CIPROFLOXACIN Cipro, Cipro XR, Proquin XR CLASSIFICATION(S) Therapeutic: anti-infectives Pharmacologic: fluoroquinolones Pregnancy Category C INDICATIONS PO: IV:

: Treatment of the following bacterial infections: Urinary tract and gynecologic infections, including cystitis, gonorrhea, and prostatitis Respiratory tract infections including acute sinusitis, acute exacerbations of chronic bronchitis, and pneumonia Skin and skin structure infections Bone and joint infections Infectious diarrhea Complicated intra-abdominal infections (with metronidazole) Typhoid fever Post-exposure prophylaxis of inhalational anthrax Cutaneous anthrax Unlabelled Uses: Febrile neutropenia ACTION Inhibits bacterial DNA synthesis by inhibiting DNA gyrase enzyme Therapeutic Effects: Death of susceptible bacteria Spectrum: Active against gram-positive pathogens, including:

 Staphylococcus aureus Staphylococcus epidermidis Staphylococcus saprophyticus Streptococcus pyogenes Streptococcus pneumoniae Enterococcus faecalis Bacillus anthracis (anthrax) Gram-negative spectrum notable for activity against: Escherichia coli Klebsiella pneumoniae Enterobacter cloacae Salmonella typhi Shigella spp Proteus mirabilis Proteus vulgaris Providencia stuartii Providencia rettgeri Morganella morganii Pseudomonas aeruginosa Serratia marcescens Haemophilus influenzae Neisseria gonorrhoeae Moraxella catarrhalis Campylobacter jejuni PHARMACOKINETICS

Absorption: 70% absorbed after oral administration; IV administration results in complete bioavailability Distribution: Widely distributed. High tissue and urinary levels are achieved. Crosses the placenta; enters breast milk Metabolism and Excretion: --15% metabolized by the liver, 40-50% excreted unchanged by the kidneys Half-life: 4 hr TIME OF ACTION blood levels ROUTE ONSET PO rapid PO-ER rapid IV rapid

PEAK 1-2 hr 1-4 hr end of infusion

DURATION 12 hr 24 hr 12 hr

CONTRAINDICATIONS/PRECAUTIONS Contraindicated in: Hypersensitivity (cross-sensitivity within class may exist) OB: Pregnancy Pedi: Children <18 yr; except for treatment of anthrax and complicated urinary tract infections (indicated in children 117 years for these infections) Use Cautiously in: Known or suspected CNS disorder Renal impairment (dose reduction if CCr <50 ml/min) Geri: Geriatric patients, dialysis patients (increased risk of adverse reactions)

 OB: Lactation (safety not established, except for treatment of anthrax) ADVERSE REACTIONS/SIDE EFFECTS* *CAPITALS indicate life threatening; underlines indicate most frequent. CNS: SEIZURES, dizziness, drowsiness, headache, insomniaagitation, confusion, GI: PSEUDOMEMBRANOUS COLITIS, abdominal pain, diarrhea, abnormal liver enzymes , nausea, GU: vaginitis, Derm: photosensitivity, rash, Endo: hyperglycemia, hypoglycemia, Hemat: eosinophilia , Local: phlebitis at IV site, MS: tendonitis, tendon rupture, Neuro: peripheral neuropathy, Misc: hypersensitivity reactions including : ANAPHYLAXIS , INTERACTIONS Drug-Drug: Concurrent use with theophylline may result in increased theophylline concentrations and therefore serious and potentially fatal reactions due to theophylline toxicity; if concurrent use cannot be avoided serum theophylline levels should be monitored Administration with antacids, iron salts, bismuth subsalicylate , sucralfate , and zinc salts absorption May alter the effects of warfarin May blood levels and effectiveness of phenytoin

 Serum levels may be by antineoplastics Cimetidine may interfere with elimination Beneficial effects may be antagonized by nitrofurantoin Probenecid renal elimination May risk of nephrotoxicity from cyclosporine Concurrent use with foscarnet may risk of seizures Concurrent therapy with corticosteroids may risk of tendon rupture Drug-Natural: Fennel decreases bioavailability Drug-Food: Absorption is impaired by concurrent enteral feeding (because of metal cations) Absorption of norfloxacin is decreased by food and/or dairy products (take 1 hr before or 2 hr after) ROUTE AND DOSAGE Most infections PO (Adults ): 500-750 mg q 12 hr IV (Adults ): --400 mg q 12 hr Urinary tract infections PO (Adults ): 250-500 mg q 12 hr; or 1000 mg q 24 hr for 10-14 days as extended-release tablets.Uncomplicated urinary tract infections--100 mg q 12 hr for 3 days or 500 mg q 24 hr for 3 days as extended-release tablets PO (Children 1-17 yr): Complicated urinary tract infections -- 10-20 mg/kg every 12 hr (not to exceed 750 mg/dose)for 10-21 days IV (Adults ): 200 mg q 12 hr IV (Children 1-17 yr): Complicated urinary tract infections -- 6-10 mg/kg every 8 hr (not to exceed 400 mg/dose)for 1021 days

