Editing Ciprofloxacin (section)

==Medical uses==
Ciprofloxacin is used to treat a wide variety of infections, including [[osteomylitis|infections of bones and joints]], [[endocarditis]], bacterial [[gastroenteritis]], [[malignant otitis externa]], [[bubonic plague]], [[respiratory tract infections]], [[cellulitis]], [[urinary tract infections]], [[prostatitis]], [[anthrax]], and [[chancroid]].<ref name=AHFS2015/>

Ciprofloxacin occupies an important role in treatment guidelines issued by major medical societies for the treatment of serious infections, especially those likely to be caused by Gram-negative bacteria, including ''[[Pseudomonas aeruginosa]]''. For example, ciprofloxacin in combination with [[metronidazole]] is one of several first-line antibiotic regimens recommended by the [[Infectious Diseases Society of America]] for the treatment of community-acquired abdominal infections in adults.<ref>{{cite journal |vauthors = Solomkin JS, Mazuski JE, Bradley JS, Rodvold KA, Goldstein EJ, Baron EJ, O'Neill PJ, Chow AW, Dellinger EP, Eachempati SR, Gorbach S, Hilfiker M, May AK, Nathens AB, Sawyer RG, Bartlett JG |title = Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America |journal = Clinical Infectious Diseases |volume = 50 |issue = 2 |pages = 133–64 |date = January 2010 |pmid = 20034345 |doi = 10.1086/649554 |author-link11 = Sherwood Gorbach |doi-access = free | title-link = doi }}</ref> It also features prominently in treatment guidelines for acute pyelonephritis, complicated or hospital-acquired urinary tract infection, acute or chronic prostatitis,<ref name=uroweb2013>{{cite web |vauthors = Grabe M, Bjerklund-Johansen TE, Botto H, Çek M, Naber KG, Pickard RS, Tenke P, Wagenlehner F, Wullt B |title = Guidelines on Urological Infections |publisher = European Association of Urology |archive-url = https://web.archive.org/web/20131231000606/http://www.uroweb.org/gls/pdf/18_Urological%20infections_LR.pdf |archive-date=31 December 2013 |date=2013 |url=http://www.uroweb.org/gls/pdf/18_Urological%20infections_LR.pdf |url-status=dead}}</ref> certain types of endocarditis,<ref>{{cite journal |vauthors = Baddour LM, Wilson WR, Bayer AS, Fowler VG, Bolger AF, Levison ME, Ferrieri P, Gerber MA, Tani LY, Gewitz MH, Tong DC, Steckelberg JM, Baltimore RS, Shulman ST, Burns JC, Falace DA, Newburger JW, Pallasch TJ, Takahashi M, Taubert KA |title = Infective endocarditis: diagnosis, antimicrobial therapy, and management of complications: a statement for healthcare professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association: endorsed by the Infectious Diseases Society of America |journal = Circulation |volume = 111 |issue = 23 |pages = e394–434 |date = June 2005 |pmid = 15956145 |doi = 10.1161/CIRCULATIONAHA.105.165564 |author23 = Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia |author22 = Council on Cardiovascular Disease in the Young |author21 = Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease |author25 = Infectious Diseases Society of America |author24 = American Heart Association |doi-access = free | title-link = doi }}</ref> certain skin infections,<ref>{{cite journal |vauthors = Stevens DL, Bisno AL, Chambers HF, Everett ED, Dellinger P, Goldstein EJ, Gorbach SL, Hirschmann JV, Kaplan EL, Montoya JG, Wade JC |title = Practice guidelines for the diagnosis and management of skin and soft-tissue infections |journal = Clinical Infectious Diseases |volume = 41 |issue = 10 |pages = 1373–406 |date = November 2005 |pmid = 16231249 |doi = 10.1086/497143 |doi-access = free | title-link = doi }}</ref> and prosthetic joint infections.<ref>{{cite journal |vauthors = Osmon DR, Berbari EF, Berendt AR, Lew D, Zimmerli W, Steckelberg JM, Rao N, Hanssen A, Wilson WR |title = Diagnosis and management of prosthetic joint infection: clinical practice guidelines by the Infectious Diseases Society of America |journal = Clinical Infectious Diseases |volume = 56 |issue = 1 |pages = e1–e25 |date = January 2013 |pmid = 23223583 |doi = 10.1093/cid/cis803 |author10 = Infectious Diseases Society of America. |doi-access = free | title-link = doi }}</ref>

