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Components:
Ciprofloxacin
Method of action:
Antibacterial Broad Spectrum (Bactericidal), Bactericidal
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Medically reviewed by Militian Inessa Mesropovna, PharmD. Last updated on 2019.12.11

Name of the medicinal product

Kinox

Qualitative and quantitative composition

Ciprofloxacin

Therapeutic indications

The information provided in Therapeutic indications of Kinox is based on data of another medicine with exactly the same composition as the Kinox of the medicine (Ciprofloxacin). Be careful and be sure to specify the information on the section Therapeutic indications in the instructions to the drug Kinox directly from the package or from the pharmacist at the pharmacy.
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Kinox 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 Kinox 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)

Kinox 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)

Kinox 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.

Dosage (Posology) and method of administration

The information provided in Dosage (Posology) and method of administration of Kinox is based on data of another medicine with exactly the same composition as the Kinox of the medicine (Ciprofloxacin). Be careful and be sure to specify the information on the section Dosage (Posology) and method of administration in the instructions to the drug Kinox directly from the package or from the pharmacist at the pharmacy.
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Posology

The dosage is determined by the indication, the severity and the site of the infection, the susceptibility to Kinox 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 Kinox 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 Kinox 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.

Kinox 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

Kinox should be checked visually prior to use. It must not be used if cloudy.

Kinox 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 Kinox and 30 minutes for 200 mg Kinox. 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.

Contraindications

The information provided in Contraindications of Kinox is based on data of another medicine with exactly the same composition as the Kinox of the medicine (Ciprofloxacin). Be careful and be sure to specify the information on the section Contraindications in the instructions to the drug Kinox directly from the package or from the pharmacist at the pharmacy.
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-

- Concomitant administration of Kinox and tizanidine.

Special warnings and precautions for use

The information provided in Special warnings and precautions for use of Kinox is based on data of another medicine with exactly the same composition as the Kinox of the medicine (Ciprofloxacin). Be careful and be sure to specify the information on the section Special warnings and precautions for use in the instructions to the drug Kinox directly from the package or from the pharmacist at the pharmacy.
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Severe infections and mixed infections with Gram-positive and anaerobic pathogens

Kinox monotherapy is not suited for treatment of severe infections and infections that might be due to Gram-positive or anaerobic pathogens. In such infections Kinox must be co-administered with other appropriate antibacterial agents.

Streptococcal Infections (including Streptococcus pneumoniae)

Kinox 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 Kinox should only be considered in combination with another appropriate antibacterial agent (e.g. a cephalosporin) unless Kinox-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 Kinox in the treatment of post-surgical intra-abdominal infections.

Travellers' diarrhoea

The choice of Kinox should take into account information on resistance to Kinox in relevant pathogens in the countries visited.

Infections of the bones and joints

Kinox 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 Kinox in children and adolescents should follow available official guidance. Kinox treatment should be initiated only by physicians who are experienced in the treatment of cystic fibrosis and/or severe infections in children and adolescents.

Kinox has been shown to cause arthropathy in weight-bearing joints of immature animals. Safety data from a randomised double-blind study on Kinox use in children (Kinox: 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

Kinox 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 Kinox use.

The use of Kinox 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, Kinox should be discontinued and an adequate medical treatment is required.

Musculoskeletal System

Kinox 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, Kinox 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 Kinox.

Tendinitis and tendon rupture (especially Achilles tendon), sometimes bilateral, may occur with Kinox, even within the first 48 hours of treatment. Inflammation and ruptures of tendon may occur even up to several months after discontinuation of Kinox 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), Kinox treatment should be discontinued. Care should be taken to keep the affected limb at rest.

Kinox should be used with caution in patients with myasthenia gravis.

Photosensitivity

Kinox has been shown to cause photosensitivity reactions. Patients taking Kinox should be advised to avoid direct exposure to either extensive sunlight or UV irradiation during treatment.

