Components:
Method of action:
Treatment option:
Medically reviewed by Fedorchenko Olga Valeryevna, PharmD. Last updated on 26.06.2023
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Cipro-Hexal 2 mg/ml solution for infusion is indicated for the treatment of the following infections. Special attention should be paid to available information on resistance to Cipro-Hexal before commencing therapy.
Consideration should be given to official guidance on the appropriate use of antibacterial agents.
Adults
- Lower respiratory tract infections due to Gram-negative bacteria
- exacerbations of chronic obstructive pulmonary disease
- broncho-pulmonary infections in cystic fibrosis or in bronchiectasis
- pneumonia
- Chronic suppurative otitis media
- Acute exacerbation of chronic sinusitis especially if these are caused by Gram-negative bacteria
- Urinary tract infections
- Genital tract infections
- epididymo-orchitis including cases due to susceptible Neisseria gonorrhoeae
- pelvic inflammatory disease including cases due to susceptible Neisseria gonorrhoeae
- Infections of the gastro-intestinal tract (e.g. travellers` diarrhoea)
- Intra-abdominal infections
- Infections of the skin and soft tissue caused by Gram-negative bacteria
- Malignant external otitis
- Infections of the bones and joints
- Inhalation anthrax (post-exposure prophylaxis and curative treatment)
Cipro-Hexal may be used in the management of neutropenic patients with fever that is suspected to be due to a bacterial infection.
Children and adolescents
- Broncho-pulmonary infections in cystic fibrosis caused by Pseudomonas aeruginosa
- Complicated urinary tract infections and pyelonephritis
- Inhalation anthrax (post-exposure prophylaxis and curative treatment)
Cipro-Hexal may also be used to treat severe infections in children and adolescents when this is considered to be necessary.
Treatment should be initiated only by physicians who are experienced in the treatment of cystic fibrosis and/or severe infections in children and adolescents.
Posology
The dosage is determined by the indication, the severity and the site of the infection, the susceptibility to Cipro-Hexal of the causative organism(s), the renal function of the patient and, in children and adolescents the body weight.
The duration of treatment depends on the severity of the illness and on the clinical and bacteriological course.
After intravenous initiation of treatment, the treatment can be switched to oral treatment with tablet or suspension if clinically indicated at the discretion of the physician. IV treatment should be followed by oral route as soon as possible.
In severe cases or if the patient is unable to take tablets (e.g. patients on enteral nutrition), it is recommended to commence therapy with intravenous Cipro-Hexal until a switch to oral administration is possible.
Treatment of infections due to certain bacteria (e.g. Pseudomonas aeruginosa, Acinetobacter or Staphylococci) may require higher Cipro-Hexal doses and co-administration with other appropriate antibacterial agents.
Treatment of some infections (e.g. pelvic inflammatory disease, intra-abdominal infections, infections in neutropenic patients and infections of bones and joints) may require co-administration with other appropriate antibacterial agents depending on the pathogens involved.
Adults
| Indications | Daily dose in mg | Total duration of treatment (including switch to oral therapy as soon as possible) | |
| Infections of the lower respiratory tract | 400 mg twice daily to 400 mg three times a day | 7 to 14 days | |
| Infections of the upper respiratory tract | Acute exacerbation of chronic sinusitis | 400 mg twice daily to 400 mg three times a day | 7 to 14 days |
| Chronic suppurative otitis media | 400 mg twice daily to 400 mg three times a day | 7 to 14 days | |
| Malignant external otitis | 400 mg three times a day | 28 days up to 3 months | |
| Urinary tract infections | Complicated and uncomplicated pyelonephritis | 400 mg twice daily to 400 mg three times a day | 7 to 21 days, it can be continued for longer than 21 days in some specific circumstances (such as abscesses) |
| Prostatitis | 400 mg twice daily to 400 mg three times a day | 2 to 4 weeks (acute) | |
| Genital tract infections | Epididymo-orchitis and pelvic inflammatory diseases | 400 mg twice daily to 400 mg three times a day | at least 14 days |
| Infections of the gastro-intestinal tract and intra-abdominal infections | Diarrhoea caused by bacterial pathogens including Shigella spp. other than Shigella dysenteriae type 1 and empirical treatment of severe travellers' diarrhoea | 400 mg twice daily | 1 day |
| Diarrhoea caused by Shigella dysenteriae type 1 | 400 mg twice daily | 5 days | |
| Diarrhoea caused by Vibrio cholerae | 400 mg twice daily | 3 days | |
| Typhoid fever | 400 mg twice daily | 7 days | |
