic valve regurgitation
• Aortic aneurysm and dissection, sometimes complicated by rupture
• Regurgitation/incompetence of any of the heart valves

Respiratory Disorders

• Dyspnoea

Gastrointestinal Disorders

• Nausea and vomiting
• Diarrhoea
• Gastrointestinal and abdominal pains
• Dyspepsia
• Flatulence
• Antibiotic-associated colitis
• Pancreatitis
• Increase in amylase

Hepatobiliary Disorders

• Increased transaminases
• Increased bilirubin
• Hepatic impairment
• Cholestatic icterus
• Hepatitis
• Hepatic necrosis

Genitourinary Disorders

• Renal impairment
• Renal failure
• Haematuria
• Crystalluria
• Tubulointerstitial nephritis

Endocrine and Metabolic Disorders

• Decreased appetite
• Hyperglycaemia
• Hypoglycaemia
• Hypoglycaemic coma
• Increased serum alkaline phosphatase
• Syndrome of inappropriate secretion of antidiuretic hormone

Musculoskeletal Disorders

• Musculoskeletal pain
  - Extremity pain
  - Back pain
  - Chest pain
• Arthralgia
• Myalgia
• Arthritis
• Increased muscle tone and cramping
• Muscular weakness
• Tendinitis
• Tendon rupture (predominantly Achilles tendon)
• Exacerbation of symptoms of myasthenia gravis

Skin and Subcutaneous Tissue Disorders

• Rash
• Pruritus
• Urticaria
• Photosensitivity reactions
• Petechiae
• Erythema multiforme
• Erythema nodosum
• Stevens-Johnson syndrome
• Toxic epidermal necrolysis
• Acute generalised exanthematous pustulosis
• Drug reaction with eosinophilia and systemic symptoms
• Sweating (hyperhidrosis)

Immune, Blood and Lymphatic System Disorders

• Mycotic superinfections
• Eosinophilia
• Leukopenia
• Anaemia
• Neutropenia
• Leukocytosis
• Thrombocytopenia
• Thrombocytaemia
• Haemolytic anaemia
• Agranulocytosis
• Pancytopenia (life-threatening)
• Increased INR (in patients treated with Vitamin K antagonists)
• Bone marrow depression (life-threatening)
• Allergic reaction
• Allergic oedema
• Angioedema
• Anaphylactic reaction
• Anaphylactic shock (life-threatening)
• Serum sickness-like reaction
• Fever

Sensory Disorders

• Taste disorders
• Olfactory nerve disorders
• Vertigo
• Visual disturbances
• Diplopia
• Visual colour distortions
• Tinnitus
• Hearing impairment or loss

• Tizanidine
• Corticosteroids
• QT-prolonging agents
• Class IA and III antiarrhythmics
• Tricyclic antidepressants
• Macrolides
• Antipsychotics
• Multivalent cation-containing drugs and mineral supplements
• Calcium
• Magnesium
• Aluminium
• Iron
• Polymeric phosphate binders
• Sevelamer
• Lanthanum carbonate
• Sucralfate
• Antacids
• Highly buffered agents containing magnesium, aluminium, or calcium
• Didanosine
• Probenecid
• Metoclopramide
• Omeprazole
• Methotrexate
• Xanthine derivatives
• Theophylline
• Caffeine
• Pentoxifylline (oxypentifylline)
• Phenytoin
• Ciclosporin
• Clozapine
• Vitamin K antagonists
• Warfarin
• Acenocoumarol
• Phenprocoumon
• Fluindione
• Duloxetine 
• Ropinirole 
• Lidocaine 
• Agomelatine 
• Sildenafil
• Zolpidem
• CYP1A2 substrates
• Olanzapine
• ACE inhibitors
• Angiotensin-receptor blockers

Other interactions

• Dairy products or mineral-fortified drinks
• Milk  
• Yoghurt
• Calcium-fortified orange juice

None routine. Specific cases may require

• Renal function
• Hepatic function
• Full blood count
• Blood glucose
• INR

Additional observations

• Mental status
• Signs and symptoms of tendinopathy or peripheral neuropathy
• Signs and symptoms of disordered glucose regulation

Test incompatibilities

• The in-vitro activity of ciprofloxacin against Mycobacterium tuberculosis might give false negative bacteriological test results in specimens from patients currently taking ciprofloxacin

