Intra-abdominal infections
Acute pyelonephritis
Complicated urinary tract infections
Bacterial prostatitis
Epididymo-orchitis
Pelvic inflammatory infections
Skin and soft tissue infections
Bone and joint infections
Necrotising otitis externa

500 – 750mg 12 hourly

Infective exacerbations of bronchiectasis with susceptible Pseudomonas species
Infections associated with suspected or proven susceptible Pseudomonas species or Staphylococcus species

750mg 12 hourly

Renal impairment

Baseline

Urea and Electrolytes (U&Es), liver function tests (LFTs), C-reactive protein (CRP) and full blood count (FBC).

Perform Electrocardiography (ECG) particularly if known QTc prolongation, non-modifiable risk factors for prolonged QTc interval or taking other drugs that can prolong the QTc interval.

Further monitoring

Weekly U&Es, LFTs and FBC for at least two weeks after starting ciprofloxacin.

Monthly U&Es following initial weekly monitoring whilst patient remains with OPAT service.

CRP can be measured to monitor patient’s clinical progress.

If concerns of QTc prolongation and ECG performed at baseline, repeat ECG 48 to 72 hours after starting ciprofloxacin. Perform or repeat ECG if new concerns of QTc prolongation, or when adding any new medication that is known to prolong the QTc interval.

Further monitoring once discharged from OPAT service is dependent upon patient and other clinical factors.

Follow up

Drugs metabolised by CYP450 1A2 isoenzyme

Corticosteroids

The Medicines and Healthcare products Regulatory Agency (MHRA) Drug Safety Update, January 2024, recommends to avoid prescribing fluroquinolones (including ciprofloxacin) with corticosteroids because of an increased risk of tendon damage and rupture. The clinical need for both drugs should be assessed and if indicated patients should be advised to report any painful swelling or inflammation of tendons or joints to the OPAT team or GP immediately.

Hormonal contraception

Additional precautions are no longer necessary when ciprofloxacin (non-enzyme inducing drug) is taken with combined or progestogen-only contraceptive preparation unless diarrhoea, vomiting, or both occur. See manufacturer guidance.

Methotrexate

The renal tubular transport of methotrexate may be reduced by ciprofloxacin leading to potential toxicity. Methotrexate is likely to already have been withheld in acute infection. Avoid co-administration where possible.

Oral cations (calcium, magnesium, aluminium and iron) and phosphate binders (sevelamer or lanthanum carbonate)

These drugs may reduce the bioavailability of ciprofloxacin. Take ciprofloxacin two hours before or at least four hours after these preparations.

Other drugs known to prolong QT interval

Ciprofloxacin (and all fluoroquinolones) may prolong the QTc interval. Incidence may be increased in presence of the following additional risk factors:

• Co-administration with other drugs also known to cause QT prolongation. These include anti-arrhythmic drugs (eg amiodarone, beta-blockers), tricyclic antidepressants (eg amitriptyline, nortriptyline), selective serotonin reuptake inhibitors (eg citalopram, sertraline, fluoxetine) antipsychotics (eg risperidone, quetiapine, olanzapine, clozapine), loperamide etc.
• Patients with congenital or pre-existing prolonged QT interval.
• Electrolyte disturbance (eg hypokalaemia, hypomagnesaemia).
• Known underlying cardiac disease (eg heart failure, myocardial infarction, bradycardia).

Avoid co-administration of two or more drugs known to prolong the QT interval where possible. If this is not possible, perform baseline and steady state ECGs to assess for any change in the QT interval.

Warfarin

Ciprofloxacin may enhance anticoagulant effect. Ensure follow up with Anticoagulant Service for International Normalised Ratio (INR) monitoring and any necessary dosage adjustments. Patients should also be counselled on signs of over anticoagulation (eg bruising, bleeding).

Drug/ Food interactions

Nutritional supplements containing cations (calcium, magnesium, aluminium and iron), dairy products or calcium-fortified fruit juice may reduce the bioavailability of ciprofloxacin. Take ciprofloxacin one to two hours before or at least four hours after these products.

Caffeine: Ciprofloxacin may inhibit the metabolism of caffeine leading to potential toxicity (eg hepatic disorder, arrhythmias); avoid combination if symptomatic.

Tendinitis and tendon rupture

Tendinitis (especially but not limited to Achilles tendon) sometimes bilateral, may occur as early as within 48 hours of starting treatment with ciprofloxacin (and all fluoroquinolones) and have been reported to occur even up to several months after discontinuation of treatment.

The risk of tendinitis and tendon rupture is increased in patients over 60 years of age, patients with underlying chronic renal impairment, patients with solid organ transplants, and those treated concurrently with corticosteroids.

Patients should be advised to report any painful swelling or inflammation of tendons or joints to the OPAT team or GP immediately.

Aortic aneurysm and dissection, and heart valve regurgitation or incompetence

Epidemiologic studies report an increased risk of aortic aneurysm and dissection, particularly in elderly patients, and of aortic and mitral valve regurgitation following ciprofloxacin (and all fluoroquinolone) use.

Risk factors include; patients with congenital or pre-existing heart valve disease, patients diagnosed with connective tissue disorders, patients with other risk factors for heart valve regurgitation and patients with personal or family risk factors which may predispose them to aortic aneurysm and dissection.

Patients should be advised to seek immediate medical attention if they experience sudden abdominal, chest or back pain, acute dyspnoea, new onset of heart palpitations, or development of oedema of the abdomen, ankles or feet feet.

Cardiac disorders

Ciprofloxacin (and all fluoroquinolones) may cause prolongation of the QT interval leading to heart arrhythmias and possible sudden cardiac death.

Caution should be taken when using ciprofloxacin in patients with known risk factors including congenital long QT syndrome, concomitant use of drugs that are known to prolong the QT interval, uncorrected electrolyte imbalance and known underlying cardiac disease (eg heart failure, myocardial infarction, bradycardia), elderly patients and women.

Psychiatric reactions

There have been reports of rare cases of depression or psychosis progressing to suicidal ideations and thoughts following ciprofloxacin (and all fluoroquinolone) use.

Any changes in mood during therapy should be discussed immediately with the OPAT team, GP or both.

Reduced seizure threshold

Ciprofloxacin (and all fluoroquinolones) may lower the seizure threshold which can trigger a seizure. Additional risk factors include underlying infection, renal impairment, a history of epilepsy and concomitant administration of non-steroidal anti-inflammatory drugs. Avoid where possible in patients with known history of seizures. Patients should be advised to stop ciprofloxacin and seek medical attention if they experience new onset of seizures.

Sensory reactions

Taste disorders, tinnitus or hearing impairment, visual disturbances, smell disturbances and peripheral neuropathy may occur with ciprofloxacin (and all fluoroquinolones). The patient should be advised to discuss any of these symptoms with the OPAT team, GP or both.

Myasthenia gravis symptoms

Medication including ciprofloxacin (and all fluoroquinolones) can trigger symptoms of myasthenia gravis. Ciprofloxacin should be used with caution in patients with known or suspected myasthenia gravis.

The Myaware page on drugs to avoid and Myasthenia Gravis Foundation of America page on cautionary drugs provide further information.