Central Nervous System

Kinox like other quinolones are known to trigger seizures or lower the seizure threshold. Cases of status epilepticus have been reported. Kinox should be used with caution in patients with CNS disorders which may be predisposed to seizure. If seizures occur Kinox should be discontinued. Psychiatric reactions may occur even after the first administration of Kinox. 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, Kinox 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 Kinox. Kinox 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 Kinox, 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 Kinox, 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, Kinox 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 Kinox has been reported. Patients receiving Kinox 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 Kinox. 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 Kinox in patients with glucose-6-phosphate dehydrogenase deficiency. Kinox 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 Kinox bacteria that demonstrate resistance to Kinox may be isolated, with or without a clinically apparent superinfection. There may be a particular risk of selecting for Kinox-resistant bacteria during extended durations of treatment and when treating nosocomial infections and/or infections caused by Staphylococcus and Pseudomonas species.

Cytochrome P450

Kinox 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 Kinox and tizanidine is contra-indicated. Therefore, patients taking these substances concomitantly with Kinox 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 Kinox with methotrexate is not recommended.

Interaction with tests

The in-vitro activity of Kinox against Mycobacterium tuberculosis might give false negative bacteriological test results in specimens from patients currently taking Kinox.

Injection Site Reaction

Local intravenous site reactions have been reported with the intravenous administration of Kinox. 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.

Effects on ability to drive and use machines

The information provided in Effects on ability to drive and use machines of Kinox is based on data of another medicine with exactly the same composition as the Kinox of the medicine (Ciprofloxacin). Be careful and be sure to specify the information on the section Effects on ability to drive and use machines in the instructions to the drug Kinox directly from the package or from the pharmacist at the pharmacy.
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Due to its neurological effects, Kinox may affect reaction time. Thus, the ability to drive or to operate machinery may be impaired.

Undesirable effects

The information provided in Undesirable effects of Kinox is based on data of another medicine with exactly the same composition as the Kinox of the medicine (Ciprofloxacin). Be careful and be sure to specify the information on the section Undesirable effects in the instructions to the drug Kinox directly from the package or from the pharmacist at the pharmacy.
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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 Kinox (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 Kinox.

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.

Overdose

The information provided in Overdose of Kinox is based on data of another medicine with exactly the same composition as the Kinox of the medicine (Ciprofloxacin). Be careful and be sure to specify the information on the section Overdose in the instructions to the drug Kinox directly from the package or from the pharmacist at the pharmacy.
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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 Kinox in overdoses.

Only a small quantity of Kinox (< 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.

Pharmacodynamic properties

The information provided in Pharmacodynamic properties of Kinox is based on data of another medicine with exactly the same composition as the Kinox of the medicine (Ciprofloxacin). Be careful and be sure to specify the information on the section Pharmacodynamic properties in the instructions to the drug Kinox directly from the package or from the pharmacist at the pharmacy.
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Pharmacotherapeutic group: Fluoroquinolones, ATC code: J01MA02

Mechanism of action

As a fluoroquinolone antibacterial agent, the bactericidal action of Kinox 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 Kinox for a bacterial pathogen and the relation between the area under the curve (AUC) and the MIC.

Mechanism of resistance

In-vitro resistance to Kinox can be acquired through a stepwise process by target site mutations in both DNA gyrase and topoisomerase IV. The degree of cross-resistance between Kinox 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 Kinox.

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 Kinox 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 Kinox 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 (BLACK DIAMOND SUIT (9830))

Chlamydia pneumoniae (BLACK DIAMOND SUIT (9830))

Mycoplasma hominis (BLACK DIAMOND SUIT (9830))

Mycoplasma pneumoniae (BLACK DIAMOND SUIT (9830))

SPECIES FOR WHICH ACQUIRED RESISTANCE MAY BE A PROBLEM

Aerobic Gram-positive micro-organisms

Enterococcus faecalis (BLACK DIAMOND SUIT (9830))

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.

(BLACK DIAMOND SUIT (9830)): Natural intermediate susceptibility in the absence of acquired mechanism of resistance.

(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 Kinox 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.