| Intra-abdominal infections due to Gram-negative bacteria | 400 mg twice daily to 400 mg three times a day | 5 to 14 days | |
| Infections of the skin and soft tissue | 400 mg twice daily to 400 mg three times a day | 7 to 14 days | |
| Bone and joint infections | 400 mg twice daily to 400 mg three times a day | max. of 3 months | |
| Neutropenic patients with fever that is suspected to be due to a bacterial infection. Cipro-Hexal should be co-administered with appropriate antibacterial agent(s) in accordance to official guidance. | 400 mg twice daily to 400 mg three times a day | Therapy should be continued over the entire period of neutropenia | |
| Inhalation anthrax post-exposure prophylaxis and curative treatment for persons requiring parenteral treatment Drug administration should begin as soon as possible after suspected or confirmed exposure. | 400 mg twice daily | 60 days from the confirmation of Bacillus anthracis exposure | |
Paediatric population
| Indications | Daily dose in mg | Total duration of treatment (including switch to oral therapy as soon as possible) |
| Cystic fibrosis | 10 mg/kg body weight three times a day with a maximum of 400 mg per dose. | 10 to 14 days |
| Complicated urinary tract infections and pyelonephritis | 6 mg/kg body weight three times a day to 10 mg/kg body weight three times a day with a maximum of 400 mg per dose. | 10 to 21 days |
| Inhalation anthrax post-exposure curative treatment for persons requiring parenteral treatment Drug administration should begin as soon as possible after suspected or confirmed exposure. | 10 mg/kg body weight twice daily to 15 mg/kg body weight twice daily with a maximum of 400 mg per dose. | 60 days from the confirmation of Bacillus anthracis exposure |
| Other severe infections | 10 mg/kg body weight three times a day with a maximum of 400 mg per dose. | According to the type of infections. |
Elderly patients
Elderly patients should receive a dose selected according to the severity of the infection and the patient`s creatinine clearance.
Patients with renal and hepatic impairment
Recommended starting and maintenance doses for patients with impaired renal function:
| Creatinine Clearance [ml/min/1.73 m2] | Serum Creatinine [µmol/l] | Intravenous Dose [mg] |
| > 60 | < 124 | See usual dosage. |
| 30 - 60 | 124 to 168 | 200 - 400 mg every 12 h |
| < 30 | > 169 | 200 - 400 mg every 24 h |
| Patients on haemodialysis | > 169 | 200 - 400 mg every 24 h (after dialysis) |
| Patients on peritoneal dialysis | > 169 | 200 - 400 mg every 24 h |
In patients with impaired liver function no dose adjustment is required.
Dosing in children with impaired renal and/or hepatic function has not been studied.
Method of administration
Cipro-Hexal should be checked visually prior to use. It must not be used if cloudy.
Cipro-Hexal should be administered by intravenous infusion. For children, the infusion duration is 60 minutes.
In adult patients, infusion time is 60 minutes for 400 mg Cipro-Hexal and 30 minutes for 200 mg Cipro-Hexal. Slow infusion into a large vein will minimize patient discomfort and reduce the risk of venous irritation.
The infusion solution can be infused either directly or after mixing with other compatible infusion solutions.
-
- Concomitant administration of Cipro-Hexal and tizanidine.
Severe infections and mixed infections with Gram-positive and anaerobic pathogens
Cipro-Hexal monotherapy is not suited for treatment of severe infections and infections that might be due to Gram-positive or anaerobic pathogens. In such infections Cipro-Hexal must be co-administered with other appropriate antibacterial agents.
Streptococcal Infections (including Streptococcus pneumoniae)
Cipro-Hexal is not recommended for the treatment of streptococcal infections due to inadequate efficacy.
Genital tract infections
Epididymo-orchitis and pelvic inflammatory diseases may be caused by fluoroquinolone-resistant Neisseria gonorrhoeae. For epididymo-orchitis and pelvic inflammatory diseases, empirical Cipro-Hexal should only be considered in combination with another appropriate antibacterial agent (e.g. a cephalosporin) unless Cipro-Hexal-resistant Neisseria gonorrhoeae can be excluded. If clinical improvement is not achieved after 3 days of treatment, the therapy should be reconsidered.
Urinary tract infections
Resistance to fluoroquinolones of Escherichia coli - the most common pathogen involved in urinary tract infections - varies across the European Union. Prescribers are advised to take into account the local prevalence of resistance in Escherichia coli to fluoroquinolones.
Intra-abdominal infections
There are limited data on the efficacy of Cipro-Hexal in the treatment of post-surgical intra-abdominal infections.
Travellers' diarrhoea
The choice of Cipro-Hexal should take into account information on resistance to Cipro-Hexal in relevant pathogens in the countries visited.
