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Ciloxan
Classes
Fluoroquinolone Antibiotics
Ophthalmological Anti-infectives
Otic Anti-infectives
Administration
NOTE: Ciprofloxacin extended-release tablets and immediate-release tablets are NOT interchangeable.
Ciprofloxacin may be administered with or without meals. Administer at least 2 hours before or 6 hours after any of the following: magnesium/aluminum antacids, sucralfate, didanosine chewable/buffered tablets or pediatric powder for oral solution, or other products containing calcium, iron, or zinc. Do not administer with dairy products or calcium-fortified juices alone; however, ciprofloxacin may be taken with a meal that contains these products.[43411] [43570]
Immediate-release tablets
Tablets should be swallowed whole or may be broken in half on the scored line. Do not crush or chew.
If a dose is missed, it should be taken anytime but not later than 6 hours before the next scheduled dose. If less than 6 hours remain before the next dose, do not administer the missed dose and continue with the next scheduled dose. Do not take double doses to compensate for a missed dose.[43411]
Extended-release tablets
Swallow whole; do not split, crush, or chew.
If a dose is missed, it should be taken anytime but not later than 8 hours before the next scheduled dose. If less than 8 hours remain before the next dose, do not administer the missed dose and continue with the next scheduled dose. Do not take double doses to compensate for a missed dose.[43570]
Reconstitution
Pour the microcapsules from the small bottle into the large bottle of supplied diluent. Do not add water to the suspension. Close the large bottle and shake vigorously for about 15 seconds. The 5% ciprofloxacin oral suspension will contain 250 mg ciprofloxacin per 5 mL and the 10% suspension will contain 500 mg ciprofloxacin per 5 mL. Each bottle will contain 100 mL total volume.
Storage: The reconstituted suspension is stable for 14 days when stored below 30 degrees C (86 degrees F). Do not freeze.
Administration
Shake vigorously for about 15 seconds before each use. Use a calibrated oral syringe or other calibrated oral device to measure accurate dosage. Instruct patient not to chew microcapsules when taking the dose.
Do not administer ciprofloxacin oral suspension through a feeding tube due to its physical characteristics.
If a dose is missed, it should be taken anytime but not later than 6 hours before the next scheduled dose. If less than 6 hours remain before the next dose, do not administer the missed dose and continue with the next scheduled dose. Do not take double doses to compensate for a missed dose.
Visually inspect parenteral products for particulate matter and discoloration prior to administration whenever solution and container permit.
Vials:
Withdraw appropriate dose and dilute with a compatible solution to a concentration of 1 to 2 mg/mL.
Compatible solutions include 0.9% Sodium Chloride Injection, 5% Dextrose Injection, Sterile Water for Injection, 10% Dextrose for Injection, 5% Dextrose and 0.225% Sodium Chloride for Injection, 5% Dextrose and 0.45% Sodium Chloride for Injection, and Lactated Ringer's for Injection.
Storage: Diluted infusions (0.5 to 2 mg/mL) may be stored for up to 14 days at either room temperature or under refrigeration.[46655]
Prefilled flexible IV infusion containers:
Already diluted in 5% Dextrose at a concentration of 2 mg/mL; no further dilution is necessary.[65102]
Intermittent IV Infusion
Infuse IV over 60 minutes via a large vein to minimize discomfort and reduce the risk of venous irritation.
Infusion may occur via direct infusion or via Y-site. If Y-site administration is chosen, discontinue the administration of other parenteral drug products during the infusion. If this is not possible, then administer ciprofloxacin and the other medication separately (i.e., not at the same time through the Y-site).[46655] [65102]
Commercially available ophthalmic solutions are not for injection subconjunctivally or into the anterior chamber of the eye.
Apply topically to the eye taking care to avoid contamination. For ophthalmic use only.
Instruct patient on proper instillation of eye solution or ointment.
Do not to touch the tip of the dropper to the eye, fingertips, or other surface.
Otic Solution (Cetraxal)
Commercially available otic solutions are not for injection, inhalation, or topical ophthalmic use.
Instruct patient on proper instillation of otic solution.
Warm the container in the hands for at least 1 minute prior to administration to minimize dizziness that may result from the instillation of a cold solution into the ear canal.
The patient should lie with the affected ear upward for instillation and continue to maintain this position for at least 1 minute after instillation.
Instill the contents of 1 single use container (0.25 mL) into the affected ear.
Discard used container.
Otic Suspension (Otiprio)
Gather all materials needed:
Acute otitis externa: one vial of ciprofloxacin otic suspension; one 1 mL luer lock syringe for each affected ear; one 18 to 21 gauge preparation needle for each affected ear; one 20 to 24 gauge, 1.5 inch blunt, flexible administration needle for each affected ear; and alcohol pads. Ice pack and drape to keep the otic suspension vial cold is optional.
Otitis media with effusion: one vial of ciprofloxacin otic suspension; two 1 mL luer lock syringes; two 18 to 21 gauge preparation needles; two 20 to 24 gauge, 2 to 3 inch blunt, flexible administration needles; and alcohol pads. Ice pack and drape to keep the otic suspension vial cold is optional.
Ciprofloxacin suspension MUST be kept cold during preparation; if the suspension thickens during preparation, place vial back in refrigeration.
Hold vial by the aluminum seal while shaking to prevent gelation. Shake the vial for 5 to 8 seconds to mix well until a visually homogenous suspension is obtained.
Withdraw 0.3 mL of the suspension into the 1 mL syringe using an 18 to 21 gauge needle.
Replace the needle with a 20 to 24 gauge, 1.5 inch (acute otitis externa) or 2 to 3 inch (otitis media with effusion) blunt, flexible needle to be used for administration.
Prime the needle leaving a dose of 0.2 mL (acute otitis externa) or 0.1 mL (otitis media with effusion).
Using a different syringe, but the same vial, prepare a second syringe for the other ear (if needed) and dispose of the vial.
Storage: Syringes can be kept at room temperature or in the refrigerator for up to 3 hours prior to administration. Keep syringes on their side.
Adverse Reactions
ileus / Delayed / 0-1.0
GI bleeding / Delayed / 0-1.0
bronchospasm / Rapid / 0-1.0
laryngeal edema / Rapid / 0-1.0
respiratory arrest / Rapid / 0-1.0
seizures / Delayed / 0-1.0
hemorrhagic cystitis / Delayed / 0-1.0
renal failure (unspecified) / Delayed / 0-1.0
interstitial nephritis / Delayed / 0-1.0
anaphylactoid reactions / Rapid / 0-1.0
toxic epidermal necrolysis / Delayed / 0-1.0
vasculitis / Delayed / 0-1.0
angioedema / Rapid / 0-1.0
anaphylactic shock / Rapid / 0-1.0
erythema nodosum / Delayed / 0-1.0
exfoliative dermatitis / Delayed / 0-1.0
erythema multiforme / Delayed / 0-1.0
Stevens-Johnson syndrome / Delayed / 0-1.0
cardiac arrest / Early / 0-1.0
myocardial infarction / Delayed / 0-1.0
bradycardia / Rapid / 0-1.0
hearing loss / Delayed / 0-1.0
keratitis / Delayed / 0-1.0
keratoconjunctivitis / Early / 0-1.0
visual impairment / Early / 0-1.0
agranulocytosis / Delayed / 0-1.0
hepatic necrosis / Delayed / 0-1.0
pancreatitis / Delayed / 0-1.0
increased intracranial pressure / Early / Incidence not known
suicidal ideation / Delayed / Incidence not known
myasthenia gravis / Delayed / Incidence not known
tendon rupture / Delayed / Incidence not known
azotemia / Delayed / Incidence not known
serum sickness / Delayed / Incidence not known
acute generalized exanthematous pustulosis (AGEP) / Delayed / Incidence not known
aortic dissection / Delayed / Incidence not known
torsade de pointes / Rapid / Incidence not known
C. difficile-associated diarrhea / Delayed / Incidence not known
aplastic anemia / Delayed / Incidence not known
methemoglobinemia / Early / Incidence not known
pancytopenia / Delayed / Incidence not known
thrombotic thrombocytopenic purpura (TTP) / Delayed / Incidence not known
hemolytic anemia / Delayed / Incidence not known
hepatic failure / Delayed / Incidence not known
hyperkalemia / Delayed / Incidence not known
coma / Early / Incidence not known
corneal deposits / Delayed / 16.6-16.6
conjunctival hyperemia / Early / 0-10.0
superinfection / Delayed / 2.0-3.0
oral ulceration / Delayed / 0-1.0
constipation / Delayed / 0-1.0
dyspnea / Early / 0-1.0
hemoptysis / Delayed / 0-1.0
psychosis / Early / 0-1.0
hallucinations / Early / 0-1.0
depression / Delayed / 0-1.0
ataxia / Delayed / 0-1.0
mania / Early / 0-1.0
hypertonia / Delayed / 0-1.0
myasthenia / Delayed / 0-1.0
hematuria / Delayed / 0-1.0
crystalluria / Delayed / 0-1.0
vaginitis / Delayed / 0-1.0
bullous rash / Early / 0-1.0
sinus tachycardia / Rapid / 0-1.0
migraine / Early / 0-1.0
phlebitis / Rapid / 0-1.0
angina / Early / 0-1.0
hypotension / Rapid / 0-1.0
peripheral vasodilation / Rapid / 0-1.0
hypertension / Early / 0-1.0
photopsia / Delayed / 0-1.0
blurred vision / Early / 0-1.0
nystagmus / Delayed / 0-1.0
photophobia / Early / 0-1.0
cholestasis / Delayed / 0-1.0
hepatitis / Delayed / 0-1.0
jaundice / Delayed / 0-1.0
hyperglycemia / Delayed / 0-1.0
hypoglycemia / Early / 0-1.0
bone pain / Delayed / Incidence not known
myoclonia / Delayed / Incidence not known
confusion / Early / Incidence not known
neurotoxicity / Early / Incidence not known
pseudotumor cerebri / Delayed / Incidence not known
delirium / Early / Incidence not known
memory impairment / Delayed / Incidence not known
peripheral neuropathy / Delayed / Incidence not known
hyperesthesia / Delayed / Incidence not known
tendinitis / Delayed / Incidence not known
pneumonitis / Delayed / Incidence not known
QT prolongation / Rapid / Incidence not known
candidiasis / Delayed / Incidence not known
pseudomembranous colitis / Delayed / Incidence not known
leukopenia / Delayed / Incidence not known
bleeding / Early / Incidence not known
eosinophilia / Delayed / Incidence not known
hypoalbuminemia / Delayed / Incidence not known
anemia / Delayed / Incidence not known
thrombocytopenia / Delayed / Incidence not known
elevated hepatic enzymes / Delayed / Incidence not known
hyperbilirubinemia / Delayed / Incidence not known
hyperuricemia / Delayed / Incidence not known
hypokalemia / Delayed / Incidence not known
hypercalcemia / Delayed / Incidence not known
hypercholesterolemia / Delayed / Incidence not known
hypertriglyceridemia / Delayed / Incidence not known
dysgeusia / Early / 0-10.0
ocular pruritus / Rapid / 0-10.0
pharyngitis / Delayed / 5.0-5.0
irritability / Delayed / 0-5.0
vomiting / Early / 1.0-4.8
diarrhea / Early / 1.6-4.8
nausea / Early / 2.5-4.0
abdominal pain / Early / 0-3.3
rhinorrhea / Early / 3.0-3.0
dyspepsia / Early / 1.0-2.7
fever / Early / 0-2.1
dizziness / Early / 0-2.0
rash / Early / 0-1.8
arthralgia / Delayed / 0-1.0
xerostomia / Early / 0-1.0
anorexia / Delayed / 0-1.0
flatulence / Early / 0-1.0
nightmares / Early / 0-1.0
abnormal dreams / Early / 0-1.0
phobia / Delayed / 0-1.0
malaise / Early / 0-1.0
drowsiness / Early / 0-1.0
paranoia / Early / 0-1.0
tremor / Early / 0-1.0
insomnia / Early / 0-1.0
vertigo / Early / 0-1.0
paresthesias / Delayed / 0-1.0
asthenia / Delayed / 0-1.0
weakness / Early / 0-1.0
cylindruria / Delayed / 0-1.0
increased urinary frequency / Early / 0-1.0
dysmenorrhea / Delayed / 0-1.0
gynecomastia / Delayed / 0-1.0
xerosis / Delayed / 0-1.0
urticaria / Rapid / 0-1.0
vesicular rash / Delayed / 0-1.0
diaphoresis / Early / 0-1.0
pruritus / Rapid / 0-1.0
purpura / Delayed / 0-1.0
flushing / Rapid / 0-1.0
maculopapular rash / Early / 0-1.0
photosensitivity / Delayed / 0-1.0
syncope / Early / 0-1.0
ocular pain / Early / 0-1.0
diplopia / Early / 0-1.0
ocular irritation / Rapid / 0-1.0
tinnitus / Delayed / 0-1.0
petechiae / Delayed / 0-1.0
headache / Early / 1.0
restlessness / Early / 1.0
injection site reaction / Rapid / 1.0
arthropathy / Delayed / Incidence not known
back pain / Delayed / Incidence not known
myalgia / Early / Incidence not known
agitation / Early / Incidence not known
anxiety / Delayed / Incidence not known
dysesthesia / Delayed / Incidence not known
hypoesthesia / Delayed / Incidence not known
anosmia / Delayed / Incidence not known
xerophthalmia / Early / Incidence not known
leukocytosis / Delayed / Incidence not known
Boxed Warning
Systemic quinolones have been associated with disabling and potentially irreversible serious adverse reactions such as tendinopathy, including tendinitis and tendon rupture requiring surgical repair or resulting in prolonged disability. These reactions can occur within hours to weeks after starting these agents in patients of any age, with or without pre-existing risk factors. Because of this risk for serious and potentially permanent side effects, quinolones should only be used for the treatment of uncomplicated urinary tract infection, acute bacterial exacerbation of chronic bronchitis, or acute bacterial sinusitis in cases where alternative treatment options cannot be used. Discontinue quinolones at the first sign of tendon inflammation or tendon pain as these are symptoms that may precede rupture of the tendon. Avoid quinolone use in patients with a history of tendon disorders or tendon rupture. Tendon rupture typically involves the Achilles tendon; however, ruptures of the hand, shoulder, biceps, thumb, and other tendons have also been reported. Tendinitis and tendon rupture can occur bilaterally. Rupture can occur during therapy or up to a few months after therapy has been stopped. The risk of tendon rupture is further increased in older adults (more than 60 years of age), those receiving concomitant corticosteroid therapy, and in organ transplant recipients (including kidney, heart, and lung transplants). Reasons for tendon ruptures also include physical activity or exercise, kidney failure, or tendon problems in the past. If patients experience tendon inflammation or pain, they should rest and refrain from exercise until the diagnosis of tendonitis or tendon rupture has been confidently excluded.
Systemic quinolones have been associated with disabling and potentially irreversible serious neurotoxicity, including central nervous system effects, peripheral neuropathy, or psychiatric event. These reactions can occur within hours to weeks after starting these agents in patients of any age, with or without pre-existing risk factors. Because of this risk for serious and potentially permanent side effects, use quinolones for the treatment of uncomplicated urinary tract infection, acute bacterial exacerbation of chronic bronchitis, or acute bacterial sinusitis only in cases where alternative treatment options cannot be used. Avoid quinolone use in patients who have previously experienced peripheral neuropathy. Additionally, use quinolones with caution in patients with a known or suspected CNS disorder (e.g., severe cerebrovascular disease or arteriosclerosis, seizure disorder, reduced cerebral blood flow, altered brain structure, or stroke) or in the presence of other risk factors (e.g., certain drug therapy, renal dysfunction) that may predispose to seizures or lower seizure threshold. Discontinue quinolone therapy at the first signs or symptoms of neuropathy (e.g., pain, burning, tingling, numbness, and/or weakness, or other alterations in sensations such as light touch, pain, temperature, position sense, and vibratory sensation, and/or motor strength), central nervous system adverse events (seizures or convulsions, increased intracranial pressure (including pseudotumor cerebri), dizziness, or tremors), or psychiatric adverse events (toxic psychosis, hallucinations, paranoia, depression, suicidal thoughts or acts, confusion, delirium, disorientation, disturbances in attention, anxiety, agitation, nervousness, insomnia, nightmares, or memory impairment).
Avoid systemic quinolones, like ciprofloxacin, in patients with a history of myasthenia gravis. Quinolones may exacerbate the signs of myasthenia gravis and lead to life threatening weakness of the respiratory muscles. Serious postmarketing events, including deaths and the requirement for ventilatory support, have been associated with quinolone use in patients with myasthenia gravis. Because of this risk for serious and potentially permanent side effects, quinolones should only be used for the treatment of uncomplicated urinary tract infection, acute bacterial exacerbation of chronic bronchitis, or acute bacterial sinusitis in cases where alternative treatment options cannot be used.
Common Brand Names
Cetraxal, Ciloxan, Cipro, Cipro XR, OTIPRIO, Proquin XR
Dea Class
Rx
Description
Oral, intravenous, ophthalmic, otic broad-spectrum fluoroquinolone anti-infective
Used for urinary tract infections, respiratory tract infections, skin and skin structure infections, infectious diarrhea, anthrax, plague, corneal ulcers, bacterial conjunctivitis, acute otitis externa, and bilateral otitis media with effusion in patients undergoing tympanostomy tube placement
Associated with disabling and potentially irreversible adverse events, including tendonitis, tendon rupture, and peripheral neuropathy
Dosage And Indications
250 mg PO every 12 hours for 3 days. Due to the risk for serious and potentially permanent side effects associated with fluoroquinolone antibiotics, ciprofloxacin should only be used in cases where alternative treatment options cannot be used.
500 mg PO once daily for 3 days. Due to the risk for serious and potentially permanent side effects associated with fluoroquinolone antibiotics, ciprofloxacin should only be used in cases where alternative treatment options cannot be used.
250 to 750 mg PO every 12 hours for 7 to 14 days. Consider an initial intravenous dose.
10 to 20 mg/kg/dose (Max: 750 mg/dose) PO every 12 hours for 7 to 14 days. Ciprofloxacin is not considered a drug of first choice due to increased incidence of adverse reactions. The FDA approved duration of therapy is 10 to 21 days.
1,000 mg PO once daily for 7 to 14 days.
200 to 400 mg IV every 8 to 12 hours for 7 to 14 days.
6 to 10 mg/kg/dose (Max: 400 mg/dose) IV every 8 hours for 7 to 14 days. Ciprofloxacin is not considered a drug of first choice due to increased incidence of adverse reactions. The FDA-approved duration of therapy is 10 to 21 days.
250 to 500 mg PO every 12 hours for 7 to 14 days.
10 to 20 mg/kg/dose (Max: 750 mg/dose) PO every 12 hours for 7 to 14 days. Ciprofloxacin is not considered a drug of first choice due to increased incidence of adverse reactions.
1,000 mg PO once daily for 7 to 14 days.
200 to 400 mg IV every 8 to 12 hours for 7 to 14 days.
6 to 10 mg/kg/dose (Max: 400 mg/dose) IV every 8 hours for 7 to 14 days. Ciprofloxacin is not considered a drug of first choice due to increased incidence of adverse reactions.
750 mg PO every 12 hours for 3 days.
750 mg PO every 12 hours for 7 to 14 days.
400 mg IV every 8 hours for 7 to 14 days.
500 to 750 mg PO every 12 hours for 7 days. [61215] The FDA-approved duration is 10 to 14 days.
400 mg IV every 8 hours for 7 days.[28764] [61215] The FDA-approved duration is 10 to 14 days.
NOTE: Ciprofloxacin is not a drug of first choice in the treatment of presumed or confirmed pneumonia secondary to Streptococcus pneumoniae.[28764] [43411]
Oral dosage (immediate-release) Adults
500 to 750 mg PO every 12 hours for at least 5 days.[34362] The FDA-approved duration is 7 to 14 days.
400 mg IV every 8 to 12 hours for at least 5 days.[28764] [34362] The FDA-approved duration is 7 to 14 days.[28764]
15 mg/kg/dose (Max: 400 mg/dose) IV every 8 to 12 hours for 5 to 10 days.[34362] [46963] Guidelines recommend ciprofloxacin as an alternative therapy for patients with severe beta-lactam allergy and infections due to H. influenzae.
15 mg/kg/dose (Max: 400 mg/dose) IV every 12 hours for 10 days. Guidelines recommend ciprofloxacin as an alternative therapy for patients with severe beta-lactam allergy and infections due to H. influenzae.
500 to 750 mg PO every 12 hours for 5 to 7 days. Due to the risk for serious and potentially permanent side effects associated with fluoroquinolone antibiotics, ciprofloxacin should only be used in cases where alternative treatment options cannot be used.[43411] The FDA-approved duration is 7 to 14 days.
400 mg IV every 8 to 12 hours for 5 to 7 days. Due to the risk for serious and potentially permanent side effects associated with fluoroquinolone antibiotics, ciprofloxacin should only be used in cases where alternative treatment options cannot be used. The FDA-approved duration is 7 to 14 days.
750 mg PO every 12 hours.
400 mg IV every 8 hours.
500 to 750 mg PO every 12 hours for 7 to 14 days.[43411]
400 mg IV every 8 to 12 hours for 7 to 14 days.
500 to 750 mg PO every 12 hours for 7 to 14 days for mild infections in patients allergic or intolerant to beta-lactams or with recent antibiotic exposure or for moderate or severe infections in patients with risk factors for resistant gram-negative infections. Consider adding clindamycin for moderate or severe infections. Continue treatment for up to 28 days if infection is improving but is extensive and resolving slower than expected or if patient has severe peripheral artery disease.
400 mg IV every 8 to 12 hours for 7 to 14 days for mild infections in patients allergic or intolerant to beta-lactams or with recent antibiotic exposure or for moderate or severe infections in patients with risk factors for resistant gram-negative infections. Consider adding clindamycin for moderate or severe infections. Continue treatment for up to 28 days if infection is improving but is extensive and resolving slower than expected or if patient has severe peripheral artery disease.
750 mg PO every 12 hours plus metronidazole for incisional surgical site infections of the intestinal or genitourinary tract or axilla or perineum.
400 mg IV every 12 hours plus metronidazole for incisional surgical site infections of the intestinal or genitourinary tract or axilla or perineum.
500 to 750 mg PO every 12 hours plus an anaerobic agent. In setting of a cat or dog bite, preemptive early antimicrobial therapy for 3 to 5 days is recommended for patients who are immunocompromised, asplenic, have advanced liver disease, have edema of the bite area, have moderate to severe injuries, particularly of the hand or face, or have penetrating injuries to the periosteum or joint capsule.
400 mg IV every 12 hours plus an anaerobic agent. In setting of a cat or dog bite, preemptive early antimicrobial therapy for 3 to 5 days is recommended for patients who are immunocompromised, asplenic, have advanced liver disease, have edema of the bite area, have moderate to severe injuries, particularly of the hand or face, or have penetrating injuries to the periosteum or joint capsule.
400 mg IV every 12 hours until further debridement is not necessary, the patient has improved clinically, and fever has been absent for 48 to 72 hours plus doxycycline for Aeromonas hydrophila infections or clindamycin or metronidazole for mixed infections.
500 to 750 mg PO every 12 hours for 7 to 14 days.
400 mg IV every 8 to 12 hours for 7 to 14 days.
750 mg PO every 12 hours for 7 to 14 days.
400 mg IV every 8 hours for 7 to 14 days.
500 to 750 mg PO every 12 hours for 5 to 14 days.
400 mg IV every 8 to 12 hours for 5 to 14 days.
Not recommended by guidelines. The FDA-approved dosage is 250 mg PO as a single dose.
500 mg PO every 12 hours for 10 days. Ciprofloxacin is not included in clinical practice guidelines for sinusitis; other respiratory quinolones (levofloxacin, moxifloxacin) are preferred. Due to the risk for serious and potentially permanent side effects associated with fluoroquinolone antibiotics, they should only be used in cases where alternative treatment options cannot be used.
400 mg IV every 12 hours. Ciprofloxacin is not included in clinical practice guidelines for sinusitis; other respiratory quinolones (levofloxacin, moxifloxacin) are preferred. Due to the risk for serious and potentially permanent side effects associated with fluoroquinolone antibiotics, they should only be used in cases where alternative treatment options cannot be used.
500 to 750 mg PO every 12 hours. Complicated or severe infections may require prolonged therapy.
200 mg IV every 12 hours.
400 mg IV every 12 hours.
500 mg PO every 12 hours for 28 days.
400 mg IV every 12 hours for 28 days; convert to oral when applicable.
400 mg IV every 8 to 12 hours plus an antipseudomonal beta-lactam. Guidelines suggest ciprofloxacin may be used as an adjunctive therapy in high-risk neutropenic patients.
750 mg PO every 8 to 12 hours plus amoxicillin; clavulanate. Guidelines suggest ciprofloxacin plus amoxicillin; clavulanate as an empiric treatment option for low-risk neutropenic patients.
10 to 12.5 mg/kg/dose (Max: 500 mg/dose) PO every 12 hours has been studied in low-risk outpatients and is often administered after initial IV therapy. Treatment is generally continued until fever is absent for 24 to 48 hours with a rising neutrophil count. Oral therapy for low-risk outpatients with quinolones is suggested by guidelines; however, quinolones are not part of the empiric treatment regimens for inpatients.
1 to 2 drops in the affected eye(s) every 2 hours while awake for 2 days, then 1 to 2 drops in the affected eye(s) every 4 hours while awake for 5 days.
1 to 2 drops in the affected eye(s) every 2 hours while awake for 2 days, then 1 to 2 drops in the affected eye(s) every 4 hours while awake for 5 days.
1 to 2 drops in the affected eye(s) every 2 hours while awake for 2 days, then 1 to 2 drops in the affected eye(s) every 4 hours while awake for 5 days.
0.5 inch ribbon in the affected eye(s) 3 times daily for 2 days, then 0.5 inch ribbon in the affected eye(s) twice daily for 5 days.
0.5 inch ribbon in the affected eye(s) 3 times daily for 2 days, then 0.5 inch ribbon in the affected eye(s) twice daily for 5 days.
2 drops in affected eye(s) every 15 minutes for 6 hours then every 30 minutes for the remainder of the first day. For the second day, 2 drops every 1 hour. For days 3 to 14, 2 drops every 4 hours. Treatment may be continued after 14 days if corneal re-epithelialization has not occurred.
2 drops in affected eye(s) every 15 minutes for 6 hours then every 30 minutes for the remainder of the first day. For the second day, 2 drops every 1 hour. For days 3 to 14, 2 drops every 4 hours. Treatment may be continued after 14 days if corneal re-epithelialization has not occurred.
2 drops in affected eye(s) every 15 minutes for 6 hours then every 30 minutes for the remainder of the first day. For the second day, 2 drops every 1 hour. For days 3 to 14, 2 drops every 4 hours. Treatment may be continued after 14 days if corneal re-epithelialization has not occurred.
500 mg PO every 12 hours for 60 days after exposure. Ciprofloxacin is recommended as one of the preferred therapies for postexposure prophylaxis.
15 mg/kg/dose PO every 12 hours (Max: 500 mg/dose) for 60 days after exposure. Ciprofloxacin is recommended as one of the preferred therapies for postexposure prophylaxis.
15 mg/kg/dose PO every 12 hours for 60 days after exposure. Ciprofloxacin is recommended as one of the preferred therapies for postexposure prophylaxis.
10 mg/kg/dose PO every 12 hours for 60 days after exposure is recommended in guidelines. 15 mg/kg/dose PO every 12 hours is the general FDA-approved pediatric dosage. Ciprofloxacin is recommended as one of the preferred therapies for postexposure prophylaxis.
400 mg IV every 12 hours for 60 days after exposure. Ciprofloxacin is recommended as one of the preferred therapies for postexposure prophylaxis.
10 mg/kg/dose IV every 12 hours (Max: 400 mg/dose) for 60 days after exposure. Ciprofloxacin is recommended as one of the preferred therapies for postexposure prophylaxis.
10 mg/kg/dose IV every 12 hours for 60 days after exposure. Ciprofloxacin is recommended as one of the preferred therapies for postexposure prophylaxis.
750 mg PO every 12 hours for 10 to 14 days as first-line therapy. Monotherapy is recommended for stable patients with naturally occurring plague, although dual therapy can be considered for patients with large buboes. Use dual therapy with 2 distinct classes of antimicrobials for initial treatment in patients infected after intentional release of Y. pestis. The FDA-approved dosage is 500 to 750 mg PO every 12 hours.
500 mg PO every 8 hours for 10 to 14 days in combination with gentamicin as first-line therapy. Use dual therapy with 2 distinct classes of antimicrobials for initial treatment of naturally occurring plague and in patients infected after intentional release of Y. pestis. The FDA-approved dosage is 500 to 750 mg PO every 12 hours.
15 mg/kg/dose PO every 8 to 12 hours (Max: 500 mg/dose every 8 hours or 750 mg/dose every 12 hours) for 10 to 14 days as first-line therapy. Monotherapy is recommended for stable patients with naturally occurring plague, although dual therapy can be considered for patients with large buboes. Use dual therapy with 2 distinct classes of antimicrobials for initial treatment in patients infected after intentional release of Y. pestis.
15 mg/kg/dose PO every 8 to 12 hours for 10 to 14 days as first-line therapy. Use dual therapy with 2 distinct classes of antimicrobials for initial treatment in patients infected after intentional release of Y. pestis.
400 mg IV every 8 hours for 10 to 14 days as first-line therapy. Monotherapy is recommended for stable patients with naturally occurring plague, although dual therapy can be considered for patients with large buboes. Use dual therapy with 2 distinct classes of antimicrobials for initial treatment in patients infected after intentional release of Y. pestis. The FDA-approved dosage is 400 mg IV every 8 to 12 hours.
400 mg IV every 8 hours for 10 to 14 days in combination with gentamicin as first-line therapy. Use dual therapy with 2 distinct classes of antimicrobials for initial treatment of naturally occurring plague and in patients infected after intentional release of Y. pestis. The FDA-approved dosage is 400 mg IV every 8 to 12 hours.
10 mg/kg/dose (Max: 400 mg/dose) IV every 8 to 12 hours for 10 to 14 days as first-line therapy. Monotherapy is recommended for stable patients with naturally occurring plague, although dual therapy can be considered for patients with large buboes. Use dual therapy with 2 distinct classes of antimicrobials for initial treatment in patients infected after intentional release of Y. pestis.
10 mg/kg/dose IV every 8 to 12 hours for 10 to 14 days as first-line therapy. Use dual therapy with 2 distinct classes of antimicrobials for initial treatment in patients infected after intentional release of Y. pestis.
750 mg PO every 12 hours for 10 to 14 days as first-line therapy. Monotherapy can be considered for mild-to-moderate disease in patients with naturally occurring plague. Use dual therapy with 2 distinct classes of antimicrobials for initial treatment in patients with severe disease and patients infected after intentional release of Y. pestis. The FDA-approved dosage is 500 to 750 mg PO every 12 hours.
500 mg PO every 8 hours for 10 to 14 days in combination with gentamicin as first-line therapy. Use dual therapy with 2 distinct classes of antimicrobials for initial treatment of naturally occurring plague and in patients infected after intentional release of Y. pestis. The FDA-approved dosage is 500 to 750 mg PO every 12 hours.
15 mg/kg/dose PO every 8 to 12 hours (Max: 500 mg/dose every 8 hours or 750 mg/dose every 12 hours) for 10 to 14 days as first-line therapy. Monotherapy can be considered for mild-to-moderate disease in patients with naturally occurring plague. Use dual therapy with 2 distinct classes of antimicrobials for initial treatment in patients with severe disease and patients infected after intentional release of Y. pestis.
15 mg/kg/dose PO every 8 to 12 hours for 10 to 14 days as first-line therapy. Use dual therapy with 2 distinct classes of antimicrobials for initial treatment in patients with severe disease and patients infected after intentional release of Y. pestis.
400 mg IV every 8 hours for 10 to 14 days as first-line therapy. Monotherapy can be considered for mild-to-moderate disease in patients with naturally occurring plague. Use dual therapy with 2 distinct classes of antimicrobials for initial treatment in patients with severe disease and patients infected after intentional release of Y. pestis. The FDA-approved dosage is 400 mg IV every 8 to 12 hours.
400 mg IV every 8 hours for 10 to 14 days in combination with gentamicin as first-line therapy. Use dual therapy with 2 distinct classes of antimicrobials for initial treatment of naturally occurring plague and in patients infected after intentional release of Y. pestis. The FDA-approved dosage is 400 mg IV every 8 to 12 hours.
10 mg/kg/dose (Max: 400 mg/dose) IV every 8 to 12 hours for 10 to 14 days as first-line therapy. Monotherapy can be considered for mild-to-moderate disease in patients with naturally occurring plague. Use dual therapy with 2 distinct classes of antimicrobials for initial treatment in patients with severe disease and patients infected after intentional release of Y. pestis.
10 mg/kg/dose IV every 8 to 12 hours for 10 to 14 days. Use dual therapy with 2 distinct classes of antimicrobials for initial treatment in patients with severe disease and patients infected after intentional release of Y. pestis.
500 to 750 mg PO every 12 hours until 48 hours after the last perceived exposure as first-line therapy.
500 mg PO every 8 hours or 750 mg PO every 12 hours until 48 hours after the last perceived exposure as first-line therapy.
15 mg/kg/dose (Max: 750 mg/dose) PO every 12 hours until 48 hours after the last perceived exposure as first-line therapy.
500 to 750 mg PO every 12 hours for 7 days as first-line therapy. The FDA-approved duration is 14 days.
500 mg PO every 8 hours or 750 mg PO every 12 hours for 7 days as first-line therapy. The FDA-approved dosage is 500 to 750 mg PO every 12 hours for 14 days.
15 mg/kg/dose (Max: 750 mg/dose) PO every 12 hours for 7 days as first-line therapy. The FDA-approved dosage is 15 mg/kg/dose (Max: 500 mg/dose) every 8 to 12 hours 14 days.
15 mg/kg/dose PO every 12 hours for 7 days as first-line therapy. The FDA-approved dosage is 15 mg/kg/dose every 8 to 12 hours 14 days.
400 mg IV every 8 to 12 hours for 7 days as first-line therapy. The FDA-approved duration is 14 days.
400 mg IV every 8 to 12 hours for 7 days as first-line therapy. The FDA-approved duration is 14 days.
10 mg/kg/dose (Max: 400 mg/dose) IV every 8 to 12 hours for 7 days as first-line therapy. The FDA-approved duration is 14 days.
10 mg/kg/dose IV every 8 to 12 hours for 7 days as first-line therapy. The FDA-approved duration is 14 days.
0.5 mg (one 0.25 mL single-use container) in the affected ear(s) every 12 hours for 7 days.
0.5 mg (one 0.25 mL single-use container) in the affected ear(s) every 12 hours for 7 days.
Instill 12 mg (0.2 mL) in the external ear canal of each affected ear as a single dose.
Instill 12 mg (0.2 mL) in the external ear canal of each affected ear as a single dose.
0.1 mL (6 mg) intratympanically in each ear during tympanostomy tube placement.
15 to 20 mg/kg/day PO divided twice daily for 5 to 7 days. Usual dose: 500 mg PO twice daily. A 3-day regimen is also effective; short courses are usually reserved for outbreaks when antibiotics are in short supply.
15 to 30 mg/kg/day PO divided twice daily (Max: 500 mg/dose) for 5 to 10 days. A 3-day regimen is also effective; short courses are usually reserved for outbreaks when antibiotics are in short supply.
15 to 20 mg/kg/day PO divided twice daily for 5 to 7 days. Usual dose: 500 mg PO twice daily.
15 to 30 mg/kg/day PO divided twice daily (Max: 500 mg/dose) for 5 to 10 days.
15 to 20 mg/kg/day IV divided twice daily for 10 to 14 days.
15 to 30 mg/kg/day IV divided twice daily for 10 to 14 days.
20 mg/kg/day IV divided twice daily for 7 to 14 days as an alternative.
20 to 30 mg/kg/day IV divided twice daily for 7 to 14 days as an alternative.
500 to 750 mg PO every 12 hours for 5 days. Routine use is not recommended.
500 to 750 mg PO every 12 hours for 5 days. Routine use is not recommended.
400 mg IV every 12 hours for 5 days. Routine use is not recommended.
400 mg IV every 12 hours for 5 days. Routine use is not recommended.
500 mg PO every 12 hours for 3 days. Routine use is not recommended.
10 to 15 mg/kg/dose (Max: 500 mg/dose) PO every 12 hours for 3 days. Routine use is not recommended.
500 mg PO every 12 hours for 5 to 7 days or 750 mg PO as a single dose as an alternative.
10 to 20 mg/kg/dose (Max: 750 mg/dose) PO every 12 hours for 5 to 7 days as an alternative.
500 to 750 mg PO every 12 hours for 7 to 10 days as first-line therapy; add an aminoglycoside and treat for at least 14 days if concurrent bacteremia. Treat for 2 to 6 weeks for recurrent infections.
