Technical Information Leaflet Ciprofloxacin 2 mg/ml Solution for Infusion Ciprofloxacin

This leaflet provides Technical Information for the healthcare professional. There is a separate Patient Information Leaflet.

Ciprofloxacin 2 mg/ml Solution for Infusion.

xacin 2 mg/ml Soli QUALITATIVE ANI

1 ml of solution for infusion contains 2 mg of ciprofloxacin. Excipients: Contains 30.8 mmol (707.70 mg) sodium per 200 ml of solution for infusion. For a full list of excipients, see section 6.1

3. PHARMACEUTICAL FORM

Solution for infusion. Clear, yellowish, sterile and non-pyrogenic aqueous solution.

4.1    Therapeutic indications

Ciprofloxacin 2 mg/ml Solution for Infusion is indicated for the treatment of the following infections (see sections 4.4 and 5.1). Special attention should be paid to available information on resistance to ciprofloxacin 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

•    Epididymo-orchitis including cases due    to Neisseria gonorrhoeae

•    Pelvic inflammatory disease including cases due to Neisseria gonorrhoeae

In the above genital tract infections when thought or known to be due to Neisseria gonorrhoeae it is particularly important to obtain local information on the prevalence of resistance to ciprofloxacin and to confirm susceptibility based on laboratory testing.

•    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

•    Treatment of infections in neutropenic patients

•    Prophylaxis of infections in neutropenic    patients

•    inhalation anthrax (post-exposure prophylaxis and curative treatment)

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)

Ciprofloxacin 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 (see sections 4.4 and 5.1).

4.2    Posology and method of administration

The dosage is determined by the indication, the severity and the site of the infection, the susceptibility to ciprofloxacin 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 intravenou s ciprofloxacin 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 ciprofloxacin 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_

Chjjdrenadaoiescente

Geriatric patients: Geriatric patients should receive a dose selected according to the severity of the infection and the patient's creatinine clearance. Renal and hepatc impairment: Recommended starting and maintenance doses for patients with impaired renal function:_

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: Ciprofloxacin 2 mg/ml Solution for Infusion should be checked visually prior to use. It must not be used if cloudy. Ciprofloxacin 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 Ciprofloxacin 2 mg/ml Solution for Infusion and 30 minutes for 200 mg Ciprofloxacin 2 mg/ml Solution for Infusion. Slow infusion into a large vein will minimise 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 (see section 6.2).

4.3 Contraindications

•    Hypersensitivity to the active substance, to other quinolones or to any of the excipients (see section 6.1).

•    Concomitant administration of ciprofloxacin and tizanidine (see section 4.5).

Severe infections and mixed infections with Gram-positive and anaerobic pathogens: Ciprofloxacin monotherapy is not suited for treatment of severe infections and infections that might be due to Grampositive or anaerobic pathogens. In such infections ciprofloxacin must be coadministered with other appropriate antibacterial agents.

Streptococcal Infections lincludina Streptococcus pneumoniae): Ciprofloxacin 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. Ciprofloxacin should be co-administered with another appropriate antibacterial agent unless ciprofloxacin-resistant Neisseria gonorrhoeae can be excluded. If clinical improvement is not achieved after 3 days of treatment, the therapy should be reconsidered. Intra-abdominal infections: There are limited data on the efficacy of ciprofloxacin in the treatment of post-surgical intra-abdominal infections.

Travellers' diarrhoea: The choice of ciprofloxacin should take into account information on resistance to ciprofloxacin in relevant pathogens in the countries visited.

Infections of the bones and joints: Ciprofloxacin should be used in combination with other antimicrobial agents depending on the results of the microbiological documentation.

Inhalationalanthrax: 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.

Children and adolescents: The use of ciprofloxacin in children and adolescents should follow available official guidance. Ciprofloxacin treatment should be initiated only by physicians who are experienced in the treatment of cystic fibrosis and/or severe infections in children and adolescents. Ciprofloxacin has been shown to cause arthropathy in weight-bearing joints of immature animals. Safety data from a randomised double-blind study on ciprofloxacin use in children (ciprofloxacin: 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: Ciprofloxacin 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 ciprofloxacin use. The use of ciprofloxacin 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 (see section 4.8) and may be life-threatening. If such reaction occurs, ciprofloxacin should be discontinued and an adequate medical treatment is required.

