Ciprofloxacin

Fluoroquinolones, including ciprofloxacin are associated with disabling and potentially long-lasting or irreversible side effects. See Fluoroquinolone antibiotics - severe adverse effects

When using fluoroquinolones:

• DO NOT prescribe for:
  • non-severe or self-limiting infections.
  • mild to moderate infections (unless other antibiotics that are commonly recommended for these infections are considered inappropriate).
• DO read the Antimicrobial Guideline section: Fluoroquinolone antibiotics - severe adverse effects
• DO ensure penicillin allergies are properly clarified and consider de-labelling in appropriate patients to avoid the use of fluoroquinolones. See guidelines: Penicillin allergy assessment and overview and Penicillin allergy challenge and delabelling
• DO ensure all patients are given the MHRA fluoroquinolone patient leaflet (this is usually given to patients with their discharge and outpatient medications).

Renal impairment 

Treating for pseudomonas or other microorganisms sensitive at higher doses: Discuss with pharmacy or Micro/ID

Patients that would have received standard dose: See table below:

Hepatic impairment

• Dose as in normal hepatic function
• Cases of hepatic necrosis and life-threatening hepatic failure have been reported. In the event of any signs and symptoms of hepatic disease (such as anorexia, jaundice, dark urine, pruritus, or tender abdomen), treatment should be discontinued.

Pregnancy

Discuss with pharmacy

• A single dose of ciprofloxacin may be used for the prevention of a secondary case of meningococcal meningitis.

Breastfeeding

Caution. Discuss with pharmacy

• Use safer alternatives where possible, though ciprofloxacin can be taken whilst breastfeeding. Limited published evidence of safety. Small amounts in breast milk.
• Avoid in infants with known G6PD deficiency due to the risk of haemolysis.
• Use with caution in infants with epilepsy.
• Monitor infant for gastro-intestinal disturbances and oral candida infection, especially if used in high doses, although these effects are unlikely to occur.

The list below is not exhaustive. There are multiple interactions between ciprofloxacin and other medications. Ensure interactions are checked with the BNF and SPC. Discussion with a pharmacist is advised.

Key interactions:

• NSAIDs: CAUTION. Taking NSAIDs at the same time as ciprofloxacin may induce convulsions in patients with or without a history of convulsions.
• QT interval-prolongators: CAUTION: Use with caution in patients receiving other drugs known to prolong the QT interval or with other risk factors for QT interval prolongation.
• Tizanidine: CONTRAINDICATED. Concomitant administration of ciprofloxacin and tizanidine is contraindicated
• Vitamin K antagonists: anticoagulant effect enhanced- monitor INR closely and within 3-5 days of starting ciprofloxacin

The following medications reduce oral ciprofloxacin absorption. The ciprofloxacin SPC states take oral ciprofloxacin 1-2 hours before or 4 hours afTer these medications. Consult the BNF and SPC for guidance on administration:

• mineral and cation-containing drugs and supplements,
• antacids,
• sucralfate,
• polymeric phosphate binders
• didanosine chewable or buffered tablets

Oral ciprofloxacin absorption is also reduced by:

• dairy products. Avoid concurrent use.
• mineral-fortified drinks. Avoid concurrent use.

• Ciprofloxacin may induce convulsions in patients with or without a history of convulsions; taking NSAIDs at the same time may also induce them.
• Patients should be advised to avoid exposure to either extensive and/or strong sunlight or UV irradiation (e.g. tanning beds) during treatment with ciprofloxacin.
• Ciprofloxacin is not recommended in patients with a known history of myasthenia gravis. Fluoroquinolones, including ciprofloxacin, have neuromuscular blocking activity and may exacerbate muscle weakness in patients with myasthenia gravis. 
• Use with caution in G6PD deficiency.
• Cases of bullous skin reactions like Stevens-Johnson syndrome or toxic epidermal necrolysis have been reported with fluoroquinolones. Treatment should be immediately reviewed if skin and/or mucosal reactions occur.

Broad spectrum antibiotics such as ciprofloxacin carry a high risk of C.difficile infection. 