Pharmacokinetic properties

The information provided in Pharmacokinetic properties of Kinox is based on data of another medicine with exactly the same composition as the Kinox of the medicine (Ciprofloxacin). Be careful and be sure to specify the information on the section Pharmacokinetic properties in the instructions to the drug Kinox directly from the package or from the pharmacist at the pharmacy.
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Absorption

Following an intravenous infusion of Kinox the mean maximum serum concentrations were achieved at the end of infusion. Pharmacokinetics of Kinox 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 Kinox and its metabolites.

A 60-minute intravenous infusion of 200 mg Kinox or the oral administration of 250 mg Kinox, both given every 12 hours, produced an equivalent area under the serum concentration time curve (AUC).

A 60-minute intravenous infusion of 400 mg Kinox 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 Kinox every 8 hours is equivalent with respect to AUC to 750 mg oral regimen given every 12 hours.

Distribution

Protein binding of Kinox is low (20-30%). Kinox 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. Kinox 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: desethyleneKinox (M 1), sulphoKinox (M 2), oxoKinox (M 3) and formylKinox (M 4). The metabolites display in-vitro antimicrobial activity but to a lower degree than the parent compound.

Kinox is known to be a moderate inhibitor of the CYP 450 1A2 iso-enzymes.

Elimination

Kinox is largely excreted unchanged both renally and, to a smaller extent, faecally.

Excretion of Kinox (% of dose)

Intravenous administration

Urine

Faeces

Kinox

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. Kinox undergoes both glomerular filtration and tubular secretion. Severely impaired renal function leads to increased half lives of Kinox of up to 12 h.

Non-renal clearance of Kinox is mainly due to active trans-intestinal secretion and metabolism. 1% of the dose is excreted via the biliary route. Kinox 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 mgDOT OPERATOR (8901)h/l (range 11.8-32.0 mgDOT OPERATOR (8901)h/l) and 16.5 mgDOT OPERATOR (8901)h/l (range 11.0-23.8 mgDOT OPERATOR (8901)h/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%.

Pharmacotherapeutic group

The information provided in Pharmacotherapeutic group of Kinox is based on data of another medicine with exactly the same composition as the Kinox of the medicine (Ciprofloxacin). Be careful and be sure to specify the information on the section Pharmacotherapeutic group in the instructions to the drug Kinox directly from the package or from the pharmacist at the pharmacy.
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Fluoroquinolones, ATC code: J01MA02

Preclinical safety data

The information provided in Preclinical safety data of Kinox is based on data of another medicine with exactly the same composition as the Kinox of the medicine (Ciprofloxacin). Be careful and be sure to specify the information on the section Preclinical safety data in the instructions to the drug Kinox directly from the package or from the pharmacist at the pharmacy.
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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, Kinox is phototoxic in animals at clinically relevant exposure levels. Data on photomutagenicity / photocarcinogenicity show a weak photomutagenic or phototumorigenic effect of Kinox in-vitro and in animal experiments. This effect was comparable to that of other gyrase inhibitors.

Articular tolerability

As reported for other gyrase inhibitors, Kinox 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, Kinox caused severe articular changes at therapeutic doses after two weeks of treatment, which were still observed after 5 months.

Incompatibilities

The information provided in Incompatibilities of Kinox is based on data of another medicine with exactly the same composition as the Kinox of the medicine (Ciprofloxacin). Be careful and be sure to specify the information on the section Incompatibilities in the instructions to the drug Kinox directly from the package or from the pharmacist at the pharmacy.
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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 Kinox solutions: 3.9 - 4.5).

Special precautions for disposal and other handling

The information provided in Special precautions for disposal and other handling of Kinox is based on data of another medicine with exactly the same composition as the Kinox of the medicine (Ciprofloxacin). Be careful and be sure to specify the information on the section Special precautions for disposal and other handling in the instructions to the drug Kinox directly from the package or from the pharmacist at the pharmacy.
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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.

Kinox 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 Kinox 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:

Kinox 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.

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