Musculoskeletal System: Ciprofloxacin 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, ciprofloxacin 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 ciprofloxacin. Tendinitis and tendon rupture (especially Achilles tendon), sometimes bilateral, may occur with ciprofloxacin, as soon as the first 48 hours of treatment. The risk of tendinopathy may be increased in elderly patients or in patients concomitantly treated with corticosteroids (see section 4.8). At any sign of tendinitis (e.g. painful swelling, inflammation), ciprofloxacin treatment should be discontinued. Care should be taken to keep the affected limb at rest. Ciprofloxacin should be used with caution in patients with myasthenia gravis (see section 4.8).

Photosensitiviv: Ciprofloxacin has been shown to cause photosensitivity reactions. Patients taking ciprofloxacin should be advised to avoid direct exposure to either extensive sunlight or UV irradiation during treatment (see section 4.8).

Central Nervous System: Quinolones are known to trigger seizures or lower the seizure threshold. Ciprofloxacin should be used with caution in patients with CNS disorders which may be predisposed to seizure. If seizures occur ciprofloxacin should be discontinued (see section 4.8). Psychiatric reactions may occur even after the first administration of ciprofloxacin. In rare cases, depression or psychosis can progress to self-endangering behaviour. In these cases, ciprofloxacin 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 ciprofloxacin.

Ciprofloxacin 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 (see section 4.8).

Cardiac disorders:

Caution should be taken when using fluoroquinolones, including ciprofloxacin, 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 ciprofloxacin, in these populations (See section 4.2 Elderly, section 4.5, section 4.8, section 4.9).

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 (see section 4.8). In such cases, ciprofloxacin 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 ciprofloxacin has been reported (see section 4.8). Patients receiving ciprofloxacin should be well hydrated and excessive alkalinity of the urine should be avoided.

Hepatobilia ry system: Cases of hepatic necrosis and life-threatening hepatic failure have been reported with ciprofloxacin (see section 4.8). 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 ciprofloxacin in patients with glucose-6-phosphate dehydrogenase deficiency. Ciprofloxacin 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 ciprofloxacin bacteria that demonstrate resistance to ciprofloxacin may be isolated, with or without a clinically apparent superinfection. There may be a particular risk of selecting for ciprofloxacin-resistant bacteria during extended durations of treatment and when treating nosocomial infections and/or infections caused by Staphylococcus and Pseudomonas species.

Cytochrome P450: Ciprofloxacin inhibits CYP1A2 and thus may cause increased serum concentration of concomitantly administered substances metabolised by this enzyme (e.g. theophylline, clozapine, ropinirole, tizanidine). Co-administration of ciprofloxacin and tizanidine is contra-indicated. Therefore, patients taking these substances concomitantly with ciprofloxacin should be monitored closely for clinical signs of overdose, and determination of serum concentrations (e.g. of theophylline) may be necessary (see section 4.5).

Methotrexate: The concomitant use of ciprofloxacin with methotrexate is not recommended (see section 4.5).

Interaction wth tests: The in-vtro activity of ciprofloxacin against Mycobacterium tuberculosis might give false negative bacteriological test results in specimens from patients currently taking ciprofloxacin. Injection Ste Reaction: Local intravenous site reactions have been reported with the intravenous administration of ciprofloxacin. 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, nephritic syndrome, etc.), the additional sodium load should be taken into account.

Vision disorders: If vision becomes impaired or any effects on the eyes are experienced, an eye specialist should be consulted immediately (see section 4.8).

4.5    Interaction with other medicinal products and other forms of interaction

Effects of other medicinal products on ciprofloxacin:

Probenecid: Probenecid interferes with renal secretion of ciprofloxacin. Co-administration of probenecid and ciprofloxacin increases ciprofloxacin serum concentrations.