500 to 750 mg PO every 12 hours for 7 to 10 days as first-line therapy; add an aminoglycoside and treat for at least 14 days if concurrent bacteremia. Treat for 2 to 6 weeks for recurrent infections.
400 mg IV every 12 hours for 7 to 10 days as first-line therapy; add an aminoglycoside and treat for at least 14 days if concurrent bacteremia. Treat for 2 to 6 weeks for recurrent infections.
400 mg IV every 12 hours for 7 to 10 days as first-line therapy; add an aminoglycoside and treat for at least 14 days if concurrent bacteremia. Treat for 2 to 6 weeks for recurrent infections.
500 mg PO every 12 hours for 7 days as an alternative.
500 mg PO every 12 hours for 7 days as an alternative. Follow with long-term suppressive therapy in persons with a CD4 count less than 200 cells/mm3.
500 mg PO every 12 hours for 7 days as an alternative. Follow with long-term suppressive therapy in persons with a CD4 count less than 200/mm3.
10 to 20 mg/kg/dose (Max: 500 mg/dose) PO every 12 hours for 7 days as an alternative. Follow with long-term suppressive therapy in persons with severe immunosuppression.
500 to 750 mg PO every 12 hours for 7 to 14 days as first-line therapy; treat for at least 14 days if concurrent bacteremia in persons with a CD4 count more than 200 cells/mm3. Treat for 2 to 6 weeks in persons with a CD4 count less than 200 cells/mm3. Follow with long-term suppressive therapy if persistent bacteremia or with recurrent gastroenteritis with a CD4 count less than 200 cells/mm3 and severe diarrhea.
500 to 750 mg PO every 12 hours for 7 to 14 days as first-line therapy; treat for at least 14 days if concurrent bacteremia in persons with a CD4 count more than 200 cells/mm3. Treat for 2 to 6 weeks in persons with a CD4 count less than 200 cells/mm3. Follow with long-term suppressive therapy if persistent bacteremia or with recurrent gastroenteritis with a CD4 count less than 200 cells/mm3 and severe diarrhea.
400 mg IV every 12 hours for 7 to 14 days as first-line therapy; treat for at least 14 days if concurrent bacteremia in persons with a CD4 count more than 200 cells/mm3. Treat for 2 to 6 weeks in persons with a CD4 count less than 200 cells/mm3. Follow with long-term suppressive therapy if persistent bacteremia or with recurrent gastroenteritis with a CD4 count less than 200 cells/mm3 and severe diarrhea.
400 mg IV every 12 hours for 7 to 14 days as first-line therapy; treat for at least 14 days if concurrent bacteremia in persons with a CD4 count more than 200 cells/mm3. Treat for 2 to 6 weeks in persons with a CD4 count less than 200 cells/mm3. Follow with long-term suppressive therapy if persistent bacteremia or with recurrent gastroenteritis with a CD4 count less than 200 cells/mm3 and severe diarrhea.
500 mg PO every 12 hours for 3 days or 2 g PO as a single dose as first-line therapy. The FDA-labeled duration is 5 to 7 days.
10 to 15 mg/kg/dose (Max: 750 mg/dose) PO every 12 hours for 3 days as first-line therapy.
500 to 750 mg PO every 12 hours for 7 to 10 days as first-line therapy; treat for at least 14 days if concurrent bacteremia. Treat for up to 6 weeks for recurrent infections.
500 to 750 mg PO every 12 hours for 7 to 10 days as first-line therapy; treat for at least 14 days if concurrent bacteremia. Treat for up to 6 weeks for recurrent infections.
400 mg IV every 12 hours for 7 to 10 days as first-line therapy; treat for at least 14 days if concurrent bacteremia. Treat up to 6 weeks for recurrent infections.
400 mg IV every 12 hours for 7 to 10 days as first-line therapy depending on resistance; treat for at least 14 days if concurrent bacteremia. Treat up to 6 weeks for recurrent infections.
500 mg PO every 12 hours for 3 days or 1 to 2 g PO as a single dose.
15 to 20 mg/kg/dose (Max: 500 mg/dose) PO every 12 hours for 3 days or 20 mg/kg/dose (Max: 1 g) PO as a single dose.
500 mg PO every 12 hours for 3 days or 750 mg PO as a single dose; if symptoms are not resolved after single dose, continue treatment for up to 3 days. Antibiotic treatment is not recommended for mild cases, may be considered for moderate cases, and should be used for severe cases.
10 to 15 mg/kg/dose (Max: 750 mg/dose) PO every 12 hours for 3 days as an alternative. Antibiotic treatment is not recommended for mild cases, may be considered for moderate cases, and should be used for severe cases.
500 to 750 mg PO every 12 hours for 7 to 14 days; treat for 14 days if concurrent bacteremia.
10 to 15 mg/kg/dose (Max: 750 mg/dose) PO every 12 hours for 7 to 14 days; treat for 14 days if concurrent bacteremia.
500 mg PO every 12 hours for 48 to 72 hours or until the patient becomes afebrile. Routine use is not recommended; reserve for patients at high risk for invasive infection.
10 to 15 mg/kg/dose (Max: 750 mg/dose) PO every 12 hours for 48 to 72 hours or until the patient becomes afebrile. Routine use is not recommended; reserve for patients at high risk for invasive infection.
500 mg PO every 8 to 12 hours for 6 to 12 weeks or 750 mg PO every 8 hours for 6 to 8 weeks.
500 mg PO twice daily for 3 days. Complicated or severe infections may require prolonged therapy. A longer course of therapy may be required in persons living with HIV and uncircumcised males.
500 mg PO twice daily for 3 days. Complicated or severe infections may require prolonged therapy. A longer course of therapy may be required in persons living with HIV and uncircumcised males.
500 mg PO as a single dose. Initiate prophylaxis as soon as possible after exposure (ideally less than 24 hours after identification of index patient); prophylaxis initiated more than 14 days after onset of illness in the index patient has very limited or no value.
20 mg/kg/dose (Max: 500 mg/dose) PO as a single dose. Initiate prophylaxis as soon as possible after exposure (ideally less than 24 hours after identification of index patient); prophylaxis initiated more than 14 days after onset of illness in the index patient has very limited or no value.
400 mg IV every 12 hours as part of combination therapy for 7 to 14 days.
10 to 15 mg/kg/dose (Max: 400 mg/dose) IV every 12 hours. FDA-approved labeling for other populations suggests combination therapy and a duration of 7 to 14 days.
500 mg PO every 12 hours as part of combination therapy for 7 to 14 days.
10 to 20 mg/kg/dose (Max: 500 mg/dose) PO every 12 hours. FDA-approved labeling for other populations suggests combination therapy and a duration of 7 to 14 days.
400 mg IV every 8 to 12 hours as part of combination therapy for 3 to 7 days. Complicated infections include peritonitis and appendicitis complicated by rupture, intraabdominal abscess, and complicated diverticulitis .
10 to 15 mg/kg/dose (Max: 400 mg/dose) IV every 12 hours as part of combination therapy for 3 to 7 days. Complicated infections include peritonitis and appendicitis complicated by rupture, and intraabdominal abscess.
500 mg PO every 12 hours as part of combination therapy for 3 to 7 days. Complicated infections include peritonitis and appendicitis complicated by rupture, intraabdominal abscess, and complicated diverticulitis.
10 to 20 mg/kg/dose (Max: 500 mg/dose) PO every 12 hours as part of combination therapy for 3 to 7 days. Complicated infections include peritonitis and appendicitis complicated by rupture, and intraabdominal abscess.
400 mg IV every 8 hours as part of combination therapy for 3 to 7 days. Complicated infections include peritonitis and appendicitis complicated by rupture, and intraabdominal abscess.
750 mg PO every 12 hours as part of combination therapy for 3 to 7 days. Complicated infections include peritonitis and appendicitis complicated by rupture, and intraabdominal abscess.
400 mg IV every 12 hours as part of combination therapy. Antibiotics should be discontinued within 24 hours. Uncomplicated infections include acute appendicitis without perforation, abscess, or local peritonitis; traumatic bowel perforations repaired within 12 hours; acute cholecystitis without perforation; and ischemic, non-perforated bowel.
10 to 15 mg/kg/dose (Max: 400 mg/dose) IV every 12 hours as part of combination therapy. Antibiotics should be discontinued within 24 hours. Uncomplicated infections include acute appendicitis without perforation, abscess, or local peritonitis; traumatic bowel perforations repaired within 12 hours; acute cholecystitis without perforation; and ischemic, non-perforated bowel.
500 mg PO every 12 hours as part of combination therapy. Antibiotics should be discontinued within 24 hours. Uncomplicated infections include acute appendicitis without perforation, abscess, or local peritonitis; traumatic bowel perforations repaired within 12 hours; acute cholecystitis without perforation; and ischemic, non-perforated bowel.
10 to 20 mg/kg/dose (Max: 500 mg/dose) PO every 12 hours as part of combination therapy. Antibiotics should be discontinued within 24 hours. Uncomplicated infections include acute appendicitis without perforation, abscess, or local peritonitis; traumatic bowel perforations repaired within 12 hours; acute cholecystitis without perforation; and ischemic, non-perforated bowel.
50 mg/L in each dialysate exchange. Treat for 21 to 28 days.
50 mg/L intraperitoneal loading dose, followed by 25 mg/L in each dialysate exchange. Treat for 14 to 21 days.
250 to 500 mg PO every 12 hours for 21 to 28 days.
250 mg PO every 12 hours or 500 mg PO every 24 hours for at least 14 days to 21 days.
10 to 15 mg/kg/dose (Max: 500 mg/dose) PO every 24 hours for at least 14 to 28 days.
400 mg IV every 12 hours for at least 48 hours, followed by oral step-down therapy for a total treatment duration of 5 to 10 days as part of combination therapy. Uncomplicated infections include acute appendicitis without perforation, abscess, or local peritonitis; traumatic bowel perforations repaired within 12 hours; acute cholecystitis without perforation; and ischemic, non-perforated bowel.
10 to 15 mg/kg/dose (Max: 400 mg/dose) IV every 12 hours for at least 48 hours, followed by oral step-down therapy for a total treatment duration of 5 to 10 days as part of combination therapy. Uncomplicated infections include acute appendicitis without perforation, abscess, or local peritonitis; traumatic bowel perforations repaired within 12 hours; acute cholecystitis without perforation; and ischemic, non-perforated bowel.
500 mg PO every 12 hours for a total treatment duration of 5 to 10 days as step-down therapy after initial parenteral therapy as part of combination therapy. Uncomplicated infections include acute appendicitis without perforation, abscess, or local peritonitis; traumatic bowel perforations repaired within 12 hours; acute cholecystitis without perforation; and ischemic, non-perforated bowel.
10 to 20 mg/kg/dose (Max: 500 mg/dose) PO every 12 hours for a total treatment duration of 5 to 10 days as step-down therapy after initial parenteral therapy as part of combination therapy. Uncomplicated infections include acute appendicitis without perforation, abscess, or local peritonitis; traumatic bowel perforations repaired within 12 hours; acute cholecystitis without perforation; and ischemic, non-perforated bowel.
500 mg PO twice daily for 8 days.
500 mg PO twice daily in combination with metronidazole for 8 days.
500 mg PO every 12 hours is a preferred therapy for cutaneous anthrax infection. Treat for 7 to 10 days for naturally acquired infection. For a bioterrorism-related event, treat for a total duration of 60 days. Ciprofloxacin is a preferred therapy for cutaneous anthrax infection.
15 mg/kg/dose PO every 12 hours (Max: 500 mg/dose). Treat for 7 to 10 days for naturally acquired infection. For a bioterrorism-related event, treat for a total duration of 60 days. Ciprofloxacin is the preferred therapy for cutaneous anthrax infection.
15 mg/kg/dose PO every 12 hours. Treat for 7 to 10 days for naturally acquired infection. For a bioterrorism-related event, treat for a total duration of 60 days. Ciprofloxacin is the preferred therapy for cutaneous anthrax infection.
10 mg/kg/dose PO every 12 hours. Treat for 7 to 10 days for naturally acquired infection. For a bioterrorism-related event, treat for a total duration of 60 days. Ciprofloxacin is the preferred therapy for cutaneous anthrax infection.
400 mg IV every 8 hours. For systemic infection in which meningitis can be excluded, IV treatment should continue for at least 14 days or until clinical criteria for improvement are met. For systemic infection in which meningitis cannot be excluded, IV treatment should continue for at least 2 to 3 weeks or until clinical criteria for improvement are met. Prophylaxis to complete an antimicrobial course of up to 60 days will be required in both cases. Ciprofloxacin, in combination with appropriate antimicrobial therapy, is a preferred therapy for systemic anthrax infection. For systemic infection without CNS involvement, dual combination IV therapy with ciprofloxacin and a protein synthesis inhibitor (i.e., clindamycin, linezolid, doxycycline) or rifampin is recommended. For documented or suspected CNS infection, triple IV therapy with ciprofloxacin, a beta-lactam/glycopeptide, and a protein synthesis inhibitor (i.e., linezolid, clindamycin, chloramphenicol) or rifampin is recommended.
10 mg/kg/dose IV every 8 hours (Max: 400 mg/dose). For systemic infection in which meningitis can be excluded, treatment should continue for at least 14 days or until clinical criteria for improvement are met. For systemic infection in which meningitis cannot be excluded, treatment should continue for at least 2 to 3 weeks or until clinical criteria for improvement are met. Prophylaxis to complete an antimicrobial course of up to 60 days will be required in both cases. Ciprofloxacin, in combination with appropriate antimicrobial therapy, is a preferred therapy for systemic anthrax infection. For systemic infection without CNS involvement, dual combination IV therapy with ciprofloxacin and a protein synthesis inhibitor (e.g., clindamycin, linezolid, doxycycline) is recommended. For documented or suspected CNS infection, triple IV therapy with ciprofloxacin, a beta-lactam/glycopeptide, and a protein synthesis inhibitor (e.g., linezolid, clindamycin) is recommended.
15 mg/kg/dose IV every 12 hours. For systemic infection in which meningitis can be excluded, treatment should continue for at least 14 days or until clinical criteria for improvement are met. For systemic infection in which meningitis cannot be excluded, treatment should continue for at least 2 to 3 weeks or until clinical criteria for improvement are met. Prophylaxis to complete an antimicrobial course of up to 60 days will be required in both cases. Ciprofloxacin, in combination with appropriate antimicrobial therapy, is a preferred therapy for systemic anthrax infection. For systemic infection without CNS involvement, dual combination IV therapy with ciprofloxacin and a protein synthesis inhibitor (e.g., clindamycin, linezolid, doxycycline) is recommended. For documented or suspected CNS infection, triple IV therapy with ciprofloxacin, a beta-lactam/glycopeptide, and a protein synthesis inhibitor (e.g., linezolid, clindamycin) is recommended.
10 mg/kg/dose IV every 12 hours. For systemic infection in which meningitis can be excluded, treatment should continue for at least 14 days or until clinical criteria for improvement are met. For systemic infection in which meningitis cannot be excluded, treatment should continue for at least 2 to 3 weeks or until clinical criteria for improvement are met. Prophylaxis to complete an antimicrobial course of up to 60 days will be required in both cases. Ciprofloxacin, in combination with appropriate antimicrobial therapy, is a preferred therapy for systemic anthrax infection. For systemic infection without CNS involvement, dual combination IV therapy with ciprofloxacin and a protein synthesis inhibitor (e.g., clindamycin, linezolid, doxycycline) is recommended. For documented or suspected CNS infection, triple IV therapy with ciprofloxacin, a beta-lactam/glycopeptide, and a protein synthesis inhibitor (e.g., linezolid, clindamycin) is recommended.
15 mg/kg/dose PO every 12 hours (Max: 500 mg/dose). Treatment should continue to complete a treatment course of at least 14 days. Prophylaxis to complete an antimicrobial course of up to 60 days may be required. Ciprofloxacin, in combination with a protein synthesis inhibitor (e.g., clindamycin, doxycycline, linezolid), is recommended as the preferred oral follow-up combination therapy for severe anthrax (non-CNS infection).
15 mg/kg/dose PO every 12 hours. Treatment should continue to complete a treatment course of at least 14 days. Prophylaxis to complete an antimicrobial course of up to 60 days may be required. Ciprofloxacin, in combination with a protein synthesis inhibitor (e.g., clindamycin, doxycycline, linezolid), is recommended as the preferred oral follow-up combination therapy for severe anthrax (non-CNS infection).
10 mg/kg/dose PO every 12 hours. Treatment should continue to complete a treatment course of at least 14 days. Prophylaxis to complete an antimicrobial course of up to 60 days may be required. Ciprofloxacin, in combination with a protein synthesis inhibitor (e.g., clindamycin, doxycycline, linezolid), is recommended as the preferred oral follow-up combination therapy for severe anthrax (non-CNS infection).
NOTE: Streptomycin is the drug of choice to treat tularemia in most patients; gentamicin is the preferred agent in pregnant women.
Intravenous dosage Adults
400 mg IV every 12 hours for 10 days. Patients should be switched to oral antibiotic therapy when clinically indicated. The risk of serious infection after tularemia exposure supports the use of ciprofloxacin if antibiotic susceptibility testing, exhaustion of drug supplies, or allergic reactions preclude the use of streptomycin. Women who are breast-feeding should be treated with the same antibiotic as the infant.
15 mg/kg/dose IV every 12 hours (Max: 400 mg/dose) for 10 days as alternative therapy. Switch to oral antibiotic therapy when clinically indicated. Ciprofloxacin is recommended if antibiotic susceptibility testing, exhaustion of drug supplies, or allergic reactions preclude the use of streptomycin or gentamicin.
15 mg/kg/dose IV every 12 hours for 10 days as alternative therapy. Switch to oral antibiotic therapy when clinically indicated. Ciprofloxacin is recommended if antibiotic susceptibility testing, exhaustion of drug supplies, or allergic reactions preclude the use of streptomycin or gentamicin.
NOTE: Doxycycline is the treatment of choice for tularemia in the most patients. Ciprofloxacin is the drug of choice for pregnant women; if ciprofloxacin is contraindicated, doxycycline should be used.
Oral dosage Adults
500 PO every 12 hours for 14 days may be reasonable for mild to moderate illness. The risk of serious infection after tularemia exposure supports the use of ciprofloxacin if antibiotic susceptibility testing, exhaustion of drug supplies, or allergic reactions preclude the use of doxycycline.
15 mg/kg/dose PO every 12 hours (Max: 500 mg/dose) for 14 days.
15 mg/kg/dose PO every 12 hours for 14 days.
10 mg/kg/dose PO every 12 hours (Max: 500 mg/dose) with or without azithromycin for up to 20 weeks has been studied.
10 mg/kg/dose PO every 12 hours (Max: 500 mg/dose) with or without azithromycin for up to 20 weeks has been studied.
400 mg IV as a single dose within 120 minutes prior to the surgical incision; no intraoperative redosing is necessary. The duration of prophylaxis should not exceed 24 hours.
10 mg/kg/dose IV as a single dose (Max: 400 mg/dose) within 120 minutes prior to the surgical incision; no intraoperative redosing is necessary. The duration of prophylaxis should not exceed 24 hours.
400 mg IV every 8 hours for 7 days followed by at least 3 days of oral therapy. Current dosage recommendations may be suboptimal to achieve an adequate AUC:MIC ratio with P. aeruginosa MICs exceeding 0.125 mg/L; however, data supporting higher dosages are not available.
10 mg/kg/dose (Max: 400 mg/dose) IV every 8 hours for 7 days followed by at least 3 days of oral therapy. Limited pharmacodynamic data suggest current dosage strategies may be suboptimal in achieving an adequate AUC:MIC ratio for P. aeruginosa isolates with MICs exceeding 0.125 mg/L; however, data supporting higher dosages are not available.
500 mg by mouth 3 times daily for a total of 10 days. Current dosage recommendations may be suboptimal to achieve an adequate AUC:MIC ratio with P. aeruginosa MICs exceeding 0.125 mg/L; however, data supporting higher dosages are not available.
15 to 20 mg/kg/dose (Max: 1,000 mg/dose) PO twice daily for a total of 10 to 14 days.[30691] [55149] [59080] [59081] Limited pharmacodynamic data suggest current dosage strategies may be suboptimal in achieving an adequate AUC:MIC ratio for P. aeruginosa isolates with MICs exceeding 0.125 mg/L; however, data supporting higher dosages are not available.[55151]
750 mg PO every 8 to 12 hours for 3 weeks to 3 months in combination with a nebulized antimicrobial. Usual duration for chronic infection: 2 weeks.[42097]
20 mg/kg/dose (Max: 750 mg/dose) PO every 12 hours for 3 weeks to 3 months in combination with a nebulized antimicrobial. Usual duration for chronic infection: 2 weeks.[42097] However, adding ciprofloxacin to nebulized therapy produced no benefit in 1 study (n = 304).[55152]
15 mg/kg/dose PO every 12 hours for 3 weeks to 3 months in combination with a nebulized antimicrobial. Usual duration for chronic infection: 2 weeks.[42097] However, adding ciprofloxacin to nebulized therapy produced no benefit in 1 study (n = 304).[55152]
500 mg PO once daily.
400 mg IV every 8 to 12 hours for 4 to 6 weeks. The FDA-approved duration of therapy is 4 to 8 weeks.
10 mg/kg/dose (Max: 400 mg/dose) IV every 8 to 12 hours. Treat for 2 to 4 days or until clinically improved, followed by oral step-down therapy for a total duration of 3 to 4 weeks for uncomplicated cases. A longer course (i.e., 4 to 6 weeks or longer) may be needed for severe or complicated infections.
10 mg/kg/dose IV every 8 to 12 hours. Treat for 14 to 21 days or until clinically improved, followed by oral step-down therapy for a total duration of 4 to 6 weeks. A longer course (several months) may be needed for severe or complicated infections.
500 to 750 mg PO every 12 hours for 4 to 6 weeks. The FDA-approved duration of therapy is 4 to 8 weeks.
10 to 20 mg/kg/dose (Max: 750 mg/dose) PO every 12 hours as step-down therapy after initial parenteral therapy. Treat for a total duration of 3 to 4 weeks (parenteral plus oral) for uncomplicated cases. A longer course (i.e., 4 to 6 weeks or longer) may be needed for severe or complicated infections.
10 to 20 mg/kg/dose PO every 12 hours as step-down therapy after initial parenteral therapy. Treat for a total duration of 4 to 6 weeks (parenteral plus oral). A longer course (several months) may be needed for severe or complicated infections.
400 mg IV every 12 hours for 6 weeks as an alternative therapy.
500 to 750 mg PO every 12 hours for 6 weeks as an alternative therapy.
400 mg IV every 12 hours for 4 to 6 weeks as alternative therapy for Enterobacter sp. or P. aeruginosa, which may be followed by long-term suppressive therapy. May consider addition of an aminoglycoside for P. aeruginosa infections; if aminoglycoside is in spacer and organism is aminoglycoside-susceptible, then double coverage is provided with IV or oral monotherapy.
750 mg PO every 12 hours for 4 to 6 weeks as first-line therapy for infections due to Enterobacterales and alternative therapy for Enterobacter sp. or P. aeruginosa, which may be followed by long-term suppressive therapy. May consider addition of an aminoglycoside for P. aeruginosa infections; if aminoglycoside is in spacer and organism is aminoglycoside-susceptible, then double coverage is provided with IV or oral monotherapy.
400 mg IV every 8 hours for 6 weeks as alternative therapy. May consider double coverage (i.e., beta-lactam and ciprofloxacin).
750 mg PO every 12 hours for 6 weeks as alternative therapy. May consider double coverage (i.e., beta-lactam and ciprofloxacin).
400 mg IV every 12 hours for 6 to 8 weeks as first-line therapy.
500 mg PO every 12 hours for 6 to 8 weeks as first-line therapy.
400 mg IV every 8 hours for 4 to 8 weeks.
750 mg PO every 12 hours for 4 to 8 weeks.
250 to 500 mg PO every 12 hours in combination with rifampin for 3 to 6 months, which may be followed by long-term suppressive therapy.
250 to 500 mg PO every 12 hours.
400 mg IV every 8 to 12 hours. Treat for 1 to 2 weeks or until clinically improved, followed by oral step-down therapy for 2 to 4 weeks. The FDA-approved duration of therapy is 4 to 8 weeks.
10 mg/kg/dose (Max: 400 mg/dose) IV every 8 to 12 hours. Treat for 2 to 4 days or until clinically improved, followed by oral step-down therapy for a total duration of 2 to 3 weeks for uncomplicated cases. A longer course (i.e., 4 to 6 weeks or longer) may be needed for septic hip arthritis or severe or complicated infections.
10 mg/kg/dose IV every 8 to 12 hours. Treat for 14 to 21 days or until clinically improved, followed by oral step-down therapy for a total duration of 4 to 6 weeks. A longer course (several months) may be needed for severe or complicated infections.
500 to 750 mg PO every 12 hours as step-down therapy after initial parenteral therapy. Treat for a total duration of 3 to 6 weeks (parenteral plus oral). The FDA-approved duration is 4 to 8 weeks.
10 to 20 mg/kg/dose (Max: 750 mg/dose) PO every 12 hours as step-down therapy after initial parenteral therapy. Treat for a total duration of 2 to 3 weeks (parenteral plus oral) for uncomplicated cases. A longer course (i.e., 4 to 6 weeks or longer) may be needed for septic hip arthritis or severe or complicated infections.
10 to 20 mg/kg/dose PO every 12 hours as step-down therapy after initial parenteral therapy. Treat for a total duration of 4 to 6 weeks (parenteral plus oral). A longer course (several months) may be needed for severe or complicated infections.
400 mg IV every 12 hours as alternative for 4 weeks for native valve endocarditis and for 6 weeks for prosthetic valve endocarditis due to HACEK organisms in patients unable to tolerate cephalosporin or ampicillin therapy.
10 to 15 mg/kg/dose IV every 12 hours (Max: 400 mg/dose) as alternative for 4 to 6 weeks in combination with vancomycin and gentamicin for culture-negative native valve endocarditis in patients unable to tolerate penicillins.
500 mg PO every 12 hours as alternative for 4 weeks for native valve endocarditis and for 6 weeks for prosthetic valve endocarditis due to HACEK organisms in patients unable to tolerate cephalosporin or ampicillin therapy.
10 to 15 mg/kg/dose PO every 12 hours (Max: 750 mg/dose) as alternative for 4 to 6 weeks in combination with vancomycin and gentamicin for culture-negative native valve endocarditis in patients unable to tolerate penicillins.
10 to 15 mg/kg/dose (Max: 750 mg/dose) PO every 12 hours plus clarithromycin or azithromycin and ethambutol. May consider addition of ciprofloxacin if rifabutin cannot be administered for severe disease or if a fourth drug is needed for patients with more severe symptoms or disseminated disease. Duration of treatment depends on clinical response but should continue for at least 12 months.[34361]
500 mg PO 3 times weekly in patients with CD4 count less than 200 cells/mm3 as an alternative. Discontinuation may be considered in patients without evidence of active infection who have sustained increase in CD4 count to more than 200 cells/mm3 for more than 6 months in response to antiretroviral therapy.
500 mg PO 3 times weekly in patients with CD4 count less than 200 cells/mm3 as an alternative. Discontinuation may be considered in patients without evidence of active infection who have sustained increase in CD4 count to more than 200 cells/mm3 for more than 6 months in response to antiretroviral therapy.
10 to 20 mg/kg/dose (Max: 500 mg/dose) PO 3 times weekly in patients with severe immunosuppression (CDC immunologic category 3) as an alternative. Discontinuation may be considered in patients without evidence of active infection who have sustained improvement in immunologic status (CDC immunologic category 1 or 2) for more than 6 months in response to antiretroviral therapy.
600 mg IV every 12 hours. Start within 1 hour for septic shock or within 3 hours for possible sepsis without shock. Duration of therapy is not well-defined and dependent on patient- and infection-specific factors. Assess patient daily for deescalation of antimicrobial therapy based on pathogen identification and/or adequate clinical response.
400 mg IV every 8 hours. Start within 1 hour for septic shock or within 3 hours for possible sepsis without shock. Duration of therapy is not well-defined and dependent on patient- and infection-specific factors. Assess patient daily for deescalation of antimicrobial therapy based on pathogen identification and/or adequate clinical response.
500 to 750 mg PO twice daily for 4 weeks.
20 to 40 mg/kg/day PO divided twice daily (Max: 750 mg/dose) for 4 weeks.
500 mg PO every 12 hours for 10 to 14 days as first-line therapy.
10 to 20 mg/kg/dose (Max: 500 mg/dose) PO every 12 hours for 10 to 14 days as second-line therapy.
500 mg PO every 12 hours for 3 days, then 250 mg PO every 12 hours for 11 days plus ceftriaxone as first-line therapy and ceftazidime or amikacin as second-line therapy.
10 to 20 mg/kg/dose (Max: 500 mg/dose) PO every 12 hours for 14 days plus ceftriaxone as first-line therapy and ceftazidime or amikacin as second-line therapy.
400 mg IV every 12 hours for 3 days, then 200 mg IV every 12 hours for 11 days plus ceftriaxone as first-line therapy and ceftazidime or amikacin as second-line therapy.
10 to 15 mg/kg/dose (Max: 400 mg/dose) IV every 12 hours for 14 days plus ceftriaxone as first-line therapy and ceftazidime or amikacin as second-line therapy.
500 mg PO every 12 hours for 14 days as second-line therapy.
10 to 20 mg/kg/dose (Max: 500 mg/dose) PO every 12 hours for 14 days as second-line therapy.
500 to 750 mg PO every 12 hours in persons with recurrent bacteremia or gastroenteritis with a CD4 count of less than 200 cells/mm3 and severe diarrhea. Discontinuation may be considered after resolution of infection in persons with a response to antiretroviral therapy with sustained viral suppression and CD4 count more than 200 cells/mm3.
500 to 750 mg PO every 12 hours in persons with recurrent bacteremia or gastroenteritis with a CD4 count of less than 200 cells/mm3 and severe diarrhea. Discontinuation may be considered after resolution of infection in persons with a response to antiretroviral therapy with sustained viral suppression and CD4 count more than 200 cells/mm3.
400 mg IV every 8 to 12 hours plus vancomycin for 5 days or until CSF leak is closed, whichever is longer, as an alternative. Add metronidazole for penetrating spinal cord injury if abdominal cavity is involved and consider adding metronidazole for penetrating brain injury if gross contamination with organic debris.
20 to 30 mg/kg/day IV divided every 8 to 12 hours (Max: 1.2 g/day) plus vancomycin for 5 days or until CSF leak is closed, whichever is longer, as an alternative. Add metronidazole for penetrating spinal cord injury if abdominal cavity is involved and consider adding metronidazole for penetrating brain injury if gross contamination with organic debris.
250 to 500 mg PO every 12 hours for 7 to 10 days.
10 to 20 mg/kg/dose (Max: 500 mg/dose) PO every 12 hours for 7 to 10 days.
500 to 750 mg PO every 12 hours for 14 days.
10 to 20 mg/kg/dose (Max: 750 mg/dose) PO every 12 hours for 14 days.
400 mg IV every 8 hours for 14 days.
10 mg/kg/dose (Max: 400 mg/dose) IV every 8 hours for 14 days.
500 to 750 mg PO every 12 hours for 14 days with or without inhaled antibiotics, followed by inhaled antibiotics for 4 to 12 weeks.
10 to 20 mg/kg/dose (Max: 750 mg/dose) PO every 12 hours for 14 days with or without inhaled antibiotics, followed by inhaled antibiotics for 4 to 12 weeks.
†Indicates off-label use
Dosing Considerations
In studies in patients with stable chronic cirrhosis, no significant changes in pharmacokinetics have been observed; it appears no dosage adjustment is needed. Ciprofloxacin has not been studied in patients with acute hepatic insufficiency.
Renal ImpairmentAdults
FDA-labeled renal dosing adjustment recommendations:
CrCl more than 50 mL/minute: No dosage adjustment needed.
CrCl 30 to 50 mL/minute: For oral administration of the regular tablets and suspension, the recommended dosage is 250 to 500 mg PO every 12 hours; doses of 750 mg may also be used, but with careful monitoring. No dosage adjustment is recommended for the IV formulation or extended-release tablets.
CrCl 5 to 29 mL/minute: For the regular tablets and suspension, 250 to 500 mg PO every 18 hours; doses of 750 mg may also be used, but with careful monitoring. For the IV formulation 200 to 400 mg IV every 18 to 24 hours. For the extended-release tablets, 500 mg PO every 24 hours.
Other renal dosing adjustment recommendations:
CrCl more than 50 mL/minute: No dosage adjustment needed.
CrCl 10 to 50 mL/minute: Administer 50 to 75% of the regular dose.
CrCl less than 10 mL/minute: Administer 50% of the regular dose.
Pediatric patients
The following dose adjustments are based on a usual pediatric dose of 10 to 15 mg/kg/dose every 12 hours:
GFR 30 mL/minute/1.73 m2 or more: No dosage adjustment needed.
GFR 10 to 29 mL/minute/1.73 m2: 10 to 15 mg/kg/dose IV/PO every 18 hours.
GFR less than 10 mL/minute/1.73 m2: 10 to 15 mg/kg/dose IV/PO every 24 hours.
Intermittent hemodialysis
Adults
For the regular tablets and suspension, the FDA-labeled adjustment is 250 to 500 mg PO every 24 hours; doses of 750 mg may also be used, but with careful monitoring. Other recommendations suggest 250 mg PO every 12 hours. For the IV formulation, the FDA-labeled dosage adjustment is 200 to 400 mg IV every 18 to 24 hours. Other recommendations suggest 200 mg IV every 12 hours. For the extended-release tablets, 500 mg PO every 24 hours. Administer the dose after hemodialysis on dialysis days.
Pediatric patients
10 to 15 mg/kg/dose IV/PO every 24 hours administered after hemodialysis on dialysis days.
Continuous renal replacement therapy
Adults
200 to 400 mg IV every 12 to 24 hours for CVVH, 400 mg IV every 12 to 24 hours for CVVHD, and 400 mg IV every 12 hours for CVVHDF.
Pediatric patients
10 to 15 mg/kg/dose IV/PO every 12 hours.
Peritoneal dialysis
Adults
For the regular tablets and suspension, the FDA-labeled adjustment is 250 to 500 mg PO every 24 hours; doses of 750 mg may also be used, but with careful monitoring. Other recommendations suggest 250 mg PO every 8 hours. For the IV formulation, the FDA-labeled adjustment is 200 to 400 mg IV every 18 to 24 hours. Other recommendations suggest 200 mg IV every 8 hours. For the extended-release tablets, 500 mg PO every 24 hours.
Pediatric patients
10 to 15 mg/kg/dose IV/PO every 24 hours.
Drug Interactions
Abarelix: (Moderate) Since abarelix can cause QT prolongation, abarelix should be used cautiously with other drugs that are associated with QT prolongation, such as ciprofloxacin.
Abemaciclib: (Moderate) Monitor for an increase in abemaciclib-related adverse reactions if coadministration with ciprofloxacin is necessary; consider reducing the dose of abemaciclib in 50-mg decrements if toxicities occur. Discontinue abemaciclib for patients unable to tolerate 50 mg twice daily. Abemaciclib is a CYP3A4 substrate and ciprofloxacin is a moderate CYP3A4 inhibitor. Coadministration with other moderate CYP3A4 inhibitors is predicted to increase the relative potency adjusted unbound AUC of abemaciclib plus its active metabolites (M2, M18, and M20) by approximately 1.6- to 2.4-fold.
Acalabrutinib: (Major) Decrease the acalabrutinib dose to 100 mg PO once daily if coadministered with ciprofloxacin. Coadministration may result in increased acalabrutinib exposure and toxicity (e.g., infection, bleeding, and atrial arrhythmias). Acalabrutinib is a CYP3A4 substrate; ciprofloxacin is a moderate CYP3A4 inhibitor. In physiologically based pharmacokinetic (PBPK) simulations, the Cmax and AUC values of acalabrutinib were increased by 2- to almost 3-fold when acalabrutinib was coadministered with moderate CYP3A inhibitors.
Acarbose: (Moderate) Monitor blood glucose carefully when systemic quinolones and antidiabetic agents, including alpha-glucosidase inhibitors, are coadministered. Discontinue the quinolone if a hypoglycemic reaction occurs and initiate appropriate therapy immediately. Disturbances of blood glucose, including hyperglycemia and hypoglycemia, have been reported in patients treated concomitantly with quinolones and an antidiabetic agent. Hypoglycemia, sometimes resulting in coma, can occur.
Acetaminophen; Aspirin, ASA; Caffeine: (Moderate) Reduction or limitation of the caffeine dosage in medications and limitation of caffeine in beverages and food may be necessary during concurrent ciprofloxacin therapy. Ciprofloxacin can decrease the clearance of caffeine. Caffeine toxicity may occur and can manifest as nausea, vomiting, anxiety, tachycardia, or seizures. Ciprofloxacin is a CYP1A2 inhibitor and caffeine is a CYP1A2 substrate.
