patients with renal impairment or solid-organ
transplants as they are at a higher risk of tendon injury.
l CONTRA-INDICATIONS History of tendon disorders related
l CAUTIONS Can prolong the QT interval . children or
adolescents (arthropathy has developed in weight-bearing
joints in young animals) (in children). conditions that
▶ Use in children Quinolones cause arthropathy in the
weight-bearing joints of immature animals and are
therefore generally not recommended in children and
growing adolescents. However, the significance of this
effect in humans is uncertain and in some specific
circumstances short-term use of ciprofloxacin may be
disorders .taste altered .tinnitus . vision disorders . vomiting
disorders . seizure . sensation abnormal . smell altered (in
adults).tendon disorders .thrombocytopenia . thrombocytosis .tremor. vasodilation . vertigo
anaemia . hyperglycaemia . hypoglycaemia . idiopathic
intracranial hypertension . muscle weakness . myasthenia
adverse reactions (SCARs). stomatitis (in adults). suicidal
tendencies . syncope . vasculitis
▶ Frequency not known Corneal deposits (reversible after
completion of treatment). hypoglycaemic coma . increased
elderly). ligament rupture .rhabdomyolysis (in adults). self-endangering behaviour
SIDE-EFFECTS, FURTHER INFORMATION The drug should be
discontinued if neurological, psychiatric, tendon disorders
or hypersensitivity reactions (including severe rash) occur.
For more information regarding the safety of
fluoroquinolones, please see Important Safety
l ALLERGY AND CROSS-SENSITIVITY Use of quinolones
contra-indicated in quinolone hypersensitivity.
l PREGNANCY Avoid in pregnancy—shown to cause
arthropathy in animal studies; safer alternatives are
l PATIENT AND CARER ADVICE The MHRA has produced an
advice sheet on serious adverse reactions affecting
musculoskeletal and nervous systems associated with
fluoroquinolone use, which should be provided to patients
▶ Adult: 500–750 mg twice daily
▶ Adult: 400 mg every 8–12 hours, to be given over
Pseudomonal lower respiratory-tract infection in cystic
▶ Adult: 250–750 mg twice daily
▶ Adult: 400 mg every 8–12 hours, to be given over
Acute uncomplicated cystitis in women
▶ Adult: 250 mg twice daily for 3 days
▶ Adult: 500 mg twice daily for 28 days
▶ Adult: 400 mg every 8–12 hours, to be given over
▶ Adult: Initially 500 mg twice daily; increased to 750 mg
twice daily, in severe or deep-seated infection
▶ Adult: 400 mg every 8–12 hours, to be given over
▶ Adult: 750 mg, to be taken 60 minutes before procedure
Anthrax (treatment and post-exposure prophylaxis)
▶ Adult: 400 mg every 12 hours, to be given over
Prevention of secondary case of meningococcal meningitis
▶ Child 1 month–4 years: 30 mg/kg (max. per dose 125 mg)
▶ Child 5–11 years: 250 mg for 1 dose
▶ Child 12–17 years: 500 mg for 1 dose
l UNLICENSED USE Not licensed for use in children for
prophylaxis of meningococcal meningitis.
l CAUTIONS Acute myocardial infarction (risk factor for QT
interval prolongation). avoid excessive alkalinity of urine
(risk of crystalluria). bradycardia (risk factor for QT
interval prolongation). congenital long QT syndrome (risk
factor for QT interval prolongation). electrolyte
disturbances (risk factor for QT interval prolongation).