Infections of the bones and joints
Cipro-Hexal should be used in combination with other antimicrobial agents depending on the results of the microbiological documentation.
Inhalational anthrax
Use in humans is based on in-vitro susceptibility data and on animal experimental data together with limited human data. Treating physicians should refer to national and /or international consensus documents regarding the treatment of anthrax.
Paediatric population
The use of Cipro-Hexal in children and adolescents should follow available official guidance. Cipro-Hexal treatment should be initiated only by physicians who are experienced in the treatment of cystic fibrosis and/or severe infections in children and adolescents.
Cipro-Hexal has been shown to cause arthropathy in weight-bearing joints of immature animals. Safety data from a randomised double-blind study on Cipro-Hexal use in children (Cipro-Hexal: n=335, mean age = 6.3 years; comparators: n=349, mean age = 6.2 years; age range = 1 to 17 years) revealed an incidence of suspected drug-related arthropathy (discerned from joint-related clinical signs and symptoms) by Day +42 of 7.2% and 4.6%. Respectively, an incidence of drug-related arthropathy by 1-year follow-up was 9.0% and 5.7%. The increase of suspected drug-related arthropathy cases over time was not statistically significant between groups. Treatment should be initiated only after a careful benefit/risk evaluation, due to possible adverse events related to joints and/or surrounding tissue.
Broncho-pulmonary infections in cystic fibrosis
Clinical trials have included children and adolescents aged 5-17 years. More limited experience is available in treating children between 1 and 5 years of age.
Complicated urinary tract infections and pyelonephritis
Cipro-Hexal treatment of urinary tract infections should be considered when other treatments cannot be used, and should be based on the results of the microbiological documentation.
Clinical trials have included children and adolescents aged 1-17 years.
Other specific severe infections
Other severe infections in accordance with official guidance, or after careful benefit-risk evaluation when other treatments cannot be used, or after failure to conventional therapy and when the microbiological documentation can justify a Cipro-Hexal use.
The use of Cipro-Hexal for specific severe infections other than those mentioned above has not been evaluated in clinical trials and the clinical experience is limited. Consequently, caution is advised when treating patients with these infections.
Hypersensitivity
Hypersensitivity and allergic reactions, including anaphylaxis and anaphylactoid reactions, may occur following a single dose and may be life-threatening. If such reaction occurs, Cipro-Hexal should be discontinued and an adequate medical treatment is required.
Musculoskeletal System
Cipro-Hexal should generally not be used in patients with a history of tendon disease/disorder related to quinolone treatment. Nevertheless, in very rare instances, after microbiological documentation of the causative organism and evaluation of the risk/benefit balance, Cipro-Hexal may be prescribed to these patients for the treatment of certain severe infections, particularly in the event of failure of the standard therapy or bacterial resistance, where the microbiological data may justify the use of Cipro-Hexal.
Tendinitis and tendon rupture (especially Achilles tendon), sometimes bilateral, may occur with Cipro-Hexal, even within the first 48 hours of treatment. Inflammation and ruptures of tendon may occur even up to several months after discontinuation of Cipro-Hexal therapy. The risk of tendinopathy may be increased in elderly patients or in patients concomitantly treated with corticosteroids.
At any sign of tendinitis (e.g. painful swelling, inflammation), Cipro-Hexal treatment should be discontinued. Care should be taken to keep the affected limb at rest.
Cipro-Hexal should be used with caution in patients with myasthenia gravis.
Photosensitivity
Cipro-Hexal has been shown to cause photosensitivity reactions. Patients taking Cipro-Hexal should be advised to avoid direct exposure to either extensive sunlight or UV irradiation during treatment.
Central Nervous System
Cipro-Hexal like other quinolones are known to trigger seizures or lower the seizure threshold. Cases of status epilepticus have been reported. Cipro-Hexal should be used with caution in patients with CNS disorders which may be predisposed to seizure. If seizures occur Cipro-Hexal should be discontinued. Psychiatric reactions may occur even after the first administration of Cipro-Hexal. In rare cases, depression or psychosis can progress to suicidal ideations/thoughts culminating in attempted suicide or completed suicide. In the occurrence of such cases, Cipro-Hexal should be discontinued.
Cases of polyneuropathy (based on neurological symptoms such as pain, burning, sensory disturbances or muscle weakness, alone or in combination) have been reported in patients receiving Cipro-Hexal. Cipro-Hexal should be discontinued in patients experiencing symptoms of neuropathy, including pain, burning, tingling, numbness, and/or weakness in order to prevent the development of an irreversible condition.