Chelation complex formation

• The simultaneous administration of ciprofloxacin (oral) and multivalent cation-containing drugs and mineral supplements (e.g. calcium, magnesium, aluminium, iron), polymeric phosphate binders (e.g. sevelamer or lanthanum carbonate), sucralfate or antacids, and highly buffered drugs (e.g. didanosine tablets) containing magnesium, aluminium, or calcium reduces the absorption of ciprofloxacin
• Consequently, ciprofloxacin should be administered either 1-2 hours before or at least 4 hours after these preparations. The restriction does not apply to antacids belonging to the class of H2 receptor blockers

Risk of mitral and aortic regurgitation

• There is some evidence, although inconclusive, of a possible association between fluoroquinolone use and mitral valve and/or aortic valve regurgitation
• A thorough cardiovascular examination, including an echocardiogram (ECG), should be performed before oral fluoroquinolones are prescribed
• Fluoroquinolones should not be prescribed to patients with mitral valve and/or aortic valve regurgitation

As a fluoroquinolone antibacterial agent, the bactericidal action of ciprofloxacin results from the inhibition of both type II topoisomerase (DNA-gyrase) and topoisomerase IV, required for bacterial DNA replication, transcription, repair and recombination.

Spectrum of activity: Enterobacter cloacae, Escherichia coli, Haemophilus influenzae, Haemophilus parainfluenzae, Klebsiella pneumoniae, Proteus mirabilis, Pseudomonas aeruginosa; Citrobacter diversus, Citrobacter freundii, Morganella morganii, Providencia rettgeri, Serratia marcescens, Staphylococcus epidermidis, Streptococcus faecalis; Proteus vulgaris, Providencia stuartii, Staphylococcus aureus, Streptococcus pyogenes; Campylobacter jejuni, Shigella flexneri and Shigella sonnei; Sensitive Gram-negative organisms

Tablet 250mg

• Austell ciprofloxacin (Austell)
• Biocip (Ranbaxy)
• Biotech ciprofloxacin (Biotech)
• Cifran (Ranbaxy)
• Cifloc (Dr Reddy's)
• Cilofloc (Be-Tabs) 
• Ciprofloxacin actor (Cipla Medpro)
• Ciprofloxacin 250 Pharma-Q (Pharma-Q)
• Ciploxx (Cipla Medpro)
• Ciprobay (Bayer) originator
• Ciprogen (Trinity Pharm)
• Cipro-Hexal (Sandoz)
• Ciprol (Arrow)
• Loxip (Aurobindo)
• Orpic (Pharmacare) Discontinued: 01/04/2018
• Profloxin (Dezzo Trading)
• Sandoz ciprofloxacin (Sandoz)
• Simayla ciprofloxacin (Ranbaxy)
• Spec-Topistin (Specpharm)

Tablet 500mg

• Austell ciprofloxacin (Austell)
• Biocip (Ranbaxy)
• Biofloxx (Biotech)
• Biotech ciprofloxacin (Biotech)
• Cifran (Ranbaxy)
• Cifloc (Dr Reddy's)
• Cilofloc (Be-Tabs)
• Ciprofloxacin actor (Cipla Medpro)
• Ciprofloxacin 500 Pharma-Q (Pharma-Q)
• Ciprofloxacin unicorn (Dezzo Trading)
• Ciploxx (Cipla Medpro)
• Ciprobay (Bayer) originator
• Ciprogen (Trinity Pharm)
• Cipro-Hexal (Sandoz)
• Ciprol (Arrow Pharma)
• Dynafloc (Pharma Dynamics)
• Flopro (Novagen)
• Loxip (Aurobindo)
• Orpic (Pharmacare)
• Profloxin (Dezzo Trading)
• Sandoz ciprofloxacin (Sandoz)
• Simayla ciprofloxacin (Ranbaxy)

Tablet 750mg

• Austell ciprofloxacin (Austell)
• Biotech ciprofloxacin (Biotech)
• Ciprobay (Bayer) originator
• Orpic (Pharmacare) Discontinued: 01/04/2018

Tablet XR 500mg

• Ciprobay XR (Bayer) originator

Tablet XR 1000mg

• Ciprobay XR (Bayer) originator

Suspension (per 5ml) 250mg

• Ciprobay (Bayer) originator

Injection (per ml) 2mg

• Adco Ciprofloxacin (Adcock Ingram)
• Ciprocina (Dezzo)
• Ciprobay  (Bayer) originator
• Ciprogen (Mylan)
• Ciprofloxacin Fresenius (Fresenius Kabi)
• Floqin (Austell)
• Orpic (Litha)
• Sabax ciprofloxacin (Adcock Ingram) originator
• Spec-Topistin (Specpharm)

Also available in the following forms: Eye drop, eye ointment and ear drop