Ciprofloxacin has high oral bioavailability; IV ciprofloxacin should only be used if the patient is NBM or there are concerns over absorption (i.e. nausea). 

• Ranbaxy (UK) Limited a Sun Pharmaceutical Company. Ciprofloxacin 500 mg film coated tablets summary of product characteristics: Electronic Medicines Compendium [Internet]. Last revision of the text:14/11/22. Accessed 23/1/24. Available from: https://www.medicines.org.uk/emc/product/4346/smpc
• Fresenius Kabi Limited. Ciprofloxacin 100 mg/50 ml, solution for infusion summary of product characteristics. Last revision of the text: 8/4/21. Accessed 23/1/24. Available from: https://mhraproducts4853.blob.core.windows.net/docs/8e59e2fc94f6f0374c9e4627967bc0a9a508a21d
• The Renal Drug Database. Ciprofloxacin [Internet]. Last revision of the text 16/5/21. Accessed 23/1/24 Available from: https://renaldrugdatabase.com/monographs/ciprofloxacin
• Joint Formulary Committee. British National Formulary (BNF). 1 November 2023 [Internet]. 2023 [cited 2023 Nov 23]. Available from: https://www.medicinescomplete.com
• UK Medicines Information. How should antibiotics be dosed in obesity? [Internet]. 2017 [cited 2023 Nov 23] Available from: https://www.gloshospitals.nhs.uk/media/documents/Obese_Dosing_2016_update.pdf
• UK Clinical Pharmacy Association. Drug dosing in extremes of body weight in critically ill patients, 1st edition [Internet]. 2013 [cited 2023 Nov 23]. Available from: https://ukclinicalpharmacy.org/wp-content/uploads/2023/06/Drug-dosing-extreme-body-weight-2013-1Ed.pdf.
• Meng L, Mui E, Ha DR, Stave C, Deresinski SC, Holubar M. Comprehensive guidance for antibiotic dosing in obese adults: 2022 update. Pharmacotherapy. 2023; 43(3):177-259.
• UK Teratology Information Service. Use of quinolones in pregnancy [Internet]. 2017 [cited 2023 Nov 23]. Available from: https://uktis.org/monographs/use-of-quinolones-in-pregnancy/
• Specialist Pharmacy Service. Lactation safety information – ciprofloxacin [Internet]. Last revision of the text 17/9/2020. Accessed 23/1/24. Available from: https://www.sps.nhs.uk/medicines/ciprofloxacin/
• The Breastfeeding Network. Antibiotics and Breastfeeding [Internet]. 2022 [cited 2023 Nov 23]. Available from: https://www.breastfeedingnetwork.org.uk/factsheet/antibiotics
• Briggs GG, Freeman RK, Tower CV, Forinash AB. Drugs in pregnancy and lactation. 11th ed. Philadelphia: Lippincott Williams and Wilkins; 2017.
• Public Health England. Guidance for public health management of meningococcal disease in the UK Updated August 2019. Accessed 25/1/24. Available at Guidance for public health management of meningococcal disease in the UK (publishing.service.gov.uk)
• MHRA. Drug Safety update (January 2024) Fluoroquinolone antibiotics: must now only be prescribed when other commonly recommended antibiotics are inappropriate. Accessed HERE
• MHRA. Drug Safety update (September 2023) Fluoroquinolone antibiotics: suicidal thoughts and behaviour. Accessed HERE
• MHRA. Drug Safety update (August 2023) Fluoroquinolone antibiotics: reminder of the risk of disabling and potentially long-lasting or irreversible side effects. Accessed HERE
• MHRA. Drug Safety update (December 2020) Systemic and inhaled fluoroquinolones: small risk of heart valve regurgitation; consider other therapeutic options first in patients at risk. Accessed HERE 
• MHRA. Drug Safety update (March 2019) Fluoroquinolone antibiotics: new restrictions and precautions for use due to very rare reports of disabling and potentially long-lasting or irreversible side effects. Accessed HERE
• MHRA. Drug Safety update (November 2018) Systemic and inhaled fluoroquinolones: small increased risk of aortic aneurysm and dissection; advice for prescribing in high-risk patients. Accessed HERE