558 Bacterial infection BNF 78
ensure adequate fluid intake (risk of crystalluria) . heart
failure with reduced left ventricular ejection fraction (risk
factor for QT interval prolongation). history of
symptomatic arrhythmias (risk factor for QT interval
l INTERACTIONS → Appendix 1: quinolones
▶ Common or very common Arthropathy (in children)
increased . leucocytosis . migraine . muscle tone increased . status epilepticus
▶ Frequency not known Mood altered
l PREGNANCY A single dose of ciprofloxacin may be used for
the prevention of a secondary case of meningococcal
l BREAST FEEDING Amount too small to be harmful but
Dose adjustments ▶ With oral use in adults Give 250–500 mg
every 12 hours if eGFR 30–60 mL/minute/1.73 m2 (every
24 hours if eGFR less than 30 mL/minute/1.73 m2
▶ With intravenous use in adults Give (200 mg over
30 minutes), 200–400 mg every 12 hours if eGFR
30–60 mL/minute/1.73m2 (every 24 hours if eGFR less than
▶ In children Reduce dose if estimated glomerular filtration
rate less than 30 mL/minute/1.73 m2
l PRESCRIBING AND DISPENSING INFORMATION
▶ With oral use Flavours of oral liquid formulations may
Medicines for Children leaflet: Ciprofloxacin for bacterial infections
www.medicinesforchildren.org.uk/ciprofloxacin-bacterialinfection
Driving and skilled tasks May impair performance of skilled
tasks (e.g. driving); effects enhanced by alcohol.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: oral suspension
CAUTIONARY AND ADVISORY LABELS 7, 9, 25
▶ Ciprofloxacin (Non-proprietary)
Ciprofloxacin (as Ciprofloxacin hydrochloride)
100 mg Ciprofloxacin 100mg tablets | 6 tablet P £2.11 DT =
Ciprofloxacin (as Ciprofloxacin hydrochloride)
250 mg Ciprofloxacin 250mg tablets | 10 tablet P £5.60 DT =
£0.74 | 20 tablet P £1.18–£11.20 | 100 tablet P £5.90–£7.90
Ciprofloxacin (as Ciprofloxacin hydrochloride)
500 mg Ciprofloxacin 500mg tablets | 10 tablet P £10.62 DT =
£0.91 | 20 tablet P £1.64–£21.23 | 100 tablet P £8.20–£9.10
Ciprofloxacin (as Ciprofloxacin hydrochloride)
750 mg Ciprofloxacin 750mg tablets | 10 tablet P £15.11 DT =
Ciprofloxacin (as Ciprofloxacin hydrochloride) 500 mg Ciproxin
500mg tablets | 10 tablet P £12.49 DT = £0.91
CAUTIONARY AND ADVISORY LABELS 7, 9, 25
Ciprofloxacin 50 mg per 1 ml Ciproxin 250mg/5ml oral suspension
ELECTROLYTES: May contain Sodium
▶ Ciprofloxacin (Non-proprietary)
Ciprofloxacin (as Ciprofloxacin lactate) 2 mg per
1 ml Ciprofloxacin 200mg/100ml solution for infusion vials | 1 vial P £10.00
Ciprofloxacin 200mg/100ml solution for infusion bottles | 10 bottle P £124.80–£144.50
Ciprofloxacin 100mg/50ml solution for infusion vials | 1 vial P £10.00–£13.00
Ciprofloxacin 400mg/200ml solution for infusion bottles |
1 bottle P £10.00 | 10 bottle P £189.70–£195.90
Ciprofloxacin 400mg/200ml solution for infusion vials | 1 vial P £10.00
Ciprofloxacin (as Ciprofloxacin lactate) 2 mg per 1 ml Ciproxin
Infusion 100mg/50ml solution for infusion bottles | 1 bottle P £7.61 (Hospital only)
Ciproxin Infusion 400mg/200ml solution for infusion bottles | 5 bottle P £114.23 (Hospital only)
Ciproxin Infusion 200mg/100ml solution for infusion bottles | 5 bottle P £75.06 (Hospital only)
▶ Ciprofloxacin (Non-proprietary)