Acetaminophen; Caffeine: (Moderate) Reduction or limitation of the caffeine dosage in medications and limitation of caffeine in beverages and food may be necessary during concurrent ciprofloxacin therapy. Ciprofloxacin can decrease the clearance of caffeine. Caffeine toxicity may occur and can manifest as nausea, vomiting, anxiety, tachycardia, or seizures. Ciprofloxacin is a CYP1A2 inhibitor and caffeine is a CYP1A2 substrate.
Acetaminophen; Caffeine; Dihydrocodeine: (Moderate) Concomitant use of dihydrocodeine with ciprofloxacin may increase dihydrocodeine plasma concentrations, resulting in greater metabolism by CYP2D6, increased dihydromorphine concentrations, and prolonged opioid adverse reactions, including hypotension, respiratory depression, profound sedation, coma, and death. If coadministration is necessary, monitor patients closely at frequent intervals and consider a dosage reduction of dihydrocodeine until stable drug effects are achieved. Discontinuation of ciprofloxacin could decrease dihydrocodeine plasma concentrations, decrease opioid efficacy, and potentially lead to a withdrawal syndrome in those with physical dependence to dihydrocodeine. If ciprofloxacin is discontinued, monitor the patient carefully and consider increasing the opioid dosage if appropriate. Ciprofloxacin is a moderate inhibitor of CYP3A4, an isoenzyme partially responsible for the metabolism of dihydrocodeine. (Moderate) Reduction or limitation of the caffeine dosage in medications and limitation of caffeine in beverages and food may be necessary during concurrent ciprofloxacin therapy. Ciprofloxacin can decrease the clearance of caffeine. Caffeine toxicity may occur and can manifest as nausea, vomiting, anxiety, tachycardia, or seizures. Ciprofloxacin is a CYP1A2 inhibitor and caffeine is a CYP1A2 substrate.
Acetaminophen; Caffeine; Pyrilamine: (Moderate) Reduction or limitation of the caffeine dosage in medications and limitation of caffeine in beverages and food may be necessary during concurrent ciprofloxacin therapy. Ciprofloxacin can decrease the clearance of caffeine. Caffeine toxicity may occur and can manifest as nausea, vomiting, anxiety, tachycardia, or seizures. Ciprofloxacin is a CYP1A2 inhibitor and caffeine is a CYP1A2 substrate.
Acetaminophen; Codeine: (Moderate) Concomitant use of codeine with ciprofloxacin may increase codeine plasma concentrations, resulting in greater metabolism by CYP2D6 and, increased morphine concentrations, and prolonged opioid adverse reactions, including hypotension, respiratory depression, profound sedation, coma, and death. It is recommended to avoid this combination when codeine is being used for cough. If coadministration is necessary, monitor patients closely at frequent intervals and consider a dosage reduction of codeine until stable drug effects are achieved. Discontinuation of ciprofloxacin could decrease codeine plasma concentrations, decrease opioid efficacy, and potentially lead to a withdrawal syndrome in those with physical dependence to codeine. If ciprofloxacin is discontinued, monitor the patient carefully and consider increasing the opioid dosage if appropriate. Codeine is primarily metabolized by CYP2D6 to morphine, and by CYP3A4 to norcodeine; norcodeine does not have analgesic properties. Ciprofloxacin is a moderate inhibitor of CYP3A4.
Acetaminophen; Hydrocodone: (Moderate) Consider a reduced dose of hydrocodone with frequent monitoring for respiratory depression and sedation if concurrent use of ciprofloxacin is necessary. It is recommended to avoid this combination when hydrocodone is being used for cough. Hydrocodone is a CYP3A4 substrate, and coadministration with CYP3A4 inhibitors like ciprofloxacin can increase hydrocodone exposure resulting in increased or prolonged opioid effects including fatal respiratory depression, particularly when an inhibitor is added to a stable dose of hydrocodone. These effects could be more pronounced in patients also receiving a CYP2D6 inhibitor. If ciprofloxacin is discontinued, hydrocodone plasma concentrations will decrease resulting in reduced efficacy of the opioid and potential withdrawal syndrome in a patient who has developed physical dependence to hydrocodone.
Acetaminophen; Ibuprofen: (Moderate) Use quinolones and nonsteroidal anti-inflammatory drugs (NSAIDs) concomitantly with caution due to potential increased risk of CNS stimulation and convulsive seizures. NSAIDs in combination with very high doses of quinolones have been shown to provoke convulsions in preclinical studies and postmarketing.
Acetaminophen; Oxycodone: (Moderate) Consider a reduced dose of oxycodone with frequent monitoring for respiratory depression and sedation if concurrent use of ciprofloxacin is necessary. If ciprofloxacin is discontinued, consider increasing the oxycodone dose until stable drug effects are achieved and monitor for evidence of opioid withdrawal. Oxycodone is a CYP3A4 substrate, and coadministration with a moderate inhibitor like ciprofloxacin can increase oxycodone exposure resulting in increased or prolonged opioid effects including fatal respiratory depression, particularly when an inhibitor is added to a stable dose of oxycodone. If ciprofloxacin is discontinued, oxycodone plasma concentrations will decrease resulting in reduced efficacy of the opioid and potential withdrawal syndrome in a patient who has developed physical dependence to oxycodone.
Acetazolamide: (Minor) A large proportion of ciprofloxacin is normally excreted unchanged in the urine. If urinary alkalinizing agents such as carbonic anhydrase inhibitors are used concomitantly, the solubility of ciprofloxacin can be decreased because of alkaline urine. Patients should be monitored for crystalluria and nephrotoxicity.
Adagrasib: (Major) Concomitant use of adagrasib and ciprofloxacin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Ado-Trastuzumab emtansine: (Major) Avoid concomitant use of ado-trastuzumab emtansine with ciprofloxacin, as plasma exposure to the cytotoxic small molecule of ado-trastuzumab emtansine, DM1, may be increased. Treatment with ado-trastuzumab emtansine should be delayed until ciprofloxacin is cleared from the circulation (approximately 3 elimination half-lives), or an alternate medication with less potential to inhibit CYP3A4 should be considered. If co-administration is necessary, monitor for an increase in ado-trastuzumab emtansine-related adverse events. Ciprofloxacin is a moderate CYP3A4 inhibitor. While formal drug interaction studies have not been conducted, DM1 is mainly metabolized by CYP3A4 (and to a lesser extent, CYP3A5) in vitro. Coadministration may result in potentially increased DM1 exposure and toxicity.
Albuterol; Budesonide: (Moderate) Avoid coadministration of oral budesonide with ciprofloxacin due to increased budesonide exposure; use caution with inhaled budesonide, as systemic exposure may increase. Budesonide is a CYP3A substrate and ciprofloxacin is a moderate CYP3A inhibitor. Also, quinolones have been associated with an increased risk of tendon rupture requiring surgical repair or resulting in prolonged disability; this risk is further increased in those receiving concomitant corticosteroids. Discontinue quinolone therapy at the first sign of tendon inflammation or tendon pain, as these are symptoms that may precede rupture of the tendon.
Alfentanil: (Moderate) The plasma concentrations of alfentanil may be elevated when administered concurrently with ciprofloxacin. Clinical monitoring for adverse effects, such as hypotension, nausea, itching, and respiratory depression, is recommended during coadministration. Ciprofloxacin is a CYP3A4 inhibitor and alfentanil is a CYP3A4 substrate.
Alfuzosin: (Moderate) Concomitant use of ciprofloxacin and alfuzosin may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Aliskiren: (Moderate) The plasma concentrations of aliskiren may be elevated when administered concurrently with ciprofloxacin. Clinical monitoring for adverse effects, such as decreased blood pressure, is recommended during coadministration. Ciprofloxacin is a CYP3A4 inhibitor and aliskiren is a CYP3A4 substrate.
Aliskiren; Hydrochlorothiazide, HCTZ: (Moderate) The plasma concentrations of aliskiren may be elevated when administered concurrently with ciprofloxacin. Clinical monitoring for adverse effects, such as decreased blood pressure, is recommended during coadministration. Ciprofloxacin is a CYP3A4 inhibitor and aliskiren is a CYP3A4 substrate.
Alogliptin: (Moderate) Monitor blood glucose during concomitant dipeptidyl peptidase-4 inhibitors and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Alogliptin; Metformin: (Moderate) Monitor blood glucose carefully when systemic quinolones and antidiabetic agents, including metformin, are coadministered. Discontinue the quinolone if a hypoglycemic reaction occurs and initiate appropriate therapy immediately. Disturbances of blood glucose, including hyperglycemia and hypoglycemia, have been reported in patients treated concomitantly with quinolones and an antidiabetic agent. Hypoglycemia, sometimes resulting in coma, can occur. (Moderate) Monitor blood glucose during concomitant dipeptidyl peptidase-4 inhibitors and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Alogliptin; Pioglitazone: (Moderate) Monitor blood glucose during concomitant dipeptidyl peptidase-4 inhibitors and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia. (Moderate) Monitor blood glucose during concomitant thiazolidinedione and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Alosetron: (Major) Avoid coadministration of alosetron and ciprofloxacin due to the potential for increased exposure and half-life of alosetron. Ciprofloxacin is a strong inhibitor of CYP1A2; alosetron is a CYP1A2 substrate. Coadministration of another strong CYP1A2 inhibitor increased the mean alosetron AUC by about 6-fold and prolonged the half-life by 3-fold.
Alpha-glucosidase Inhibitors: (Moderate) Monitor blood glucose carefully when systemic quinolones and antidiabetic agents, including alpha-glucosidase inhibitors, are coadministered. Discontinue the quinolone if a hypoglycemic reaction occurs and initiate appropriate therapy immediately. Disturbances of blood glucose, including hyperglycemia and hypoglycemia, have been reported in patients treated concomitantly with quinolones and an antidiabetic agent. Hypoglycemia, sometimes resulting in coma, can occur.
Alprazolam: (Major) Avoid coadministration of alprazolam and ciprofloxacin due to the potential for elevated alprazolam concentrations, which may cause prolonged sedation and respiratory depression. If coadministration is necessary, consider reducing the dose of alprazolam as clinically appropriate and monitor for an increase in alprazolam-related adverse reactions. Alprazolam is a CYP3A4 substrate and ciprofloxacin may be a CYP3A4 inhibitor but in vivo data are conflicting. Coadministration with other moderate CYP3A4 inhibitors increased alprazolam exposure by 1.6- to 1.98-fold.
Aluminum Hydroxide: (Moderate) Administer oral ciprofloxacin at least 2 hours before or 6 hours after products that contain aluminum hydroxide. Ciprofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Examples of compounds that may interfere with quinolone bioavailability include antacids that contain aluminum hydroxide.
Aluminum Hydroxide; Magnesium Carbonate: (Moderate) Administer oral ciprofloxacin at least 2 hours before or 6 hours after magnesium carbonate. Ciprofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. (Moderate) Administer oral ciprofloxacin at least 2 hours before or 6 hours after products that contain aluminum hydroxide. Ciprofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Examples of compounds that may interfere with quinolone bioavailability include antacids that contain aluminum hydroxide.
Aluminum Hydroxide; Magnesium Hydroxide: (Moderate) Administer oral ciprofloxacin at least 2 hours before or 6 hours after magnesium hydroxide. Ciprofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. (Moderate) Administer oral ciprofloxacin at least 2 hours before or 6 hours after products that contain aluminum hydroxide. Ciprofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Examples of compounds that may interfere with quinolone bioavailability include antacids that contain aluminum hydroxide.
Aluminum Hydroxide; Magnesium Hydroxide; Simethicone: (Moderate) Administer oral ciprofloxacin at least 2 hours before or 6 hours after magnesium hydroxide. Ciprofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. (Moderate) Administer oral ciprofloxacin at least 2 hours before or 6 hours after products that contain aluminum hydroxide. Ciprofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Examples of compounds that may interfere with quinolone bioavailability include antacids that contain aluminum hydroxide.
Aluminum Hydroxide; Magnesium Trisilicate: (Moderate) Administer oral ciprofloxacin at least 2 hours before or 6 hours after products that contain aluminum hydroxide. Ciprofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Examples of compounds that may interfere with quinolone bioavailability include antacids that contain aluminum hydroxide. (Moderate) Administer oral ciprofloxacin at least 2 hours before or 6 hours after products that contain magnesium trisilicate. Ciprofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations.
Amiodarone: (Major) Concomitant use of ciprofloxacin and amiodarone increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary. Due to the extremely long half-life of amiodarone, a drug interaction is possible for days to weeks after drug discontinuation.
Amisulpride: (Major) Concomitant use of ciprofloxacin and amisulpride increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Amlodipine: (Moderate) Monitor for symptoms of hypotension and edema if coadministration of amlodipine with ciprofloxacin is necessary; adjust the dose of amlodipine as clinically appropriate. Amlodipine is a CYP3A substrate and ciprofloxacin is a moderate CYP3A inhibitor. Coadministration with a moderate CYP3A4 inhibitor in elderly hypertensive patients increased systemic exposure to amlodipine by 60%. However, coadministration with another moderate CYP3A4 inhibitor in healthy volunteers did not significantly change amlodipine exposure.
Amlodipine; Atorvastatin: (Moderate) Closely monitor for signs and symptoms of myopathy and rhabdomyolysis and consider atorvastatin dosage adjustment in patients also taking ciprofloxacin. Coadministration of ciprofloxacin, a moderate CYP3A4 inhibitor, with atorvastatin, a CYP3A4 substrate, may increase atorvastatin exposure resulting in atorvastatin-related toxicity; the risk may be increased with higher statin doses. (Moderate) Monitor for symptoms of hypotension and edema if coadministration of amlodipine with ciprofloxacin is necessary; adjust the dose of amlodipine as clinically appropriate. Amlodipine is a CYP3A substrate and ciprofloxacin is a moderate CYP3A inhibitor. Coadministration with a moderate CYP3A4 inhibitor in elderly hypertensive patients increased systemic exposure to amlodipine by 60%. However, coadministration with another moderate CYP3A4 inhibitor in healthy volunteers did not significantly change amlodipine exposure.
Amlodipine; Benazepril: (Moderate) Monitor for symptoms of hypotension and edema if coadministration of amlodipine with ciprofloxacin is necessary; adjust the dose of amlodipine as clinically appropriate. Amlodipine is a CYP3A substrate and ciprofloxacin is a moderate CYP3A inhibitor. Coadministration with a moderate CYP3A4 inhibitor in elderly hypertensive patients increased systemic exposure to amlodipine by 60%. However, coadministration with another moderate CYP3A4 inhibitor in healthy volunteers did not significantly change amlodipine exposure.
Amlodipine; Celecoxib: (Moderate) Monitor for symptoms of hypotension and edema if coadministration of amlodipine with ciprofloxacin is necessary; adjust the dose of amlodipine as clinically appropriate. Amlodipine is a CYP3A substrate and ciprofloxacin is a moderate CYP3A inhibitor. Coadministration with a moderate CYP3A4 inhibitor in elderly hypertensive patients increased systemic exposure to amlodipine by 60%. However, coadministration with another moderate CYP3A4 inhibitor in healthy volunteers did not significantly change amlodipine exposure. (Moderate) Use quinolones and nonsteroidal anti-inflammatory drugs (NSAIDs) concomitantly with caution due to potential increased risk of CNS stimulation and convulsive seizures. NSAIDs in combination with very high doses of quinolones have been shown to provoke convulsions in preclinical studies and postmarketing.
Amlodipine; Olmesartan: (Moderate) Monitor for symptoms of hypotension and edema if coadministration of amlodipine with ciprofloxacin is necessary; adjust the dose of amlodipine as clinically appropriate. Amlodipine is a CYP3A substrate and ciprofloxacin is a moderate CYP3A inhibitor. Coadministration with a moderate CYP3A4 inhibitor in elderly hypertensive patients increased systemic exposure to amlodipine by 60%. However, coadministration with another moderate CYP3A4 inhibitor in healthy volunteers did not significantly change amlodipine exposure.
Amlodipine; Valsartan: (Moderate) Monitor for symptoms of hypotension and edema if coadministration of amlodipine with ciprofloxacin is necessary; adjust the dose of amlodipine as clinically appropriate. Amlodipine is a CYP3A substrate and ciprofloxacin is a moderate CYP3A inhibitor. Coadministration with a moderate CYP3A4 inhibitor in elderly hypertensive patients increased systemic exposure to amlodipine by 60%. However, coadministration with another moderate CYP3A4 inhibitor in healthy volunteers did not significantly change amlodipine exposure.
Amlodipine; Valsartan; Hydrochlorothiazide, HCTZ: (Moderate) Monitor for symptoms of hypotension and edema if coadministration of amlodipine with ciprofloxacin is necessary; adjust the dose of amlodipine as clinically appropriate. Amlodipine is a CYP3A substrate and ciprofloxacin is a moderate CYP3A inhibitor. Coadministration with a moderate CYP3A4 inhibitor in elderly hypertensive patients increased systemic exposure to amlodipine by 60%. However, coadministration with another moderate CYP3A4 inhibitor in healthy volunteers did not significantly change amlodipine exposure.
Amoxicillin; Clarithromycin; Omeprazole: (Major) Concomitant use of clarithromycin and ciprofloxacin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary. (Minor) Concomitant use of ciprofloxacin and omeprazole may decrease the AUC and Cmax of ciprofloxacin, but the clinical significance of this interaction is unknown. Codministration of a single tablet dose of 500 mg ciprofloxacin and once-daily administration of 20 mg omeprazole pretreatment for 4 days resulted in a 16% reduction of mean Cmax and mean AUC of ciprofloxacin. A single 1000 mg oral dose of Cipro XR administered with omeprazole (40 mg once daily for 3 days) to 18 healthy volunteers resulted in a decrease in the ciprofloxacin mean AUC by 20% and Cmax by 23%. However, coadministration of a single 1000 mg oral dose of Proquin XR given 2 hours after the third dose of omeprazole (40 mg once daily for 3 days) to 27 healthy volunteers resulted in no changes in the ciprofloxacin AUC and Cmax. If ciprofloxacin is administered with omeprazole with magnesium, chelation of the ciprofloxacin would be expected; in general, it is recommended that ciprofloxacin be administered 2 hours before or 6 hours after any divalent cations like magnesium to help limit an interaction.
Anagrelide: (Major) Torsades de pointes (TdP) and ventricular tachycardia have been reported with anagrelide. In addition, dose-related increases in mean QTc and heart rate were observed in healthy subjects. A cardiovascular examination, including an ECG, should be obtained in all patients prior to initiating anagrelide therapy. Monitor patients during anagrelide therapy for cardiovascular effects and evaluate as necessary. Ciprofloxacin is associated with a possible risk for QT prolongation and TdP and should be used cautiously and with close monitoring with anagrelide. In addition, anagrelide is partially metabolized by CYP1A2. Coadministration of anagrelide with drugs that inhibit CYP1A2, such as ciprofloxacin, could theoretically decrease the elimination of anagrelide and increase the risk of side effects or toxicity. Patients should be monitored for increased adverse effects if anagrelide is coadministered with ciprofloxacin.
Apomorphine: (Moderate) Concomitant use of ciprofloxacin and apomorphine may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Aprepitant, Fosaprepitant: (Major) Avoid the concomitant use due to substantially increased exposure of aprepitant with ciprofloxacin use. If coadministration cannot be avoided, use caution and monitor for an increase in aprepitant-related adverse effects for several days after administration of a multi-day aprepitant regimen. Ciprofloxacin is a moderate CYP3A4 inhibitor and aprepitant is a CYP3A4 substrate. Coadministration of daily oral aprepitant (230 mg, or 1.8 times the recommended single dose) with another moderate CYP3A4 inhibitor increased the aprepitant AUC 2-fold; clinically meaningful changes in ECG, heart rate, or blood pressure did not occur. After administration, fosaprepitant is rapidly converted to aprepitant and shares many of the same drug interactions.
Aripiprazole: (Moderate) Patients receiving both a CYP2D6 inhibitor plus ciprofloxacin may require an aripiprazole dosage adjustment. Dosing recommendations vary based on aripiprazole dosage form, CYP2D6 inhibitor strength, and CYP2D6 metabolizer status. See prescribing information for details. Additionally, concomitant use may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP. Aripiprazole is a CYP3A and CYP2D6 substrate; ciprofloxacin is a moderate CYP3A inhibitor. Both medications have been associated with QT prolongation.
Arsenic Trioxide: (Major) Concomitant use of ciprofloxacin and arsenic trioxide increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Artemether; Lumefantrine: (Major) Concomitant use of ciprofloxacin and artemether increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary. (Major) Concomitant use of ciprofloxacin and lumefantrine increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Asenapine: (Major) Asenapine has been associated with QT prolongation. According to the manufacturer, asenapine should not be used with other agents also known to have this effect. Ciprofloxacin is associated with a possible risk for QT prolongation and torsade de pointes; therefore, caution is advised during combination therapy. In addition, in vitro studies indicate that CYP1A2 is a primary metabolic pathway of asenapine. In theory, inhibitors of this isoenzyme such as ciprofloxacin may decrease the elimination of asenapine.
Aspirin, ASA; Butalbital; Caffeine: (Moderate) Reduction or limitation of the caffeine dosage in medications and limitation of caffeine in beverages and food may be necessary during concurrent ciprofloxacin therapy. Ciprofloxacin can decrease the clearance of caffeine. Caffeine toxicity may occur and can manifest as nausea, vomiting, anxiety, tachycardia, or seizures. Ciprofloxacin is a CYP1A2 inhibitor and caffeine is a CYP1A2 substrate.
Aspirin, ASA; Caffeine: (Moderate) Reduction or limitation of the caffeine dosage in medications and limitation of caffeine in beverages and food may be necessary during concurrent ciprofloxacin therapy. Ciprofloxacin can decrease the clearance of caffeine. Caffeine toxicity may occur and can manifest as nausea, vomiting, anxiety, tachycardia, or seizures. Ciprofloxacin is a CYP1A2 inhibitor and caffeine is a CYP1A2 substrate.
Aspirin, ASA; Caffeine; Orphenadrine: (Moderate) Reduction or limitation of the caffeine dosage in medications and limitation of caffeine in beverages and food may be necessary during concurrent ciprofloxacin therapy. Ciprofloxacin can decrease the clearance of caffeine. Caffeine toxicity may occur and can manifest as nausea, vomiting, anxiety, tachycardia, or seizures. Ciprofloxacin is a CYP1A2 inhibitor and caffeine is a CYP1A2 substrate.
Aspirin, ASA; Carisoprodol; Codeine: (Moderate) Concomitant use of codeine with ciprofloxacin may increase codeine plasma concentrations, resulting in greater metabolism by CYP2D6 and, increased morphine concentrations, and prolonged opioid adverse reactions, including hypotension, respiratory depression, profound sedation, coma, and death. It is recommended to avoid this combination when codeine is being used for cough. If coadministration is necessary, monitor patients closely at frequent intervals and consider a dosage reduction of codeine until stable drug effects are achieved. Discontinuation of ciprofloxacin could decrease codeine plasma concentrations, decrease opioid efficacy, and potentially lead to a withdrawal syndrome in those with physical dependence to codeine. If ciprofloxacin is discontinued, monitor the patient carefully and consider increasing the opioid dosage if appropriate. Codeine is primarily metabolized by CYP2D6 to morphine, and by CYP3A4 to norcodeine; norcodeine does not have analgesic properties. Ciprofloxacin is a moderate inhibitor of CYP3A4.
Aspirin, ASA; Citric Acid; Sodium Bicarbonate: (Moderate) Crystalluria related to ciprofloxacin has been reported only rarely in humans because human urine is usually acidic. Avoid alkalinity of the urine in patients receiving ciprofloxacin when possible. A large proportion of ciprofloxacin is normally excreted unchanged in the urine. If sodium bicarbonate is used concomitantly, the solubility of ciprofloxacin might be decreased because of alkaline urine. Patients should be monitored for crystalluria, proper urination,and altered kidney function. Hydrate patients well to prevent the formation of highly concentrated urine.
Aspirin, ASA; Omeprazole: (Minor) Concomitant use of ciprofloxacin and omeprazole may decrease the AUC and Cmax of ciprofloxacin, but the clinical significance of this interaction is unknown. Codministration of a single tablet dose of 500 mg ciprofloxacin and once-daily administration of 20 mg omeprazole pretreatment for 4 days resulted in a 16% reduction of mean Cmax and mean AUC of ciprofloxacin. A single 1000 mg oral dose of Cipro XR administered with omeprazole (40 mg once daily for 3 days) to 18 healthy volunteers resulted in a decrease in the ciprofloxacin mean AUC by 20% and Cmax by 23%. However, coadministration of a single 1000 mg oral dose of Proquin XR given 2 hours after the third dose of omeprazole (40 mg once daily for 3 days) to 27 healthy volunteers resulted in no changes in the ciprofloxacin AUC and Cmax. If ciprofloxacin is administered with omeprazole with magnesium, chelation of the ciprofloxacin would be expected; in general, it is recommended that ciprofloxacin be administered 2 hours before or 6 hours after any divalent cations like magnesium to help limit an interaction.
Aspirin, ASA; Oxycodone: (Moderate) Consider a reduced dose of oxycodone with frequent monitoring for respiratory depression and sedation if concurrent use of ciprofloxacin is necessary. If ciprofloxacin is discontinued, consider increasing the oxycodone dose until stable drug effects are achieved and monitor for evidence of opioid withdrawal. Oxycodone is a CYP3A4 substrate, and coadministration with a moderate inhibitor like ciprofloxacin can increase oxycodone exposure resulting in increased or prolonged opioid effects including fatal respiratory depression, particularly when an inhibitor is added to a stable dose of oxycodone. If ciprofloxacin is discontinued, oxycodone plasma concentrations will decrease resulting in reduced efficacy of the opioid and potential withdrawal syndrome in a patient who has developed physical dependence to oxycodone.
Atomoxetine: (Moderate) Concomitant use of atomoxetine and ciprofloxacin may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Atorvastatin: (Moderate) Closely monitor for signs and symptoms of myopathy and rhabdomyolysis and consider atorvastatin dosage adjustment in patients also taking ciprofloxacin. Coadministration of ciprofloxacin, a moderate CYP3A4 inhibitor, with atorvastatin, a CYP3A4 substrate, may increase atorvastatin exposure resulting in atorvastatin-related toxicity; the risk may be increased with higher statin doses.
Atorvastatin; Ezetimibe: (Moderate) Closely monitor for signs and symptoms of myopathy and rhabdomyolysis and consider atorvastatin dosage adjustment in patients also taking ciprofloxacin. Coadministration of ciprofloxacin, a moderate CYP3A4 inhibitor, with atorvastatin, a CYP3A4 substrate, may increase atorvastatin exposure resulting in atorvastatin-related toxicity; the risk may be increased with higher statin doses.
Avanafil: (Major) Do not exceed an avanafil dose of 50 mg once every 24 hours in patients receiving ciprofloxacin. Coadministration may increase avanafil exposure. Avanafil is a sensitive CYP3A4 substrate and ciprofloxacin is a moderate CYP3A4 inhibitor. Coadministration with another moderate CYP3A4 inhibitor increased the avanafil AUC by 3-fold and prolonged the half-life to approximately 8 hours.
Avapritinib: (Major) Avoid coadministration of avapritinib with ciprofloxacin due to the risk of increased avapritinib-related adverse reactions. If concurrent use is unavoidable, reduce the starting dose of avapritinib from 300 mg PO once daily to 100 mg PO once daily in patients with gastrointestinal stromal tumor or from 200 mg PO once daily to 50 mg PO once daily in patients with advanced systemic mastocytosis. Avapritinib is a CYP3A4 substrate and ciprofloxacin is a moderate CYP3A4 inhibitor. Coadministration of avapritinib 300 mg PO once daily with a moderate CYP3A4 inhibitor is predicted to increase the AUC of avapritinib by 210% at steady-state.
Azithromycin: (Major) Concomitant use of azithromycin and ciprofloxacin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Bacillus Calmette-Guerin Vaccine, BCG: (Major) Ciprofloxacin may interfere with the effectiveness of Bacillus Calmette-Guerin Live, BCG. The TheraCys product is made from the Connaught strain of Bacillus Calmette and Guerin, which is an attenuated strain of Mycobacterium bovis. Sensitivity of the Connaught strain to several antibiotics was tested in vitro. Bacteria were susceptible to ciprofloxacin. Urinary concentrations of these antibiotics could interfere with the therapeutic effectiveness of BCG. Furthermore, the minimum inhibitory concentrations associated with each drug render them potentially useful for the treatment of systemic BCG reactions or infections. Although the TICE BCG product is obtained from a different strain (Tice strain), similar antimicrobial sensitivities may occur. Postpone instillation of BCG if the patient is receiving antibiotics. BCG Live should not be used in patients with an active infection.
Bedaquiline: (Major) Concomitant use of ciprofloxacin and bedaquiline increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Bendamustine: (Major) Consider the use of an alternative therapy if ciprofloxacin treatment is needed in patients receiving bendamustine. Ciprofloxacin may increase bendamustine exposure, which may increase the risk of adverse reactions (e.g., myelosuppression, infection, hepatotoxicity). Bendamustine is a CYP1A2 substrate and ciprofloxacin is a CYP1A2 inhibitor.
Benzhydrocodone; Acetaminophen: (Moderate) Concurrent use of benzhydrocodone with ciprofloxacin may increase the risk of increased opioid-related adverse reactions, such as fatal respiratory depression. Consider a dose reduction of benzhydrocodone until stable drug effects are achieved. Monitor patients for respiratory depression and sedation at frequent intervals. Discontinuation of ciprofloxacin in a patient taking benzhydrocodone may decrease hydrocodone plasma concentrations, decrease opioid efficacy, and potentially lead to a withdrawal syndrome in those with physical dependence to opioid agonists. If ciprofloxacin is discontinued, monitor the patient carefully and consider increasing the opioid dosage if appropriate. Benzhydrocodone is a prodrug for hydrocodone. Hydrocodone is a substrate for CYP3A4. Ciprofloxacin is an inhibitor of CYP3A4.
Betamethasone: (Moderate) Quinolones have been associated with an increased risk of tendon rupture requiring surgical repair or resulting in prolonged disability; this risk is further increased in those receiving concomitant corticosteroids. Discontinue quinolone therapy at the first sign of tendon inflammation or tendon pain, as these are symptoms that may precede rupture of the tendon.
Bismuth Subcitrate Potassium; Metronidazole; Tetracycline: (Moderate) Concomitant use of metronidazole and ciprofloxacin may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Bismuth Subsalicylate; Metronidazole; Tetracycline: (Moderate) Concomitant use of metronidazole and ciprofloxacin may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Bortezomib: (Minor) Plasma concentrations of bortezomib may be elevated when administered concurrently with ciprofloxacin. Clinical monitoring for adverse effects, such as gastrointestinal side effects, hypotension, or peripheral neuropathy, is recommended during coadministration. Ciprofloxacin is a CYP3A4 inhibitor, while bortezomib is a CYP3A4 substrate.
Bosentan: (Moderate) Coadministration of bosentan, a CYP3A4 substrate, with ciprofloxacin, a CYP3A4 inhibitor, may increase the plasma concentrations of bosentan. No dosage adjustment of bosentan is needed, however, the potential for increased bosentan effects, such as hepatic injury or decreased blood pressure, should be monitored.
Bosutinib: (Major) Avoid concomitant use of bosutinib and ciprofloxacin; bosutinib plasma exposure may be significantly increased resulting in an increased risk of bosutinib adverse events (e.g., myelosuppression, GI toxicity). Bosutinib is a CYP3A4 substrate and ciprofloxacin is a moderate CYP3A4 inhibitor. In a cross-over trial in 18 healthy volunteers, the Cmax and AUC values of bosutinib were increased 1.5-fold and 2-fold, respectively, when bosutinib 500 mg PO was administered with a single dose of a moderate CYP3A4 inhibitor.
Brentuximab vedotin: (Moderate) Clinical monitoring for adverse effects, such as peripheral neuropathy or gastrointestinal side effects, is recommended during coadministration of brentuximab vedotin and ciprofloxacin. Plasma concentrations of monomethyl auristatin E (MMAE), one of the 3 components released from brentuximab vedotin, may be elevated when administered concurrently with ciprofloxacin. Ciprofloxacin is a CYP3A4 inhibitor, while MMAE is a CYP3A4 substrate.
Brexpiprazole: (Moderate) Because brexpiprazole is primarily metabolized by CYP3A4 and CYP2D6, the manufacturer recommends that the brexpiprazole dose be reduced to one-quarter (25%) of the usual dose in patients receiving a moderate to strong inhibitor of CYP3A4 in combination with a moderate to strong inhibitor of CYP2D6. Ciprofloxacin is a moderate inhibitor of CYP3A4. If ciprofloxacin is used in combination with brexpiprazole and a moderate to strong CYP2D6 inhibitor, the brexpiprazole dose should be adjusted and the patient should be carefully monitored for brexpiprazole-related adverse reactions. A reduction of the brexpiprazole dose to 25% of the usual dose is also recommended in patients who are poor metabolizers of CYP2D6 and are receiving a moderate CYP3A4 inhibitor.
Brigatinib: (Major) Avoid coadministration of brigatinib with ciprofloxacin if possible due to increased plasma exposure of brigatinib; an increase in brigatinib-related adverse reactions may occur. If concomitant use is unavoidable, reduce the dose of brigatinib by approximately 40% without breaking tablets (i.e., from 180 mg to 120 mg; from 120 mg to 90 mg; from 90 mg to 60 mg); after discontinuation of ciprofloxacin, resume the brigatinib dose that was tolerated prior to initiation of ciprofloxacin. Brigatinib is a CYP3A4 substrate; ciprofloxacin is a moderate CYP3A4 inhibitor. Coadministration with a moderate CYP3A4 inhibitor is predicted to increase the AUC of brigatinib by approximately 40%.
Bromocriptine: (Major) When bromocriptine is used for diabetes, do not exceed a dose of 1.6 mg once daily during concomitant use of ciprofloxacin. Use this combination with caution in patients receiving bromocriptine for other indications. Concurrent use may increase bromocriptine concentrations. Bromocriptine is extensively metabolized in the liver via CYP3A4; ciprofloxacin is a moderate inhibitor of CYP3A4. Administration of bromocriptine with a moderate inhibitor of CYP3A4 increased the bromocriptine mean AUC and Cmax by 3.7-fold and 4.6-fold, respectively.
Budesonide: (Moderate) Avoid coadministration of oral budesonide with ciprofloxacin due to increased budesonide exposure; use caution with inhaled budesonide, as systemic exposure may increase. Budesonide is a CYP3A substrate and ciprofloxacin is a moderate CYP3A inhibitor. Also, quinolones have been associated with an increased risk of tendon rupture requiring surgical repair or resulting in prolonged disability; this risk is further increased in those receiving concomitant corticosteroids. Discontinue quinolone therapy at the first sign of tendon inflammation or tendon pain, as these are symptoms that may precede rupture of the tendon.
Budesonide; Formoterol: (Moderate) Avoid coadministration of oral budesonide with ciprofloxacin due to increased budesonide exposure; use caution with inhaled budesonide, as systemic exposure may increase. Budesonide is a CYP3A substrate and ciprofloxacin is a moderate CYP3A inhibitor. Also, quinolones have been associated with an increased risk of tendon rupture requiring surgical repair or resulting in prolonged disability; this risk is further increased in those receiving concomitant corticosteroids. Discontinue quinolone therapy at the first sign of tendon inflammation or tendon pain, as these are symptoms that may precede rupture of the tendon.
Budesonide; Glycopyrrolate; Formoterol: (Moderate) Avoid coadministration of oral budesonide with ciprofloxacin due to increased budesonide exposure; use caution with inhaled budesonide, as systemic exposure may increase. Budesonide is a CYP3A substrate and ciprofloxacin is a moderate CYP3A inhibitor. Also, quinolones have been associated with an increased risk of tendon rupture requiring surgical repair or resulting in prolonged disability; this risk is further increased in those receiving concomitant corticosteroids. Discontinue quinolone therapy at the first sign of tendon inflammation or tendon pain, as these are symptoms that may precede rupture of the tendon.
Bupivacaine Liposomal: (Moderate) Clinical monitoring for adverse effects, such as cardiotoxic effects, hypotension, or CNS toxicity, is recommended during coadministration as plasma concentrations of bupivacaine may be elevated when administered concurrently with ciprofloxacin. Ciprofloxacin is a CYP3A4 inhibitor, while bupivacaine is a CYP3A4 substrate.
Bupivacaine: (Moderate) Clinical monitoring for adverse effects, such as cardiotoxic effects, hypotension, or CNS toxicity, is recommended during coadministration as plasma concentrations of bupivacaine may be elevated when administered concurrently with ciprofloxacin. Ciprofloxacin is a CYP3A4 inhibitor, while bupivacaine is a CYP3A4 substrate.
Bupivacaine; Epinephrine: (Moderate) Clinical monitoring for adverse effects, such as cardiotoxic effects, hypotension, or CNS toxicity, is recommended during coadministration as plasma concentrations of bupivacaine may be elevated when administered concurrently with ciprofloxacin. Ciprofloxacin is a CYP3A4 inhibitor, while bupivacaine is a CYP3A4 substrate.