In other cases, treatment guidelines are more restrictive, recommending in most cases that older, narrower-spectrum drugs be used as first-line therapy for less severe infections to minimize fluoroquinolone-resistance development. For example, the Infectious Diseases Society of America recommends the use of ciprofloxacin and other fluoroquinolones in urinary tract infections be reserved to cases of proven or expected resistance to narrower-spectrum drugs such as [[nitrofurantoin]] or [[trimethoprim/sulfamethoxazole]].<ref>{{cite journal |vauthors = Gupta K, Hooton TM, Naber KG, Wullt B, Colgan R, Miller LG, Moran GJ, Nicolle LE, Raz R, Schaeffer AJ, Soper DE |title = International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases |journal = Clinical Infectious Diseases |volume = 52 |issue = 5 |pages = e103–20 |date = March 2011 |pmid = 21292654 |doi = 10.1093/cid/ciq257 |doi-access = free | title-link = doi }}</ref> The [[European Association of Urology]] recommends ciprofloxacin as an alternative regimen for the treatment of uncomplicated urinary tract infections, but cautions that the potential for "adverse events have to be considered".<ref name=uroweb2013/>

Although approved by regulatory authorities for the treatment of respiratory infections, ciprofloxacin is not recommended for respiratory infections by most treatment guidelines due in part to its modest activity against the common respiratory pathogen ''[[Streptococcus pneumoniae]]''.<ref name=cfaeocb>{{cite journal |vauthors=Hoogkamp-Korstanje JA, Klein SJ |title=Ciprofloxacin in acute exacerbations of chronic bronchitis |journal=The Journal of Antimicrobial Chemotherapy |volume=18 |issue=3 |pages=407–413 |date=September 1986 |pmid=3490468 |doi=10.1093/jac/18.3.407}}</ref><ref>{{cite journal |vauthors=Vardakas KZ, Siempos II, Grammatikos A, Athanassa Z, Korbila IP, Falagas ME |title=Respiratory fluoroquinolones for the treatment of community-acquired pneumonia: a meta-analysis of randomized controlled trials |journal=[[Canadian Medical Association Journal]] |volume=179 |issue=12 |pages=1269–1277 |date=December 2008 |pmid= 19047608 |pmc=2585120 |doi=10.1503/cmaj.080358}}</ref><ref name="pmid8019264">{{cite journal |vauthors=Donaldson PM, Pallett AP, Carroll MP |title=Ciprofloxacin in general practice |journal=BMJ |volume=308 |issue=6941 |page=1437 |date=May 1994 |pmid=8019264 |pmc=2540361 |doi=10.1136/bmj.308.6941.1437}}</ref> "Respiratory quinolones" such as [[levofloxacin]], having greater activity against this pathogen, are recommended as first line agents for the treatment of community-acquired pneumonia in patients with important co-morbidities and in patients requiring hospitalization (Infectious Diseases Society of America 2007). Similarly, ciprofloxacin is not recommended as a first-line treatment for [[acute sinusitis]].<ref name="Karageorgopoulos-2008">{{cite journal |vauthors=Karageorgopoulos DE, Giannopoulou KP, Grammatikos AP, Dimopoulos G, Falagas ME |title=Fluoroquinolones compared with beta-lactam antibiotics for the treatment of acute bacterial sinusitis: a meta-analysis of randomized controlled trials |journal=Canadian Medical Association Journal |volume=178 |issue=7 |pages=845–854 |date=March 2008 |pmid=18362380 |pmc=2267830 |doi=10.1503/cmaj.071157}}</ref><ref>{{cite journal |vauthors=Chow AW, Benninger MS, Brook I, Brozek JL, Goldstein EJ, Hicks LA, Pankey GA, Seleznick M, Volturo G, Wald ER, File TM |title=IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults |journal=Clinical Infectious Diseases |volume=54 |issue=8 |pages=e72–e112 |date=April 2012 |s2cid=1946193 |pmid=22438350 |doi=10.1093/cid/cir1043|doi-access = free | title-link = doi }}</ref>