Cardiac disorders
Caution should be taken when using fluoroquinolones, including Cipro-Hexal, in patients with known risk factors for prolongation of the QT interval such as, for example:
- congenital long QT syndrome
- concomitant use of drugs that are known to prolong the QT interval (e.g. Class IA and III anti-arrhythmics, tricyclic antidepressants, macrolides, antipsychotics)
- uncorrected electrolyte imbalance (e.g. hypokalaemia, hypomagnesaemia)
- cardiac disease (e.g. heart failure, myocardial infarction, bradycardia)
Elderly patients and women may be more sensitive to QTc-prolonging medications.
Therefore, caution should be taken when using fluoroquinolones, including Cipro-Hexal, in these populations.
<5, ).Hypoglycemia
As with other quinolones, hypoglycemia has been reported most often in diabetic patients, predominantly in the elderly population. In all diabetic patients, careful monitoring of blood glucose is recommended.
Gastrointestinal System
The occurrence of severe and persistent diarrhoea during or after treatment (including several weeks after treatment) may indicate an antibiotic-associated colitis (life-threatening with possible fatal outcome), requiring immediate treatment. In such cases, Cipro-Hexal should immediately be discontinued, and an appropriate therapy initiated. Anti-peristaltic drugs are contraindicated in this situation.
Renal and urinary system
Crystalluria related to the use of Cipro-Hexal has been reported. Patients receiving Cipro-Hexal should be well hydrated and excessive alkalinity of the urine should be avoided.
Impaired renal function
Hepatobiliary system
Cases of hepatic necrosis and life-threatening hepatic failure have been reported with Cipro-Hexal. In the event of any signs and symptoms of hepatic disease (such as anorexia, jaundice, dark urine, pruritus, or tender abdomen), treatment should be discontinued.
Glucose-6-phosphate dehydrogenase deficiency
Haemolytic reactions have been reported with Cipro-Hexal in patients with glucose-6-phosphate dehydrogenase deficiency. Cipro-Hexal should be avoided in these patients unless the potential benefit is considered to outweigh the possible risk. In this case, potential occurrence of haemolysis should be monitored.
Resistance
During or following a course of treatment with Cipro-Hexal bacteria that demonstrate resistance to Cipro-Hexal may be isolated, with or without a clinically apparent superinfection. There may be a particular risk of selecting for Cipro-Hexal-resistant bacteria during extended durations of treatment and when treating nosocomial infections and/or infections caused by Staphylococcus and Pseudomonas species.
Cytochrome P450
Cipro-Hexal inhibits CYP1A2 and thus may cause increased serum concentration of concomitantly administered substances metabolised by this enzyme (e.g. theophylline, clozapine, olanzapine, ropinirole, tizanidine, duloxetine, agomelatine). Co-administration of Cipro-Hexal and tizanidine is contra-indicated. Therefore, patients taking these substances concomitantly with Cipro-Hexal should be monitored closely for clinical signs of overdose, and determination of serum concentrations (e.g. of theophylline) may be necessary.
Methotrexate
The concomitant use of Cipro-Hexal with methotrexate is not recommended.
Interaction with tests
The in-vitro activity of Cipro-Hexal against Mycobacterium tuberculosis might give false negative bacteriological test results in specimens from patients currently taking Cipro-Hexal.
Injection Site Reaction
Local intravenous site reactions have been reported with the intravenous administration of Cipro-Hexal. These reactions are more frequent if the infusion time is 30 minutes or less. These may appear as local skin reactions which resolve rapidly upon completion of the infusion. Subsequent intravenous administration is not contraindicated unless the reactions recur or worsen.
NaCl Load
In patients for whom sodium intake is of medical concern (patients with congestive heart failure, renal failure, nephrotic syndrome, etc.), the additional sodium load should be taken into account (for sodium chloride content, see section 2).
Vision disorders
If vision becomes impaired or any effects on the eyes are experienced, an eye specialist should be consulted immediately.
Due to its neurological effects, Cipro-Hexal may affect reaction time. Thus, the ability to drive or to operate machinery may be impaired.
The most commonly reported adverse drug reactions (ADRs) are nausea and diarrhea, vomiting, transient increase in transaminases, rash, and injection and infusion site reactions.