Ciprofloxacin (as Ciprofloxacin lactate) 2 mg per
1 ml Ciprofloxacin 200mg/100ml infusion bags | 5 bag P £60.00
Ciprofloxacin 400mg/200ml infusion bags | 5 bag P £85.00
(Hospital only) | 10 bag P £200.00–£228.46 (Hospital only)
▶ Adult: 500 mg once daily for 10–14 days
Acute exacerbation of chronic obstructive pulmonary
▶ Adult: 500 mg once daily for 5 days
Acute exacerbation of bronchiectasis
▶ Adult: 500 mg 1–2 times a day for 7–14 days
▶ Adult: 500 mg 1–2 times a day, to be given over at least
▶ Adult: 500 mg 1–2 times a day for 7–14 days
▶ Adult: 500 mg 1–2 times a day, to be given over at least
▶ Adult: 500 mg once daily for 7–14 days
Urinary-tract infections (uncomplicated infection)
▶ Adult: 250 mg once daily for 3 days
Complicated urinary-tract infections
▶ Adult: 500 mg once daily, to be given over at least
▶ Adult: 500 mg once daily for 28 days
▶ Adult: 500 mg once daily, to be given over at least
Complicated skin infections | Complicated soft-tissue
▶ Adult: 500 mg 1–2 times a day for 7–14 days
▶ Adult: 500 mg 1–2 times a day, to be given over at least
Inhalation of anthrax (treatment and post-exposure
▶ Adult: 500 mg once daily for 8 weeks continued→
BNF 78 Bacterial infection 559
▶ Adult: 500 mg once daily, to be given over at least
Chronic pulmonary infections due to Pseudomonas
▶ BY INHALATION OF NEBULISED SOLUTION
▶ Adult: 240 mg twice daily for 28 days, subsequent
courses repeated after 28-day interval without
levofloxacin nebuliser solution
l UNLICENSED USE g Duration of treatment for acute
exacerbation of chronic obstructive pulmonary disease
differs from product literature and adheres to national
guidelines. h See Respiratory system infections,
antibacterial therapy p. 515 for further information.
g Levofloxacin is used for the treatment of acute
exacerbation of bronchiectasis, hbut is not licensed for
this indication. See Respiratory system infections,
antibacterial therapy p. 515 for further information.
l CAUTIONS History of psychiatric illness .risk factors for
QT interval prolongation (e.g. electrolyte disturbances,
acute myocardial infarction, heart failure with reduced left
ventricular ejection fraction, bradycardia, congenital long
QT syndrome, history of symptomatic arrhythmias)
l INTERACTIONS → Appendix 1: quinolones
▶ When used by inhalation Bronchial secretion changes . dysphonia . haemoptysis . weight decreased
▶ When used by inhalation Costochondritis . hyperbilirubinaemia . joint stiffness
▶ With oral and intravenous use Paranoia
▶ With oral and intravenous use Diarrhoea haemorrhagic
SIDE-EFFECTS, FURTHER INFORMATION Systemic sideeffects may occur with nebulised levofloxacin.
Bronchospasm Manufacturer advises if acute
symptomatic bronchospasm occurs after receiving
nebulised levofloxacin, patients may benefit from the use
of a short-acting inhaled bronchodilator at least
15 minutes to 4 hours prior to subsequent doses.
l BREAST FEEDING Manufacturer advises avoid.
Dose adjustments ▶ With intravenous use or oral use Usual
initial dose, then use half normal dose if eGFR
; consult product literature if
eGFR less than 20 mL/minute/1.73 m2
▶ When used by inhalation Manufacturer advises avoid if
creatinine clearance less than 20 mL/minute.