Ciprofloxacin is approved for the treatment of gonorrhea in many countries, but this recommendation is widely regarded as obsolete due to resistance development.<ref>{{cite web |title=Gonococcal Isolate Surveillance Project (GISP) Annual Report – 2003 |url=https://www.cdc.gov/STD/gisp2003/GISP2003.pdf |publisher=U.S. [[Centers for Disease Control and Prevention]] (CDC) |date=November 2004 |access-date=31 August 2009 |url-status=live |archive-url=https://web.archive.org/web/20090424062831/http://www.cdc.gov/std/GISP2003/GISP2003.pdf |archive-date=24 April 2009}}</ref><ref>{{cite journal |vauthors = Young H, Palmer J, Winter A |date=22 July 2003 |title=Ciprofloxacin resistant gonorrhoea: the situation in Scotland and implications for therapy |journal=SCIEH Weekly Report |volume=37 |issn=1357-4493 |url=http://www.documents.hps.scot.nhs.uk/ewr/pdf2003/0329.pdf |url-status=dead |archive-url= https://web.archive.org/web/20110722204213/http://www.documents.hps.scot.nhs.uk/ewr/pdf2003/0329.pdf |archive-date=22 July 2011|access-date=30 August 2009}}</ref><ref>{{cite journal |title = Update to CDC's sexually transmitted diseases treatment guidelines, 2006: fluoroquinolones no longer recommended for treatment of gonococcal infections |journal = MMWR. Morbidity and Mortality Weekly Report |volume = 56 |issue = 14 |pages = 332–336 |date = April 2007 |pmid = 17431378 |url = https://www.cdc.gov/mmwr/PDF/wk/mm5614.pdf |author1 = Centers for Disease Control and Prevention (CDC) }}</ref>

===Pregnancy===
An expert review of published data on experiences with ciprofloxacin use during pregnancy concluded therapeutic doses during pregnancy are unlikely to pose a substantial teratogenic risk (quantity and quality of data=fair), but the data is insufficient to state that no risks exist.<ref>{{cite journal |vauthors = Barolin GS |title = [Illness, anxiety and the physician. An example from neurology and neurorehabilitation] |journal = Wiener Medizinische Wochenschrift |volume = 141 |issue = 22 |pages = 512–25 |date = May 1995 |pmid = 1801454 |pmc = 1801454 }}</ref> Exposure to quinolones, including levofloxacin, during the first-trimester is not associated with an increased risk of stillbirths, premature births, birth defects, or low birth weight.<ref>{{cite journal |vauthors=Ziv A, Masarwa R, Perlman A, Ziv D, Matok I |title=Pregnancy Outcomes Following Exposure to Quinolone Antibiotics – a Systematic-Review and Meta-Analysis |journal=Pharm. Res. |volume=35 |issue=5 |pages=109 |date=March 2018 |pmid=29582196 |doi=10.1007/s11095-018-2383-8 |s2cid=4724821 }}</ref>

Two small post-marketing epidemiology studies of mostly short-term, first-trimester exposure found that fluoroquinolones did not increase risk of major malformations, spontaneous abortions, premature birth, or low birth weight.<ref name="pmid9624471">{{cite journal |vauthors = Loebstein R, Addis A, Ho E, Andreou R, Sage S, Donnenfeld AE, Schick B, Bonati M, Moretti M, Lalkin A, Pastuszak A, Koren G |title = Pregnancy outcome following gestational exposure to fluoroquinolones: a multicenter prospective controlled study |journal = Antimicrobial Agents and Chemotherapy |volume = 42 |issue = 6 |pages = 1336–9 |date = June 1998 |pmid = 9624471 |pmc = 105599 |doi = 10.1128/AAC.42.6.1336 }}</ref><ref name="pmid8902438">{{cite journal |vauthors = Schaefer C, Amoura-Elefant E, Vial T, Ornoy A, Garbis H, Robert E, Rodriguez-Pinilla E, Pexieder T, Prapas N, Merlob P |title = Pregnancy outcome after prenatal quinolone exposure. Evaluation of a case registry of the European Network of Teratology Information Services (ENTIS) |journal = European Journal of Obstetrics, Gynecology, and Reproductive Biology |volume = 69 |issue = 2 |pages = 83–9 |date = November 1996 |pmid = 8902438 |doi = 10.1016/0301-2115(95)02524-3}}</ref>