Gonorrhea PO (Adults ): 250 mg single dose

Inhalational Anthrax PO, IV (Adults ): 400 mg q 12 hr IV, change to 500 mg PO twice daily when clinically appropriate for a total of 60 days; one or two other anti-infectives may be added initially, depending on clinical situation PO, IV (Children ): 10-15 mg/kg q 12 hr IV, change to 10-15 mg/kg PO q 12 hr when clinically appropriate for a total of 60 days; one or two other anti-infectives may be added initially, depending on clinical situation

Cutaneous anthrax PO (Adults ): 500 mg twice daily for 60 days; some patients may require intravenous therapy initially depending on clinical situation (for IV dose see inhalational anthrax above) PO (Children ): 10-15 mg/kg q 12 hr for 60 days; some patients may require intravenous therapy initially depending on clinical situation (for IV dose see inhalational anthrax above) AVAILABILITY Tablets: 100 mg, 250 mg, 500 mg, 750 mg Extended-release tablets: 500 mg , 1000 mg Cost: Cipro XR-500 mg 866.25/100 , 1000 mg 986.25/100 Oral suspension (strawberry flavor) : 250 mg/5 ml in 100 ml bottle, 500 mg/5 ml in 100 ml bottle Injection: 200 mg/20 ml, 400 mg/40 ml, 200 mg/100 ml premixed in D5W, 400 mg/200 ml premixed in D5W, 1200 mg/120 ml bulk package

NURSING IMPLICATIONS ASSESSMENT Assess for infection (vital signs; appearance of wound, sputum, urine, and stool; WBC; urinalysis; frequency and urgency of urination; cloudy or foul-smelling urine) at beginning of and throughout therapy Obtain specimens for culture and sensitivity before initiating therapy. First dose may be given before receiving results Observe for signs and symptoms of anaphylaxis (rash, pruritus, laryngeal edema, wheezing). Discontinue drug and notify physician or other health care professional immediately if these problems occur. Keep epinephrine, an antihistamine, and resuscitation equipment close by in case of an anaphylactic reaction Lab Test Considerations: May cause serum AST, ALT, LDH, bilirubin, and alkaline phosphatase May also cause or serum glucose IMPLEMENTATION PO: Administer on an empty stomach 1 hr before or 2 hr after meals, with a full glass of water. Products or foods containing calcium, magnesium, aluminum, iron, or zinc should not be ingested for 4 hr before and 2 hr after administration If gastric irritation occurs, ciprofloxacin may be administered with meals. Food slows and may slightly decrease absorption Regular tablets can be crushed for patients unable to swallow. Extended-release (XR) tablets should be swallowed whole; do not split, crush, or chew Do not administer 5% or 10% oral solution through an enteral feeding tube or with enteral feeds; may decrease absorption

 Intermittent Infusion: Dilute to a concentration of 1-2 mg/ml with 0.9% NaCl or D5W. Stable for 14 days at refrigerated or room temperature Rate: Administer over 60 min into a large vein to minimize venous irritation Y-Site Compatibility: amifostine amiodarone aztreonam bivalirudin calcium gluconate ceftazidime cisatracurium dexmedetomidine digoxin diltiazem diphenhydramine dobutamine docetaxel dopamine doxorubicin liposome etoposide fenoldopam gemcitabine gentamicin granisetron lidocaine linezolid lorazepam LR metoclopramide midazolam midodrine milrinone piperacillin potassium acetate potassium chloride promethazine quinupristin-dalfopristin ranitidine remifentanil 0.9% NaCL tacrolimus teniposide thiotepa tobramycin verapamil Y-Site Incompatibility: Manufacturer recommends temporarily discontinuing other solutions when administering ciprofloxacin PATIENT/FAMILY TEACHING Instruct patient to take medication as directed at evenly spaced times and to finish drug completely, even if feeling better. Take missed doses as soon as possible, unless almost time for next dose. Do not double doses. Advise patient that sharing of this medication may be dangerous Advise patients to notify health care professional immediately if they are taking theophylline Encourage patient to maintain a fluid intake of at least 1500-2000 ml/day to prevent crystalluria Advise patient that antacids or medications containing calcium, magesium, aluminum, iron, or zinc will decrease absorption and should not be taken within 4 hr before and 2 hr after taking this medication May cause dizziness and drowsiness. Caution patient to avoid driving or other activities requiring alertness until response to medication is known Caution patient to use sunscreen and protective clothing to prevent phototoxicity reactions during and for 5 days after therapy Instruct patient to consult health care professional before taking any other Rx or OTC medications Advise patient to report signs of superinfection (furry overgrowth on the tongue, vaginal itching or discharge, loose or foul-smelling stools)

 Instruct patient to notify health care professional if fever and diarrhea develop, especially if stool contains blood, pus, or mucus. Advise patient not to treat diarrhea without consulting health care professional Instruct patient to notify health care professional immediately if rash or tendon pain or inflammation occur. Therapy should be discontinued EVALUATION/DESIRED OUTCOMES Resolution of the signs and symptoms of bacterial infection. Time for complete resolution depends on organism and site of infection Avoidance of signs and symptoms of inhalational anthrax (post-exposure treatment)