Bupivacaine; Lidocaine: (Moderate) Clinical monitoring for adverse effects, such as cardiotoxic effects, hypotension, or CNS toxicity, is recommended during coadministration as plasma concentrations of bupivacaine may be elevated when administered concurrently with ciprofloxacin. Ciprofloxacin is a CYP3A4 inhibitor, while bupivacaine is a CYP3A4 substrate. (Moderate) Concomitant use of systemic lidocaine and ciprofloxacin may increase lidocaine plasma concentrations by decreasing lidocaine clearance and therefore prolonging the elimination half-life. Monitor for lidocaine toxicity if used together. Lidocaine is a CYP3A4 and CYP1A2 substrate; ciprofloxacin inhibits both of these isoenzymes. In a study of healthy volunteers (n = 9), concomitant use of lidocaine (1.5mg/kg IV) and ciprofloxacin (500 mg twice daily) resulted in an increase of lidocaine Cmax and AUC by 12% and 26%, respectively.
Bupivacaine; Meloxicam: (Moderate) Clinical monitoring for adverse effects, such as cardiotoxic effects, hypotension, or CNS toxicity, is recommended during coadministration as plasma concentrations of bupivacaine may be elevated when administered concurrently with ciprofloxacin. Ciprofloxacin is a CYP3A4 inhibitor, while bupivacaine is a CYP3A4 substrate. (Moderate) Use quinolones and nonsteroidal anti-inflammatory drugs (NSAIDs) concomitantly with caution due to potential increased risk of CNS stimulation and convulsive seizures. NSAIDs in combination with very high doses of quinolones have been shown to provoke convulsions in preclinical studies and postmarketing.
Buprenorphine: (Major) Concomitant use of buprenorphine and ciprofloxacin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Concomitant use can also increase the plasma concentration of buprenorphine, resulting in increased or prolonged opioid effects, particularly when ciprofloxacin is added after a stable buprenorphine dose is achieved. Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary. Additionally, consider dosage reduction of buprenorphine until stable drug effects are achieved. Monitor patient for respiratory depression and sedation at frequent intervals. When stopping ciprofloxacin, the buprenorphine concentration may decrease, potentially resulting in decreased opioid efficacy or a withdrawal syndrome in patients who had developed physical dependency. If ciprofloxacin is discontinued, consider increasing buprenorphine dosage until stable drug effects are achieved. Monitor for signs of opioid withdrawal. Buprenorphine is a CYP3A4 substrate and ciprofloxacin is a CYP3A4 inhibitor.
Buprenorphine; Naloxone: (Major) Concomitant use of buprenorphine and ciprofloxacin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Concomitant use can also increase the plasma concentration of buprenorphine, resulting in increased or prolonged opioid effects, particularly when ciprofloxacin is added after a stable buprenorphine dose is achieved. Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary. Additionally, consider dosage reduction of buprenorphine until stable drug effects are achieved. Monitor patient for respiratory depression and sedation at frequent intervals. When stopping ciprofloxacin, the buprenorphine concentration may decrease, potentially resulting in decreased opioid efficacy or a withdrawal syndrome in patients who had developed physical dependency. If ciprofloxacin is discontinued, consider increasing buprenorphine dosage until stable drug effects are achieved. Monitor for signs of opioid withdrawal. Buprenorphine is a CYP3A4 substrate and ciprofloxacin is a CYP3A4 inhibitor.
Buspirone: (Moderate) Monitor for an increase in buspirone-related adverse reactions if coadministration with ciprofloxacin is necessary; the effect may be more pronounced if the patient has been titrated to a stable dose of buspirone and ciprofloxacin is added or removed from therapy. Buspirone is a sensitive CYP3A substrate and ciprofloxacin is a moderate CYP3A inhibitor. Coadministration with other moderate CYP3A inhibitors increased buspirone exposure by 3.4 to 6-fold and was accompanied by increased buspirone-related adverse reactions.
Butalbital; Acetaminophen; Caffeine: (Moderate) Reduction or limitation of the caffeine dosage in medications and limitation of caffeine in beverages and food may be necessary during concurrent ciprofloxacin therapy. Ciprofloxacin can decrease the clearance of caffeine. Caffeine toxicity may occur and can manifest as nausea, vomiting, anxiety, tachycardia, or seizures. Ciprofloxacin is a CYP1A2 inhibitor and caffeine is a CYP1A2 substrate.
Butalbital; Acetaminophen; Caffeine; Codeine: (Moderate) Concomitant use of codeine with ciprofloxacin may increase codeine plasma concentrations, resulting in greater metabolism by CYP2D6 and, increased morphine concentrations, and prolonged opioid adverse reactions, including hypotension, respiratory depression, profound sedation, coma, and death. It is recommended to avoid this combination when codeine is being used for cough. If coadministration is necessary, monitor patients closely at frequent intervals and consider a dosage reduction of codeine until stable drug effects are achieved. Discontinuation of ciprofloxacin could decrease codeine plasma concentrations, decrease opioid efficacy, and potentially lead to a withdrawal syndrome in those with physical dependence to codeine. If ciprofloxacin is discontinued, monitor the patient carefully and consider increasing the opioid dosage if appropriate. Codeine is primarily metabolized by CYP2D6 to morphine, and by CYP3A4 to norcodeine; norcodeine does not have analgesic properties. Ciprofloxacin is a moderate inhibitor of CYP3A4. (Moderate) Reduction or limitation of the caffeine dosage in medications and limitation of caffeine in beverages and food may be necessary during concurrent ciprofloxacin therapy. Ciprofloxacin can decrease the clearance of caffeine. Caffeine toxicity may occur and can manifest as nausea, vomiting, anxiety, tachycardia, or seizures. Ciprofloxacin is a CYP1A2 inhibitor and caffeine is a CYP1A2 substrate.
Butalbital; Aspirin; Caffeine; Codeine: (Moderate) Concomitant use of codeine with ciprofloxacin may increase codeine plasma concentrations, resulting in greater metabolism by CYP2D6 and, increased morphine concentrations, and prolonged opioid adverse reactions, including hypotension, respiratory depression, profound sedation, coma, and death. It is recommended to avoid this combination when codeine is being used for cough. If coadministration is necessary, monitor patients closely at frequent intervals and consider a dosage reduction of codeine until stable drug effects are achieved. Discontinuation of ciprofloxacin could decrease codeine plasma concentrations, decrease opioid efficacy, and potentially lead to a withdrawal syndrome in those with physical dependence to codeine. If ciprofloxacin is discontinued, monitor the patient carefully and consider increasing the opioid dosage if appropriate. Codeine is primarily metabolized by CYP2D6 to morphine, and by CYP3A4 to norcodeine; norcodeine does not have analgesic properties. Ciprofloxacin is a moderate inhibitor of CYP3A4. (Moderate) Reduction or limitation of the caffeine dosage in medications and limitation of caffeine in beverages and food may be necessary during concurrent ciprofloxacin therapy. Ciprofloxacin can decrease the clearance of caffeine. Caffeine toxicity may occur and can manifest as nausea, vomiting, anxiety, tachycardia, or seizures. Ciprofloxacin is a CYP1A2 inhibitor and caffeine is a CYP1A2 substrate.
Cabotegravir; Rilpivirine: (Moderate) Concomitant use of ciprofloxacin and rilpivirine may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP. The degree of QT prolongation associated with rilpivirine is not clinically significant when administered within the recommended dosage range; QT prolongation has been described at 3 times the maximum recommended dose.
Caffeine: (Moderate) Reduction or limitation of the caffeine dosage in medications and limitation of caffeine in beverages and food may be necessary during concurrent ciprofloxacin therapy. Ciprofloxacin can decrease the clearance of caffeine. Caffeine toxicity may occur and can manifest as nausea, vomiting, anxiety, tachycardia, or seizures. Ciprofloxacin is a CYP1A2 inhibitor and caffeine is a CYP1A2 substrate.
Caffeine; Sodium Benzoate: (Moderate) Reduction or limitation of the caffeine dosage in medications and limitation of caffeine in beverages and food may be necessary during concurrent ciprofloxacin therapy. Ciprofloxacin can decrease the clearance of caffeine. Caffeine toxicity may occur and can manifest as nausea, vomiting, anxiety, tachycardia, or seizures. Ciprofloxacin is a CYP1A2 inhibitor and caffeine is a CYP1A2 substrate.
Calcium Acetate: (Moderate) Administer oral ciprofloxacin at least 2 hours before or 6 hours after oral products that contain calcium. Ciprofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Examples of compounds that may interfere with quinolone bioavailability include antacids and multivitamins that contain calcium.
Calcium Carbonate: (Moderate) Administer oral ciprofloxacin at least 2 hours before or 6 hours after oral products that contain calcium. Ciprofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Examples of compounds that may interfere with quinolone bioavailability include antacids and multivitamins that contain calcium.
Calcium Carbonate; Famotidine; Magnesium Hydroxide: (Moderate) Administer oral ciprofloxacin at least 2 hours before or 6 hours after oral products that contain calcium. Ciprofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Examples of compounds that may interfere with quinolone bioavailability include antacids and multivitamins that contain calcium.
Calcium Carbonate; Magnesium Hydroxide: (Moderate) Administer oral ciprofloxacin at least 2 hours before or 6 hours after oral products that contain calcium. Ciprofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Examples of compounds that may interfere with quinolone bioavailability include antacids and multivitamins that contain calcium.
Calcium Carbonate; Magnesium Hydroxide; Simethicone: (Moderate) Administer oral ciprofloxacin at least 2 hours before or 6 hours after oral products that contain calcium. Ciprofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Examples of compounds that may interfere with quinolone bioavailability include antacids and multivitamins that contain calcium.
Calcium Carbonate; Simethicone: (Moderate) Administer oral ciprofloxacin at least 2 hours before or 6 hours after oral products that contain calcium. Ciprofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Examples of compounds that may interfere with quinolone bioavailability include antacids and multivitamins that contain calcium.
Calcium Chloride: (Moderate) Administer oral ciprofloxacin at least 2 hours before or 6 hours after oral products that contain calcium. Ciprofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Examples of compounds that may interfere with quinolone bioavailability include antacids and multivitamins that contain calcium.
Calcium Gluconate: (Moderate) Administer oral ciprofloxacin at least 2 hours before or 6 hours after oral products that contain calcium. Ciprofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Examples of compounds that may interfere with quinolone bioavailability include antacids and multivitamins that contain calcium.
Calcium: (Moderate) Administer oral ciprofloxacin at least 2 hours before or 6 hours after oral products that contain calcium. Ciprofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Examples of compounds that may interfere with quinolone bioavailability include antacids and multivitamins that contain calcium.
Calcium; Vitamin D: (Moderate) Administer oral ciprofloxacin at least 2 hours before or 6 hours after oral products that contain calcium. Ciprofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Examples of compounds that may interfere with quinolone bioavailability include antacids and multivitamins that contain calcium.
Canagliflozin: (Moderate) Monitor blood glucose during concomitant SGLT2 inhibitor and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Canagliflozin; Metformin: (Moderate) Monitor blood glucose carefully when systemic quinolones and antidiabetic agents, including metformin, are coadministered. Discontinue the quinolone if a hypoglycemic reaction occurs and initiate appropriate therapy immediately. Disturbances of blood glucose, including hyperglycemia and hypoglycemia, have been reported in patients treated concomitantly with quinolones and an antidiabetic agent. Hypoglycemia, sometimes resulting in coma, can occur. (Moderate) Monitor blood glucose during concomitant SGLT2 inhibitor and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Carbamazepine: (Moderate) Monitor carbamazepine concentrations closely during coadministration of ciprofloxacin; carbamazepine dose adjustments may be needed. Concomitant use may increase carbamazepine concentrations. Carbamazepine is a CYP3A4 substrate and ciprofloxacin is a CYP3A4 inhibitor.
Carbonic anhydrase inhibitors: (Minor) A large proportion of ciprofloxacin is normally excreted unchanged in the urine. If urinary alkalinizing agents such as carbonic anhydrase inhibitors are used concomitantly, the solubility of ciprofloxacin can be decreased because of alkaline urine. Patients should be monitored for crystalluria and nephrotoxicity.
Cariprazine: (Moderate) Monitor for adverse effects, such as CNS effects and extrapyramid
Celecoxib: (Moderate) Use quinolones and nonsteroidal anti-inflammatory drugs (NSAIDs) concomitantly with caution due to potential increased risk of CNS stimulation and convulsive seizures. NSAIDs in combination with very high doses of quinolones have been shown to provoke convulsions in preclinical studies and postmarketing.
Celecoxib; Tramadol: (Moderate) Use quinolones and nonsteroidal anti-inflammatory drugs (NSAIDs) concomitantly with caution due to potential increased risk of CNS stimulation and convulsive seizures. NSAIDs in combination with very high doses of quinolones have been shown to provoke convulsions in preclinical studies and postmarketing.
Ceritinib: (Major) Concomitant use of ciprofloxacin and ceritinib increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Chlordiazepoxide: (Major) Ciprofloxacin is a CYP3A4 inhibitor and may reduce the metabolism of chlordiazepoxide and increase the potential for benzodiazepine toxicity.
Chlordiazepoxide; Amitriptyline: (Major) Ciprofloxacin is a CYP3A4 inhibitor and may reduce the metabolism of chlordiazepoxide and increase the potential for benzodiazepine toxicity.
Chlordiazepoxide; Clidinium: (Major) Ciprofloxacin is a CYP3A4 inhibitor and may reduce the metabolism of chlordiazepoxide and increase the potential for benzodiazepine toxicity.
Chloroquine: (Major) Concomitant use of ciprofloxacin and chloroquine increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Chlorpheniramine; Codeine: (Moderate) Concomitant use of codeine with ciprofloxacin may increase codeine plasma concentrations, resulting in greater metabolism by CYP2D6 and, increased morphine concentrations, and prolonged opioid adverse reactions, including hypotension, respiratory depression, profound sedation, coma, and death. It is recommended to avoid this combination when codeine is being used for cough. If coadministration is necessary, monitor patients closely at frequent intervals and consider a dosage reduction of codeine until stable drug effects are achieved. Discontinuation of ciprofloxacin could decrease codeine plasma concentrations, decrease opioid efficacy, and potentially lead to a withdrawal syndrome in those with physical dependence to codeine. If ciprofloxacin is discontinued, monitor the patient carefully and consider increasing the opioid dosage if appropriate. Codeine is primarily metabolized by CYP2D6 to morphine, and by CYP3A4 to norcodeine; norcodeine does not have analgesic properties. Ciprofloxacin is a moderate inhibitor of CYP3A4.
Chlorpheniramine; Dihydrocodeine; Phenylephrine: (Moderate) Concomitant use of dihydrocodeine with ciprofloxacin may increase dihydrocodeine plasma concentrations, resulting in greater metabolism by CYP2D6, increased dihydromorphine concentrations, and prolonged opioid adverse reactions, including hypotension, respiratory depression, profound sedation, coma, and death. If coadministration is necessary, monitor patients closely at frequent intervals and consider a dosage reduction of dihydrocodeine until stable drug effects are achieved. Discontinuation of ciprofloxacin could decrease dihydrocodeine plasma concentrations, decrease opioid efficacy, and potentially lead to a withdrawal syndrome in those with physical dependence to dihydrocodeine. If ciprofloxacin is discontinued, monitor the patient carefully and consider increasing the opioid dosage if appropriate. Ciprofloxacin is a moderate inhibitor of CYP3A4, an isoenzyme partially responsible for the metabolism of dihydrocodeine.
Chlorpheniramine; Hydrocodone: (Moderate) Consider a reduced dose of hydrocodone with frequent monitoring for respiratory depression and sedation if concurrent use of ciprofloxacin is necessary. It is recommended to avoid this combination when hydrocodone is being used for cough. Hydrocodone is a CYP3A4 substrate, and coadministration with CYP3A4 inhibitors like ciprofloxacin can increase hydrocodone exposure resulting in increased or prolonged opioid effects including fatal respiratory depression, particularly when an inhibitor is added to a stable dose of hydrocodone. These effects could be more pronounced in patients also receiving a CYP2D6 inhibitor. If ciprofloxacin is discontinued, hydrocodone plasma concentrations will decrease resulting in reduced efficacy of the opioid and potential withdrawal syndrome in a patient who has developed physical dependence to hydrocodone.
Chlorpheniramine; Ibuprofen; Pseudoephedrine: (Moderate) Use quinolones and nonsteroidal anti-inflammatory drugs (NSAIDs) concomitantly with caution due to potential increased risk of CNS stimulation and convulsive seizures. NSAIDs in combination with very high doses of quinolones have been shown to provoke convulsions in preclinical studies and postmarketing.
Chlorpheniramine; Pseudoephedrine: (Major) Administer oral ciprofloxacin at least 2 hours before or 6 hours after oral products that contain zinc. Ciprofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Examples of compounds that may interfere with quinolone bioavailability include multivitamins that contain zinc.
Chlorpromazine: (Major) Concomitant use of ciprofloxacin and chlorpromazine increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Chlorpropamide: (Moderate) Monitor blood glucose during concomitant sulfonylurea and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Cholera Vaccine: (Major) Avoid the live cholera vaccine in patients that have received ciprofloxacin within 14 days prior to vaccination. Concurrent administration of the live cholera vaccine with antibiotics active against cholera, such as ciprofloxacin, may diminish vaccine efficacy and result in suboptimal immune response. A duration of fewer than 14 days between stopping antibiotics and vaccination might also be acceptable in some clinical settings if travel cannot be avoided before 14 days have elapsed after stopping antibiotics.
Choline Salicylate; Magnesium Salicylate: (Moderate) Administer oral ciprofloxacin at least 2 hours before or 6 hours after magnesium salicylate. Ciprofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations.
Chromium: (Moderate) Administer oral ciprofloxacin at least 2 hours before or 6 hours after oral products that contain calcium. Ciprofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Examples of compounds that may interfere with quinolone bioavailability include antacids and multivitamins that contain calcium.
Cilostazol: (Major) Reduce cilostazol dose to 50 mg PO twice daily when administered with ciprofloxacin. Coadministration of moderate CYP3A4 inhibitors, such as ciprofloxacin, can increase exposure to cilostazol, a CYP3A4 substrate.
Cisapride: (Contraindicated) Avoid concomitant use of cisapride and ciprofloxacin due to an increased risk for torsade de pointes (TdP) and QT/QTc prolongation.
Citalopram: (Major) Concomitant use of citalopram and ciprofloxacin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Clarithromycin: (Major) Concomitant use of clarithromycin and ciprofloxacin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Clindamycin; Tretinoin: (Major) Avoid the concomitant use of tretinoin with other drugs known to cause photosensitivity, such as ciprofloxacin. Concomitant use with other photosensitizing agents may increase the risk of a photosensitivity reaction.
Clofazimine: (Moderate) Concomitant use of clofazimine and ciprofloxacin may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Clonazepam: (Moderate) Monitor for increased sedation and respiratory depression if clonazepam is coadministered with ciprofloxacin; adjust the dose of clonazepam if necessary. The systemic exposure of clonazepam may be increased resulting in an increase in treatment-related adverse reactions. Clonazepam is a CYP3A substrate and clonazepam is a moderate CYP3A inhibitor.
Clorazepate: (Moderate) Ciprofloxacin is a CYP3A4 inhibitor and may reduce the metabolism of clorazepate and increase the potential for benzodiazepine toxicity. Clorazepate is a pro-drug converted to N-desmethyldiazepam in the GI tract; N-desmethyldiazepam is metabolized by CYP3A4.
Clozapine: (Major) If co-administration of clozapine and a potent inhibitor of CYP1A2 such as ciprofloxacin is necessary, the manufacturer of clozapine recommends using one-third of the usual clozapine dose. If the inhibitor is discontinued, increase the clozapine dose based on clinical response. One study of 7 schizophrenic patients has shown that concurrent therapy with ciprofloxacin (250 mg twice daily) versus placebo resulted in increased clozapine plasma concentrations (29%) and N-desmethylclozapine plasma concentrations (31%). One case study has reported elevated clozapine plasma concentrations (by 80%) during ciprofloxacin coadministration at doses of 500 mg twice daily. In addition, rare cases of QT prolongation and torsade de pointes (TdP) have been reported with both ciprofloxacin and clozapine. Elevated plasma concentrations of clozapine occurring through inhibition of CYP1A2, CYP3A4, or CYP2D6 may potentially increase the risk of life-threatening arrhythmias, sedation, anticholinergic effects, seizures, orthostasis, or other adverse effects. If quinolone administration is indicated during clozapine therapy, an alternative fluoroquinolone with minimal inhibitory effects on CYP1A2, CYP2D6, or CYP3A4 should be considered.
Cobimetinib: (Major) Avoid the concurrent use of cobimetinib with chronic ciprofloxacin therapy due to the risk of cobimetinib toxicity. If concurrent short-term (14 days or less) use of ciprofloxacin is unavoidable, reduce the dose of cobimetinib to 20 mg once daily for patients normally taking 60 mg daily; after discontinuation of ciprofloxacin, resume cobimetinib at the previous dose. Use an alternative to ciprofloxacin in patients who are already taking a reduced dose of cobimetinib (40 or 20 mg daily). Cobimetinib is a CYP3A substrate in vitro, and ciprofloxacin is a moderate inhibitor of CYP3A. In healthy subjects (n = 15), coadministration of a single 10 mg dose of cobimetinib with a strong CYP3A4 inhibitor increased the mean cobimetinib AUC by 6.7-fold (90% CI, 5.6 to 8) and the mean Cmax by 3.2-fold (90% CI, 2.7 to 3.7).
Codeine: (Moderate) Concomitant use of codeine with ciprofloxacin may increase codeine plasma concentrations, resulting in greater metabolism by CYP2D6 and, increased morphine concentrations, and prolonged opioid adverse reactions, including hypotension, respiratory depression, profound sedation, coma, and death. It is recommended to avoid this combination when codeine is being used for cough. If coadministration is necessary, monitor patients closely at frequent intervals and consider a dosage reduction of codeine until stable drug effects are achieved. Discontinuation of ciprofloxacin could decrease codeine plasma concentrations, decrease opioid efficacy, and potentially lead to a withdrawal syndrome in those with physical dependence to codeine. If ciprofloxacin is discontinued, monitor the patient carefully and consider increasing the opioid dosage if appropriate. Codeine is primarily metabolized by CYP2D6 to morphine, and by CYP3A4 to norcodeine; norcodeine does not have analgesic properties. Ciprofloxacin is a moderate inhibitor of CYP3A4.
Codeine; Guaifenesin: (Moderate) Concomitant use of codeine with ciprofloxacin may increase codeine plasma concentrations, resulting in greater metabolism by CYP2D6 and, increased morphine concentrations, and prolonged opioid adverse reactions, including hypotension, respiratory depression, profound sedation, coma, and death. It is recommended to avoid this combination when codeine is being used for cough. If coadministration is necessary, monitor patients closely at frequent intervals and consider a dosage reduction of codeine until stable drug effects are achieved. Discontinuation of ciprofloxacin could decrease codeine plasma concentrations, decrease opioid efficacy, and potentially lead to a withdrawal syndrome in those with physical dependence to codeine. If ciprofloxacin is discontinued, monitor the patient carefully and consider increasing the opioid dosage if appropriate. Codeine is primarily metabolized by CYP2D6 to morphine, and by CYP3A4 to norcodeine; norcodeine does not have analgesic properties. Ciprofloxacin is a moderate inhibitor of CYP3A4.
Codeine; Guaifenesin; Pseudoephedrine: (Moderate) Concomitant use of codeine with ciprofloxacin may increase codeine plasma concentrations, resulting in greater metabolism by CYP2D6 and, increased morphine concentrations, and prolonged opioid adverse reactions, including hypotension, respiratory depression, profound sedation, coma, and death. It is recommended to avoid this combination when codeine is being used for cough. If coadministration is necessary, monitor patients closely at frequent intervals and consider a dosage reduction of codeine until stable drug effects are achieved. Discontinuation of ciprofloxacin could decrease codeine plasma concentrations, decrease opioid efficacy, and potentially lead to a withdrawal syndrome in those with physical dependence to codeine. If ciprofloxacin is discontinued, monitor the patient carefully and consider increasing the opioid dosage if appropriate. Codeine is primarily metabolized by CYP2D6 to morphine, and by CYP3A4 to norcodeine; norcodeine does not have analgesic properties. Ciprofloxacin is a moderate inhibitor of CYP3A4.
Codeine; Phenylephrine; Promethazine: (Moderate) Concomitant use of ciprofloxacin and promethazine may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP. (Moderate) Concomitant use of codeine with ciprofloxacin may increase codeine plasma concentrations, resulting in greater metabolism by CYP2D6 and, increased morphine concentrations, and prolonged opioid adverse reactions, including hypotension, respiratory depression, profound sedation, coma, and death. It is recommended to avoid this combination when codeine is being used for cough. If coadministration is necessary, monitor patients closely at frequent intervals and consider a dosage reduction of codeine until stable drug effects are achieved. Discontinuation of ciprofloxacin could decrease codeine plasma concentrations, decrease opioid efficacy, and potentially lead to a withdrawal syndrome in those with physical dependence to codeine. If ciprofloxacin is discontinued, monitor the patient carefully and consider increasing the opioid dosage if appropriate. Codeine is primarily metabolized by CYP2D6 to morphine, and by CYP3A4 to norcodeine; norcodeine does not have analgesic properties. Ciprofloxacin is a moderate inhibitor of CYP3A4.
Codeine; Promethazine: (Moderate) Concomitant use of ciprofloxacin and promethazine may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP. (Moderate) Concomitant use of codeine with ciprofloxacin may increase codeine plasma concentrations, resulting in greater metabolism by CYP2D6 and, increased morphine concentrations, and prolonged opioid adverse reactions, including hypotension, respiratory depression, profound sedation, coma, and death. It is recommended to avoid this combination when codeine is being used for cough. If coadministration is necessary, monitor patients closely at frequent intervals and consider a dosage reduction of codeine until stable drug effects are achieved. Discontinuation of ciprofloxacin could decrease codeine plasma concentrations, decrease opioid efficacy, and potentially lead to a withdrawal syndrome in those with physical dependence to codeine. If ciprofloxacin is discontinued, monitor the patient carefully and consider increasing the opioid dosage if appropriate. Codeine is primarily metabolized by CYP2D6 to morphine, and by CYP3A4 to norcodeine; norcodeine does not have analgesic properties. Ciprofloxacin is a moderate inhibitor of CYP3A4.
Colchicine: (Major) Due to the risk for serious colchicine toxicity including multi-organ failure and death, avoid coadministration of colchicine and ciprofloxacin in patients with normal renal and hepatic function unless the use of both agents is imperative. Coadministration is contraindicated in patients with renal or hepatic impairment because colchicine accumulation may be greater in these populations. Ciprofloxacin can inhibit colchicine's metabolism via CYP3A4, resulting in increased colchicine exposure. If coadministration in patients with normal renal and hepatic function cannot be avoided, adjust the dose of colchicine by either reducing the daily dose or the dosage frequency, and carefully monitor for colchicine toxicity. Specific dosage adjustment recommendations are available for the Colcrys product for patients who have taken a moderate CYP3A4 inhibitor like ciprofloxacin in the past 14 days or require concurrent use: for prophylaxis of gout flares, if the original dose is 0.6 mg twice daily, decrease to 0.3 mg twice daily or 0.6 mg once daily or if the original dose is 0.6 mg once daily, decrease the dose to 0.3 mg once daily; for treatment of gout flares, give 1.2 mg as a single dose and do not repeat for at least 3 days; for familial Mediterranean fever, do not exceed 1.2 mg/day.
Cortisone: (Moderate) Quinolones have been associated with an increased risk of tendon rupture requiring surgical repair or resulting in prolonged disability; this risk is further increased in those receiving concomitant corticosteroids. Discontinue quinolone therapy at the first sign of tendon inflammation or tendon pain, as these are symptoms that may precede rupture of the tendon.
Crizotinib: (Major) Avoid coadministration of crizotinib with ciprofloxacin due to the risk of QT prolongation; crizotinib exposure may also increase. If concomitant use is unavoidable, monitor ECGs for QT prolongation and monitor electrolytes. An interruption of therapy, dose reduction, or discontinuation of therapy may be necessary for crizotinib patients if QT prolongation occurs. Also monitor for an increase in crizotinib-related adverse reactions. Crizotinib is a CYP3A substrate that has been associated with concentration-dependent QT prolongation. Ciprofloxacin is a moderate CYP3A4 inhibitor that has had rare cases of QT prolongation and torsade de pointes (TdP) reported during postmarketing surveillance.
Cyclosporine: (Moderate) Monitor renal function during concomitant therapy. Cyclosporine serum concentrations should be monitored and suitable dosage adjustments made. Coadministration of ciprofloxacin and cyclosporine may result in elevated plasma cyclosporine concentrations. Cyclosporine is extensively metabolized by CYP3A4; ciprofloxacin is an inhibitor of CYP3A4. Additionally, some quinolones, including ciprofloxacin, have been associated with transient elevations in serum creatinine in patients receiving concomitant cyclosporine and ciprofloxacin therapy and may potentiate renal dysfunction. Cases of nephrotoxicity with and without increases in cyclosporine concentrations during concurrent cyclosporine and ciprofloxacin treatment have been reported.
Daclatasvir: (Moderate) According to the manufacturer, concurrent administration of daclatasvir, a CYP3A4 substrate, with ciprofloxacin, a moderate CYP3A4 inhibitor, may increase daclatasvir serum concentrations. If these drugs are administered together, monitor patients for daclatasvir-related adverse effects, such as headache, fatigue, nausea, and diarrhea. The manufacturer does not recommend daclatasvir dose reduction for adverse reactions.
Dapagliflozin: (Moderate) Monitor blood glucose during concomitant SGLT2 inhibitor and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Dapagliflozin; Metformin: (Moderate) Monitor blood glucose carefully when systemic quinolones and antidiabetic agents, including metformin, are coadministered. Discontinue the quinolone if a hypoglycemic reaction occurs and initiate appropriate therapy immediately. Disturbances of blood glucose, including hyperglycemia and hypoglycemia, have been reported in patients treated concomitantly with quinolones and an antidiabetic agent. Hypoglycemia, sometimes resulting in coma, can occur. (Moderate) Monitor blood glucose during concomitant SGLT2 inhibitor and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Dapagliflozin; Saxagliptin: (Moderate) Monitor blood glucose during concomitant dipeptidyl peptidase-4 inhibitors and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia. (Moderate) Monitor blood glucose during concomitant SGLT2 inhibitor and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Dapsone: (Moderate) Clinical monitoring for adverse effects, such as hemolytic anemia, methemoglobinemia, or peripheral neuropathy, is recommended during coadministration of dapsone and ciprofloxacin. Plasma concentrations of dapsone may be elevated when administered concurrently with ciprofloxacin. Ciprofloxacin is a CYP3A4 inhibitor, while dapsone is a CYP3A4 substrate.
Daridorexant: (Major) Limit the daridorexant dose to 25 mg if coadministered with ciprofloxacin. Concomitant use may increase daridorexant exposure and the risk for daridorexant-related adverse effects. Daridorexant is a CYP3A substrate and ciprofloxacin is a moderate CYP3A inhibitor. Concomitant use of another moderate CYP3A inhibitor increased daridorexant overall exposure 2.4-fold.
Darifenacin: (Moderate) Clinical monitoring for adverse effects, such as anticholinergic effects, is recommended during coadministration of darifenacin and ciprofloxacin. The plasma concentrations of darifenacin may be elevated when administered concurrently with ciprofloxacin. Ciprofloxacin is a CYP3A4 inhibitor, while darifenacin is a CYP3A4 substrate.
Darunavir: (Moderate) Caution is warranted when darunavir is administered with ciprofloxacin as there is a potential for elevated concentrations of darunavir. Clinical monitoring for adverse effects is recommended during coadministration. Ciprofloxacin is a CYP3A4 inhibitor, while darunavir is a CYP3A4 substrate.
Darunavir; Cobicistat: (Moderate) Caution is warranted when darunavir is administered with ciprofloxacin as there is a potential for elevated concentrations of darunavir. Clinical monitoring for adverse effects is recommended during coadministration. Ciprofloxacin is a CYP3A4 inhibitor, while darunavir is a CYP3A4 substrate.
Darunavir; Cobicistat; Emtricitabine; Tenofovir alafenamide: (Moderate) Caution is warranted when darunavir is administered with ciprofloxacin as there is a potential for elevated concentrations of darunavir. Clinical monitoring for adverse effects is recommended during coadministration. Ciprofloxacin is a CYP3A4 inhibitor, while darunavir is a CYP3A4 substrate.
Dasatinib: (Moderate) Concomitant use of ciprofloxacin and dasatinib may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Deflazacort: (Major) Decrease deflazacort dose to one-third of the recommended dosage when coadministered with ciprofloxacin. Concurrent use may significantly increase concentrations of 21-desDFZ, the active metabolite of deflazacort. Deflazacort is a CYP3A4 substrate; ciprofloxacin is a moderate inhibitor of CYP3A4. Also, quinolones have been associated with an increased risk of tendon rupture requiring surgical repair or resulting in prolonged disability; this risk is further increased in those receiving concomitant corticosteroids. Discontinue quinolone therapy at the first sign of tendon inflammation or tendon pain, as these are symptoms that may precede rupture of the tendon.
Degarelix: (Moderate) Concomitant use of ciprofloxacin and androgen deprivation therapy (i.e., degarelix) may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Delavirdine: (Moderate) The plasma concentrations of delavirdine may be elevated when administered concurrently with ciprofloxacin. Clinical monitoring for adverse effects is recommended during coadministration. Delavirdine is a CYP3A4 substrate and ciprofloxacin is an inhibitor of CYP3A4.
Desflurane: (Major) Concomitant use of ciprofloxacin and halogenated anesthetics increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Deutetrabenazine: (Moderate) Use ciprofloxacin with caution in patients receiving other drugs that prolong the QT interval. Rare cases of QT prolongation and torsade de pointes (TdP) have been reported with ciprofloxacin during postmarketing surveillance. Deutetrabenazine may prolong the QT interval, but the degree of QT prolongation is not clinically significant when deutetrabenazine is administered within the recommended dosage range.
Dexamethasone: (Moderate) Quinolones have been associated with an increased risk of tendon rupture requiring surgical repair or resulting in prolonged disability; this risk is further increased in those receiving concomitant corticosteroids. Discontinue quinolone therapy at the first sign of tendon inflammation or tendon pain, as these are symptoms that may precede rupture of the tendon.
Dexmedetomidine: (Moderate) Concomitant use of dexmedetomidine and ciprofloxacin may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Dextromethorphan; Quinidine: (Major) Concomitant use of quinidine and ciprofloxacin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Diazepam: (Moderate) Monitor for an increase in diazepam-related adverse reactions, including sedation and respiratory depression, if coadministration with ciprofloxacin is necessary. Concurrent use may increase diazepam exposure. Diazepam is a CYP3A substrate and ciprofloxacin is a CYP3A inhibitor.
Diclofenac: (Moderate) Use quinolones and nonsteroidal anti-inflammatory drugs (NSAIDs) concomitantly with caution due to potential increased risk of CNS stimulation and convulsive seizures. NSAIDs in combination with very high doses of quinolones have been shown to provoke convulsions in preclinical studies and postmarketing.
Diclofenac; Misoprostol: (Moderate) Use quinolones and nonsteroidal anti-inflammatory drugs (NSAIDs) concomitantly with caution due to potential increased risk of CNS stimulation and convulsive seizures. NSAIDs in combination with very high doses of quinolones have been shown to provoke convulsions in preclinical studies and postmarketing.
Didanosine, ddI: (Major) Administer oral ciprofloxacin at least 2 hours before or 6 hours after didanosine tablets or powder for oral solution. Ciprofloxacin absorption may be reduced as it can chelate with the buffering agents contained in didanosine tablets and powder. The delayed-release didanosine capsules do not contain a buffering agent and would not be expected to interact with ciprofloxacin.
Diflunisal: (Moderate) Use quinolones and nonsteroidal anti-inflammatory drugs (NSAIDs) concomitantly with caution due to potential increased risk of CNS stimulation and convulsive seizures. NSAIDs in combination with very high doses of quinolones have been shown to provoke convulsions in preclinical studies and postmarketing.
Diltiazem: (Moderate) Monitor blood pressure and heart rate if coadministration of diltiazem with ciprofloxacin is necessary. Concurrent use may result in elevated diltiazem concentrations. Diltiazem is a CYP3A substrate and ciprofloxacin is a moderate CYP3A inhibitor.
Dipeptidyl Peptidase-4 Inhibitors: (Moderate) Monitor blood glucose during concomitant dipeptidyl peptidase-4 inhibitors and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Diphenhydramine; Ibuprofen: (Moderate) Use quinolones and nonsteroidal anti-inflammatory drugs (NSAIDs) concomitantly with caution due to potential increased risk of CNS stimulation and convulsive seizures. NSAIDs in combination with very high doses of quinolones have been shown to provoke convulsions in preclinical studies and postmarketing.