===Breastfeeding===
Fluoroquinolones have been reported as present in a mother's milk and thus passed on to the nursing child.<ref>{{cite journal |vauthors = Shin HC, Kim JC, Chung MK, Jung YH, Kim JS, Lee MK, Amidon GL |title = Fetal and maternal tissue distribution of the new fluoroquinolone DW-116 in pregnant rats |journal = Comparative Biochemistry and Physiology. Toxicology & Pharmacology |volume = 136 |issue = 1 |pages = 95–102 |date = September 2003 |pmid = 14522602 |doi = 10.1016/j.cca.2003.08.004 }}</ref><ref>{{cite journal |vauthors = Dan M, Weidekamm E, Sagiv R, Portmann R, Zakut H |title = Penetration of fleroxacin into breast milk and pharmacokinetics in lactating women |journal = Antimicrobial Agents and Chemotherapy |volume = 37 |issue = 2 |pages = 293–6 |date = February 1993 |pmid = 8452360 |pmc = 187655 |doi = 10.1128/AAC.37.2.293 |doi-access=free }}</ref>

===Children===
Oral and intravenous ciprofloxacin are approved by the FDA for use in children for only two indications due to the risk of permanent injury to the musculoskeletal system:
# Inhalational [[anthrax]] (postexposure)<ref>{{cite web |url=http://www.accessdata.fda.gov/drugsatfda_docs/appletter/2000/20780S08ltr.pdf |title=Cipro Labeling Revision Letter 08/30/2000 Supplement 008 New or Modified Indication |vauthors = Murphy D |publisher=U.S. [[Food and Drug Administration]] |date=30 August 2000 |url-status=live |archive-url=https://web.archive.org/web/20121018202604/http://www.accessdata.fda.gov/drugsatfda_docs/appletter/2000/20780S08ltr.pdf |archive-date=18 October 2012}}</ref>
# Complicated urinary tract infections and [[pyelonephritis]] due to ''Escherichia coli'',<ref name=cipro2004>{{cite web |vauthors = Albrecht R |title=Cipro Labeling Revision Letter 03/25/2004 Supplement 049 Patient Population Altered |url=http://www.accessdata.fda.gov/drugsatfda_docs/appletter/2004/19537s049,19857s031,19847s027,20780s013ltr.pdf |publisher=U.S. [[Food and Drug Administration]] |date=25 March 2004 |access-date=7 September 2009 |url-status=live |archive-url=https://web.archive.org/web/20121018202556/http://www.accessdata.fda.gov/drugsatfda_docs/appletter/2004/19537s049,19857s031,19847s027,20780s013ltr.pdf |archive-date=18 October 2012}}</ref> but never as first-line agents.

===Spectrum of activity===
Its spectrum of activity includes most strains of bacterial pathogens responsible for [[community-acquired pneumonia]]s, [[bronchitis]], [[urinary tract infection]]s, and gastroenteritis.<ref>{{cite book |title=Pharmcards review cards for medical students |vauthors = Johannsen EC, Sabatine MS |date=2010 |publisher=Wolters Kluwer{{!}}Lippincott Williams & Wilkins |isbn=978-0-7817-8741-3 |edition=4th |location= Philadelphia |oclc=893525059 }}{{page needed|date=July 2018}}</ref> Ciprofloxacin is particularly effective against [[Gram-negative bacteria]] (such as ''[[Escherichia coli]]'', ''[[Haemophilus influenzae]]'', ''[[Klebsiella pneumoniae]]'', ''[[Legionella pneumophila]]'', ''[[Moraxella catarrhalis]]'', ''[[Proteus mirabilis]]'', and ''[[Pseudomonas aeruginosa]]''), but is less effective against [[Gram-positive bacteria]] (such as methicillin-sensitive ''[[Staphylococcus aureus]]'', ''[[Streptococcus pneumoniae]]'', and ''[[Enterococcus faecalis]]'') than newer fluoroquinolones.<ref>{{cite web |url=https://www.uptodate.com/contents/fluoroquinolones |title=Fluoroquinolones |vauthors = Hooper D |date=12 February 2018 |website=UpToDate |access-date=26 February 2018}}</ref>