▶ When used by inhalation Manufacturer advises patients and
carers should be given advice on how to administer
Missed doses ▶ When used by inhalation Manufacturer
advises if a dose is more than 4 hours late, the missed dose
should not be taken and the next dose should be taken at
Driving and skilled tasks May impair performance of skilled
l NATIONAL FUNDING/ACCESS DECISIONS
Scottish Medicines Consortium (SMC) decisions
The Scottish Medicines Consortium has advised (August
2016) that levofloxacin (Quinsair ®) is accepted for
restricted use within NHS Scotland for the management of
chronic pulmonary infections due to Pseudomonas
aeruginosa in patients with cystic fibrosis, as a third-line
treatment option after colistimethate sodium (first line)
and tobramycin (second line). This advice is contingent
upon the continuing availability of the Patient Access
Scheme in NHS Scotland or a list price that is equivalent or
All Wales Medicines Strategy Group (AWMSG) decisions
The All Wales Medicines Strategy Group has advised
(November 2016) that levofloxacin (Quinsair ®) is
recommended as an option for restricted use within NHS
Wales as third-line therapy for the management of chronic
pulmonary infections due to Pseudomonas aeruginosa in
patients with cystic fibrosis, who do not respond to, or are
intolerant of, second-line treatment with tobramycin, only
if the approved Wales Patient Access Scheme (WPAS) is
used or where the list price is equivalent or lower.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
CAUTIONARY AND ADVISORY LABELS 6, 9, 25
▶ Levofloxacin (Non-proprietary)
Levofloxacin (as Levofloxacin hemihydrate) 250 mg Levofloxacin
250mg tablets | 5 tablet P £2.19–£7.42 | 10 tablet P £14.84
Levofloxacin (as Levofloxacin hemihydrate) 500 mg Levofloxacin
500mg tablets | 5 tablet P £7.90–£12.93 | 10 tablet P £25.85
ELECTROLYTES: May contain Sodium
▶ Levofloxacin (Non-proprietary)
Levofloxacin (as Levofloxacin hemihydrate) 5 mg per
1 ml Levofloxacin 500mg/100ml solution for infusion vials |
1 vial P £25.00 (Hospital only)
Levofloxacin 500mg/100ml solution for infusion bottles | 1 bottle P £12.00 | 10 bottle P £260.00
Levofloxacin (as Levofloxacin hemihydrate) 100 mg per
1 ml Quinsair 240mg nebuliser solution ampoules | 56 ampoule P £2,181.53
▶ Levofloxacin (Non-proprietary)
Levofloxacin (as Levofloxacin hemihydrate) 5 mg per
▶ Adult: 400 mg once daily for 7 days
▶ Adult: 400 mg once daily for 7–14 days
▶ Adult: 400 mg once daily for 7–14 days, to be given
Exacerbations of chronic bronchitis
▶ Adult: 400 mg once daily for 5–10 days
Mild to moderate pelvic inflammatory disease
▶ Adult: 400 mg once daily for 14 days
Complicated skin and soft-tissue infections which have
failed to respond to other antibacterials or for patients
who cannot be treated with other antibacterials
▶ Adult: 400 mg once daily for 7–21 days
▶ Adult: 400 mg once daily for 7–21 days, to be given
l CONTRA-INDICATIONS Acute myocardial infarction (risk
factor for QT interval prolongation). bradycardia (risk
560 Bacterial infection BNF 78
factor for QT interval prolongation). congenital long QT
prolongation). heart failure with reduced left ventricular
l INTERACTIONS → Appendix 1: quinolones
l BREAST FEEDING Manufacturer advises avoid—present in
l HEPATIC IMPAIRMENT Manufacturer advises avoid in
severe impairment or increased transaminases (5 times
Driving and skilled tasks May impair performance of skilled