Diphenhydramine; Naproxen: (Moderate) Use quinolones and nonsteroidal anti-inflammatory drugs (NSAIDs) concomitantly with caution due to potential increased risk of CNS stimulation and convulsive seizures. NSAIDs in combination with very high doses of quinolones have been shown to provoke convulsions in preclinical studies and postmarketing.
Disopyramide: (Major) Concomitant use of disopyramide and ciprofloxacin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Disulfiram: (Moderate) The plasma concentrations of disulfiram may be elevated when administered concurrently with ciprofloxacin. Clinical monitoring for adverse effects is recommended during coadministration. Ciprofloxacin is a CYP3A4 inhibitor, while disulfiram is a CYP3A4 substrate.
Docetaxel: (Moderate) The plasma concentrations of docetaxel may be elevated when administered concurrently with ciprofloxacin. Clinical monitoring for adverse effects, such as myelosuppression and neurologic toxicity, is recommended during coadministration. Ciprofloxacin is a CYP3A4 inhibitor, while docetaxel is a CYP3A4 substrate.
Dofetilide: (Major) Concomitant use of dofetilide and ciprofloxacin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Dolasetron: (Moderate) Concomitant use of ciprofloxacin and dolasetron may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Dolutegravir; Rilpivirine: (Moderate) Concomitant use of ciprofloxacin and rilpivirine may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP. The degree of QT prolongation associated with rilpivirine is not clinically significant when administered within the recommended dosage range; QT prolongation has been described at 3 times the maximum recommended dose.
Donepezil: (Moderate) Concomitant use of ciprofloxacin and donepezil may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Donepezil; Memantine: (Moderate) Concomitant use of ciprofloxacin and donepezil may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Doxorubicin Liposomal: (Major) Avoid coadministration of ciprofloxacin with doxorubicin due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Ciprofloxacin is a moderate CYP3A4 inhibitor, and doxorubicin is a major substrate of CYP3A4. Concurrent use of CYP3A4 inhibitors with doxorubicin has resulted in clinically significant interactions.
Doxorubicin: (Major) Avoid coadministration of ciprofloxacin with doxorubicin due to increased systemic exposure of doxorubicin resulting in increased treatment-related adverse reactions. Ciprofloxacin is a moderate CYP3A4 inhibitor, and doxorubicin is a major substrate of CYP3A4. Concurrent use of CYP3A4 inhibitors with doxorubicin has resulted in clinically significant interactions.
Dronabinol: (Moderate) Use caution if coadministration of dronabinol with ciprofloxacin is necessary, and closely monitor for an increase in dronabinol-related adverse reactions (e.g., feeling high, dizziness, confusion, somnolence). Dronabinol is a CYP3A4 substrate; ciprofloxacin is a moderate inhibitor of CYP3A4. Concomitant use may result in elevated plasma concentrations of dronabinol.
Dronedarone: (Contraindicated) Avoid concomitant use of dronedarone and ciprofloxacin due to an increased risk for torsade de pointes (TdP) and QT/QTc prolongation.
Droperidol: (Major) Concomitant use of ciprofloxacin and droperidol increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Dulaglutide: (Moderate) Monitor blood glucose during concomitant incretin mimetic and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Duloxetine: (Major) Coadministration of duloxetine and potent inhibitors of CYP1A2, such as ciprofloxacin, should be avoided. Duloxetine is partially metabolized by CYP1A2. One study involving a potent CYP1A2 inhibitor in concomitant use with duloxetine showed that duloxetine exposure was significantly increased.
Duvelisib: (Moderate) Monitor for increased toxicity of duvelisib if coadministered with ciprofloxacin. Coadministration may increase the exposure of duvelisib. Duvelisib is a CYP3A substrate; ciprofloxacin is a moderate CYP3A inhibitor.
Efavirenz: (Moderate) Concomitant use of ciprofloxacin and efavirenz may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Efavirenz; Emtricitabine; Tenofovir Disoproxil Fumarate: (Moderate) Concomitant use of ciprofloxacin and efavirenz may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Efavirenz; Lamivudine; Tenofovir Disoproxil Fumarate: (Moderate) Concomitant use of ciprofloxacin and efavirenz may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Elacestrant: (Major) Avoid concomitant use of elacestrant and ciprofloxacin due to the risk of increased elacestrant exposure which may increase the risk for adverse effects. Elacestrant is a CYP3A substrate and ciprofloxacin is a moderate CYP3A inhibitor. Concomitant use with another moderate CYP3A inhibitor increased elacestrant overall exposure by 2.3-fold.
Elbasvir; Grazoprevir: (Moderate) Administering elbasvir; grazoprevir with ciprofloxacin may cause the plasma concentrations of elbasvir and grazoprevir to increase; thereby increasing the potential for adverse effects (i.e., elevated ALT concentrations and hepatotoxicity). Ciprofloxacin is a moderate inhibitor of CYP3A; both elbasvir and grazoprevir are metabolized by CYP3A. If these drugs are used together, closely monitor for signs of hepatotoxicity.
Eletriptan: (Moderate) Monitor for increased eletriptan-related adverse effects if coadministered with ciprofloxacin. Systemic concentrations of eletriptan may be increased. Eletriptan is a substrate for CYP3A4, and ciprofloxacin is a moderate CYP3A4 inhibitor. Coadministration of other moderate CYP3A4 inhibitors increased the eletriptan AUC by 2 to 4-fold.
Elexacaftor; tezacaftor; ivacaftor: (Major) If ciprofloxacin and ivacaftor are taken together, administer ivacaftor at the usual recommended dose but reduce the frequency to once daily. Coadministration is not recommended in patients younger than 6 months. Ivacaftor is a CYP3A substrate and ciprofloxacin is a moderate CYP3A inhibitor. Coadministration with another moderate CYP3A inhibitor increased ivacaftor exposure by 3-fold. (Moderate) Monitor patients closely for tezacaftor; ivacaftor-related adverse reactions if coadministration with ciprofloxacin is necessary. Pharmacokinetic data suggest that no dose adjustment is necessary if tezacaftor; ivacaftor is coadministered with ciprofloxacin. However, because ciprofloxacin is a moderate CYP3A inhibitor, there is a potential for increased tezacaftor; ivacaftor exposure and adverse reactions with concurrent use of ciprofloxacin. Of note, FDA-approved labeling generally recommends tezacaftor; ivacaftor dosage adjustment when coadministered with a moderate CYP3A inhibitor (1 tezacaftor; ivacaftor combination tablet every other day in the morning and 1 ivacaftor tablet every other day in the morning on alternate days).
Eliglustat: (Major) Coadministration of eliglustat and ciprofloxacin is contraindicated in intermediate or poor CYP2D6 metabolizers (IMs or PMs). In extensive CYP2D6 metabolizers (EMs), coadministration of these agents requires dosage reduction of eliglustat to 84 mg PO once daily. The coadministration of eliglustat with ciprofloxacin and a moderate or strong CYP2D6 inhibitor is contraindicated in all patients. Eliglustat is a CYP3A and CYP2D6 substrate. Coadministration of eliglustat with moderate CYP3A inhibitors, such as ciprofloxacin, increases eliglustat exposure and the risk of serious adverse events (e.g., QT prolongation and cardiac arrhythmias); this risk is the highest in CYP2D6 IMs and PMs because a larger portion of the eliglustat dose is metabolized via CYP3A. Both eliglustat and ciprofloxacin can independently prolong the QT interval, and coadministration increases this risk.
Eltrombopag: (Moderate) Eltrombopag is metabolized by CYP1A2. The significance of administering inhibitors of CYP1A2, such as ciprofloxacin, on the systemic exposure of eltrombopag has not been established. Monitor patients for signs of eltrombopag toxicity if these drugs are coadministered.
Empagliflozin: (Moderate) Monitor blood glucose during concomitant SGLT2 inhibitor and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Empagliflozin; Linagliptin: (Moderate) Monitor blood glucose during concomitant dipeptidyl peptidase-4 inhibitors and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia. (Moderate) Monitor blood glucose during concomitant SGLT2 inhibitor and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Empagliflozin; Linagliptin; Metformin: (Moderate) Monitor blood glucose carefully when systemic quinolones and antidiabetic agents, including metformin, are coadministered. Discontinue the quinolone if a hypoglycemic reaction occurs and initiate appropriate therapy immediately. Disturbances of blood glucose, including hyperglycemia and hypoglycemia, have been reported in patients treated concomitantly with quinolones and an antidiabetic agent. Hypoglycemia, sometimes resulting in coma, can occur. (Moderate) Monitor blood glucose during concomitant dipeptidyl peptidase-4 inhibitors and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia. (Moderate) Monitor blood glucose during concomitant SGLT2 inhibitor and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Empagliflozin; Metformin: (Moderate) Monitor blood glucose carefully when systemic quinolones and antidiabetic agents, including metformin, are coadministered. Discontinue the quinolone if a hypoglycemic reaction occurs and initiate appropriate therapy immediately. Disturbances of blood glucose, including hyperglycemia and hypoglycemia, have been reported in patients treated concomitantly with quinolones and an antidiabetic agent. Hypoglycemia, sometimes resulting in coma, can occur. (Moderate) Monitor blood glucose during concomitant SGLT2 inhibitor and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Emtricitabine; Rilpivirine; Tenofovir alafenamide: (Moderate) Concomitant use of ciprofloxacin and rilpivirine may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP. The degree of QT prolongation associated with rilpivirine is not clinically significant when administered within the recommended dosage range; QT prolongation has been described at 3 times the maximum recommended dose.
Emtricitabine; Rilpivirine; Tenofovir Disoproxil Fumarate: (Moderate) Concomitant use of ciprofloxacin and rilpivirine may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP. The degree of QT prolongation associated with rilpivirine is not clinically significant when administered within the recommended dosage range; QT prolongation has been described at 3 times the maximum recommended dose.
Encorafenib: (Major) Avoid coadministration of encorafenib and ciprofloxacin due to increased encorafenib exposure and QT prolongation. If concurrent use cannot be avoided, reduce the encorafenib dose to one-half of the dose used prior to the addition of ciprofloxacin. Monitor ECGs for QT prolongation and monitor electrolytes; correct hypokalemia and hypomagnesemia prior to treatment. If ciprofloxacin is discontinued, the original encorafenib dose may be resumed after 3 to 5 elimination half-lives of ciprofloxacin. Encorafenib is a CYP3A4 substrate that has been associated with dose-dependent QT prolongation; ciprofloxacin is a moderate CYP3A4 inhibitor that has been associated with rare cases of QT prolongation and torsade de pointes (TdP) during postmarketing surveillance. Coadministration of a moderate CYP3A4 inhibitor with a single 50 mg dose of encorafenib (0.1 times the recommended dose) increased the encorafenib AUC and Cmax by 2-fold and 45%, respectively.
Enteral Feedings: (Major) Enteral feedings may decrease the serum concentrations of quinolone antimicrobials. The enteral formulation Ensure significantly decreased the serum concentrations of ciprofloxacin, levofloxacin, and ofloxacin tablets by 83%, 61%, and 46%, respectively, when they were crushed and mixed with 240 ml of Ensure. One study showed that enteral feedings given concurrently with ciprofloxacin via the oral or jejunostomy routes decreased the mean bioavailability of ciprofloxacin by 27 to 67%; however, ciprofloxacin serum concentrations after coadministration with enteral feedings via a gastrostomy tube were similar to concentrations following administration of ciprofloxacin on an empty stomach. Administration of ciprofloxacin and enteral feedings together through a nasogastric (NG) tube decreased the gastrointestinal absorption of ciprofloxacin minimally; MIC values remained high for many pathogenic bacteria. Ciprofloxacin should be taken either 2 hours before or 6 hours after enteral feedings.
Entrectinib: (Major) Avoid coadministration of entrectinib with ciprofloxacin due to additive risk of QT prolongation and increased entrectinib exposure resulting in increased treatment-related adverse effects. If coadministration cannot be avoided in adults and pediatric patients 12 years and older with BSA greater than 1.5 m2, reduce the entrectinib dose to 200 mg PO once daily. If ciprofloxacin is discontinued, resume the original entrectinib dose after 3 to 5 elimination half-lives of ciprofloxacin. Entrectinib is a CYP3A4 substrate that has been associated with QT prolongation; ciprofloxacin is a moderate CYP3A4 inhibitor that has been associated with rare cases of QT prolongation and torsade de pointes (TdP) during postmarketing surveillance. Coadministration of a moderate CYP3A4 inhibitor is predicted to increase the AUC of entrectinib by 3-fold.
Eplerenone: (Major) Do not exceed an eplerenone dose of 25 mg PO once daily if given concurrently with a CYP3A4 inhibitor in a post-myocardial infarction patient with heart failure. In patients with hypertension receiving a concurrent CYP3A4 inhibitor, initiate eplerenone at 25 mg PO once daily; the dose may be increased to a maximum of 25 mg PO twice daily for inadequate blood pressure response. In addition, measure serum creatinine and serum potassium within 3 to 7 days of initiating a CYP3A4 inhibitor and periodically thereafter. Eplerenone is a CYP3A4 substrate. Ciprofloxacin is a CYP3A4 inhibitor. Coadministration with moderate CYP3A4 inhibitors increased eplerenone exposure by 100% to 190%. Increased eplerenone concentrations may lead to a risk of developing hyperkalemia and hypotension.
Ergot alkaloids: (Moderate) Monitor for an increase in ergotamine-related adverse effects and adjust the ergot alkaloid dosage as necessary if concomitant use of ciprofloxacin is required. Concomitant use may increase the systemic exposure of ergot alkaloids and increase the risk for adverse reactions such as vasospasm which may lead to cerebral ischemia and ischemia of the extremities. Ergot alkaloids are CYP3A substrates and ciprofloxacin is a moderate CYP3A inhibitor.
Ergotamine; Caffeine: (Moderate) Reduction or limitation of the caffeine dosage in medications and limitation of caffeine in beverages and food may be necessary during concurrent ciprofloxacin therapy. Ciprofloxacin can decrease the clearance of caffeine. Caffeine toxicity may occur and can manifest as nausea, vomiting, anxiety, tachycardia, or seizures. Ciprofloxacin is a CYP1A2 inhibitor and caffeine is a CYP1A2 substrate.
Eribulin: (Major) Concomitant use of eribulin and ciprofloxacin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Erlotinib: (Major) Avoid coadministration of erlotinib with ciprofloxacin if possible due to the increased risk of erlotinib-related adverse reactions. If concomitant use is unavoidable and severe reactions occur, reduce the dose of erlotinib by 50 mg decrements. Erlotinib is primarily metabolized by CYP3A4 and to a lesser extent by CYP1A2. Ciprofloxacin is a CYP3A4 and CYP1A2 inhibitor. Coadministration with ciprofloxacin increased erlotinib exposure by 39% and increased the erlotinib Cmax by 17%.
Ertugliflozin: (Moderate) Monitor blood glucose during concomitant SGLT2 inhibitor and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Ertugliflozin; Metformin: (Moderate) Monitor blood glucose carefully when systemic quinolones and antidiabetic agents, including metformin, are coadministered. Discontinue the quinolone if a hypoglycemic reaction occurs and initiate appropriate therapy immediately. Disturbances of blood glucose, including hyperglycemia and hypoglycemia, have been reported in patients treated concomitantly with quinolones and an antidiabetic agent. Hypoglycemia, sometimes resulting in coma, can occur. (Moderate) Monitor blood glucose during concomitant SGLT2 inhibitor and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Ertugliflozin; Sitagliptin: (Moderate) Monitor blood glucose during concomitant dipeptidyl peptidase-4 inhibitors and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia. (Moderate) Monitor blood glucose during concomitant SGLT2 inhibitor and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Erythromycin: (Major) Concomitant use of ciprofloxacin and erythromycin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Escitalopram: (Moderate) Concomitant use of ciprofloxacin and escitalopram may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Esomeprazole: (Minor) Use caution when administering ciprofloxacin and esomeprazole concurrently. Ciprofloxacin is an inhibitor of CYP3A, and esomeprazole is partially metabolized by CYP3A. Coadministration of ciprofloxacin with CYP3A substrates, such as esomeprazole, can theoretically increase esomeprazole exposure leading to increased or prolonged therapeutic effects and adverse events; however, the clinical impact of this has not yet been determined.
Estazolam: (Moderate) Ciprofloxacin is a CYP3A4 inhibitor and may reduce the metabolism of estazolam and increase the potential for benzodiazepine toxicity.
Ethosuximide: (Moderate) Close clinical monitoring is advised when administering ethosuximide with ciprofloxacin due to an increased potential for ethosuximide-related adverse events. If ethosuximide dose adjustments are made, re-adjust the dose upon completion of ciprofloxacin treatment. Although this interaction has not been studied, predictions about the interaction can be made based on the metabolic pathway of ethosuximide. Ethosuximide is metabolized by the hepatic isoenzyme CYP3A4; ciprofloxacin inhibits this isoenzyme. Coadministration may result in elevated ethosuximide plasma concentrations.
Etodolac: (Moderate) Use quinolones and nonsteroidal anti-inflammatory drugs (NSAIDs) concomitantly with caution due to potential increased risk of CNS stimulation and convulsive seizures. NSAIDs in combination with very high doses of quinolones have been shown to provoke convulsions in preclinical studies and postmarketing.
Etonogestrel: (Minor) Coadministration of etonogestrel and moderate CYP3A4 inhibitors such as ciprofloxacin may increase the serum concentration of etonogestrel.
Etonogestrel; Ethinyl Estradiol: (Minor) Coadministration of etonogestrel and moderate CYP3A4 inhibitors such as ciprofloxacin may increase the serum concentration of etonogestrel.
Everolimus: (Moderate) Monitor everolimus whole blood trough concentrations as appropriate and watch for everolimus-related adverse reactions if coadministration with ciprofloxacin is necessary. The dose of everolimus may need to be reduced. Everolimus is a sensitive CYP3A4 substrate and a P-glycoprotein (P-gp) substrate. Ciprofloxacin is a moderate CYP3A4 inhibitor. Coadministration with moderate CYP3A4/P-gp inhibitors increased the AUC of everolimus by 3.5 to 4.4-fold.
Exenatide: (Moderate) Monitor blood glucose during concomitant incretin mimetic and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Ezetimibe; Simvastatin: (Moderate) Monitor for evidence of myopathy, including rhabdomyolysis, during coadministration of ciprofloxacin and simvastatin. There are case reports of rhabdomyolysis in patients stabilized on a simvastatin regimen after the addition of ciprofloxacin. Ciprofloxacin may increase simvastatin exposure. Simvastatin is a substrate for CYP3A; ciprofloxacin is a moderate CYP3A inhibitor.
Felodipine: (Moderate) Concurrent administration of felodipine with ciprofloxacin may result in elevated felodipine plasma concentrations. This increase in felodipine concentration may lead to increased therapeutic and adverse effects, such as lower blood pressure, dizziness, and headache. Felodipine is metabolized by the hepatic isoenzyme CYP3A4; ciprofloxacin is an inhibitor of this enzyme. If coadministration of these drugs is warranted, do so with caution and careful monitoring.
Fenfluramine: (Major) Do not exceed a maximum dose of fenfluramine 20 mg per day if coadministered with ciprofloxacin; for patients also receiving stiripentol plus clobazam, do not exceed a maximum dose of fenfluramine 17 mg per day. Concomitant use may increase fenfluramine plasma concentrations and the risk of adverse reactions. Fenfluramine is a CYP1A2 substrate and ciprofloxacin is a strong CYP1A2 inhibitor. Coadministration with another strong CYP1A2 inhibitor increased fenfluramine overall exposure by 102% and decreased norfenfluramine overall exposure by 22%.
Fenoprofen: (Moderate) Use quinolones and nonsteroidal anti-inflammatory drugs (NSAIDs) concomitantly with caution due to potential increased risk of CNS stimulation and convulsive seizures. NSAIDs in combination with very high doses of quinolones have been shown to provoke convulsions in preclinical studies and postmarketing.
Fentanyl: (Moderate) Consider a reduced dose of fentanyl with frequent monitoring for respiratory depression and sedation if concurrent use of ciprofloxacin is necessary. If ciprofloxacin is discontinued, consider increasing the fentanyl dose until stable drug effects are achieved and monitor for evidence of opioid withdrawal. Fentanyl is a CYP3A4 substrate, and coadministration with CYP3A4 inhibitors like ciprofloxacin can increase fentanyl exposure resulting in increased or prolonged opioid effects including fatal respiratory depression, particularly when an inhibitor is added to a stable dose of fentanyl. If ciprofloxacin is discontinued, fentanyl plasma concentrations will decrease resulting in reduced efficacy of the opioid and potential withdrawal syndrome in a patient who has developed physical dependence to fentanyl.
Ferric Maltol: (Moderate) Administer oral ciprofloxacin at least 2 hours before or 6 hours after oral products that contain iron. Ciprofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations.
Fezolinetant: (Contraindicated) Concomitant use of fezolinetant and ciprofloxacin is contraindicated due to the risk of increased fezolinetant exposure which may increase the risk of fezolinetant-related adverse effects. Fezolinetant is a CYP1A2 substrate; ciprofloxacin is a strong CYP1A2 inhibitor. Concomitant use with another strong CYP1A2 inhibitor increased fezolinetant overall exposure by 840%.
Finerenone: (Moderate) Monitor serum potassium during initiation or dose adjustment of either finerenone or ciprofloxacin; a finerenone dosage reduction may be necessary. Concomitant use may increase finerenone exposure and the risk of hyperkalemia. Finerenone is a CYP3A substrate and ciprofloxacin is a moderate CYP3A inhibitor. Coadministration with another moderate CYP3A inhibitor increased overall exposure to finerenone by 248%.
Fingolimod: (Moderate) Concomitant use of ciprofloxacin and fingolimod may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Flecainide: (Major) Concomitant use of ciprofloxacin and flecainide increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Flibanserin: (Contraindicated) The concomitant use of flibanserin and moderate CYP3A4 inhibitors, such as ciprofloxacin, is contraindicated. Moderate CYP3A4 inhibitors can increase flibanserin concentrations, which can cause severe hypotension and syncope. If initiating flibanserin following use of a moderate CYP3A4 inhibitor, start flibanserin at least 2 weeks after the last dose of the CYP3A4 inhibitor. If initiating a moderate CYP3A4 inhibitor following flibanserin use, start the moderate CYP3A4 inhibitor a t least 2 days after the last dose of flibanserin.
Fluconazole: (Moderate) Concomitant use of ciprofloxacin and fluconazole may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Fludrocortisone: (Moderate) Quinolones have been associated with an increased risk of tendon rupture requiring surgical repair or resulting in prolonged disability; this risk is further increased in those receiving concomitant corticosteroids. Discontinue quinolone therapy at the first sign of tendon inflammation or tendon pain, as these are symptoms that may precede rupture of the tendon.
Fluocinolone; Hydroquinone; Tretinoin: (Major) Avoid the concomitant use of tretinoin with other drugs known to cause photosensitivity, such as ciprofloxacin. Concomitant use with other photosensitizing agents may increase the risk of a photosensitivity reaction.
Fluoxetine: (Moderate) Concomitant use of ciprofloxacin and fluoxetine may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Fluphenazine: (Minor) QT/QTc prolongation can occur with concomitant use of ciprofloxacin and fluphenazine although the risk of developing torsade de pointes (TdP) is low. Additional steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, may be considered in patients with additional risk factors for TdP.
Flurazepam: (Moderate) Ciprofloxacin is a CYP3A4 inhibitor and may reduce the metabolism of flurazepam and increase the potential for benzodiazepine toxicity.
Flurbiprofen: (Moderate) Use quinolones and nonsteroidal anti-inflammatory drugs (NSAIDs) concomitantly with caution due to potential increased risk of CNS stimulation and convulsive seizures. NSAIDs in combination with very high doses of quinolones have been shown to provoke convulsions in preclinical studies and postmarketing.
Flutamide: (Moderate) Coadministration of ciprofloxacin and flutamide could lead to increases in the serum concentrations of flutamide. Ciprofloxacin has been shown to inhibit CYP1A2 and CYP3A4 and flutamide is a substrate of these enzymes.
Fluvoxamine: (Moderate) Concomitant use of ciprofloxacin and fluvoxamine may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Folic Acid, Vitamin B9: (Moderate) Administer oral ciprofloxacin at least 2 hours before or 6 hours after oral products that contain calcium. Ciprofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Examples of compounds that may interfere with quinolone bioavailability include antacids and multivitamins that contain calcium.
Food: (Major) Do not administer oral ciprofloxacin with dairy products (e.g., milk, yogurt) or calcium-fortified juices alone; however, oral ciprofloxacin may be taken with a meal that contains these products. The absorption of oral ciprofloxacin may be decreased if taken with calcium-containing foods or beverages.
Fosamprenavir: (Moderate) Monitor for increased fosamprenavir toxicity if coadministered with ciprofloxacin. Concurrent use may increase the plasma concentrations of fosamprenavir. Fosamprenavir is a CYP3A substrate and ciprofloxacin is a moderate CYP3A inhibitor.
Foscarnet: (Major) When possible, avoid concurrent use of foscarnet with other drugs known to prolong the QT interval, such as ciprofloxacin. Foscarnet has been associated with postmarketing reports of both QT prolongation and torsade de pointes (TdP). Rare cases of QT prolongation and TdP have also been reported with ciprofloxacin during postmarketing surveillance. If these drugs are administered together, obtain an electrocardiogram and electrolyte concentrations before and periodically during treatment. In addition, use of ciprofloxacin with foscarnet may increase the risk of seizures. Since foscarnet is not metabolized by the liver and since renal dysfunction was not present, it is unlikely that drug accumulation is responsible for seizures. An additive effect is proposed since seizures have been associated with ciprofloxacin and foscarnet independently.
Fosphenytoin: (Moderate) Monitor phenytoin concentration and for phenytoin toxicity during and shortly after concomitant ciprofloxacin and fosphenytoin use. Concurrent use may result in altered phenytoin concentrations (increased or decreased).
Fostemsavir: (Moderate) Concomitant use of ciprofloxacin and fostemsavir may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP. The degree of QT prolongation associated with fostemsavir is not clinically significant when administered within the recommended dosage range; QT prolongation has been described at 4 times the recommended daily dose.
Gemtuzumab Ozogamicin: (Moderate) Concomitant use of ciprofloxacin and gemtuzumab ozogamicin may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Gilteritinib: (Moderate) Concomitant use of ciprofloxacin and gilteritinib may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Glasdegib: (Major) Concomitant use of ciprofloxacin and glasdegib increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Glimepiride: (Moderate) Monitor blood glucose during concomitant sulfonylurea and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Glipizide: (Moderate) Monitor blood glucose during concomitant sulfonylurea and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Glipizide; Metformin: (Moderate) Monitor blood glucose carefully when systemic quinolones and antidiabetic agents, including metformin, are coadministered. Discontinue the quinolone if a hypoglycemic reaction occurs and initiate appropriate therapy immediately. Disturbances of blood glucose, including hyperglycemia and hypoglycemia, have been reported in patients treated concomitantly with quinolones and an antidiabetic agent. Hypoglycemia, sometimes resulting in coma, can occur. (Moderate) Monitor blood glucose during concomitant sulfonylurea and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Glyburide: (Moderate) Monitor blood glucose during concomitant sulfonylurea and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Glyburide; Metformin: (Moderate) Monitor blood glucose carefully when systemic quinolones and antidiabetic agents, including metformin, are coadministered. Discontinue the quinolone if a hypoglycemic reaction occurs and initiate appropriate therapy immediately. Disturbances of blood glucose, including hyperglycemia and hypoglycemia, have been reported in patients treated concomitantly with quinolones and an antidiabetic agent. Hypoglycemia, sometimes resulting in coma, can occur. (Moderate) Monitor blood glucose during concomitant sulfonylurea and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Goserelin: (Moderate) Concomitant use of ciprofloxacin and androgen deprivation therapy (i.e., goserelin) may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Granisetron: (Moderate) Concomitant use of ciprofloxacin and granisetron may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Green Tea: (Moderate) Some, but not all, green tea products contain caffeine. Ciprofloxacin can inhibit the hepatic clearance of caffeine and theobromine which are commonly found in coffee and tea. Caffeine toxicity can result and can manifest as nausea/vomiting, nervousness, anxiety, tachycardia, or seizures.
Guaifenesin; Hydrocodone: (Moderate) Consider a reduced dose of hydrocodone with frequent monitoring for respiratory depression and sedation if concurrent use of ciprofloxacin is necessary. It is recommended to avoid this combination when hydrocodone is being used for cough. Hydrocodone is a CYP3A4 substrate, and coadministration with CYP3A4 inhibitors like ciprofloxacin can increase hydrocodone exposure resulting in increased or prolonged opioid effects including fatal respiratory depression, particularly when an inhibitor is added to a stable dose of hydrocodone. These effects could be more pronounced in patients also receiving a CYP2D6 inhibitor. If ciprofloxacin is discontinued, hydrocodone plasma concentrations will decrease resulting in reduced efficacy of the opioid and potential withdrawal syndrome in a patient who has developed physical dependence to hydrocodone.
Guanfacine: (Major) Ciprofloxacin may significantly increase guanfacine plasma concentrations. FDA-approved labeling for extended-release (ER) guanfacine recommends decreasing the guanfacine dosage to half the recommended dose if these agents are taken together. Specific recommendations for immediate-release (IR) guanfacine are not available. Monitor patients closely for alpha-adrenergic effects including hypotension, drowsiness, lethargy, and bradycardia. Upon ciprofloxacin discontinuation, the guanfacine ER dosage should be increased back to the recommended dose. Guanfacine is primarily metabolized by CYP3A4, and ciprofloxacin is a moderate CYP3A4 inhibitor.
Halobetasol; Tazarotene: (Moderate) Use tazarotene with caution in patients who are also taking drugs known to be photosensitizers, such as ciprofloxacin, as concomitant use may augment phototoxicity. Patients should take care and use proper techniques to limit sunlight and UV exposure of treated areas.
Halogenated Anesthetics: (Major) Concomitant use of ciprofloxacin and halogenated anesthetics increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Haloperidol: (Moderate) Concomitant use of ciprofloxacin and haloperidol may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP. The intravenous route may carry a higher risk for haloperidol-induced QT/QTc prolongation than other routes of administration.
Histrelin: (Moderate) Concomitant use of ciprofloxacin and androgen deprivation therapy (i.e., histrelin) may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Homatropine; Hydrocodone: (Moderate) Consider a reduced dose of hydrocodone with frequent monitoring for respiratory depression and sedation if concurrent use of ciprofloxacin is necessary. It is recommended to avoid this combination when hydrocodone is being used for cough. Hydrocodone is a CYP3A4 substrate, and coadministration with CYP3A4 inhibitors like ciprofloxacin can increase hydrocodone exposure resulting in increased or prolonged opioid effects including fatal respiratory depression, particularly when an inhibitor is added to a stable dose of hydrocodone. These effects could be more pronounced in patients also receiving a CYP2D6 inhibitor. If ciprofloxacin is discontinued, hydrocodone plasma concentrations will decrease resulting in reduced efficacy of the opioid and potential withdrawal syndrome in a patient who has developed physical dependence to hydrocodone.
Hydrocodone: (Moderate) Consider a reduced dose of hydrocodone with frequent monitoring for respiratory depression and sedation if concurrent use of ciprofloxacin is necessary. It is recommended to avoid this combination when hydrocodone is being used for cough. Hydrocodone is a CYP3A4 substrate, and coadministration with CYP3A4 inhibitors like ciprofloxacin can increase hydrocodone exposure resulting in increased or prolonged opioid effects including fatal respiratory depression, particularly when an inhibitor is added to a stable dose of hydrocodone. These effects could be more pronounced in patients also receiving a CYP2D6 inhibitor. If ciprofloxacin is discontinued, hydrocodone plasma concentrations will decrease resulting in reduced efficacy of the opioid and potential withdrawal syndrome in a patient who has developed physical dependence to hydrocodone.
Hydrocodone; Ibuprofen: (Moderate) Consider a reduced dose of hydrocodone with frequent monitoring for respiratory depression and sedation if concurrent use of ciprofloxacin is necessary. It is recommended to avoid this combination when hydrocodone is being used for cough. Hydrocodone is a CYP3A4 substrate, and coadministration with CYP3A4 inhibitors like ciprofloxacin can increase hydrocodone exposure resulting in increased or prolonged opioid effects including fatal respiratory depression, particularly when an inhibitor is added to a stable dose of hydrocodone. These effects could be more pronounced in patients also receiving a CYP2D6 inhibitor. If ciprofloxacin is discontinued, hydrocodone plasma concentrations will decrease resulting in reduced efficacy of the opioid and potential withdrawal syndrome in a patient who has developed physical dependence to hydrocodone. (Moderate) Use quinolones and nonsteroidal anti-inflammatory drugs (NSAIDs) concomitantly with caution due to potential increased risk of CNS stimulation and convulsive seizures. NSAIDs in combination with very high doses of quinolones have been shown to provoke convulsions in preclinical studies and postmarketing.
Hydrocodone; Pseudoephedrine: (Moderate) Consider a reduced dose of hydrocodone with frequent monitoring for respiratory depression and sedation if concurrent use of ciprofloxacin is necessary. It is recommended to avoid this combination when hydrocodone is being used for cough. Hydrocodone is a CYP3A4 substrate, and coadministration with CYP3A4 inhibitors like ciprofloxacin can increase hydrocodone exposure resulting in increased or prolonged opioid effects including fatal respiratory depression, particularly when an inhibitor is added to a stable dose of hydrocodone. These effects could be more pronounced in patients also receiving a CYP2D6 inhibitor. If ciprofloxacin is discontinued, hydrocodone plasma concentrations will decrease resulting in reduced efficacy of the opioid and potential withdrawal syndrome in a patient who has developed physical dependence to hydrocodone.
Hydrocortisone: (Moderate) Quinolones have been associated with an increased risk of tendon rupture requiring surgical repair or resulting in prolonged disability; this risk is further increased in those receiving concomitant corticosteroids. Discontinue quinolone therapy at the first sign of tendon inflammation or tendon pain, as these are symptoms that may precede rupture of the tendon.
Hydroxychloroquine: (Major) Concomitant use of hydroxychloroquine and ciprofloxacin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Hydroxyzine: (Moderate) Concomitant use of ciprofloxacin and hydroxyzine may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Ibrutinib: (Major) If ibrutinib is coadministered with ciprofloxacin, reduce the ibrutinib dosage to 280 mg/day PO in patients receiving ibrutinib for B-cell malignancy. Resume ibrutinib at the previous dose if ciprofloxacin is discontinued. No initial ibrutinib dosage adjustment is necessary in patients receiving ibrutinib for chronic graft-versus-host disease. Monitor patients for ibrutinib toxicity (e.g., hematologic toxicity, bleeding, infection); modify the ibrutinib dosage as recommended if toxicity occurs. Ibrutinib is a CYP3A4 substrate; ciprofloxacin is a moderate CYP3A4 inhibitor. When ibrutinib was administered with multiple doses of another moderate CYP3A4 inhibitor, the AUC value of ibrutinib was increased by 3-fold.
Ibuprofen: (Moderate) Use quinolones and nonsteroidal anti-inflammatory drugs (NSAIDs) concomitantly with caution due to potential increased risk of CNS stimulation and convulsive seizures. NSAIDs in combination with very high doses of quinolones have been shown to provoke convulsions in preclinical studies and postmarketing.
Ibuprofen; Famotidine: (Moderate) Use quinolones and nonsteroidal anti-inflammatory drugs (NSAIDs) concomitantly with caution due to potential increased risk of CNS stimulation and convulsive seizures. NSAIDs in combination with very high doses of quinolones have been shown to provoke convulsions in preclinical studies and postmarketing.
Ibuprofen; Oxycodone: (Moderate) Consider a reduced dose of oxycodone with frequent monitoring for respiratory depression and sedation if concurrent use of ciprofloxacin is necessary. If ciprofloxacin is discontinued, consider increasing the oxycodone dose until stable drug effects are achieved and monitor for evidence of opioid withdrawal. Oxycodone is a CYP3A4 substrate, and coadministration with a moderate inhibitor like ciprofloxacin can increase oxycodone exposure resulting in increased or prolonged opioid effects including fatal respiratory depression, particularly when an inhibitor is added to a stable dose of oxycodone. If ciprofloxacin is discontinued, oxycodone plasma concentrations will decrease resulting in reduced efficacy of the opioid and potential withdrawal syndrome in a patient who has developed physical dependence to oxycodone. (Moderate) Use quinolones and nonsteroidal anti-inflammatory drugs (NSAIDs) concomitantly with caution due to potential increased risk of CNS stimulation and convulsive seizures. NSAIDs in combination with very high doses of quinolones have been shown to provoke convulsions in preclinical studies and postmarketing.