ADRs derived from clinical studies and post-marketing surveillance with Cipro-Hexal (oral, intravenous and sequential therapy) sorted by categories of frequency are listed below. The frequency analysis takes into account data from both oral and intravenous administration of Cipro-Hexal.
| System Organ Class | Common (>1/100 to <1/10) | Uncommon (>1/1,000 to <1/100) | Rare (>1/10,000 to <1/1,000) | Very rare (<1/10,000) | Frequency not known (cannot be estimated from the available data) |
| Infections and infestations | Mycotic superinfections | ||||
| Blood and lymphatic system disorders | Eosinophilia | Leukopenia Anaemia Neutropenia Leukocytosis Thrombocytopenia Thrombocytaemia | Haemolytic anaemia Agranulocytosis Pancytopenia (life-threatening) Bone marrow depression (life-threatening) | ||
| Immune system disorders | Allergic reaction Allergic oedema / angioedema | Anaphylactic reaction Anaphylactic shock (life-threatning) Serum sickness-like reaction | |||
| Metabolism and nutrition disorders | Decreased appetite | Hyperglycaemia Hypoglycaemia | |||
| Psychiatric disorders | Psychomotor hyperactivity / agitation | Confusion and disorientation Anxiety reaction Abnormal dreams Depression (potentially culminating in suicidal ideations/thoughts or suicide attempts and completed suicide) Hallucinations | Psychotic reactions (potentially culminating in suicidal ideations/thoughts or suicide attempts and completed suicide) | Mania, hypomania | |
| Nervous system disorders | Headache Dizziness Sleep disorders Taste disorders | Par- and dysaesthesia Hypoaesthesia Tremor Seizures Vertigo | Migraine disturbed coordination Gait disturbance Olfactory nerve disorders Intracranial hypertension and pseudotumor cerebri | Peripheral neuropathy | |
| Eye disorders | Visual disturbances (e.g. diplopia) | Visual colour distortions | |||
| Ear and labyrinth disorders | Tinnitus Hearing loss / hearing impaired | ||||
| Cardiac disorders | Tachycardia | Ventricular arrhythmia and torsades de pointes (reported predominantly in patients with risk factors for QT prolongation), ECG QT prolonged | |||
| Vascular disorders | Vasodilatation Hypotension Syncope | Vasculitis | |||
| Respiratory, thoracic and mediastinal disorders | Dyspnoea (including asthmatic condition) | ||||
| Gastrointestinal disorders | Nausea Diarrhoea | Vomiting Gastrointestinal and abdominal pains Dyspepsia Flatulence | Antibiotic associated colitis (very rarely with possible fatal outcome) | Pancreatitis | |
| Hepatobiliary disorders | Increase in transaminases Increased bilirubin | Hepatic impairment Cholestatic icterus Hepatitis | Liver necrosis (very rarely progressing to life-threatening hepatic failure) | ||
| Skin and subcutaneous tissue disorders | Rash Pruritus Urticaria | Photosensitivity reactions | Petechia Erythema multiforme Erythema nodosum Stevens-Johnson syndrome (potentially life-threatening) Toxic epidermal necrolysis (potencially life-threatening) | Acute generalised exanthematous pustulosis (AGEP), DRESS | |
| Musculoskeletal, connective tissue and bone disorders | Musculoskeletelal pain (e.g. extremity pain, back pain, chest pain) Arthralgia | Myalgia Arthritis Increased muscle tone and cramping | Muscular weakness Tendinitis Tendon rupture (predominantly Achilles tendon) Exacerbation of symptoms of myasthenia gravis | ||
| Renal and urinary disorders | Renal impairment | Renal failure Haematuria Crystalluria Tubulointerstitial nephritis | |||
| General disorders and administration site conditions | Injection and infusion site reactions (only intravenous administration) | Asthenia Fever | Oedema Sweating (hyperhidrosis) | ||
| Investigations | Increase in blood alkaline phosphatase | Increase amylase | International normalised ratio increased (in patients treated with Vitamin K antagonists) |
The following undesirable effects have a higher frequency category in the subgroups of patients receiving intravenous or sequential (intravenous to oral) treatment:
| Common | Vomiting Transient increase in transaminases Rash |
| Uncommon | Thrombocytopenia Thrombocytaemia Confusion and disorientation Hallucinations Par- and dysaesthesia Seizures Vertigo Visual disturbances Hearing loss Tachycardia Vasodilatation Hypotension Transient hepatic impairment Cholestatic icterus Renal failure Oedema |
| Rare | Pancytopenia Bone marrow depression Anaphylactic shock Psychotic reactions Migraine Olfactory nerve disorders Hearing impaired Vasculitis Pancreatitis Liver necrosis Petechiae Tendon rupture |
Paediatric population
The incidence of arthropathy, mentioned above, is referring to data collected in studies with adults. In children, arthropathy is reported to occur commonly.
Reporting of suspected adverse reactions
Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via: Yellow Card Scheme - Website: www.mhra.gov.uk/yellowcard.
An overdose of 12 g has been reported to lead to mild symptoms of toxicity. An acute overdose of 16 g has been reported to cause acute renal failure.