===Bacterial resistance===
{{see also|Antibiotic abuse|Antibiotic resistance}}

As a result of its widespread use to treat minor infections readily treatable with older, narrower-spectrum antibiotics, many bacteria have developed resistance to this drug, leaving it significantly less effective than it would have been otherwise.<ref name="pmid10341191">{{cite journal |vauthors = Vatopoulos AC, Kalapothaki V, Legakis NJ |title = Bacterial resistance to ciprofloxacin in Greece: results from the National Electronic Surveillance System. Greek Network for the Surveillance of Antimicrobial Resistance |journal = Emerging Infectious Diseases |volume = 5 |issue = 3 |pages = 471–6 |date = 1999 |pmid = 10341191 |pmc = 2640758 |doi = 10.3201/eid0503.990325 }}</ref><ref>{{cite web |url = http://www.health.state.mn.us/news/pressrel/2009/bacterial022609.html |title=Bacterial resistance prompts concern among health officials |publisher= Minnesota Department of Health |date=26 February 2009 |url-status=dead |archive-url=https://web.archive.org/web/20090305232555/http://www.health.state.mn.us/news/pressrel/2009/bacterial022609.html |archive-date=5 March 2009 }}</ref>

[[Antibiotic resistance|Resistance]] to ciprofloxacin and other [[fluoroquinolone]]s may evolve rapidly, even during a course of treatment. Numerous [[pathogen]]s, including [[enterococci]], ''[[Streptococcus pyogenes]]'', and ''[[Klebsiella pneumoniae]]'' (quinolone-resistant) now exhibit resistance.<ref>M Jacobs, Worldwide Overview of Antimicrobial Resistance. International Symposium on Antimicrobial Agents and Resistance 2005.</ref> Widespread veterinary usage of fluoroquinolones, particularly in Europe, has been implicated.<ref>{{cite press release |title=Update on Extra-Label Use of Fluoroquinolones |url=https://www.fda.gov/AnimalVeterinary/NewsEvents/CVMUpdates/ucm127657.htm |publisher=[[Center for Veterinary Medicine]] (CVM) |date=16 July 1996 |access-date=12 August 2009 |url-status=live |archive-url=https://web.archive.org/web/20100309003153/https://www.fda.gov/AnimalVeterinary/NewsEvents/CVMUpdates/ucm127657.htm |archive-date=9 March 2010}}</ref> Meanwhile, some ''[[Burkholderia cepacia]]'', ''[[Clostridium innocuum]]'', and ''[[Enterococcus faecium]]'' strains have developed resistance to ciprofloxacin to varying degrees.<ref>{{cite web |title=Ciprofloxacin Data Sheet |url=http://www.toku-e.com/Upload/Products/PDS/20120618005735.pdf |date=1 December 2010 |publisher=Toku-E |url-status=dead |archive-url=https://web.archive.org/web/20131009014110/http://www.toku-e.com/Upload/Products/PDS/20120618005735.pdf |archive-date=9 October 2013 |access-date=20 June 2012}}</ref>

Fluoroquinolones had become the class of antibiotics most commonly prescribed to adults in 2002.<ref name="pmid15745724">{{cite journal |vauthors = Linder JA, Huang ES, Steinman MA, Gonzales R, Stafford RS |title = Fluoroquinolone prescribing in the United States: 1995 to 2002 |journal = The American Journal of Medicine |volume = 118 |issue = 3 |pages = 259–68 |date = March 2005 |pmid = 15745724 |doi = 10.1016/j.amjmed.2004.09.015 }}</ref> Nearly half (42%) of those prescriptions in the US were for conditions not approved by the FDA, such as acute bronchitis, otitis media, and acute upper respiratory tract infection.<ref name="pmid15745724"/>