Ibuprofen; Pseudoephedrine: (Moderate) Use quinolones and nonsteroidal anti-inflammatory drugs (NSAIDs) concomitantly with caution due to potential increased risk of CNS stimulation and convulsive seizures. NSAIDs in combination with very high doses of quinolones have been shown to provoke convulsions in preclinical studies and postmarketing.
Ibutilide: (Major) Concomitant use of ciprofloxacin and ibutilide increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Ifosfamide: (Moderate) Monitor for a decrease in the efficacy of ifosfamide if coadministration with ciprofloxacin is necessary. Ifosfamide is metabolized by CYP3A4 to its active alkylating metabolites. Ciprofloxacin is a moderate CYP3A4 inhibitor. Coadministration may decrease plasma concentrations of these active metabolites, decreasing the effectiveness of ifosfamide treatment.
Iloperidone: (Major) Concomitant use of iloperidone and ciprofloxacin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Imatinib: (Moderate) Increased imatinib serum levels and toxicity may result with concurrent use of ciprofloxacin. Close monitor patients for any signs of toxicity, such as meylosuppression, fluid retention, and bleeding. Ciprofloxacin may inhibit the metabolism of imatinib via CYP3A4 inhibition.
Incretin Mimetics: (Moderate) Monitor blood glucose during concomitant incretin mimetic and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Indinavir: (Moderate) Use caution with the coadministration of ciprofloxacin and indinavir. The plasma concentrations of indinavir may be elevated when administered concurrently with ciprofloxacin. Ciprofloxacin is a CYP3A4 inhibitor and may decrease the systemic clearance of indinavir, a CYP3A4 substrate.
Indomethacin: (Moderate) Use quinolones and nonsteroidal anti-inflammatory drugs (NSAIDs) concomitantly with caution due to potential increased risk of CNS stimulation and convulsive seizures. NSAIDs in combination with very high doses of quinolones have been shown to provoke convulsions in preclinical studies and postmarketing.
Infigratinib: (Major) Avoid concomitant use of infigratinib and ciprofloxacin. Coadministration may increase infigratinib exposure, increasing the risk of adverse effects. Infigratinib is a CYP3A4 substrate and ciprofloxacin is a moderate CYP3A4 inhibitor.
Inotuzumab Ozogamicin: (Major) Concomitant use of ciprofloxacin and inotuzumab ozogamicin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Insulin Aspart: (Moderate) Monitor blood glucose during concomitant insulin and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Insulin Aspart; Insulin Aspart Protamine: (Moderate) Monitor blood glucose during concomitant insulin and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Insulin Degludec: (Moderate) Monitor blood glucose during concomitant insulin and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Insulin Degludec; Liraglutide: (Moderate) Monitor blood glucose during concomitant incretin mimetic and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia. (Moderate) Monitor blood glucose during concomitant insulin and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Insulin Detemir: (Moderate) Monitor blood glucose during concomitant insulin and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Insulin Glargine: (Moderate) Monitor blood glucose during concomitant insulin and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Insulin Glargine; Lixisenatide: (Moderate) Monitor blood glucose during concomitant incretin mimetic and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia. (Moderate) Monitor blood glucose during concomitant insulin and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Insulin Glulisine: (Moderate) Monitor blood glucose during concomitant insulin and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Insulin Lispro: (Moderate) Monitor blood glucose during concomitant insulin and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Insulin Lispro; Insulin Lispro Protamine: (Moderate) Monitor blood glucose during concomitant insulin and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Insulin, Inhaled: (Moderate) Monitor blood glucose during concomitant insulin and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Insulins: (Moderate) Monitor blood glucose during concomitant insulin and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Iron Salts: (Moderate) Administer oral ciprofloxacin at least 2 hours before or 6 hours after oral products that contain iron. Ciprofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations.
Iron: (Moderate) Administer oral ciprofloxacin at least 2 hours before or 6 hours after oral products that contain iron. Ciprofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations.
Isavuconazonium: (Moderate) Concomitant use of isavuconazonium with ciprofloxacin may result in increased serum concentrations of isavuconazonium. Caution and close monitoring for adverse effects, such as hepatotoxicity, are advised if these drugs are used together. Isavuconazole, the active moiety of isavuconazonium, is a sensitive substrate CYP3A4; ciprofloxacin is an inhibitor of this enzyme.
Isoflurane: (Major) Concomitant use of ciprofloxacin and halogenated anesthetics increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Isoniazid, INH; Pyrazinamide, PZA; Rifampin: (Moderate) It may be necessary to adjust the dosage of ciprofloxacin if given concurrently with rifampin. Rifampin may induce the metabolism of ciprofloxacin; coadministration may result in decreased ciprofloxacin plasma concentrations. Ciprofloxacin and rifampin have been used concomitantly in some cases for the treatment of MRSA.
Isoniazid, INH; Rifampin: (Moderate) It may be necessary to adjust the dosage of ciprofloxacin if given concurrently with rifampin. Rifampin may induce the metabolism of ciprofloxacin; coadministration may result in decreased ciprofloxacin plasma concentrations. Ciprofloxacin and rifampin have been used concomitantly in some cases for the treatment of MRSA.
Isophane Insulin (NPH): (Moderate) Monitor blood glucose during concomitant insulin and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Isradipine: (Moderate) Coadministration of ciprofloxacin, a CYP3A4 inhibitor, with isradipine, a CYP3A4 substrate, may result in elevated isradipine serum concentrations. If used concurrently, close clinical monitoring of blood pressure is advised.
Itraconazole: (Moderate) Concomitant use of ciprofloxacin and itraconazole may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Ivabradine: (Major) Avoid coadministration of ivabradine and ciprofloxacin as increased concentrations of ivabradine are possible. Ivabradine is primarily metabolized by CYP3A4; ciprofloxacin inhibits CYP3A4. Increased ivabradine concentrations may result in bradycardia exacerbation and conduction disturbances.
Ivacaftor: (Major) If ciprofloxacin and ivacaftor are taken together, administer ivacaftor at the usual recommended dose but reduce the frequency to once daily. Coadministration is not recommended in patients younger than 6 months. Ivacaftor is a CYP3A substrate and ciprofloxacin is a moderate CYP3A inhibitor. Coadministration with another moderate CYP3A inhibitor increased ivacaftor exposure by 3-fold.
Ivosidenib: (Major) Avoid coadministration of ivosidenib with ciprofloxacin due to increased plasma concentrations of ivosidenib, which increases the risk of QT prolongation. If concomitant use is unavoidable, monitor ECGs for QTc prolongation and monitor electrolytes; correct any electrolyte abnormalities as clinically appropriate. Ivosidenib is a CYP3A4 substrate that has been associated with QTc prolongation and ventricular arrhythmias. Ciprofloxacin is a moderate CYP3A4 inhibitor; rare cases of QT prolongation and torsade de pointes (TdP) have been reported with ciprofloxacin during postmarketing surveillance. Coadministration with another moderate CYP3A4 inhibitor is predicted to increase the ivosidenib single-dose AUC to 173% of control based on physiologically-based pharmacokinetic modeling, with no change in Cmax. Multiple doses of the moderate CYP3A4 inhibitor are predicted to increase the ivosidenib steady-state AUC to 152% of control and AUC to 190% of control.
Ixabepilone: (Moderate) Monitor for ixabepilone toxicity and reduce the ixabepilone dose as needed if concurrent use of ciprofloxacin is necessary. Concomitant use may increase ixabepilone exposure and the risk of adverse reactions. Ixabepilone is a CYP3A substrate and ciprofloxacin is a moderate CYP3A inhibitor.
Ketoconazole: (Contraindicated) Avoid concomitant use of ketoconazole and ciprofloxacin due to an increased risk for torsade de pointes (TdP) and QT/QTc prolongation. Ciprofloxacin may further prolong the QT interval in patients receiving drugs known to prolong the QT interval, such as ketoconazole.
Ketoprofen: (Moderate) Use quinolones and nonsteroidal anti-inflammatory drugs (NSAIDs) concomitantly with caution due to potential increased risk of CNS stimulation and convulsive seizures. NSAIDs in combination with very high doses of quinolones have been shown to provoke convulsions in preclinical studies and postmarketing.
Ketorolac: (Moderate) Use quinolones and nonsteroidal anti-inflammatory drugs (NSAIDs) concomitantly with caution due to potential increased risk of CNS stimulation and convulsive seizures. NSAIDs in combination with very high doses of quinolones have been shown to provoke convulsions in preclinical studies and postmarketing.
Lansoprazole; Amoxicillin; Clarithromycin: (Major) Concomitant use of clarithromycin and ciprofloxacin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Lanthanum Carbonate: (Major) Administer oral ciprofloxacin at least 2 hours before or 6 hours after lanthanum carbonate. When oral quinolones are given for short courses, consider eliminating the lanthanum carbonate doses that would be normally scheduled near the time of quinolone intake. Ciprofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. The bioavailability of ciprofloxacin was decreased by approximately 50% when coadministered with lanthanum carbonate.
Lapatinib: (Moderate) Concomitant use of ciprofloxacin and lapatinib may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Larotrectinib: (Moderate) Monitor for an increase in larotrectinib-related adverse reactions if concomitant use with ciprofloxacin is necessary. Concomitant use may increase larotrectinib exposure. Larotrectinib is a CYP3A substrate and ciprofloxacin is a moderate CYP3A inhibitor. Coadministration with a moderate CYP3A inhibitor is predicted to increase larotrectinib exposure by 2.7-fold.
Lefamulin: (Major) Avoid coadministration of lefamulin with ciprofloxacin as concurrent use may increase the risk of QT prolongation; concurrent use may also increase exposure from lefamulin tablets which may increase the risk of adverse effects. If coadministration cannot be avoided, monitor ECG during treatment; additionally, monitor for lefamulin-related adverse effects if oral lefamulin is administered. Lefamulin is a CYP3A4 substrate that has a concentration dependent QTc prolongation effect. The pharmacodynamic interaction potential to prolong the QT interval of the electrocardiogram between lefamulin and other drugs that effect cardiac conduction is unknown. Ciprofloxacin is a moderate CYP3A4 inhibitor that has been associated with rare cases of QT prolongation and torsade de pointes (TdP) in postmarketing surveillance.
Leflunomide: (Moderate) Closely monitor for ciprofloxacin-induced side effects such as nausea, vomiting, diarrhea, or abdominal pain when these drugs are used together. In some patients, a dosage reduction of ciprofloxacin may be required. Following oral administration, leflunomide is metabolized to an active metabolite, teriflunomide, which is responsible for essentially all of leflunomide's in vivo activity. Teriflunomide is an inhibitor of the renal uptake organic anion transporter OAT3. Use of teriflunomide with ciprofloxacin, a substrate of OAT3, may increase ciprofloxacin plasma concentrations.
Lemborexant: (Major) Avoid coadministration of lemborexant and ciprofloxacin as concurrent use is expected to significantly increase lemborexant exposure and the risk of adverse effects. Lemborexant is a CYP3A4 substrate; ciprofloxacin is a moderate CYP3A4 inhibitor. Coadministration of lemborexant with another moderate CYP3A4 inhibitor increased the lemborexant AUC by up to 4.5-fold.
Lenvatinib: (Major) Concomitant use of lenvatinib and ciprofloxacin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Leuprolide: (Moderate) Concomitant use of ciprofloxacin and androgen deprivation therapy (i.e., leuprolide) may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Leuprolide; Norethindrone: (Moderate) Concomitant use of ciprofloxacin and androgen deprivation therapy (i.e., leuprolide) may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Levamlodipine: (Moderate) Monitor for symptoms of hypotension and edema if coadministration of amlodipine with ciprofloxacin is necessary; adjust the dose of amlodipine as clinically appropriate. Amlodipine is a CYP3A substrate and ciprofloxacin is a moderate CYP3A inhibitor. Coadministration with a moderate CYP3A4 inhibitor in elderly hypertensive patients increased systemic exposure to amlodipine by 60%. However, coadministration with another moderate CYP3A4 inhibitor in healthy volunteers did not significantly change amlodipine exposure.
Levoketoconazole: (Contraindicated) Avoid concomitant use of ketoconazole and ciprofloxacin due to an increased risk for torsade de pointes (TdP) and QT/QTc prolongation. Ciprofloxacin may further prolong the QT interval in patients receiving drugs known to prolong the QT interval, such as ketoconazole.
Levonorgestrel; Ethinyl Estradiol; Ferrous Bisglycinate: (Moderate) Administer oral ciprofloxacin at least 2 hours before or 6 hours after oral products that contain iron. Ciprofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations.
Levonorgestrel; Ethinyl Estradiol; Ferrous Fumarate: (Moderate) Administer oral ciprofloxacin at least 2 hours before or 6 hours after oral products that contain iron. Ciprofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations.
Lidocaine: (Moderate) Concomitant use of systemic lidocaine and ciprofloxacin may increase lidocaine plasma concentrations by decreasing lidocaine clearance and therefore prolonging the elimination half-life. Monitor for lidocaine toxicity if used together. Lidocaine is a CYP3A4 and CYP1A2 substrate; ciprofloxacin inhibits both of these isoenzymes. In a study of healthy volunteers (n = 9), concomitant use of lidocaine (1.5mg/kg IV) and ciprofloxacin (500 mg twice daily) resulted in an increase of lidocaine Cmax and AUC by 12% and 26%, respectively.
Lidocaine; Epinephrine: (Moderate) Concomitant use of systemic lidocaine and ciprofloxacin may increase lidocaine plasma concentrations by decreasing lidocaine clearance and therefore prolonging the elimination half-life. Monitor for lidocaine toxicity if used together. Lidocaine is a CYP3A4 and CYP1A2 substrate; ciprofloxacin inhibits both of these isoenzymes. In a study of healthy volunteers (n = 9), concomitant use of lidocaine (1.5mg/kg IV) and ciprofloxacin (500 mg twice daily) resulted in an increase of lidocaine Cmax and AUC by 12% and 26%, respectively.
Lidocaine; Prilocaine: (Moderate) Concomitant use of systemic lidocaine and ciprofloxacin may increase lidocaine plasma concentrations by decreasing lidocaine clearance and therefore prolonging the elimination half-life. Monitor for lidocaine toxicity if used together. Lidocaine is a CYP3A4 and CYP1A2 substrate; ciprofloxacin inhibits both of these isoenzymes. In a study of healthy volunteers (n = 9), concomitant use of lidocaine (1.5mg/kg IV) and ciprofloxacin (500 mg twice daily) resulted in an increase of lidocaine Cmax and AUC by 12% and 26%, respectively.
Linagliptin: (Moderate) Monitor blood glucose during concomitant dipeptidyl peptidase-4 inhibitors and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Linagliptin; Metformin: (Moderate) Monitor blood glucose carefully when systemic quinolones and antidiabetic agents, including metformin, are coadministered. Discontinue the quinolone if a hypoglycemic reaction occurs and initiate appropriate therapy immediately. Disturbances of blood glucose, including hyperglycemia and hypoglycemia, have been reported in patients treated concomitantly with quinolones and an antidiabetic agent. Hypoglycemia, sometimes resulting in coma, can occur. (Moderate) Monitor blood glucose during concomitant dipeptidyl peptidase-4 inhibitors and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Liraglutide: (Moderate) Monitor blood glucose during concomitant incretin mimetic and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Lithium: (Moderate) Concomitant use of ciprofloxacin and lithium may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Lixisenatide: (Moderate) Monitor blood glucose during concomitant incretin mimetic and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Lofexidine: (Moderate) Concomitant use of ciprofloxacin and lofexidine may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Lomitapide: (Contraindicated) Concomitant use of ciprofloxacin and lomitapide is contraindicated. If treatment with ciprofloxacin is unavoidable, lomitapide should be stopped during the course of treatment. Ciprofloxacin is a moderate CYP3A4 inhibitor. The exposure to lomitapide was increased 27-fold in the presence of ketoconazole, a strong CYP3A4 inhibitor. Although concomitant use of moderate CYP3A4 inhibitors with lomitapide has not been studied, a significant increase in lomitapide exposure is likely during concurrent use.
Lonafarnib: (Contraindicated) Coadministration of lonafarnib and ciprofloxacin is contraindicated; concurrent use may increase the exposure of lonafarnib and the risk of adverse effects. Lonafarnib is a sensitive CYP3A4 substrate and ciprofloxacin is a moderate CYP3A4 inhibitor.
Loperamide: (Moderate) Concomitant use of loperamide and ciprofloxacin may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Loperamide; Simethicone: (Moderate) Concomitant use of loperamide and ciprofloxacin may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Lopinavir; Ritonavir: (Major) Concomitant use of lopinavir and ciprofloxacin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Lumacaftor; Ivacaftor: (Major) If ciprofloxacin and ivacaftor are taken together, administer ivacaftor at the usual recommended dose but reduce the frequency to once daily. Coadministration is not recommended in patients younger than 6 months. Ivacaftor is a CYP3A substrate and ciprofloxacin is a moderate CYP3A inhibitor. Coadministration with another moderate CYP3A inhibitor increased ivacaftor exposure by 3-fold.
Lumateperone: (Major) Reduce the dose of lumateperone to 21 mg once daily if concomitant use of ciprofloxacin is necessary. Concurrent use may increase lumateperone exposure and the risk of adverse effects. Lumateperone is a CYP3A4 substrate; ciprofloxacin is a moderate CYP3A4 inhibitor. Coadministration with a moderate CYP3A4 inhibitor increased lumateperone exposure by approximately 2-fold.
Lurbinectedin: (Major) Avoid coadministration of lurbinectedin and ciprofloxacin due to the risk of increased lurbinectedin exposure which may increase the incidence of lurbinectedin-related adverse reactions. If concomitant use is unavoidable, consider reducing the dose of lurbinectedin if clinically indicated. Lurbinectedin is a CYP3A substrate and ciprofloxacin is a moderate CYP3A inhibitor.
Macimorelin: (Major) Concomitant use of ciprofloxacin and macimorelin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Magnesium Citrate: (Moderate) Administer oral ciprofloxacin at least 2 hours before or 6 hours after magnesium citrate. Ciprofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations.
Magnesium Hydroxide: (Moderate) Administer oral ciprofloxacin at least 2 hours before or 6 hours after magnesium hydroxide. Ciprofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations.
Magnesium Salicylate: (Moderate) Administer oral ciprofloxacin at least 2 hours before or 6 hours after magnesium salicylate. Ciprofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations.
Magnesium Salts: (Moderate) Administer oral ciprofloxacin at least 2 hours before or 6 hours after oral products that contain magnesium. Ciprofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations.
Magnesium Sulfate; Potassium Sulfate; Sodium Sulfate: (Major) Administer quinolones at least 2 hours before or 6 hours after administration of magnesium sulfate; potassium sulfate; sodium sulfate. The absorption of quinolones may be reduced by chelation with magnesium sulfate.
Magnesium: (Moderate) Administer oral ciprofloxacin at least 2 hours before or 6 hours after oral products that contain magnesium. Ciprofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations.
Maprotiline: (Major) Concomitant use of ciprofloxacin and maprotiline increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Maraviroc: (Minor) Use caution if coadministration of maraviroc with ciprofloxacin is necessary, due to a possible increase in maraviroc exposure. Maraviroc is a CYP3A substrate and ciprofloxacin is a weak CYP3A4 inhibitor. Monitor for an increase in adverse effects with concomitant use.
Mavacamten: (Major) Reduce the mavacamten dose by 1 level (i.e., 15 to 10 mg, 10 to 5 mg, or 5 to 2.5 mg) in patients receiving mavacamten and starting ciprofloxacin therapy. Avoid initiation of ciprofloxacin in patients who are on stable treatment with mavacamten 2.5 mg per day because a lower dose of mavacamten is not available. Initiate mavacamten at the recommended starting dose of 5 mg PO once daily in patients who are on stable ciprofloxacin therapy. Concomitant use increases mavacamten exposure, which may increase the risk of adverse drug reactions. Mavacamten is a CYP3A substrate and ciprofloxacin is a moderate CYP3A inhibitor. The impact that a CYP3A inhibitor may have on mavacamten overall exposure varies based on the patient's CYP2C19 metabolizer status. Concomitant use of a moderate CYP3A inhibitor increased mavacamten overall exposure by 15% in CYP2C19 normal and intermediate metabolizers; concomitant use in poor metabolizers is predicted to increase mavacamten exposure by up to 55%.
Meclofenamate Sodium: (Moderate) Use quinolones and nonsteroidal anti-inflammatory drugs (NSAIDs) concomitantly with caution due to potential increased risk of CNS stimulation and convulsive seizures. NSAIDs in combination with very high doses of quinolones have been shown to provoke convulsions in preclinical studies and postmarketing.
Mefenamic Acid: (Moderate) Use quinolones and nonsteroidal anti-inflammatory drugs (NSAIDs) concomitantly with caution due to potential increased risk of CNS stimulation and convulsive seizures. NSAIDs in combination with very high doses of quinolones have been shown to provoke convulsions in preclinical studies and postmarketing.
Mefloquine: (Moderate) Concomitant use of ciprofloxacin and mefloquine may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Meglitinides: (Moderate) Monitor blood glucose carefully when systemic quinolones and antidiabetic agents, including meglitinides, are coadministered. Discontinue the quinolone if a hypoglycemic reaction occurs and initiate appropriate therapy immediately. Disturbances of blood glucose, including hyperglycemia and hypoglycemia, have been reported in patients treated concomitantly with quinolones and an antidiabetic agent. Hypoglycemia, sometimes resulting in coma, can occur.
Melatonin: (Moderate) Monitor for an increase in melatonin-related adverse reactions if concomitant use of ciprofloxacin is necessary. Concomitant use may increase melatonin exposure; melatonin is a CYP1A2 substrate and ciprofloxacin is a strong CYP1A2 inhibitor.
Meloxicam: (Moderate) Use quinolones and nonsteroidal anti-inflammatory drugs (NSAIDs) concomitantly with caution due to potential increased risk of CNS stimulation and convulsive seizures. NSAIDs in combination with very high doses of quinolones have been shown to provoke convulsions in preclinical studies and postmarketing.
Metformin: (Moderate) Monitor blood glucose carefully when systemic quinolones and antidiabetic agents, including metformin, are coadministered. Discontinue the quinolone if a hypoglycemic reaction occurs and initiate appropriate therapy immediately. Disturbances of blood glucose, including hyperglycemia and hypoglycemia, have been reported in patients treated concomitantly with quinolones and an antidiabetic agent. Hypoglycemia, sometimes resulting in coma, can occur.
Metformin; Repaglinide: (Moderate) Monitor blood glucose carefully when systemic quinolones and antidiabetic agents, including meglitinides, are coadministered. Discontinue the quinolone if a hypoglycemic reaction occurs and initiate appropriate therapy immediately. Disturbances of blood glucose, including hyperglycemia and hypoglycemia, have been reported in patients treated concomitantly with quinolones and an antidiabetic agent. Hypoglycemia, sometimes resulting in coma, can occur. (Moderate) Monitor blood glucose carefully when systemic quinolones and antidiabetic agents, including metformin, are coadministered. Discontinue the quinolone if a hypoglycemic reaction occurs and initiate appropriate therapy immediately. Disturbances of blood glucose, including hyperglycemia and hypoglycemia, have been reported in patients treated concomitantly with quinolones and an antidiabetic agent. Hypoglycemia, sometimes resulting in coma, can occur.
Metformin; Rosiglitazone: (Moderate) Monitor blood glucose carefully when systemic quinolones and antidiabetic agents, including metformin, are coadministered. Discontinue the quinolone if a hypoglycemic reaction occurs and initiate appropriate therapy immediately. Disturbances of blood glucose, including hyperglycemia and hypoglycemia, have been reported in patients treated concomitantly with quinolones and an antidiabetic agent. Hypoglycemia, sometimes resulting in coma, can occur. (Moderate) Monitor blood glucose during concomitant thiazolidinedione and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Metformin; Saxagliptin: (Moderate) Monitor blood glucose carefully when systemic quinolones and antidiabetic agents, including metformin, are coadministered. Discontinue the quinolone if a hypoglycemic reaction occurs and initiate appropriate therapy immediately. Disturbances of blood glucose, including hyperglycemia and hypoglycemia, have been reported in patients treated concomitantly with quinolones and an antidiabetic agent. Hypoglycemia, sometimes resulting in coma, can occur. (Moderate) Monitor blood glucose during concomitant dipeptidyl peptidase-4 inhibitors and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Metformin; Sitagliptin: (Moderate) Monitor blood glucose carefully when systemic quinolones and antidiabetic agents, including metformin, are coadministered. Discontinue the quinolone if a hypoglycemic reaction occurs and initiate appropriate therapy immediately. Disturbances of blood glucose, including hyperglycemia and hypoglycemia, have been reported in patients treated concomitantly with quinolones and an antidiabetic agent. Hypoglycemia, sometimes resulting in coma, can occur. (Moderate) Monitor blood glucose during concomitant dipeptidyl peptidase-4 inhibitors and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Methadone: (Major) Concomitant use of ciprofloxacin and methadone increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Methazolamide: (Minor) A large proportion of ciprofloxacin is normally excreted unchanged in the urine. If urinary alkalinizing agents such as carbonic anhydrase inhibitors are used concomitantly, the solubility of ciprofloxacin can be decreased because of alkaline urine. Patients should be monitored for crystalluria and nephrotoxicity.
Methotrexate: (Moderate) Monitor for increased methotrexate-related adverse reactions during concomitant ciprofloxacin use. Ciprofloxacin may inhibit methotrexate renal tubular transport potentially resulting in increased methotrexate serum concentrations.
Methylprednisolone: (Moderate) Quinolones have been associated with an increased risk of tendon rupture requiring surgical repair or resulting in prolonged disability; this risk is further increased in those receiving concomitant corticosteroids. Discontinue quinolone therapy at the first sign of tendon inflammation or tendon pain, as these are symptoms that may precede rupture of the tendon.
Metoclopramide: (Minor) Metoclopramide accelerates the absorption of oral ciprofloxacin. This results in shorter time to reach maximum ciprofloxacin plasma concentrations. No effect was seen on the bioavailability of ciprofloxacin.
Metronidazole: (Moderate) Concomitant use of metronidazole and ciprofloxacin may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Mexiletine: (Moderate) Mexiletine is partially metabolized by CYP1A2 isoenzymes. Although more data are needed, ciprofloxacin appears to decrease the hepatic clearance of mexiletine to a modest degree. The mechanism of this interaction may be ciprofloxacin inhibition of CYP1A2. Clinicians should be aware of the potential for mexiletine related adverse reactions.
Midazolam: (Moderate) Ciprofloxacin is a CYP3A4 inhibitor and may reduce the metabolism of midazolam and increase the potential for benzodiazepine toxicity. Interactions of this type are most pronounced with oral midazolam. However, the pharmacokinetics of IV midazolam may also be affected to a lesser extent.
Midostaurin: (Major) Concomitant use of ciprofloxacin and midostaurin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Mifepristone: (Major) Concomitant use of ciprofloxacin and mifepristone increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Miglitol: (Moderate) Monitor blood glucose carefully when systemic quinolones and antidiabetic agents, including alpha-glucosidase inhibitors, are coadministered. Discontinue the quinolone if a hypoglycemic reaction occurs and initiate appropriate therapy immediately. Disturbances of blood glucose, including hyperglycemia and hypoglycemia, have been reported in patients treated concomitantly with quinolones and an antidiabetic agent. Hypoglycemia, sometimes resulting in coma, can occur.
Mirtazapine: (Moderate) Concomitant use of ciprofloxacin and mirtazapine may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Mitapivat: (Moderate) Do not exceed mitapivat 20 mg PO twice daily during coadministration with ciprofloxacin and monitor hemoglobin and for adverse reactions from mitapivat. Coadministration increases mitapivat concentrations. Mitapivat is a CYP3A substrate and ciprofloxacin is a moderate CYP3A inhibitor. Coadministration with another moderate CYP3Ainhibitor increased mitapivat overall exposure by 2.6-fold.
Mitoxantrone: (Major) Chemotherapy including mitoxantrone has been shown to decrease oral absorption of ciprofloxacin, presumably by altering the intestinal mucosa. In 6 cancer patients receiving chemotherapy and after 13 days of chemotherapy, there were decreases in mean maximum serum concentration, in mean time to reach maximum concentration, and in the area under the concentration curve of ciprofloxacin. Concomitant use of mitoxantrone with other quinolones may decrease GI absorption of the quinolone and possibly decrease the antimicrobial effect of the quinolone. The effects of mitoxantrone on the pharmacokinetics of intravenous ciprofloxacin are unclear at this time.
Mobocertinib: (Major) Avoid concomitant use of mobocertinib and ciprofloxacin; reduce the dose of mobocertinib by approximately 50% and monitor the QT interval more frequently if use is necessary. Concomitant use increases the risk of QT/QTc pro longation and torsade de pointes (TdP) and may increase mobocertinib exposure and the risk for mobocertinib-related adverse reactions. Mobocertinib is a CYP3A substrate and ciprofloxacin is a moderate CYP3A inhibitor. Use of a moderate CYP3A inhibitor is predicted to increase the overall exposure of mobocertinib and its active metabolites by 100% to 200%.
Mycophenolate: (Moderate) Drugs that alter the gastrointestinal flora such as ciprofloxacin may interact with mycophenolate by disrupting enterohepatic recirculation. Mycophenolic acid (MPA) is converted to an inactive phenolic glucuronide, MPA glucuronide (MPAG), which undergoes enterohepatic recirculation. Bacteria that express beta-glucuronidase cleave the glucuronide conjugate, which results in liberation of MPA. Normally, two peaks of MPA occur after administration. The first peak occurs after absorption of MPA, and the second peak occurs after cleavage of MPAG by beta-glucuronidase producing bacteria. Antibiotics with activity against such bacteria can reduce the second peak in MPA serum concentrations; interference of MPAG hydrolysis may lead to less MPA available for absorption. A reduction in predose MPA concentrations was noted after ciprofloxacin (500 mg PO twice daily) was administered to 24 patients taking mycophenolate mofetil and tacrolimus for renal transplant prophylaxis. The predose concentration was obtained before the morning dose and 12 hours after the evening mycophenolate dose. The mean MPA predose concentration at baseline was 2.3 mg/L. After 3 days of ciprofloxacin, the mean concentration was 1.5 mg/L. With 7 days of ciprofloxacin, the predose concentration was 1.2 mg/L, and 3 days after the 7-day course, the mean concentration was not significantly different from baseline (2.6 mg/L). A reduction in the MPA predose concentration was also noted among 21 patients who took a 14-day course of ciprofloxacin. Interestingly, the predose concentration rose with continued ciprofloxacin use. The mean predose concentration was 2.3 mg/L at baseline, 1.4 mg/L after 3 days of the antibiotic, 1.5 mg/L after 7 days of the antibiotic, and 1.9 mg/L after 14 days of the antibiotic. In addition to a rise in predose concentrations with continued antibiotic use, some patients did not have a large reduction in their predose concentration. Nine of 44 patients who got a 7-day course of ciprofloxacin or another antibiotic, and 7 of 38 patients who got a 14-day course with either ciprofloxacin or another antibiotic had MPA concentrations on day 3 of antibiotics that were greater than 80% of baseline values. Also, the predose MPA concentration may not accurately represent changes in overall MPA exposure. No deaths, graft losses, acute rejection episodes, or gastrointestinal disturbances were noted throughout the study. A mycophenolate dose increase in response to reduced MPA predose concentrations could cause toxicity in some patients. Of note, the impact of an antibiotic that reduces enterohepatic recirculation of MPA on patients also taking cyclosporine needs investigation; cyclosporine also reduces the enterohepatic recirculation of MPA.
Nabumetone: (Moderate) Use quinolones and nonsteroidal anti-inflammatory drugs (NSAIDs) concomitantly with caution due to potential increased risk of CNS stimulation and convulsive seizures. NSAIDs in combination with very high doses of quinolones have been shown to provoke convulsions in preclinical studies and postmarketing.
Naldemedine: (Major) Monitor for potential naldemedine-related adverse reactions if coadministered with ciprofloxacin. The plasma concentrations of naldemedine may be increased during concurrent use. Naldemedine is a CYP3A4 substrate; ciprofloxacin is a moderate CYP3A4 inhibitor.
Naloxegol: (Major) Avoid concomitant administration of naloxegol and ciprofloxacin due to the potential for increased naloxegol exposure. If coadministration cannot be avoided, decrease the naloxegol dosage to 12.5 mg once daily and monitor for adverse reactions including opioid withdrawal symptoms such as hyperhidrosis, chills, diarrhea, abdominal pain, anxiety, irritability, and yawning. Naloxegol is a CYP3A4 substrate; ciprofloxacin is a moderate CYP3A4 inhibitor. Coadministration with another moderate CYP3A4 inhibitor increased naloxegol exposure by approximately 3.4-fold.
Nanoparticle Albumin-Bound Paclitaxel: (Moderate) Monitor for an increase in paclitaxel-related adverse reactions if coadministration of nab-paclitaxel with ciprofloxacin is necessary due to the risk of increased plasma concentrations of paclitaxel. Nab-paclitaxel is a CYP3A4 substrate and ciprofloxacin is a moderate CYP3A4 inhibitor. In vitro, coadministration with both strong and moderate CYP3A4 inhibitors increased paclitaxel exposure; however, the concentrations used exceeded those found in vivo following normal therapeutic doses. The pharmacokinetics of paclitaxel may also be altered in vivo as a result of interactions with CYP3A4 inhibitors.
Nanoparticle Albumin-Bound Sirolimus: (Major) Reduce the nab-sirolimus dose to 56 mg/m2 during concomitant use of ciprofloxacin. Coadministration may increase sirolimus concentrations and increase the risk for sirolimus-related adverse effects. Sirolimus is a CYP3A substrate and ciprofloxacin is a moderate CYP3A inhibitor.
Naproxen: (Moderate) Use quinolones and nonsteroidal anti-inflammatory drugs (NSAIDs) concomitantly with caution due to potential increased risk of CNS stimulation and convulsive seizures. NSAIDs in combination with very high doses of quinolones have been shown to provoke convulsions in preclinical studies and postmarketing.
Naproxen; Esomeprazole: (Moderate) Use quinolones and nonsteroidal anti-inflammatory drugs (NSAIDs) concomitantly with caution due to potential increased risk of CNS stimulation and convulsive seizures. NSAIDs in combination with very high doses of quinolones have been shown to provoke convulsions in preclinical studies and postmarketing. (Minor) Use caution when administering ciprofloxacin and esomeprazole concurrently. Ciprofloxacin is an inhibitor of CYP3A, and esomeprazole is partially metabolized by CYP3A. Coadministration of ciprofloxacin with CYP3A substrates, such as esomeprazole, can theoretically increase esomeprazole exposure leading to increased or prolonged therapeutic effects and adverse events; however, the clinical impact of this has not yet been determined.
Naproxen; Pseudoephedrine: (Moderate) Use quinolones and nonsteroidal anti-inflammatory drugs (NSAIDs) concomitantly with caution due to potential increased risk of CNS stimulation and convulsive seizures. NSAIDs in combination with very high doses of quinolones have been shown to provoke convulsions in preclinical studies and postmarketing.
Nateglinide: (Moderate) Monitor blood glucose carefully when systemic quinolones and antidiabetic agents, including meglitinides, are coadministered. Discontinue the quinolone if a hypoglycemic reaction occurs and initiate appropriate therapy immediately. Disturbances of blood glucose, including hyperglycemia and hypoglycemia, have been reported in patients treated concomitantly with quinolones and an antidiabetic agent. Hypoglycemia, sometimes resulting in coma, can occur.
Neratinib: (Major) Avoid concomitant use of ciprofloxacin with neratinib due to an increased risk of neratinib-related toxicity. Neratinib is a CYP3A4 substrate and ciprofloxacin is a moderate CYP3A4 inhibitor. The effect of moderate CYP3A4 inhibition on neratinib concentrations has not been studied; however, coadministration with a strong CYP3A4 inhibitor increased neratinib exposure by 481%. Because of the significant impact on neratinib exposure from strong CYP3A4 inhibition, the potential impact on neratinib safety from concomitant use with moderate CYP3A4 inhibitors should be considered as they may also significantly increase neratinib exposure.
Niacin; Simvastatin: (Moderate) Monitor for evidence of myopathy, including rhabdomyolysis, during coadministration of ciprofloxacin and simvastatin. There are case reports of rhabdomyolysis in patients stabilized on a simvastatin regimen after the addition of ciprofloxacin. Ciprofloxacin may increase simvastatin exposure. Simvastatin is a substrate for CYP3A; ciprofloxacin is a moderate CYP3A inhibitor.
Nilotinib: (Major) Concomitant use of ciprofloxacin and nilotinib increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Nisoldipine: (Major) Avoid coadministration of nisoldipine with ciprofloxacin due to increased plasma concentrations of nisoldipine. If coadministration is unavoidable, monitor blood pressure closely during concurrent use of these medications. Nisoldipine is a CYP3A4 substrate and ciprofloxacin is a CYP3A4 inhibitor.