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
CAUTIONARY AND ADVISORY LABELS 6, 9
▶ Moxifloxacin (Non-proprietary)
Moxifloxacin (as Moxifloxacin hydrochloride)
400 mg Moxifloxacin 400mg tablets | 5 tablet P £11.81 DT =
Moxifloxacin (as Moxifloxacin hydrochloride) 400 mg Avelox
400mg tablets | 5 tablet P £12.43 DT = £9.54
ELECTROLYTES: May contain Sodium
▶ Moxifloxacin (Non-proprietary)
Moxifloxacin (as Moxifloxacin hydrochloride) 1.6 mg per
Moxifloxacin (as Moxifloxacin hydrochloride) 1.6 mg per
▶ Adult: 200–400 mg daily, preferably taken in the
morning; increased if necessary to 400 mg twice daily,
in upper urinary tract infections
Complicated urinary-tract infection
▶ Adult: 200 mg daily, increased if necessary to 400 mg
twice daily, dose increased for severe or complicated
infections, to be given over at least 30 minutes for each
▶ Adult: 200 mg twice daily for 28 days
Lower respiratory-tract infections
▶ Adult: 400 mg daily, dose preferably taken in the
morning, then increased if necessary to 400 mg twice
▶ Adult: 200 mg twice daily, increased to 400 mg twice
daily, dose to be increased for severe or complicated
infections, to be given over at least 30 minutes for each
Skin and soft-tissue infections
▶ Adult: 400 mg twice daily, to be given over at least
▶ Adult: 400 mg as a single dose
Uncomplicated genital chlamydial infection | Nongonococcal urethritis
▶ Adult: 400 mg daily for 7 days, dose may be taken as a
single daily dose or in divided doses
▶ Adult: 400 mg twice daily for 14 days
l CAUTIONS Acute myocardial infarction (risk factor for QT
interval prolongation). bradycardia (risk factor for QT
interval prolongation). congenital long QT syndrome (risk
factor for QT interval prolongation). electrolyte
(risk factor for QT interval prolongation). history of
psychiatric illness . history of symptomatic arrhythmias
(risk factor for QT interval prolongation)
l INTERACTIONS → Appendix 1: quinolones
▶ With oral and intravenous use Enterocolitis . enterocolitis
▶ With oral and intravenous use Bone marrow failure . myopathy . nephritis acute interstitial
l BREAST FEEDING Amount probably too small to be
harmful but manufacturer advises avoid.
l HEPATIC IMPAIRMENT Manufacturer advises caution.
Dose adjustments Manufacturer advises maximum 400 mg
daily in hepatic failure (risk of decreased elimination).
Dose adjustments Usual initial dose, then use half normal
dose if eGFR 20–50 mL/minute/1.73 m2
24 hours if eGFR less than 20 mL/minute/1.73 m2
Driving and skilled tasks May affect performance of skilled
tasks (e.g. driving); effects enhanced by alcohol.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: oral suspension, oral
CAUTIONARY AND ADVISORY LABELS 6, 9, 11
Ofloxacin 200 mg Ofloxacin 200mg tablets | 10 tablet P £6.75
Ofloxacin 400 mg Ofloxacin 400mg tablets | 5 tablet P £12.80
DT = £11.86 | 10 tablet P £4.59–£23.72
BNF 78 Bacterial infection 561
Ofloxacin 400 mg Tarivid 400mg tablets | 10 tablet P £14.99
Ofloxacin (as Ofloxacin hydrochloride) 2 mg per 1 ml Tarivid
200mg/100ml solution for infusion bottles | 1 bottle P £16.16
l DRUG ACTION Sulfamethoxazole and trimethoprim are
used in combination (as co-trimoxazole) because of their
synergistic activity (the importance of the sulfonamides
has decreased as a result of increasing bacterial resistance
and their replacement by antibacterials which are
generally more active and less toxic).