Symptoms in overdose consist of dizziness, tremor, headache, tiredness, seizures, hallucinations, confusion, abdominal discomfort, renal and hepatic impairment as well as crystalluria and haematuria. Reversible renal toxicity has been reported.
Apart from routine emergency measures, e.g. ventricular emptying followed by medical carbon, it is recommended to monitor renal function, including urinary pH and acidify, if required, to prevent crystalluria. Patients should be kept well hydrated. Calcium or magnesium containing antacids may theoretically reduce the absorption of Cipro-Hexal in overdoses.
Only a small quantity of Cipro-Hexal (< 10%) is eliminated by haemodialysis or peritoneal dialysis.
In the event of overdose, symptomatic treatment should be implemented. ECG monitoring should be undertaken, because of the possibility of QT interval prolongation.
Pharmacotherapeutic group: Fluoroquinolones, ATC code: J01MA02
Mechanism of action
As a fluoroquinolone antibacterial agent, the bactericidal action of Cipro-Hexal results from the inhibition of both type II topoisomerase (DNA-gyrase) and topoisomerase IV, required for bacterial DNA replication, transcription, repair and recombination.
Pharmacokinetic/pharmacodynamic relationship
Efficacy mainly depends on the relation between the maximum concentration in serum (Cmax) and the minimum inhibitory concentration (MIC) of Cipro-Hexal for a bacterial pathogen and the relation between the area under the curve (AUC) and the MIC.
Mechanism of resistance
In-vitro resistance to Cipro-Hexal can be acquired through a stepwise process by target site mutations in both DNA gyrase and topoisomerase IV. The degree of cross-resistance between Cipro-Hexal and other fluoroquinolones that results is variable. Single mutations may not result in clinical resistance, but multiple mutations generally result in clinical resistance to many or all active substances within the class.
Impermeability and/or active substance efflux pump mechanisms of resistance may have a variable effect on susceptibility to fluoroquinolones, which depends on the physiochemical properties of the various active substances within the class and the affinity of transport systems for each active substance. All in-vitro mechanisms of resistance are commonly observed in clinical isolates.
Resistance mechanisms that inactivate other antibiotics such as permeation barriers (common in Pseudomonas aeruginosa) and efflux mechanisms may affect susceptibility to Cipro-Hexal.
Plasmid-mediated resistance encoded by qnr-genes has been reported.
Spectrum of antibacterial activity
Breakpoints separate susceptible strains from strains with intermediate susceptibility and the latter from resistant strains:
EUCAST Recommendations
| Microorganisms | Susceptible | Resistant |
| Enterobacteriaceae | S ≤ 0.5 mg/l | R > 1 mg/l |
| Pseudomonas spp. | S ≤ 0.5 mg/l | R > 1 mg/l |
| Acinetobacter spp. | S ≤ 1 mg/l | R > 1 mg/l |
| Staphylococcus spp.1 | S ≤ 1 mg/l | R > 1 mg/l |
| Haemophilus influenzae and Moraxella catarrhalis | S ≤ 0.5 mg/l | R > 0.5 mg/l |
| Neisseria gonorrhoeae | S ≤ 0.03 mg/l | R > 0.06 mg/l |
| Neisseria meningitidis | S ≤ 0.03 mg/l | R > 0.06 mg/l |
| Non-species-related breakpoints* | S ≤ 0.5 mg/l | R > 1 mg/l |
1 Staphylococcus spp. - breakpoints for Cipro-Hexal relate to high dose therapy.
* Non-species-related breakpoints have been determined mainly on the basis of PK/PD data and are independent of MIC distributions of specific species. They are for use only for species that have not been given a species-specific breakpoint and not for those species where susceptibility testing is not recommended.
The prevalence of acquired resistance may vary geographically and with time for selected species and local information on resistance is desirable, particularly when treating severe infections. As necessary, expert advice should be sought when the local prevalence of resistance is such that the utility of the agent in at least some types of infections is questionable.