Nonsteroidal antiinflammatory drugs: (Moderate) Use quinolones and nonsteroidal anti-inflammatory drugs (NSAIDs) concomitantly with caution due to potential increased risk of CNS stimulation and convulsive seizures. NSAIDs in combination with very high doses of quinolones have been shown to provoke convulsions in preclinical studies and postmarketing.
Norethindrone Acetate; Ethinyl Estradiol; Ferrous fumarate: (Moderate) Administer oral ciprofloxacin at least 2 hours before or 6 hours after oral products that contain iron. Ciprofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations.
Norethindrone; Ethinyl Estradiol; Ferrous fumarate: (Moderate) Administer oral ciprofloxacin at least 2 hours before or 6 hours after oral products that contain iron. Ciprofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations.
Olanzapine: (Major) Limited data, including some case reports, suggest that olanzapine may be associated with a significant prolongation of the QTc interval in rare instances. Therefore, caution is advised when administering olanzapine with drugs having an established causal association with QT prolongation and torsade de pointes (TdP) including ciprofloxacin. Additionally, ciprofloxacin inhibits the activity of CYP1A2. Inhibitors of CYP1A2 could potentially reduce the elimination of olanzapine. However, since multiple enzyme pathways metabolize olanzapine, inhibition of only one isoenzyme may not appreciably decrease olanzapine clearance. One case study reported elevated olanzapine plasma concentrations during ciprofloxacin coadministration, possibly due to CYP1A2 inhibition of olanzapine metabolism. Ciprofloxacin inhibits the activity of CYP1A2. Inhibitors of CYP1A2 could potentially reduce the elimination of olanzapine. However, since multiple enzyme pathways metabolize olanzapine, inhibition of only one isoenzyme may not appreciably decrease olanzapine clearance. One case study reported elevated olanzapine plasma concentrations during ciprofloxacin coadministration, possibly due to CYP1A2 inhibition of olanzapine metabolism.
Olanzapine; Fluoxetine: (Major) Limited data, including some case reports, suggest that olanzapine may be associated with a significant prolongation of the QTc interval in rare instances. Therefore, caution is advised when administering olanzapine with drugs having an established causal association with QT prolongation and torsade de pointes (TdP) including ciprofloxacin. Additionally, ciprofloxacin inhibits the activity of CYP1A2. Inhibitors of CYP1A2 could potentially reduce the elimination of olanzapine. However, since multiple enzyme pathways metabolize olanzapine, inhibition of only one isoenzyme may not appreciably decrease olanzapine clearance. One case study reported elevated olanzapine plasma concentrations during ciprofloxacin coadministration, possibly due to CYP1A2 inhibition of olanzapine metabolism. Ciprofloxacin inhibits the activity of CYP1A2. Inhibitors of CYP1A2 could potentially reduce the elimination of olanzapine. However, since multiple enzyme pathways metabolize olanzapine, inhibition of only one isoenzyme may not appreciably decrease olanzapine clearance. One case study reported elevated olanzapine plasma concentrations during ciprofloxacin coadministration, possibly due to CYP1A2 inhibition of olanzapine metabolism. (Moderate) Concomitant use of ciprofloxacin and fluoxetine may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Olanzapine; Samidorphan: (Major) Limited data, including some case reports, suggest that olanzapine may be associated with a significant prolongation of the QTc interval in rare instances. Therefore, caution is advised when administering olanzapine with drugs having an established causal association with QT prolongation and torsade de pointes (TdP) including ciprofloxacin. Additionally, ciprofloxacin inhibits the activity of CYP1A2. Inhibitors of CYP1A2 could potentially reduce the elimination of olanzapine. However, since multiple enzyme pathways metabolize olanzapine, inhibition of only one isoenzyme may not appreciably decrease olanzapine clearance. One case study reported elevated olanzapine plasma concentrations during ciprofloxacin coadministration, possibly due to CYP1A2 inhibition of olanzapine metabolism. Ciprofloxacin inhibits the activity of CYP1A2. Inhibitors of CYP1A2 could potentially reduce the elimination of olanzapine. However, since multiple enzyme pathways metabolize olanzapine, inhibition of only one isoenzyme may not appreciably decrease olanzapine clearance. One case study reported elevated olanzapine plasma concentrations during ciprofloxacin coadministration, possibly due to CYP1A2 inhibition of olanzapine metabolism.
Olaparib: (Major) Avoid coadministration of olaparib with ciprofloxacin due to the risk of increased olaparib-related adverse reactions. If concomitant use is unavoidable, reduce the dose of olaparib to 150 mg twice daily; the original dose may be resumed 3 to 5 elimination half-lives after ciprofloxacin is discontinued. Olaparib is a CYP3A substrate and ciprofloxacin is a moderate CYP3A4 inhibitor; concomitant use may increase olaparib exposure. Coadministration with a moderate CYP3A inhibitor is predicted to increase the olaparib Cmax by 14% and the AUC by 121%.
Oliceridine: (Moderate) Monitor patients closely for respiratory depression and sedation at frequent intervals and base subsequent doses on the patient's severity of pain and response to treatment if concomitant administration of oliceridine and ciprofloxacin is necessary; less frequent dosing of oliceridine may be required. Concomitant use of oliceridine and ciprofloxacin may increase the plasma concentration of oliceridine, resulting in increased or prolonged opioid effects. If ciprofloxacin is discontinued, consider increasing the oliceridine dose until stable drug effects are achieved and monitor for evidence of opioid withdrawal. Oliceridine is a CYP3A4 substrate and ciprofloxacin is a moderate CYP3A4 inhibitor.
Olmesartan; Amlodipine; Hydrochlorothiazide, HCTZ: (Moderate) Monitor for symptoms of hypotension and edema if coadministration of amlodipine with ciprofloxacin is necessary; adjust the dose of amlodipine as clinically appropriate. Amlodipine is a CYP3A substrate and ciprofloxacin is a moderate CYP3A inhibitor. Coadministration with a moderate CYP3A4 inhibitor in elderly hypertensive patients increased systemic exposure to amlodipine by 60%. However, coadministration with another moderate CYP3A4 inhibitor in healthy volunteers did not significantly change amlodipine exposure.
Omaveloxolone: (Major) Avoid concomitant use of omaveloxolone and ciprofloxacin. If concomitant use is necessary, decrease omaveloxolone dose to 100 mg once daily; additional dosage reductions may be necessary. Concomitant use may increase omaveloxolone exposure and the risk for omaveloxolone-related adverse effects. Omaveloxolone is a CYP3A substrate and ciprofloxacin is a moderate CYP3A inhibitor. Concomitant use with another moderate CYP3A inhibitor increased omaveloxolone overall exposure by 1.25-fold.
Omeprazole: (Minor) Concomitant use of ciprofloxacin and omeprazole may decrease the AUC and Cmax of ciprofloxacin, but the clinical significance of this interaction is unknown. Codministration of a single tablet dose of 500 mg ciprofloxacin and once-daily administration of 20 mg omeprazole pretreatment for 4 days resulted in a 16% reduction of mean Cmax and mean AUC of ciprofloxacin. A single 1000 mg oral dose of Cipro XR administered with omeprazole (40 mg once daily for 3 days) to 18 healthy volunteers resulted in a decrease in the ciprofloxacin mean AUC by 20% and Cmax by 23%. However, coadministration of a single 1000 mg oral dose of Proquin XR given 2 hours after the third dose of omeprazole (40 mg once daily for 3 days) to 27 healthy volunteers resulted in no changes in the ciprofloxacin AUC and Cmax. If ciprofloxacin is administered with omeprazole with magnesium, chelation of the ciprofloxacin would be expected; in general, it is recommended that ciprofloxacin be administered 2 hours before or 6 hours after any divalent cations like magnesium to help limit an interaction.
Omeprazole; Amoxicillin; Rifabutin: (Minor) Concomitant use of ciprofloxacin and omeprazole may decrease the AUC and Cmax of ciprofloxacin, but the clinical significance of this interaction is unknown. Codministration of a single tablet dose of 500 mg ciprofloxacin and once-daily administration of 20 mg omeprazole pretreatment for 4 days resulted in a 16% reduction of mean Cmax and mean AUC of ciprofloxacin. A single 1000 mg oral dose of Cipro XR administered with omeprazole (40 mg once daily for 3 days) to 18 healthy volunteers resulted in a decrease in the ciprofloxacin mean AUC by 20% and Cmax by 23%. However, coadministration of a single 1000 mg oral dose of Proquin XR given 2 hours after the third dose of omeprazole (40 mg once daily for 3 days) to 27 healthy volunteers resulted in no changes in the ciprofloxacin AUC and Cmax. If ciprofloxacin is administered with omeprazole with magnesium, chelation of the ciprofloxacin would be expected; in general, it is recommended that ciprofloxacin be administered 2 hours before or 6 hours after any divalent cations like magnesium to help limit an interaction.
Omeprazole; Sodium Bicarbonate: (Moderate) Crystalluria related to ciprofloxacin has been reported only rarely in humans because human urine is usually acidic. Avoid alkalinity of the urine in patients receiving ciprofloxacin when possible. A large proportion of ciprofloxacin is normally excreted unchanged in the urine. If sodium bicarbonate is used concomitantly, the solubility of ciprofloxacin might be decreased because of alkaline urine. Patients should be monitored for crystalluria, proper urination,and altered kidney function. Hydrate patients well to prevent the formation of highly concentrated urine. (Minor) Concomitant use of ciprofloxacin and omeprazole may decrease the AUC and Cmax of ciprofloxacin, but the clinical significance of this interaction is unknown. Codministration of a single tablet dose of 500 mg ciprofloxacin and once-daily administration of 20 mg omeprazole pretreatment for 4 days resulted in a 16% reduction of mean Cmax and mean AUC of ciprofloxacin. A single 1000 mg oral dose of Cipro XR administered with omeprazole (40 mg once daily for 3 days) to 18 healthy volunteers resulted in a decrease in the ciprofloxacin mean AUC by 20% and Cmax by 23%. However, coadministration of a single 1000 mg oral dose of Proquin XR given 2 hours after the third dose of omeprazole (40 mg once daily for 3 days) to 27 healthy volunteers resulted in no changes in the ciprofloxacin AUC and Cmax. If ciprofloxacin is administered with omeprazole with magnesium, chelation of the ciprofloxacin would be expected; in general, it is recommended that ciprofloxacin be administered 2 hours before or 6 hours after any divalent cations like magnesium to help limit an interaction.
Ondansetron: (Major) If ondansetron and ciprofloxacin must be coadministered, ECG monitoring is recommended. Ondansetron has been associated with a dose-related increase in the QT interval and postmarketing reports of torsade de pointes (TdP). Additionally, rare cases of QT prolongation and torsade de pointes (TdP) have been reported with ciprofloxacin during postmarketing surveillance. Additionally ciprofloxacin inhibits the CYP1A2 isoenzyme, while ondansetron is metabolized by several isoenzymes, including CYP1A2.
Oral Contraceptives: (Moderate) It would be prudent to recommend alternative or additional contraception when oral contraceptives (OCs) are used in conjunction with antibiotics. It was previously thought that antibiotics may decrease the effectiveness of OCs containing estrogens due to stimulation of metabolism or a reduction in enterohepatic circulation via changes in GI flora. One retrospective study reviewed the literature to determine the effects of oral antibiotics on the pharmacokinetics of contraceptive estrogens and progestins, and also examined clinical studies in which the incidence of pregnancy with OCs and antibiotics was reported. It was concluded that the antibiotics ampicillin, ciprofloxacin, clarithromycin, doxycycline, metronidazole, ofloxacin, roxithromycin, temafloxacin, and tetracycline did not alter plasma concentrations of OCs. Antituberculous drugs (e.g., rifampin) were the only agents associated with OC failure and pregnancy. Based on the study results, these authors recommended that back-up contraception may not be necessary if OCs are used reliably during oral antibiotic use. Another review concurred with these data, but noted that individual patients have been identified who experienced significant decreases in plasma concentrations of combined OC components and who appeared to ovulate; the agents most often associated with these changes were rifampin, tetracyclines, and penicillin derivatives. These authors concluded that because females most at risk for OC failure or noncompliance may not be easily identified and the true incidence of such events may be under-reported, and given the serious consequence of unwanted pregnancy, that recommending an additional method of contraception during short-term antibiotic use may be justified. During long-term antibiotic administration, the risk for drug interaction with OCs is less clear, but alternative or additional contraception may be advisable in selected circumstances. Data regarding progestin-only contraceptives or for newer combined contraceptive deliveries (e.g., patches, rings) are not available.
Osilodrostat: (Major) Concomitant use of osilodrostat and ciprofloxacin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Osimertinib: (Major) Concomitant use of osimertinib and ciprofloxacin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Oxaliplatin: (Major) Concomitant use of oxaliplatin and ciprofloxacin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Oxaprozin: (Moderate) Use quinolones and nonsteroidal anti-inflammatory drugs (NSAIDs) concomitantly with caution due to potential increased risk of CNS stimulation and convulsive seizures. NSAIDs in combination with very high doses of quinolones have been shown to provoke convulsions in preclinical studies and postmarketing.
Oxycodone: (Moderate) Consider a reduced dose of oxycodone with frequent monitoring for respiratory depression and sedation if concurrent use of ciprofloxacin is necessary. If ciprofloxacin is discontinued, consider increasing the oxycodone dose until stable drug effects are achieved and monitor for evidence of opioid withdrawal. Oxycodone is a CYP3A4 substrate, and coadministration with a moderate inhibitor like ciprofloxacin can increase oxycodone exposure resulting in increased or prolonged opioid effects including fatal respiratory depression, particularly when an inhibitor is added to a stable dose of oxycodone. If ciprofloxacin is discontinued, oxycodone plasma concentrations will decrease resulting in reduced efficacy of the opioid and potential withdrawal syndrome in a patient who has developed physical dependence to oxycodone.
Ozanimod: (Major) Concomitant use of ciprofloxacin and ozanimod increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary. Ozanimod has a limited effect on the QT/QTc interval at therapeutic doses but may cause bradycardia and atrioventricular conduction delays which may increase the risk for TdP in patients with a prolonged QT/QTc interval.
Pacritinib: (Major) Avoid concurrent use of pacritinib with ciprofloxacin due to the risk of increased pacritinib exposure which increases the risk of adverse reactions. Concomitant use may also increase the risk for QT/QTc prolongation and torsade de pointes (TdP). Pacritinib is a CYP3A substrate and ciprofloxacin is a moderate CYP3A inhibitor.
Paliperidone: (Major) Concomitant use of paliperidone and ciprofloxacin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Palovarotene: (Major) Avoid concomitant use of palovarotene and ciprofloxacin due to the risk for increased palovarotene exposure which may increase the risk for adverse effects. If concomitant use is necessary, decrease the palovarotene dose by half. Palovarotene is a CYP3A substrate and ciprofloxacin is a moderate CYP3A inhibitor. Concomitant use with another moderate CYP3A inhibitor increased palovarotene overall exposure by 2.5-fold.
Panobinostat: (Major) Concomitant use of panobinostat and ciprofloxacin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Pasireotide: (Moderate) Concomitant use of ciprofloxacin and pasireotide may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Patiromer: (Moderate) Separate the administration of patiromer and oral ciprofloxacin by at least 3 hours if concomitant use is necessary. Simultaneous oral coadministration may reduce gastrointestinal absorption of ciprofloxacin and reduce its efficacy. Patiromer has been observed to bind some oral medications when given at the same time and separating administration by at least 3 hours has effectively mitigated this risk.
Pazopanib: (Major) Concomitant use of pazopanib and ciprofloxacin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Pemigatinib: (Major) Avoid coadministration of pemigatinib and ciprofloxacin due to the risk of increased pemigatinib exposure which may increase the risk of adverse reactions. If coadministration is unavoidable, reduce the dose of pemigatinib to 9 mg PO once daily if original dose was 13.5 mg per day and to 4.5 mg PO once daily if original dose was 9 mg per day. If ciprofloxacin is discontinued, resume the original pemigatinib dose after 3 elimination half-lives of ciprofloxacin. Pemigatinib is a CYP3A4 substrate and ciprofloxacin is a strong CYP3A4 inhibitor. Coadministration with another strong CYP3A4 inhibitor increased pemigatinib exposure by 88%.
Pentamidine: (Major) Concomitant use of pentamidine and ciprofloxacin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Pentoxifylline: (Moderate) Ciprofloxacin may increase pentoxifylline serum concentrations. It has been proposed that ciprofloxacin reduces hepatic CYP1A2 metabolism of pentoxifylline. Until further data are available, monitoring for increased pentoxifylline side effects (e.g., headache) is prudent when adding ciprofloxacin to pentoxifylline.
Perindopril; Amlodipine: (Moderate) Monitor for symptoms of hypotension and edema if coadministration of amlodipine with ciprofloxacin is necessary; adjust the dose of amlodipine as clinically appropriate. Amlodipine is a CYP3A substrate and ciprofloxacin is a moderate CYP3A inhibitor. Coadministration with a moderate CYP3A4 inhibitor in elderly hypertensive patients increased systemic exposure to amlodipine by 60%. However, coadministration with another moderate CYP3A4 inhibitor in healthy volunteers did not significantly change amlodipine exposure.
Perphenazine: (Minor) QT/QTc prolongation can occur with concomitant use of ciprofloxacin and perphenazine although the risk of developing torsade de pointes (TdP) is low. Additional steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, may be considered in patients with additional risk factors for TdP.
Perphenazine; Amitriptyline: (Minor) QT/QTc prolongation can occur with concomitant use of ciprofloxacin and perphenazine although the risk of developing torsade de pointes (TdP) is low. Additional steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, may be considered in patients with additional risk factors for TdP.
Pexidartinib: (Major) Avoid concomitant use of pexidartinib and ciprofloxacin due to the risk of increased pexidartinib exposure which may increase the risk for adverse effects. If concomitant use is necessary, reduce the pexidartinib dosage as follows: 500 mg/day or 375 mg/day of pexidartinib, reduce to 125 mg twice daily; 250 mg/day of pexidartinib, reduce to 125 mg once daily. If ciprofloxacin is discontinued, increase the pexidartinib dose to the original dose after 3 plasma half-lives of ciprofloxacin. Pexidartinib is a CYP3A substrate; ciprofloxacin is a moderate CYP3A inhibitor. Coadministration of another moderate CYP3A inhibitor increased pexidartinib overall exposure by 67%.
Phenytoin: (Moderate) Monitor phenytoin concentration and for phenytoin toxicity during and shortly after concomitant ciprofloxacin use. Concurrent use may result in altered phenytoin concentrations (increased or decreased).
Pimavanserin: (Major) Concomitant use of pimavanserin and ciprofloxacin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Pimozide: (Contraindicated) Pimozide is associated with a well-established risk of QT prolongation and torsade de pointes (TdP), and CYP1A2 is thought to be a minor metabolic route for pimozide. Elevated pimozide plasma concentrations due to impaired CYP1A2 metabolism may result in QT prolongation and ventricular arrhythmias. Therefore, the use of pimozide with potent CYP1A2 inhibitors such as ciprofloxacin should be avoided until more is known about the safety of these combinations. Although less likely than with most quinolones, coadministration of ciprofloxacin with drugs known to prolong the QT interval could increase the risk of developing TdP in predisposed patients. Rare cases of TdP have been reported with ciprofloxacin during post-marketing surveillance.
Pioglitazone: (Moderate) Monitor blood glucose during concomitant thiazolidinedione and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Pioglitazone; Glimepiride: (Moderate) Monitor blood glucose during concomitant sulfonylurea and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia. (Moderate) Monitor blood glucose during concomitant thiazolidinedione and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Pioglitazone; Metformin: (Moderate) Monitor blood glucose carefully when systemic quinolones and antidiabetic agents, including metformin, are coadministered. Discontinue the quinolone if a hypoglycemic reaction occurs and initiate appropriate therapy immediately. Disturbances of blood glucose, including hyperglycemia and hypoglycemia, have been reported in patients treated concomitantly with quinolones and an antidiabetic agent. Hypoglycemia, sometimes resulting in coma, can occur. (Moderate) Monitor blood glucose during concomitant thiazolidinedione and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Pirfenidone: (Major) Avoid concomitant administration of ciprofloxacin and pirfenidone because it increases exposure to pirfenidone. If concurrent use cannot be avoided, it is recommended with the use of ciprofloxacin at a dosage of 750 mg twice daily that the maintenance dose of pirfenidone be reduced to 534 mg PO 3 times daily. Careful monitoring is suggested when ciprofloxacin is used at a dosage of 250 mg or 500 mg daily. Monitor for adverse effects of pirfenidone, like elevated hepatic enzymes, arthralgia, or nausea. Ciprofloxacin is a moderate inhibitor of CYP1A2, and pirfenidone is primarily metabolized by CYP1A2. In a single-dose study, coadministration of pirfenidone 801 mg and ciprofloxacin, which was dosed at 750 mg twice daily from days 2 to 7, on day 6 increased pirfenidone exposure by 81%.
Piroxicam: (Moderate) Use quinolones and nonsteroidal anti-inflammatory drugs (NSAIDs) concomitantly with caution due to potential increased risk of CNS stimulation and convulsive seizures. NSAIDs in combination with very high doses of quinolones have been shown to provoke convulsions in preclinical studies and postmarketing.
Pitolisant: (Major) Concomitant use of pitolisant and ciprofloxacin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Polycarbophil: (Major) Administer oral ciprofloxacin at least 2 hours before or 6 hours after calcium polycarbophil. Ciprofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations.
Polyethylene Glycol; Electrolytes: (Major) Administer quinolones at least 2 hours before or 6 hours after administration of magnesium sulfate; potassium sulfate; sodium sulfate. The absorption of quinolones may be reduced by chelation with magnesium sulfate.
Polyethylene Glycol; Electrolytes; Ascorbic Acid: (Major) Administer quinolones at least 2 hours before or 6 hours after administration of magnesium sulfate; potassium sulfate; sodium sulfate. The absorption of quinolones may be reduced by chelation with magnesium sulfate.
Polysaccharide-Iron Complex: (Moderate) Administer oral ciprofloxacin at least 2 hours before or 6 hours after oral products that contain iron. Ciprofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations.
Pomalidomide: (Major) Avoid the concomitant use of pomalidomide and ciprofloxacin; significantly increased pomalidomide exposure may occur increasing the risk of pomalidomide adverse events. If concomitant use is unavoidable, decrease the pomalidomide dose to 2 mg once daily and monitor for pomalidomide adverse events. Pomalidomide is a CYP1A2 substrate and ciprofloxacin is a strong CYP1A2 inhibitor. In healthy volunteers, the AUC value for pomalidomide was increased by 125% when pomalidomide was co-administered with a strong CYP1A2 inhibitor.
Ponesimod: (Major) Concomitant use of ciprofloxacin and ponesimod increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary. Ponesimod has a limited effect on the QT/QTc interval at therapeutic doses but may cause bradycardia and atrioventricular conduction delays which may increase the risk for TdP in patients with a prolonged QT/QTc interval.
Porfimer: (Major) Avoid the concomitant use of porfimer with other drugs known to cause photosensitivity, such as ciprofloxacin. Concomitant use with other photosensitizing agents may increase the risk of a photosensitivity reaction.
Posaconazole: (Moderate) Concomitant use of ciprofloxacin and posaconazole may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Pralsetinib: (Major) Avoid concomitant use of ciprofloxacin with pralsetinib due to the risk of increased pralsetinib exposure which may increase the risk of adverse reactions. If concomitant use is necessary, reduce the daily dose of pralsetinib by 100 mg. Pralsetinib is a CYP3A substrate and ciprofloxacin is a moderate CYP3A inhibitor. Coadministration with a moderate CYP3A inhibitor is predicted to increase the overall exposure of pralsetinib by 71%.
Pramlintide: (Moderate) Monitor blood glucose carefully when systemic quinolones and antidiabetic agents, including pramlintide, are coadministered. Discontinue the quinolone if a hypoglycemic reaction occurs and initiate appropriate therapy immediately. Disturbances of blood glucose, including hyperglycemia and hypoglycemia, have been reported in patients treated concomitantly with quinolones and an antidiabetic agent. Hypoglycemia, sometimes resulting in coma, can occur.
Prednisolone: (Moderate) Quinolones have been associated with an increased risk of tendon rupture requiring surgical repair or resulting in prolonged disability; this risk is further increased in those receiving concomitant corticosteroids. Discontinue quinolone therapy at the first sign of tendon inflammation or tendon pain, as these are symptoms that may precede rupture of the tendon.
Prednisone: (Moderate) Quinolones have been associated with an increased risk of tendon rupture requiring surgical repair or resulting in prolonged disability; this risk is further increased in those receiving concomitant corticosteroids. Discontinue quinolone therapy at the first sign of tendon inflammation or tendon pain, as these are symptoms that may precede rupture of the tendon.
Primaquine: (Moderate) Concomitant use of ciprofloxacin and primaquine may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Probenecid: (Minor) Probenecid decreases renal secretion of ciprofloxacin by 50%, resulting in elevated ciprofloxacin serum concentrations and prolonging its half-life.
Probenecid; Colchicine: (Major) Due to the risk for serious colchicine toxicity including multi-organ failure and death, avoid coadministration of colchicine and ciprofloxacin in patients with normal renal and hepatic function unless the use of both agents is imperative. Coadministration is contraindicated in patients with renal or hepatic impairment because colchicine accumulation may be greater in these populations. Ciprofloxacin can inhibit colchicine's metabolism via CYP3A4, resulting in increased colchicine exposure. If coadministration in patients with normal renal and hepatic function cannot be avoided, adjust the dose of colchicine by either reducing the daily dose or the dosage frequency, and carefully monitor for colchicine toxicity. Specific dosage adjustment recommendations are available for the Colcrys product for patients who have taken a moderate CYP3A4 inhibitor like ciprofloxacin in the past 14 days or require concurrent use: for prophylaxis of gout flares, if the original dose is 0.6 mg twice daily, decrease to 0.3 mg twice daily or 0.6 mg once daily or if the original dose is 0.6 mg once daily, decrease the dose to 0.3 mg once daily; for treatment of gout flares, give 1.2 mg as a single dose and do not repeat for at least 3 days; for familial Mediterranean fever, do not exceed 1.2 mg/day. (Minor) Probenecid decreases renal secretion of ciprofloxacin by 50%, resulting in elevated ciprofloxacin serum concentrations and prolonging its half-life.
Procainamide: (Major) Concomitant use of procainamide and ciprofloxacin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Prochlorperazine: (Minor) QT/QTc prolongation can occur with concomitant use of ciprofloxacin and prochlorperazine although the risk of developing torsade de pointes (TdP) is low. Additional steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, may be considered in patients with additional risk factors for TdP.
Promethazine: (Moderate) Concomitant use of ciprofloxacin and promethazine may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Promethazine; Dextromethorphan: (Moderate) Concomitant use of ciprofloxacin and promethazine may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Promethazine; Phenylephrine: (Moderate) Concomitant use of ciprofloxacin and promethazine may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Propafenone: (Major) Concomitant use of ciprofloxacin and propafenone increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Pyridoxine, Vitamin B6: (Moderate) Administer oral ciprofloxacin at least 2 hours before or 6 hours after oral products that contain calcium. Ciprofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Examples of compounds that may interfere with quinolone bioavailability include antacids and multivitamins that contain calcium.
Quazepam: (Moderate) Ciprofloxacin is a CYP3A4 inhibitor and may reduce the metabolism of quazepam and increase the potential for benzodiazepine toxicity.
Quetiapine: (Major) Concomitant use of ciprofloxacin and quetiapine increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Quinapril: (Moderate) Administer oral ciprofloxacin at least 2 hours before or 6 hours after quinapril tablets, which contain magnesium. Ciprofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations.
Quinapril; Hydrochlorothiazide, HCTZ: (Moderate) Administer oral ciprofloxacin at least 2 hours before or 6 hours after quinapril tablets, which contain magnesium. Ciprofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations.
Quinidine: (Major) Concomitant use of quinidine and ciprofloxacin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Quinine: (Major) Concomitant use of quinine and ciprofloxacin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Quizartinib: (Major) Concomitant use of quizartinib and ciprofloxacin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Ramelteon: (Major) Ramelteon should be administered with caution to patients taking CYP1A2 inhibitors, such as systemic ciprofloxacin. Strong CYP1A2 inhibitors have been shown to have significant interactions with ramelteon, leading to elevated AUC of ramelteon > 190-fold and Cmax > 70-fold. If ciprofloxacin must be administered with ramelteon, monitor the patient closely for toxicity due to elevated ramelteon serum concentrations. Consider if an alternative fluoroquinolone with no CYP1A2 inhibition, like levofloxacin, could be utilized, or, if ramelteon therapy could be temporarily halted during use of ciprofloxacin. Non-systemic ciprofloxacin formulas, like ear drops, do not interact.
Ranolazine: (Moderate) Concomitant use of ciprofloxacin and ranolazine may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Rasagiline: (Major) Do not exceed a rasagiline dose of 0.5 mg once daily when coadministered with ciprofloxacin. Coadministration may result in increased rasagiline concentrations. Rasagiline is primarily metabolized by CYP1A2; ciprofloxacin is a strong CYP1A2 inhibitor. When rasagiline was administered with ciprofloxacin, the AUC of rasagiline increased by 83%.
Regular Insulin: (Moderate) Monitor blood glucose during concomitant insulin and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Regular Insulin; Isophane Insulin (NPH): (Moderate) Monitor blood glucose during concomitant insulin and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Relugolix: (Moderate) Concomitant use of ciprofloxacin and androgen deprivation therapy (i.e., relugolix) may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Relugolix; Estradiol; Norethindrone acetate: (Moderate) Concomitant use of ciprofloxacin and androgen deprivation therapy (i.e., relugolix) may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Repaglinide: (Moderate) Monitor blood glucose carefully when systemic quinolones and antidiabetic agents, including meglitinides, are coadministered. Discontinue the quinolone if a hypoglycemic reaction occurs and initiate appropriate therapy immediately. Disturbances of blood glucose, including hyperglycemia and hypoglycemia, have been reported in patients treated concomitantly with quinolones and an antidiabetic agent. Hypoglycemia, sometimes resulting in coma, can occur.
Ribociclib: (Major) Concomitant use of ribociclib and ciprofloxacin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Ribociclib; Letrozole: (Major) Concomitant use of ribociclib and ciprofloxacin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Rifampin: (Moderate) It may be necessary to adjust the dosage of ciprofloxacin if given concurrently with rifampin. Rifampin may induce the metabolism of ciprofloxacin; coadministration may result in decreased ciprofloxacin plasma concentrations. Ciprofloxacin and rifampin have been used concomitantly in some cases for the treatment of MRSA.
Rilpivirine: (Moderate) Concomitant use of ciprofloxacin and rilpivirine may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP. The degree of QT prolongation associated with rilpivirine is not clinically significant when administered within the recommended dosage range; QT prolongation has been described at 3 times the maximum recommended dose.
Riluzole: (Moderate) Coadministration of riluzole with ciprofloxacin may increase the risk for riluzole-related adverse reactions, such as gastrointestinal symptoms and elevated hepatic enzymes. In vitro findings suggest an increase in riluzole exposure is likely; riluzole is a CYP1A2 substrate and ciprofloxacin is a CYP1A2 inhibitor.
Rimegepant: (Major) Avoid a second dose of rimegepant within 48 hours if coadministered with ciprofloxacin; concurrent use may increase rimegepant exposure. Rimegepant is a CYP3A4 substrate and ciprofloxacin is a moderate CYP3A4 inhibitor.
Risperidone: (Moderate) Concomitant use of ciprofloxacin and risperidone may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Romidepsin: (Moderate) Concomitant use of ciprofloxacin and romidepsin may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Ropinirole: (Moderate) Ropinirole is primarily metabolized by CYP1A2. Ropinirole clearance has been shown to be reduced by coadministration of inhibitors of CYP1A2, such as ciprofloxacin. Therefore, if therapy with a drug known to be a potent inhibitor or inducer of CYP1A2 is initiated or discontinued during treatment with ropinirole, adjustment of ropinirole dose may be required. Coadministration of ciprofloxacin (500 mg twice daily) with ropinirole (2 mg three times per day) significantly increases ropinirole AUC by 84% on average, and Cmax by 60%.
Ropivacaine: (Moderate) Ropivacaine is metabolized to a 3-OH metabolite primarily by CYP1A2 and to a lesser extent to the pipecoloxylidide (PPX) metabolite by CYP3A4. In a double-blind study, ciprofloxacin reduced the mean plasma clearance of ropivacaine by 31% by inhibiting CYP1A2 and increased the formation of PPX by redirecting metabolism to CYP3A4.
Rosiglitazone: (Moderate) Monitor blood glucose during concomitant thiazolidinedione and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Saquinavir: (Major) Concomitant use of ciprofloxacin and saquinavir increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Saxagliptin: (Moderate) Monitor blood glucose during concomitant dipeptidyl peptidase-4 inhibitors and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Segesterone Acetate; Ethinyl Estradiol: (Minor) Coadministration of segesterone and moderate CYP3A4 inhibitors such as ciprofloxacin may increase the serum concentration of segesterone.
Selpercatinib: (Major) Avoid coadministration of selpercatinib and ciprofloxacin due to the risk of additive QT prolongation and increased selpercatinib exposure resulting in increased treatment-related adverse effects. If coadministration is unavoidable, reduce the dose of selpercatinib to 80 mg PO twice daily if original dose was 120 mg twice daily, and to 120 mg PO twice daily if original dose was 160 mg twice daily. Monitor ECGs for QT prolongation more frequently. If ciprofloxacin is discontinued, resume the original selpercatinib dose after 3 to 5 elimination half-lives of ciprofloxacin. Selpercatinib is a CYP3A4 substrate that has been associated with concentration-dependent QT prolongation; ciprofloxacin is a moderate CYP3A4 inhibitor that has been associated with rare cases of QT prolongation and torsade de pointes (TdP) during postmarketing surveillance. Coadministration with other moderate CYP3A4 inhibitors is predicted to increase selpercatinib exposure by 60% to 99%.
Selumetinib: (Major) Avoid coadministration of selumetinib and ciprofloxacin due to the risk of increased selumetinib exposure which may increase the risk of adverse reactions. If coadministration is unavoidable, reduce the dose of selumetinib to 20 mg/m2 PO twice daily if original dose was 25 mg/m2 twice daily and 15 mg/m2 PO twice daily if original dose was 20 mg/m2 twice daily. If ciprofloxacin is discontinued, resume the original selumetinib dose after 3 elimination half-lives of ciprofloxacin. Selumetinib is a CYP3A4 substrate and ciprofloxacin is a moderate CYP3A4 inhibitor. Coadministration with a moderate CYP3A4 inhibitor is predicted to increase selumetinib exposure by 41%.
Semaglutide: (Moderate) Monitor blood glucose during concomitant incretin mimetic and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Sertraline: (Moderate) Concomitant use of ciprofloxacin and sertraline may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP. The degree of QT prolongation associated with sertraline is not clinically significant when administered within the recommended dosage range; QT prolongation has been described at 2 times the maximum recommended dose.
Sevelamer: (Moderate) Administer oral ciprofloxacin at least 2 hours before or 6 hours after sevelamer. Ciprofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. In a study of 15 healthy subjects, the bioavailability of ciprofloxacin was decreased by approximately 50% when coadministered with sevelamer.
Sevoflurane: (Major) Concomitant use of ciprofloxacin and halogenated anesthetics increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
SGLT2 Inhibitors: (Moderate) Monitor blood glucose during concomitant SGLT2 inhibitor and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Sildenafil: (Moderate) Monitor for an increase in sildenafil-related adverse reactions if coadministration with ciprofloxacin is necessary; consider a starting dose of 25 mg of sildenafil when prescribed for erectile dysfunction. Sildenafil is a sensitive CYP3A4 substrate and ciprofloxacin is a moderate CYP3A4 inhibitor. In a drug interaction study, coadministration with a moderate CYP3A4 inhibitor increased the Cmax and AUC of sildenafil by 160% and 182%, respectively. Predictions based on a pharmacokinetic model suggest that drug-drug interactions with CYP3A4 inhibitors will be less for sildenafil injection than those observed after oral sildenafil administration.
Simvastatin: (Moderate) Monitor for evidence of myopathy, including rhabdomyolysis, during coadministration of ciprofloxacin and simvastatin. There are case reports of rhabdomyolysis in patients stabilized on a simvastatin regimen after the addition of ciprofloxacin. Ciprofloxacin may increase simvastatin exposure. Simvastatin is a substrate for CYP3A; ciprofloxacin is a moderate CYP3A inhibitor.
Siponimod: (Major) In general, do not initiate treatment with siponimod in patients receiving ciprofloxacin due to the potential for QT prolongation. Consult a cardiologist regarding appropriate monitoring if siponimod use is required. Siponimod therapy prolonged the QT interval at recommended doses in a clinical study. Ciprofloxacin has also been associated with prolongation of the QT interval. Additionally, concomitant use of siponimod and ciprofloxacin may increase siponimod exposure. If the patient is also receiving a drug regimen containing a modera te CYP2C9 inhibitor, use of siponimod is not recommended due to a significant increase in siponimod exposure. Siponimod is a CYP2C9 and CYP3A4 substrate; ciprofloxacin is a moderate CYP3A4 inhibitor. Coadministration with a moderate CYP2C9/CYP3A4 dual inhibitor led to a 2-fold increase in the exposure of siponimod.