Treatment of susceptible infections
▶ Child 6 weeks–5 months: 120 mg twice daily,
alternatively 24 mg/kg twice daily
▶ Child 6 months–5 years: 240 mg twice daily, alternatively
▶ Child 6–11 years: 480 mg twice daily, alternatively
▶ Child 12–17 years: 960 mg twice daily
▶ Adult: 960 mg every 12 hours, increased to 1.44 g every
12 hours, increased dose used in severe infection
Acute exacerbation of chronic obstructive pulmonary
▶ Adult: 960 mg twice daily for 5 days
▶ Adult: 960 mg every 12 hours, increased if necessary to
1.44 g every 12 hours, increased dose used in severe
Treatment of Pneumocystis jirovecii (Pneumocystis
carinii) infections (undertaken where facilities for
appropriate monitoring available—consult
microbiologist and product literature)
▶ BY MOUTH, OR BY INTRAVENOUS INFUSION
▶ Child: 120 mg/kg daily in 2–4 divided doses for
14–21 days, oral route preferred for children
▶ Adult: 120 mg/kg daily in 2–4 divided doses for
Prophylaxis of Pneumocystis jirovecii (Pneumocystis
▶ Child: 450 mg/m2 twice daily (max. per dose 960 mg
twice daily) for 3 days of the week (either consecutively
or on alternate days), dose regimens may vary, consult
▶ Adult: 960 mg once daily, reduced if not tolerated to
480 mg once daily, alternatively 960 mg once daily on
alternate days, alternate day dose to be given 3 times
weekly, alternatively 960 mg twice a day on alternate
days, alternate day dose to be given 3 times weekly
DOSE EQUIVALENCE AND CONVERSION
▶ 480 mg of co-trimoxazole consists of sulfamethoxazole
400 mg and trimethoprim 80 mg.
l UNLICENSED USE Not licensed for Burkholderia cepacia
infections in cystic fibrosis. Not licensed for
Stenotrophomonas maltophilia infections.
▶ In children Not licensed for use in children under 6 weeks.
RESTRICTIONS ON THE USE OF CO-TRIMOXAZOLE
Co-trimoxazole is the drug of choice in the prophylaxis
and treatment of Pneumocystis jirovecii (Pneumocystis
carinii) pneumonia; it is also indicated for nocardiasis,
Stenotrophomonas maltophilia infection [unlicensed
indication], and toxoplasmosis. It should only be
considered for use in acute exacerbations of chronic
bronchitis and infections of the urinary tract when there
to a single antibacterial; similarly it should only be used
in acute otitis media in children when there is good
reason to prefer it. Co-trimoxazole is also used for the
treatment of infections caused by Burkholderia cepacia in
cystic fibrosis [unlicensed indication].
l CONTRA-INDICATIONS Acute porphyrias p. 1058
l CAUTIONS Asthma . avoid in blood disorders (unless under
specialist supervision). avoid in infants under 6 weeks
(except for treatment or prophylaxis of pneumocystis
pneumonia) because of the risk of kernicterus . elderly
(increased risk of serious side-effects).G6PD deficiency
(risk of haemolytic anaemia). maintain adequate fluid
intake . predisposition to folate deficiency . predisposition
l INTERACTIONS → Appendix 1: sulfonamides .trimethoprim
▶ Rare or very rare Agranulocytosis . angioedema . aplastic
acidosis . methaemoglobinaemia . myalgia . myocarditis
allergic . nephritis tubulointerstitial . neutropenia . oral
disorders . pancreatitis . peripheral neuritis . photosensitivity reaction . pseudomembranous
SIDE-EFFECTS, FURTHER INFORMATION Co-trimoxazole is
associated with rare but serious side effects. Discontinue
immediately if blood disorders (including leucopenia,
thrombocytopenia, megaloblastic anaemia, eosinophilia)
or rash (including Stevens-Johnson syndrome or toxic
epidermal necrolysis) develop.
l PREGNANCY Teratogenic risk in first trimester
(trimethoprim a folate antagonist). Neonatal haemolysis
and methaemoglobinaemia in third trimester; fear of
increased risk of kernicterus in neonates appears to be
l BREAST FEEDING Small risk of kernicterus in jaundiced
infants and of haemolysis in G6PD-deficient infants (due
l HEPATIC IMPAIRMENT Manufacturer advises avoid in
▶ In adults Avoid if eGFR less than 15 mL/minute/1.73 m2 and
if plasma-sulfamethoxazole concentration cannot be
▶ In children Avoid if estimated glomerular filtration rate less
than 15 mL/minute/1.73 m2 and if plasmasulfamethoxazole concentration cannot be monitored.
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