Effects oi ciprofloxacin on other medicinal products:

Tizanidine: Tizanidine must not be administered together with ciprofloxacin (see section 4.3). In a clinical study with healthy subjects, there was an increase in serum tizanidine concentration (Cmax increase: 7-fold, range: 4 to 21-fold; AUC increase: 10-fold, range: 6 to 24-fold) when given concomitantly with ciprofloxacin. Increased serum tizanidine concentration is associated with a potentiated hypotensive and sedative effect.

Methotrexate: Renal tubular transport of methotrexate may be inhibited by concomitant administration of ciprofloxacin, potentially leading to increased plasma levels of methotrexate and increased risk of methotrexate-associated toxic reactions. The concomitant use is not recommended (see section 4.4).

Theophylline: Concurrent administration of ciprofloxacin and theophylline can cause an undesirable increase in serum theophylline concentration. This can lead to theophylline-induced side effects that may rarely be life threatening or fatal. During the combination, serum theophylline concentrations should be checked and the theophylline dose reduced as necessary (see section 4.4).

Other xanthine derivatives: On concurrent administration of ciprofloxacin and caffeine or pentoxifylline (oxpentifylline), raised serum concentrations of these xanthine derivatives were reported.

Phenytoin: Simultaneous administration of ciprofloxacin and phenytoin may result in increased or reduced serum levels of phenytoin such that monitoring of drug levels is recommended.

Oral anticoagulants: Simultaneous administration of ciprofloxacin with warfarin may augment its anti-coagulant effects. There have been many reports of increases in oral anti-coagulant activity in patients receiving antibacterial agents, including fluoroquinolones. The risk may vary with the underlying infection, age and general status of the patient so that the contribution of the fluoroquinolone to the increase in INR (international normalised ratio) is difficult to assess. It is recommended that the INR should be monitored frequently during and shortly after co-administration of ciprofloxacin with an oral anticoagulant agent.

Ropinirole: It was shown in a clinical study that concomitant use of ropinirole with ciprofloxacin, a moderate inhibitor of the CYP450 1A2 isozyme, results in an increase of Cmax and AUC of ropinirole by 60% and 84%, respectively. Monitoring of ropinirole-related side effects and dose adjustment as appropriate is recommended during and shortly after co-administration with ciprofloxacin (see section 4.4). Clozapine: Following concomitant administration of 250 mg ciprofloxacin with clozapine for 7 days, serum concentrations of clozapine and N-desmethylclozapine were increased by 29% and 31%, respectively. Clinical surveillance and appropriate adjustment of clozapine dosage during and shortly after coadministration with ciprofloxacin are advised (see section 4.4).

Drugs known to prolong QT interval: Ciprofloxacin, like other fluoroquinolones, should be used with caution in patients receiving drugs known to prolong the QT interval (e.g. Class IA and III anti-arrhythmics, tricyclic antidepressants, macrolides, antipsychotics) (see section 4.4).

4.6    Pregnancy and lactation

Pregnancy: The data that are available on administration of ciprofloxacin to pregnant women indicates no malformative or feto/neonatal toxicity of ciprofloxacin. Animal studies do not indicate direct or indirect harmful effects with respect to reproductive toxicity. In juvenile and prenatal animals exposed to quinolones, effects on immature cartilage have been observed, thus, it cannot be excluded that the drug could cause damage to articular cartilage in the human immature organism / foetus (see section 5.3). As a precautionary measure, it is preferable to avoid the use of ciprofloxacin during pregnancy. Lactation: Ciprofloxacin is excreted in breast milk. Due to the potential risk of articular damage, ciprofloxacin should not be used during breast-feeding.

4.7    Effects on ability to drive and use machines

Due to its neurological effects, ciprofloxacin may affect reaction time. Thus, the ability to drive or to operate machinery may be impaired.

4.8    Undesirable effects

The most commonly reported adverse drug reactions (ADRs) are nausea, diarrhoea, vomiting, transient increase in transaminases, rash, and injection and infusion site reactions. ADRs derived from clinical studies and post-marketing surveillance with Ciprofloxacin 2 mg/ml Solution for Infusion (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 ciprofloxacin.