Groupings of relevant species according to Cipro-Hexal susceptibility
| COMMONLY SUSCEPTIBLE SPECIES |
| Aerobic Gram-positive micro-organisms Bacillus anthracis (1) |
| Aerobic Gram-negative micro-organisms Aeromonas spp. Brucella spp. Citrobacter koseri Francisella tularensis Haemophilus ducreyi Haemophilus influenzae* Legionella spp. Moraxella catarrhalis* Neisseria meningitidis Pasteurella spp. Salmonella spp.* Shigella spp. * Vibrio spp. Yersinia pestis |
| Anaerobic micro-organisms Mobiluncus |
| Other micro-organisms Chlamydia trachomatis ( Chlamydia pneumoniae ( Mycoplasma hominis ( Mycoplasma pneumoniae ( |
| SPECIES FOR WHICH ACQUIRED RESISTANCE MAY BE A PROBLEM |
| Aerobic Gram-positive micro-organisms Enterococcus faecalis ( Staphylococcus spp. *(2) |
| Aerobic Gram-negative micro-organisms Acinetobacter baumannii+ Burkholderia cepacia +* Campylobacter spp.+* Citrobacter freundii* Enterobacter aerogenes Enterobacter cloacae * Escherichia coli* Klebsiella oxytoca Klebsiella pneumoniae* Morganella morganii* Neisseria gonorrhoeae* Proteus mirabilis* Proteus vulgaris* Providencia spp. Pseudomonas aeruginosa* Pseudomonas fluorescens Serratia marcescens* |
| Anaerobic micro-organisms Peptostreptococcus spp. Propionibacterium acnes |
| INHERENTLY RESISTANT ORGANISMS |
| Aerobic Gram-positive micro-organisms Actinomyces Enteroccus faecium Listeria monocytogenes |
| Aerobic Gram-negative micro-organisms Stenotrophomonas maltophilia |
| Anaerobic micro-organisms Excepted as listed above |
| Other micro-organisms Mycoplasma genitalium Ureaplasma urealitycum |
| * Clinical efficacy has been demonstrated for susceptible isolates in approved clinical indications. + Resistance rate > 50% in one or more EU countries. ( (1): Studies have been conducted in experimental animal infections due to inhalations of Bacillus anthracis spores; these studies reveal that antibiotics starting early after exposition avoid the occurrence of the disease if the treatment is made up to the decrease of the number of spores in the organism under the infective dose. The recommended use in human subjects is based primarily on in-vitro susceptibility and on animal experimental data together with limited human data. Two-month treatment duration in adults with oral Cipro-Hexal given at the following dose, 500 mg bid, is considered as effective to prevent anthrax infection in humans. The treating physician should refer to national and /or international consensus documents regarding treatment of anthrax. (2): Methicillin-resistant S. aureus very commonly express co-resistance to fluoroquinolones. The rate of resistance to methicillin is around 20 to 50% among all staphylococcal species and is usually higher in nosocomial isolates. |
)Absorption
Following an intravenous infusion of Cipro-Hexal the mean maximum serum concentrations were achieved at the end of infusion. Pharmacokinetics of Cipro-Hexal were linear over the dose range up to 400 mg administered intravenously.
Comparison of the pharmacokinetic parameters for a twice a day and three times a day intravenous dose regimen indicated no evidence of drug accumulation for Cipro-Hexal and its metabolites.
A 60-minute intravenous infusion of 200 mg Cipro-Hexal or the oral administration of 250 mg Cipro-Hexal, both given every 12 hours, produced an equivalent area under the serum concentration time curve (AUC).
A 60-minute intravenous infusion of 400 mg Cipro-Hexal every 12 hours was bioequivalent to a 500 mg oral dose every 12 hours with regard to AUC.
The 400 mg intravenous dose administered over 60 minutes every 12 hours resulted in a Cmax similar to that observed with a 750 mg oral dose.
A 60-minute infusion of 400 mg Cipro-Hexal every 8 hours is equivalent with respect to AUC to 750 mg oral regimen given every 12 hours.
Distribution
Protein binding of Cipro-Hexal is low (20-30%). Cipro-Hexal is present in plasma largely in a non-ionised form and has a large steady state distribution volume of 2-3 l/kg body weight. Cipro-Hexal reaches high concentrations in a variety of tissues such as lung (epithelial fluid, alveolar macrophages, biopsy tissue), sinuses, inflamed lesions (cantharides blister fluid), and the urogenital tract (urine, prostate, endometrium) where total concentrations exceeding those of plasma concentrations are reached.
Biotransformation
Low concentrations of four metabolites have been reported, which were identified as: desethyleneCipro-Hexal (M 1), sulphoCipro-Hexal (M 2), oxoCipro-Hexal (M 3) and formylCipro-Hexal (M 4). The metabolites display in-vitro antimicrobial activity but to a lower degree than the parent compound.
Cipro-Hexal is known to be a moderate inhibitor of the CYP 450 1A2 iso-enzymes.
Elimination
Cipro-Hexal is largely excreted unchanged both renally and, to a smaller extent, faecally.
| Excretion of Cipro-Hexal (% of dose) | ||
| Intravenous administration | ||
| Urine | Faeces | |
| Cipro-Hexal | 61.5 | 15.2 |
| Metabolites (M1 - M4) | 9.5 | 2.6 |
Renal clearance is between 180-300 ml/kg/h and the total body clearance is between 480-600 ml/kg/h. Cipro-Hexal undergoes both glomerular filtration and tubular secretion. Severely impaired renal function leads to increased half lives of Cipro-Hexal of up to 12 h.