Sirolimus: (Moderate) Monitor sirolimus concentrations and adjust sirolimus dosage as appropriate during concomitant use of ciprofloxacin. Coadministration may increase sirolimus concentrations and increase the risk for sirolimus-related adverse effects. Sirolimus is a CYP3A substrate and ciprofloxacin is a moderate CYP3A inhibitor. Concomitant use with another moderate CYP3A inhibitor increased sirolimus overall exposure 1.6-fold.
Sitagliptin: (Moderate) Monitor blood glucose during concomitant dipeptidyl peptidase-4 inhibitors and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Sodium Bicarbonate: (Moderate) Crystalluria related to ciprofloxacin has been reported only rarely in humans because human urine is usually acidic. Avoid alkalinity of the urine in patients receiving ciprofloxacin when possible. A large proportion of ciprofloxacin is normally excreted unchanged in the urine. If sodium bicarbonate is used concomitantly, the solubility of ciprofloxacin might be decreased because of alkaline urine. Patients should be monitored for crystalluria, proper urination,and altered kidney function. Hydrate patients well to prevent the formation of highly concentrated urine.
Sodium Ferric Gluconate Complex; ferric pyrophosphate citrate: (Moderate) Administer oral ciprofloxacin at least 2 hours before or 6 hours after oral products that contain iron. Ciprofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations.
Sodium picosulfate; Magnesium oxide; Anhydrous citric acid: (Major) Prior or concomitant use of antibiotics with sodium picosulfate; magnesium oxide; anhydrous citric acid may reduce efficacy of the bowel preparation as conversion of sodium picosulfate to its active metabolite bis-(p-hydroxy-phenyl)-pyridyl-2-methane (BHPM) is mediated by colonic bacteria. If possible, avoid coadministration. Certain antibiotics (i.e., tetracyclines and quinolones) may chelate with the magnesium in sodium picosulfate; magnesium oxide; anhydrous citric acid solution. Therefore, these antibiotics should be taken at least 2 hours before and not less than 6 hours after the administration of sodium picosulfate; magnesium oxide; anhydrous citric acid solution.
Sodium Stibogluconate: (Moderate) Concomitant use of sodium stibogluconate and ciprofloxacin may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Sodium Sulfate; Magnesium Sulfate; Potassium Chloride: (Moderate) Administer oral ciprofloxacin at least 2 hours before or 6 hours after oral products that contain magnesium. Ciprofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations.
Sofosbuvir; Velpatasvir: (Moderate) Use caution when administering velpatasvir with ciprofloxacin. Taking these drugs together may increase velpatasvir plasma concentrations, potentially resulting in adverse events. Ciprofloxacin is a weak CYP3A4 inhibitor; velpatasvir is a substrate of CYP3A4.
Sofosbuvir; Velpatasvir; Voxilaprevir: (Moderate) Use caution when administering velpatasvir with ciprofloxacin. Taking these drugs together may increase velpatasvir plasma concentrations, potentially resulting in adverse events. Ciprofloxacin is a weak CYP3A4 inhibitor; velpatasvir is a substrate of CYP3A4.
Solifenacin: (Moderate) Concomitant use of ciprofloxacin and solifenacin may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Sonidegib: (Major) Avoid the concomitant use of sonidegib and ciprofloxacin; sonidegib exposure may be significantly increased resulting in increased risk of adverse events, particularly musculoskeletal toxicity. If concomitant use cannot be avoided, administer ciprofloxacin for less than 14 days; monitor patients closely for adverse reactions (e.g., elevated serum creatine kinase and serum creatinine levels). Sonidegib is a CYP3A substrate and ciprofloxacin is a moderate CYP3A4 inhibitor. Physiologic-based pharmacokinetic (PBPK) simulations indicate a moderate 3A4 inhibitor would increase the sonidegib AUC by 1.8-fold if administered for 14 days and by 2.8-fold if the moderate CYP3A inhibitor is administered with sonidegib for more than 14 days.
Sorafenib: (Major) Concomitant use of sorafenib and ciprofloxacin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Sotagliflozin: (Moderate) Monitor blood glucose during concomitant SGLT2 inhibitor and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Sotalol: (Major) Concomitant use of ciprofloxacin and sotalol increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Sparsentan: (Moderate) Monitor for an increase in sparsentan-related adverse effects if concomitant use with ciprofloxacin is necessary. Concomitant use may increase sparsentan exposure. Sparsentan is a CYP3A substrate and ciprofloxacin is a moderate CYP3A inhibitor. Concomitant use with another moderate CYP3A inhibitor increased sparsentan overall exposure by 70%.
Sucralfate: (Moderate) Administer oral ciprofloxacin at least 2 hours before or 6 hours after sucralfate. Ciprofloxacin absorption may be reduced as quinolone antibiotics can chelate with sucralfate. This interaction appears to be the result of chelation by the aluminum content of sucralfate.
Sufentanil: (Moderate) Because the dose of the sufentanil sublingual tablets cannot be titrated, consider an alternate opiate if ciprofloxacin must be administered. Consider a reduced dose of sufentanil injection with frequent monitoring for respiratory depression and sedation if concurrent use of ciprofloxacin is necessary. If ciprofloxacin is discontinued, consider increasing the sufentanil injection dose until stable drug effects are achieved and monitor for evidence of opioid withdrawal. Sufentanil is a CYP3A4 substrate, and coadministration with a moderate CYP3A4 inhibitor like ciprofloxacin can increase sufentanil exposure resulting in increased or prolonged opioid effects including fatal respiratory depression, particularly when an inhibitor is added to a stable dose of sufentanil. If ciprofloxacin is discontinued, sufentanil plasma concentrations will decrease resulting in reduced efficacy of the opioid and potential withdrawal syndrome in a patient who has developed physical dependence to sufentanil.
Sulfonylureas: (Moderate) Monitor blood glucose during concomitant sulfonylurea and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Sulindac: (Moderate) Use quinolones and nonsteroidal anti-inflammatory drugs (NSAIDs) concomitantly with caution due to potential increased risk of CNS stimulation and convulsive seizures. NSAIDs in combination with very high doses of quinolones have been shown to provoke convulsions in preclinical studies and postmarketing.
Sumatriptan; Naproxen: (Moderate) Use quinolones and nonsteroidal anti-inflammatory drugs (NSAIDs) concomitantly with caution due to potential increased risk of CNS stimulation and convulsive seizures. NSAIDs in combination with very high doses of quinolones have been shown to provoke convulsions in preclinical studies and postmarketing.
Sunitinib: (Moderate) Concomitant use of ciprofloxacin and sunitinib may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Suvorexant: (Major) A dose reduction to 5 mg of suvorexant is recommended during concurrent use with ciprofloxacin. The suvorexant dose may be increased to 10 mg if needed for efficacy. Suvorexant is a CYP3A4 substrate and ciprofloxacin is a moderate CYP3A4 inhibitor. Coadministration with a moderate CYP3A4 inhibitor increased the suvorexant AUC by 2-fold.
Tacrolimus: (Moderate) Concomitant use of ciprofloxacin and tacrolimus may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Tamoxifen: (Moderate) Concomitant use of tamoxifen and ciprofloxacin may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Tasimelteon: (Moderate) Caution is recommended during concurrent use of tasimelteon and enoxacin or ciprofloxacin. Because tasimelteon is partially metabolized via CYP1A2, use with CYP1A2 inhibitors, such as enoxacin or ciprofloxacin, may increase exposure to tasimelteon and the potential for adverse reactions.
Tazarotene: (Moderate) Use tazarotene with caution in patients who are also taking drugs known to be photosensitizers, such as ciprofloxacin, as concomitant use may augment phototoxicity. Patients should take care and use proper techniques to limit sunlight and UV exposure of treated areas.
Tazemetostat: (Major) Avoid coadministration of tazemetostat with ciprofloxacin as concurrent use may increase tazemetostat exposure and the frequency and severity of adverse reactions. If concomitant use is unavoidable, decrease current tazemetostat daily dosage by 50% (e.g., decrease 800 mg PO twice daily to 400 mg PO twice daily; 600 mg PO twice daily to 400 mg PO for first dose and 200 mg PO for second dose; 400 mg PO twice daily to 200 mg PO twice daily). If ciprofloxacin is discontinued, wait at least 3 half-lives of ciprofloxacin before increasing the dose of tazemetostat to the previous tolerated dose. Tazemetostat is a CYP3A4 substrate and ciprofloxacin is a moderate CYP3A4 inhibitor. Coadministration of another moderate CYP3A4 inhibitor increased tazemetostat exposure by 3.1-fold.
Telavancin: (Moderate) Concomitant use of ciprofloxacin and telavancin may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Telmisartan; Amlodipine: (Moderate) Monitor for symptoms of hypotension and edema if coadministration of amlodipine with ciprofloxacin is necessary; adjust the dose of amlodipine as clinically appropriate. Amlodipine is a CYP3A substrate and ciprofloxacin is a moderate CYP3A inhibitor. Coadministration with a moderate CYP3A4 inhibitor in elderly hypertensive patients increased systemic exposure to amlodipine by 60%. However, coadministration with another moderate CYP3A4 inhibitor in healthy volunteers did not significantly change amlodipine exposure.
Terbinafine: (Moderate) Due to the risk for terbinafine related adverse effects, caution is advised when coadministering ciprofloxacin. Although this interaction has not been studied by the manufacturer, and published literature suggests the potential for interactions to be low, taking these drugs together may increase the systemic exposure of terbinafine. Predictions about the interaction can be made based on the metabolic pathways of both drugs. Terbinafine is metabolized by at least 7 CYP isoenyzmes, with major contributions coming from CYP1A2; ciprofloxacin is an inhibitor of this enzyme. Monitor patients for adverse reactions if these drugs are coadministered.
Teriflunomide: (Moderate) Teriflunomide is an inhibitor of the renal uptake organic anion transporter OAT3. Use of teriflunomide with ciprofloxacin, a substrate of OAT3, may increase ciprofloxacin plasma concentrations. Monitor for increased adverse effects from ciprofloxacin, such as nausea, vomiting, diarrhea, or abdominal pain. Adjust the dose of ciprofloxacin as necessary and clinically appropriate.
Tetrabenazine: (Major) Concomitant use of tetrabenazine and ciprofloxacin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Tezacaftor; Ivacaftor: (Major) If ciprofloxacin and ivacaftor are taken together, administer ivacaftor at the usual recommended dose but reduce the frequency to once daily. Coadministration is not recommended in patients younger than 6 months. Ivacaftor is a CYP3A substrate and ciprofloxacin is a moderate CYP3A inhibitor. Coadministration with another moderate CYP3A inhibitor increased ivacaftor exposure by 3-fold. (Moderate) Monitor patients closely for tezacaftor; ivacaftor-related adverse reactions if coadministration with ciprofloxacin is necessary. Pharmacokinetic data suggest that no dose adjustment is necessary if tezacaftor; ivacaftor is coadministered with ciprofloxacin. However, because ciprofloxacin is a moderate CYP3A inhibitor, there is a potential for increased tezacaftor; ivacaftor exposure and adverse reactions with concurrent use of ciprofloxacin. Of note, FDA-approved labeling generally recommends tezacaftor; ivacaftor dosage adjustment when coadministered with a moderate CYP3A inhibitor (1 tezacaftor; ivacaftor combination tablet every other day in the morning and 1 ivacaftor tablet every other day in the morning on alternate days).
Theophylline, Aminophylline: (Major) Avoid coadministration of ciprofloxacin and aminophylline due to the potential for increased and prolonged plasma exposure of theophylline. Monitor theophylline concentrations and adjust dosage as appropriate if concurrent administration cannot be avoided. Ciprofloxacin reduces the clearance of theophylline by 31%. Serious and fatal reactions have occurred in patients receiving concurrent ciprofloxacin and theophylline. These reactions have included cardiac arrest, seizure, status epilepticus, and respiratory failure. Although similar serious adverse reactions have been reported in patients receiving theophylline alone, the possibility that these reactions may be potentiated by ciprofloxacin cannot be eliminated. Ciprofloxacin is CYP1A2 inhibitor, and theophylline is a substrate of CYP1A2. (Major) Avoid coadministration of ciprofloxacin and theophylline due to the potential for increased and prolonged plasma exposure of theophylline. Monitor theophylline concentrations and adjust dosage as appropriate if concurrent administration cannot be avoided. Ciprofloxacin reduces the clearance of theophylline by 31%. Serious and fatal reactions have occurred in patients receiving concurrent ciprofloxacin and theophylline. These reactions have included cardiac arrest, seizure, status epilepticus, and respiratory failure. Although similar serious adverse reactions have been reported in patients receiving theophylline alone, the possibility that these reactions may be potentiated by ciprofloxacin cannot be eliminated. Ciprofloxacin is CYP1A2 inhibitor, and theophylline is a substrate of CYP1A2.
Thiazolidinediones: (Moderate) Monitor blood glucose during concomitant thiazolidinedione and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Thioridazine: (Contraindicated) Avoid concomitant use of thioridazine and ciprofloxacin due to an increased risk for torsade de pointes (TdP) and QT/QTc prolongation.
Tirzepatide: (Moderate) Monitor blood glucose during concomitant incretin mimetic and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Tizanidine: (Contraindicated) Concomitant use of tizanidine and ciprofloxacin is contraindicated due to the risk of tizanidine toxicity, including clinically significant hypotension, bradycardia, and sedation. Tizanidine is a CYP1A2 substrate and ciprofloxacin is a strong CYP1A2 inhibitor. After a single 4 mg tizanidine dose, Cmax and AUC increased by 7-fold and 10-fold, respectively, when administered with ciprofloxacin during pharmacokinetic trials.
Tolazamide: (Moderate) Monitor blood glucose during concomitant sulfonylurea and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Tolbutamide: (Moderate) Monitor blood glucose during concomitant sulfonylurea and quinolone use. Concomitant use may cause an increased blood glucose-lowering effect with risk of hypoglycemia.
Tolmetin: (Moderate) Use quinolones and nonsteroidal anti-inflammatory drugs (NSAIDs) concomitantly with caution due to potential increased risk of CNS stimulation and convulsive seizures. NSAIDs in combination with very high doses of quinolones have been shown to provoke convulsions in preclinical studies and postmarketing.
Tolterodine: (Moderate) Tolterodine is associated with dose-dependent prolongation of the QT interval, especially in poor metabolizers of CYP2D6. Drugs that are also associated with QT prolongation and have antimuscarinic properties that should be used cautiously and with close monitoring with tolterodine include ciprofloxacin.
Tolvaptan: (Major) Avoid coadministration of ciprofloxacin when tolvaptan is administered for hyponatremia. In patients with autosomal dominant polycystic kidney disease (ADPKD), reduce tolvaptan dosage if administered with ciprofloxacin. In ADPKD patients receiving tolvaptan 90mg every morning and 30 mg every evening, reduce the dose to 45 mg every morning and 15 mg every evening; for those receiving tolvaptan 60 mg every morning and 30 mg every evening, reduce the dose to 30 mg every morning and 15 mg every evening; for those receiving tolvaptan 45 mg every morning and 15 mg every evening, reduce the dose to 15 mg every morning and 15 mg every evening. Consider additional dosage reduction if the reduced dose is not tolerated. Interrupt tolvaptan in ADPKD patients if the recommended reduced doses are not available in patients requiring short-term therapy of ciprofloxacin. Tolvaptan is a sensitive CYP3A4 substrate; ciprofloxacin is a moderate CYP3A4 inhibitor. Coadministration of another moderate CYP3A4 inhibitor increased the tolvaptan AUC by 200%.
Toremifene: (Major) Concomitant use of toremifene and ciprofloxacin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Trazodone: (Major) Concomitant use of ciprofloxacin and trazodone increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Tretinoin, ATRA: (Major) Avoid the concomitant use of tretinoin with other drugs known to cause photosensitivity, such as ciprofloxacin. Concomitant use with other photosensitizing agents may increase the risk of a photosensitivity reaction.
Tretinoin; Benzoyl Peroxide: (Major) Avoid the concomitant use of tretinoin with other drugs known to cause photosensitivity, such as ciprofloxacin. Concomitant use with other photosensitizing agents may increase the risk of a photosensitivity reaction.
Triamcinolone: (Moderate) Quinolones have been associated with an increased risk of tendon rupture requiring surgical repair or resulting in prolonged disability; this risk is further increased in those receiving concomitant corticosteroids. Discontinue quinolone therapy at the first sign of tendon inflammation or tendon pain, as these are symptoms that may precede rupture of the tendon.
Triamterene: (Minor) Triamterene is a substrate for CYP1A2. Theoretically, the metabolism of triamterene may be affected by drugs that are inhibitors CYP1A2, such as ciprofloxacin.
Triamterene; Hydrochlorothiazide, HCTZ: (Minor) Triamterene is a substrate for CYP1A2. Theoretically, the metabolism of triamterene may be affected by drugs that are inhibitors CYP1A2, such as ciprofloxacin.
Triazolam: (Moderate) Monitor for signs of triazolam toxicity during coadministration with ciprofloxacin and consider appropriate dose reduction of triazolam if clinically indicated. Coadministration may increase triazolam exposure. Triazolam is a sensitive CYP3A substrate and ciprofloxacin is a moderate CYP3A inhibitor.
Triclabendazole: (Moderate) Concomitant use of triclabendazole and ciprofloxacin may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Trifluoperazine: (Minor) QT/QTc prolongation can occur with concomitant use of ciprofloxacin and trifluoperazine although the risk of developing torsade de pointes (TdP) is low. Additional steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, may be considered in patients with additional risk factors for TdP.
Triptorelin: (Moderate) Concomitant use of ciprofloxacin and androgen deprivation therapy (i.e., triptorelin) may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Ubrogepant: (Major) Limit the initial dose of ubrogepant to 50 mg and avoid a second dose within 24 hours if coadministered with ciprofloxacin. Concurrent use may increase ubrogepant exposure and the risk of adverse effects. Ubrogepant is a CYP3A4 substrate; ciprofloxacin is a moderate CYP3A4 inhibitor. Coadministration with another moderate CYP3A4 inhibitor resulted in a 3.5-fold increase in the exposure of ubrogepant.
Ursodeoxycholic Acid, Ursodiol: (Moderate) There has been one case report of reduced serum concentrations of ciprofloxacin after the administration of ursodeoxycholic acid, ursodiol to a patient with hepatobiliary disease. The mechanism of the proposed interaction is uncertain.
Valdecoxib: (Moderate) Use quinolones and nonsteroidal anti-inflammatory drugs (NSAIDs) concomitantly with caution due to potential increased risk of CNS stimulation and convulsive seizures. NSAIDs in combination with very high doses of quinolones have been shown to provoke convulsions in preclinical studies and postmarketing.
Vandetanib: (Major) Concomitant use of vandetanib and ciprofloxacin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Vardenafil: (Major) Do not use vardenafil orally disintegrating tablets with ciprofloxacin due to increased vardenafil exposure; do not exceed a single dose of 5 mg per 24-hour period of vardenafil oral tablets. Concomitant use also increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Vardenafil is primarily metabolized by CYP3A and ciprofloxacin is a moderate CYP3A inhibitor. Coadministration with another moderate CYP3A inhibitor increased the AUC of vardenafil by 4-fold.
Vemurafenib: (Major) Concomitant use of vemurafenib and ciprofloxacin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Venetoclax: (Major) Reduce the dose of venetoclax by at least 50% and monitor for venetoclax toxicity (e.g., hematologic toxicity, GI toxicity, and tumor lysis syndrome) if coadministered with ciprofloxacin due to the potential for increased venetoclax exposure. Resume the original venetoclax dose 2 to 3 days after discontinuation of ciprofloxacin. Venetoclax is a CYP3A4 substrate; ciprofloxacin is a moderate CYP3A4 inhibitor.
Venlafaxine: (Moderate) Concomitant use of ciprofloxacin and venlafaxine may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Verteporfin: (Moderate) Concomitant use of verteporfin with other photosensitizing agents, such as ciprofloxacin, may increase the potential for skin photosensitivity reactions.
Vinblastine: (Moderate) Monitor for an earlier onset and/or increased severity of vinblastine-related adverse reactions, including myelosuppression, constipation, and peripheral neuropathy, if coadministration with ciprofloxacin is necessary. Vinblastine is a CYP3A4 substrate and ciprofloxacin is a moderate CYP3A4 inhibitor. Enhanced vinblastine toxicity was reported with coadministration of another moderate CYP3A4 inhibitor.
Vinorelbine: (Moderate) Monitor for an earlier onset and/or increased severity of vinorelbine-related adverse reactions, including constipation and peripheral neuropathy, if coadministration with ciprofloxacin is necessary. Vinorelbine is a CYP3A4 substrate and ciprofloxacin is a moderate CYP3A4 inhibitor.
Voclosporin: (Major) Reduce the voclosporin dosage to 15.8 mg PO in the morning and 7.9 mg PO in the evening if coadministered with ciprofloxacin. Concomitant use may increase voclosporin exposure and the risk of voclosporin-related adverse effects such as nephrotoxicity, hypertension, and QT prolongation. Additive QT prolongation may also occur. Voclosporin is a sensitive CYP3A4 substrate and ciprofloxacin is a moderate CYP3A4 inhibitor that is associated with rare cases of QT prolongation and torsade de pointes (TdP). Coadministration with moderate CYP3A4 inhibitors is predicted to increase voclosporin exposure by 3-fold.
Vonoprazan; Amoxicillin; Clarithromycin: (Major) Concomitant use of clarithromycin and ciprofloxacin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Voriconazole: (Moderate) Concomitant use of ciprofloxacin and voriconazole may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Vorinostat: (Moderate) Concomitant use of ciprofloxacin and vorinostat may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Warfarin: (Moderate) Closely monitor the INR if coadministration of warfarin with ciprofloxacin is necessary as concurrent use may increase the exposure of warfarin leading to increased bleeding risk. Ciprofloxacin is a CYP1A2 and moderate CYP3A4 inhibitor and the R-enantiomer of warfarin is a CYP1A2/CYP3A4 substrate. The S-enantiomer of warfarin exhibits 2 to 5 times more anticoagulant activity than the R-enantiomer, but the R-enantiomer generally has a slower clearance. Interactions may be particularly problematic in the elderly.
Zanubrutinib: (Major) Decrease the zanubrutinib dose to 80 mg PO twice daily if coadministered with ciprofloxacin. Coadministration may result in increased zanubrutinib exposure and toxicity (e.g., infection, bleeding, and atrial arrhythmias). Further decrease the zanubrutinib dose as recommended if adverse reactions occur. After discontinuation of ciprofloxacin, resume the previous dose of zanubrutinib. Zanubrutinib is a CYP3A4 substrate; ciprofloxacin is a moderate CYP3A4 inhibitor. The AUC of zanubrutinib is predicted to increase by 157% to 317% when coadministered with other moderate CYP3A4 inhibitors.
Zinc Salts: (Major) Administer oral ciprofloxacin at least 2 hours before or 6 hours after oral products that contain zinc. Ciprofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Examples of compounds that may interfere with quinolone bioavailability include multivitamins that contain zinc.
Zinc: (Major) Administer oral ciprofloxacin at least 2 hours before or 6 hours after oral products that contain zinc. Ciprofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Examples of compounds that may interfere with quinolone bioavailability include multivitamins that contain zinc.
Ziprasidone: (Major) Concomitant use of ziprasidone and ciprofloxacin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
How Supplied
Cetraxal/Ciprofloxacin/Ciprofloxacin Hydrochloride Auricular (Otic) Sol: 0.2%
Ciloxan Ophthalmic Ointment: 0.3%
Ciloxan/Ciprofloxacin/Ciprofloxacin Hydrochloride Ophthalmic Sol: 0.3%
Cipro XR/Ciprofloxacin/Ciprofloxacin Hydrochloride/Proquin XR Oral Tab ER: 500mg, 1000mg
Cipro/Ciprofloxacin Oral Pwd F/Recon: 5mL, 250mg, 500mg
Cipro/Ciprofloxacin, Dextrose Intravenous Inj Sol: 2-5%
Cipro/Ciprofloxacin/Ciprofloxacin Hydrochloride Oral Tab: 100mg, 250mg, 500mg, 750mg
Maximum Dosage
1.5 g/day PO regular release products; 1 g/day PO Cipro XR; 1.2 g/day IV; 1 mg/ear/day otic solution; 12 mg/ear for otic suspension; 120 drops/eye/day of ophthalmic solution; maximum dosage not available for ophthalmic ointment.
Geriatric1.5 g/day PO regular release products; 1 g/day PO Cipro XR; 1.2 g/day IV; 1 mg/ear/day otic solution; 12 mg/ear for otic suspension; 120 drops/eye/day of ophthalmic solution; maximum dosage not available for ophthalmic ointment.
Adolescents45 mg/kg/day PO (Max: 1.5 g/day) or 30 mg/kg/day IV (Max: 1.2 g/day); for pulmonary exacerbations of cystic fibrosis, up to 2 g/day PO has been studied off label; safety and efficacy of extended-release oral products have not been established; 1 mg/ear/day otic solution; 12 mg/ear for otic suspension; 120 drops/eye/day of ophthalmic solution; maximum dosage not available for ophthalmic ointment.
Children2 to 12 years: 45 mg/kg/day PO (Max: 1.5 g/day) or 30 mg/kg/day IV (Max: 1.2 g/day); for pulmonary exacerbations of cystic fibrosis, up to 2 g/day PO has been studied off label; safety and efficacy of extended-release oral products have not been established; 1 mg/ear/day otic solution; 12 mg/ear for otic suspension; 120 drops/eye/day of ophthalmic solution; maximum dosage not available for ophthalmic ointment.
1 year: 45 mg/kg/day PO or 30 mg/kg/day IV; safety and efficacy of extended-release oral products have not been established; 1 mg/ear/day otic solution; 12 mg/ear for otic suspension; 120 drops/eye/day of ophthalmic solution; safety and efficacy not established for ophthalmic ointment.
6 to 11 months: 45 mg/kg/day PO or 30 mg/kg/day IV; 120 drops/eye/day of ophthalmic solution; 12 mg/ear for otic suspension. Safety and efficacy of other formulations have not been established.
1 to 5 months: 45 mg/kg/day PO or 30 mg/kg/day IV; 120 drops/eye/day of ophthalmic solution. Safety and efficacy of other formulations have not been established.
45 mg/kg/day PO or 30 mg/kg/day IV; 120 drops/eye/day of ophthalmic solution. Safety and efficacy of other formulations have not been established.
Mechanism Of Action
Ciprofloxacin is bactericidal via inhibition of DNA gyrase (topoisomerase II), an enzyme responsible for counteracting the excessive supercoiling of DNA during replication or transcription and topoisomerase IV, an enzyme that helps separate the daughter DNA molecules. In gram-negative bacteria, the primary target is the DNA gyrase A subunit, while the primary target in gram-positive bacteria is generally topoisomerase IV. Ciprofloxacin exhibits concentration-dependent pharmacodynamics where the ratio of area under the concentration curve of free drug to minimal inhibitory concentration (free AUC:MIC) appears to best correlate with antibacterial activity. Additionally, ciprofloxacin and other quinolones exhibit a prolonged post-antibiotic effect (PAE) for gram-negative organisms.[34143] [43411] [55080] [55081]
The susceptibility interpretive criteria for ciprofloxacin are delineated by pathogen. The MICs are defined for S. pneumoniae, beta-hemolytic streptococci, Staphylococcus sp., Enterococcus sp. (urinary isolates only), Acinetobacter sp., other non-Enterobacterales, C. jejuni/coli, Aerococcus sp., Aeromonas sp., Aggregatibacter sp., Cardiobacterium sp., E. corrodens, Kingella sp., Abiotrophia sp., Granulicatella sp., Bacillus sp. (excluding B. anthracis) and related genera, Brevibacillus sp., Cohnella sp., Lysinibacillus sp., Paenibacillus sp., Sporolactobacillus sp., Corynebacterium sp. and related Coryneform genera, and Vibrio sp. as susceptible at 1 mcg/mL or less, intermediate at 2 mcg/mL, and resistant at 4 mcg/mL or more. The MICs are defined for P. aeruginosa as susceptible at 0.5 mcg/mL or less, intermediate at 1 mcg/mL, and resistant at 2 mcg/mL or more (based on a dosage regimen of 400 mg IV every 8 hours). The MICs are defined for Enterobacterales (excluding Salmonella sp.) as susceptible at 0.25 mcg/mL or less, intermediate at 0.5 mcg/mL, and resistant at 1 mcg/mL or more (based on a dosage regimen of 400 mg IV or 500 mg PO every 12 hours). The MICs are defined for Salmonella sp. as susceptible at 0.06 mcg/mL or less, intermediate at 0.12 to 0.5 mcg/mL, and resistant at 1 mcg/mL or more. The MICs are defined for H. influenzae, H. parainfluenzae, E. rhusiopathiae, and M. catarrhalis as susceptible at 1 mcg/mL or less. The MICs are defined for N. meningitidis as susceptible at 0.03 mcg/mL or less, intermediate at 0.06 mcg/mL, and resistant at 0.12 mcg/mL or more and may be appropriate only for prophylaxis of meningococcal case contacts. These breakpoints do not apply to therapy of patients with invasive meningococcal disease. The MICs are defined for N. gonorrhoeae as susceptible at 0.06 mcg/mL or less, intermediate at 0.12 to 0.5 mcg/mL, and resistant at 1 mcg/mL or more. The MICs are defined for B. anthracis and Y. pestis as susceptible at 0.25 mcg/mL or less. The MIC is defined for F. tularensis as susceptible at 0.5 mcg/mL or less.
Resistance to quinolones, including ciprofloxacin, can occur due to multiple-step mutations in defined regions of the target bacterial enzymes topoisomerase IV and DNA gyrase, referred to as Quinolone-Resistance Determining Regions (QRDRs), or through altered efflux.[34162] [49843] [63728]
Pharmacokinetics
Ciprofloxacin is administered orally as extended-release tablets, immediate-release tablets, oral suspension, and intravenously as an infusion. It is also administered via the ophthalmic and otic routes.
Plasma protein binding is low (20—40%) and the antibiotic is widely distributed into most tissues. Tissue concentrations often exceed serum concentrations, particularly in genital tissue, including the prostate. Penetration into CSF is minimal (< 10% of peak serum concentrations) when meninges are not inflamed. Concentrations are present in the saliva, nasal and bronchial secretions, mucosa of the sinuses, sputum, skin blister fluid, lymph, peritoneal fluid, bile, prostatic secretions, lung, skin, fat, muscle, cartilage, and bone. Low concentrations have been detected in the aqueous and vitreous humors of the eye.
Four metabolites of ciprofloxacin have been identified in human urine, which account for approximately 15% of the oral dose: oxociprofloxacin (M3), sulfociprofloxacin (M2), desethylene ciprofloxacin (M1), and formylciprofloxacin (M4). M3 and M2 are the primary metabolites while M1 and M4 are minor metabolites. All have antimicrobial activity, but are less active than unchanged ciprofloxacin. Ciprofloxacin is eliminated via renal and nonrenal routes. Roughly 35—50% of an orally administered dose is excreted in urine as unchanged drug. In patients with normal renal function, the elimination half-life is approximately 4 hours. Fecal excretion of the drug and its metabolites accounts for 20—35% of the dose. Approximately 1—2% of the dose is recovered in the bile as unchanged drug.
Affected cytochrome P450 isoenzymes: CYP1A2, possibly CYP3A4
Ciprofloxacin is an inhibitor of the CYP1A2 isoenzyme. Coadministration with other drugs primarily metabolized by CYP1A2 may result in increased plasma concentrations, and potentially clinically significant pharmacodynamic side effects, of the coadministered drug. In vitro, ciprofloxacin is an inhibitor of the CYP3A4 isoenzyme; however, data from in vivo studies are conflicting. One study postulated that in vivo concentrations usually reached with routine dosing may be consistently below the inhibition constant for CYP3A4 activity.
Following oral administration of immediate-release tablets or suspension, ciprofloxacin hydrochloride is rapidly absorbed from the GI tract and undergoes minimal first-pass metabolism. The absolute bioavailability is approximately 70%. Peak serum concentrations ranging from 1.6—2.9 mcg/mL are reached in 1—2 hours after a 500 mg oral dose. Serum concentrations increase proportionately with doses up to 1000 mg. A 500 mg oral dose given every 12 hours produces an AUC similar to a dose of 400 mg IV every 12 hours; a 750 mg oral dose given every 12 hours produces an AUC similar to a dose of 400 mg IV every 8 hours; and a 250 mg oral dose given every 12 hours produces a similar AUC to a dose of 200 mg IV every 12 hours. When the immediate-release tablets are given with food, the time to peak concentration is delayed (e.g., 2 hours after dosing rather than 1 hour); there is no delay when the oral suspension is given with food. The overall absorption of ciprofloxacin from immediate-release tablets or suspension is not substantially affected by food.
Cipro XR extended-release tablets consist of two parts, an immediate-release component and a slow-release matrix. The immediate-release portion contains approximately 35% of the dose as ciprofloxacin hydrochloride and the slow-release portion contains the remaining 65% as ciprofloxacin. Peak plasma concentrations occur between 1 and 4 hours after dosing. Compared to the 250 mg immediate-release tablets twice daily, Cipro XR extended-release tablets produce a higher Cmax (1.14 mg/L vs 1.59 mg/L) with an equivalent AUC. Cipro XR extended-release tablets may be administered with or without food (e.g., high-fat and low-fat meals or under fasted condition).
The pharmacokinetics of ciprofloxacin are linear over the dose range of 200—400 mg IV. There is no evidence of drug accumulation.
Other Route(s)Ophthalmic Route
Administration of the ciprofloxacin ophthalmic preparations should not result in clinically significant plasma concentrations. After ophthalmic solution administration, the maximum plasma concentration is < 5 ng/mL and the mean concentration is usually < 2.5 ng/mL.
Otic Route
Administration of the ciprofloxacin otic preparation should not result in clinically significant plasma concentrations. The plasma concentrations of the otic preparation have not been measured; however, the manufacturer anticipates that plasma concentrations should be < 5 ng/mL.
Pregnancy And Lactation
Published studies regarding adverse pregnancy outcomes with quinolone use during pregnancy have reported conflicting outcomes. Most systematic reviews and meta-analyses of observational studies have indicated no significant increases in rates of major malformations and adverse pregnancy outcomes for quinolone exposure during pregnancy. Some studies have demonstrated an increased risk of miscarriage or major malformations; however, some of these studies had significant methodological limitations, which could have led to a higher risk. The manufacturer states that available data on ciprofloxacin administration during pregnancy have not identified any drug-associated risk of major birth defects, miscarriage or adverse maternal or fetal outcomes.[43411] Because of the minimal systemic absorption of ciprofloxacin after topical otic/ophthalmic administration, there is expected to be minimal risk of maternal and fetal toxicity when administered during pregnancy. [43892] [43893] [60436]
Ciprofloxacin is present in human breast milk after intravenous and oral administration. In a study of lactating women given 3 oral ciprofloxacin doses of 750 mg, ciprofloxacin breast milk concentrations were higher than serum concentrations with peak concentrations occurring in 2 hours and the lowest concentration occurring at 24 hours; the mean milk to serum ratio varied from 0.85 to 2.14.[31576] There is no information regarding the effects of ciprofloxacin on milk production or the breast-fed infant. Because of the potential for serious adverse reactions (e.g., arthropathy) in the breast-fed infant, for most indications, a lactating woman may consider pumping and discarding breast milk during treatment with systemic ciprofloxacin and for an additional 2 days after the last dose. Alternatively, advise a woman that breast-feeding is not recommended during treatment with systemic ciprofloxacin and for an additional 2 days after the last dose. However, for inhalational anthrax (post-exposure), during an incident resulting in exposure to anthrax, the risk-benefit assessment of continuing breast-feeding while the mother (and potentially the infant) is receiving ciprofloxacin may be acceptable. Consider the developmental and health benefits of breast-feeding along with the mother's clinical need for ciprofloxacin and any potential adverse effects on the breast-fed child from ciprofloxacin or the underlying maternal condition. Ciprofloxacin may cause intestinal flora alteration of the breast-feeding infant. Monitor the breast-fed infant for loose or bloody stools and candidiasis (i.e., thrush, diaper rash).[43411] Otic and ophthalmic use of ciprofloxacin would result in minimal absorption. To minimize the amount of drug that reaches the systemic circulation and breast milk, apply pressure over the tear duct by the corner of the eye for 1 minute after ophthalmic administration.[43891] [43892] [43893] [60436] Sulfamethoxazole; trimethoprim, ceftazidime, cefepime, and piperacillin; tazobactam may be potential systemic alternatives to consider during breast-feeding. However, assess site of infection, patient factors, local susceptibility patterns, and specific microbial susceptibility before choosing an alternative agent.[27500] [46945] [46946] [46947]