Non-renal clearance of Cipro-Hexal is mainly due to active trans-intestinal secretion and metabolism. 1% of the dose is excreted via the biliary route. Cipro-Hexal is present in the bile in high concentrations.
Paediatric population
The pharmacokinetic data in paediatric patients are limited.
In a study in children Cmax and AUC were not age-dependent (above one year of age). No notable increase in Cmax and AUC upon multiple dosing (10 mg/kg three times daily) was observed.
In 10 children with severe sepsis Cmax was 6.1 mg/l (range 4.6-8.3 mg/l) after a 1-hour intravenous infusion of 10 mg/kg in children aged less than 1 year compared to 7.2 mg/l (range 4.7-11.8 mg/l) for children between 1 and 5 years of age. The AUC values were 17.4 mg
h/l (range 11.8-32.0 mgh/l) and 16.5 mgh/l (range 11.0-23.8 mgh/l) in the respective age groups.
These values are within the range reported for adults at therapeutic doses. Based on population pharmacokinetic analysis of paediatric patients with various infections, the predicted mean half-life in children is approx. 4-5 hours and the bioavailability of the oral suspension ranges from 50 to 80%.
Non-clinical data reveal no special hazard for humans based on conventional studies of single dose toxicity, repeated dose toxicity, carcinogenic potential, or toxicity to reproduction.
Like a number of other quinolones, Cipro-Hexal is phototoxic in animals at clinically relevant exposure levels. Data on photomutagenicity / photocarcinogenicity show a weak photomutagenic or phototumorigenic effect of Cipro-Hexal in-vitro and in animal experiments. This effect was comparable to that of other gyrase inhibitors.
Articular tolerability
As reported for other gyrase inhibitors, Cipro-Hexal causes damage to the large weight-bearing joints in immature animals. The extent of the cartilage damage varies according to age, species and dose; the damage can be reduced by taking the weight off the joints. Studies with mature animals (rat, dog) revealed no evidence of cartilage lesions. In a study in young beagle dogs, Cipro-Hexal caused severe articular changes at therapeutic doses after two weeks of treatment, which were still observed after 5 months.
Unless compatibility with other solutions/drugs has been confirmed, the infusion solution must always be administered separately. The visual signs of incompatibility are e.g. precipitation, clouding, and discoloration.
Incompatibility appears with all infusion solutions/drugs that are physically or chemically unstable at the pH of the solutions (e.g. penicillins, heparin solutions), especially in combination with solutions adjusted to an alkaline pH (pH of Cipro-Hexal solutions: 3.9 - 4.5).
The solution should be visually inspected prior to use and only clear solutions, without particles, should be used.
The infusion contains no preservatives. For single use only. Any remaining solution and vials and/or bags should be adequately disposed of, in accordance with local requirements.
Cipro-Hexal is compatible with physiological sodium chloride solution, Ringer's solution, Ringer's lactate solution, 50 mg/ml (5 %) or 100 mg/ml (10 %) glucose solution and 50 mg/ml (5 %) glucose solution with 2.25 mg/ml (0.225 %) or 4.5 mg/ml (0.45 %) sodium chloride solution and 10% fructose solution. Compatibility with these solutions has been proven in Cipro-Hexal concentrations of 1 mg/ml. Chemical and physical in-use stability has been demonstrated immediately after dilution, after 24 hours at 2-8°C and after 24 hours at room temperature. Unless compatibility is proven, the solution for infusion should always be administered separately.
The diluted solutions should be inspected visually for particulate matter and discoloration prior to administration. Only clear and colourless solutions should be used.
Handling glass vials:
Cipro-Hexal 2 mg/ml may be infused via a suitable cannula directly or diluted with any of the fluids in the list above.
Handling plastic bags:
Do not remove unit from overwrap until ready for use. The overwrap is a moisture barrier. The inner bag maintains the sterility of the product.
To open, tear overwrap down side at slit and remove solution container. Some opacity of the plastic due to moisture absorption during the sterilization process may be observed. This is normal and does not affect the solution quality or safety. The opacity will diminish gradually. After removing overwrap, check for minute leaks by squeezing inner bag firmly. If leaks are found, discard solution as sterility may be impaired.
CAUTION: Do not use plastic containers in series connections. Such use could result in air embolism due to residual air being drawn from the primary container before administration of the fluid from the secondary container is completed.