* These events were reported during the post marketing period and were observed predominantly among patients with further risk factors for QT prolongation (see section 4.4). The following undesirable effects have a higher frequency category in the subgroups of patients receiving intravenous or sequential (intravenous to oral) treatment:_

Paediatric patients: The incidence of arthropathy, mentioned above, is referring to data collected in studies with adults. In children, arthropathy is reported to occur commonly (see section 4.4). 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:

For UK: Yellow Card Scheme, Website: (www.mhra.gov.uk/yellowcard).

For IE: HPRA Pharmacovigilance, Earlsfort Terrace, IRL - Dublin 2; Tel: +353 1 6764971; Fax: +353 1 6762517. Website: www.hpra.ie; E-mail: medsafety@hpra.ie.

4.9 Overdose

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. In the event of overdose, symptomatic treatment should be implemented. ECG monitoring should be undertaken, because of the possibility of QT interval prolongation. Apart from routine emergency measures, it is recommended to monitor renal function, including urinary pH and acidify, if required, to prevent crystalluria. Patients should be kept well hydrated. Only a small quantity of ciprofloxacin (<10%) is eliminated by haemodialysis or peritoneal dialysis.

HaRmacological properties_

5.1 Pharmacodynamic properties

Pharmacotherapeutic group: Fluoroquinolones, ATC code: J01MA02

Mechanism of action: As a fluoroquinolone antibacterial agent, the bactericidal action of ciprofloxacin results from the inhibition of both type II topoisomerase (DNA-gyrase) and topoisomerase IV, required for bacterial DNA replication, transcription, repair and recombination.

PK/PD relationship: Efficacy mainly depends on the relation between the maximum concentration in serum (Cmax) and the minimum inhibitory concentration (MIC) of ciprofloxacin for a bacterial pathogen and the relation between the area under the curve (AUC) and the MIC.

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

1 Staphylococcus spp. - breakpoints for ciprofloxacin 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 ciprofloxacin susceptibility (for Streptococcus species see section 4.4)._

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

catarrhal is', Neisseria meningtidis, Pasteurella spp., Salmonella spp.*, Shigella spp. ', Vibrio spp., Yersinia pestis_

Anaergb[c_micrg-grganjsms: 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 baumanni+, Burkholderia cepacia +*, Campylobacter spp.+*, Citrobacter freundiT, Enterobacter aerogenes, Enterobacter cloacae ', Escherichia coli*, Klebsiella oxytoca, Klebsiella pneumoniae', Morganella morganiT, Neisseria gonorrhoeae', Proteus mirabilis', Proteus vulgaris', Providencia spp., Pseudomonas aeruginosa', Pseudomonas

fluorescens, Serratia marcescens'_

Anaerobicmicro-organisms: Peptostreptococcus spp., Propionibacterium acnes_

INHERENTLY RESISTANT ORGANISMS_

Aergb[c_Gram_:-egsijtye_m[cr&-grgan[sms: Actinomyces, Enteroccus faecium, Listeria monocytogenes_

AerQbic_Gram-negative_micrQ-:Qrganisms; Stenotrophomonas maltophilia_

Anaerobicmicro-organismsi Excepted as listed above_

OtheLmicro-organisms: Mycoplasma genitalium, Ureaplasma ureaHtycum_

* Clinical efficacy has been demonstrated for susceptible isolates in approved clinical indications + Resistance rate > 50% in one or more EU countries

($): 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 ciprofloxacin 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._

5.2 Pharmacokinetic properties

Absorption: Following an intravenous infusion of ciprofloxacin the mean maximum serum concentrations were achieved at the end of infusion. Pharmacokinetics of ciprofloxacin 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 ciprofloxacin and its metabolites. A 60-minute intravenous infusion of 200 mg ciprofloxacin or the oral administration of 250 mg ciprofloxacin, both given every 12 hours, produced an equivalent area under the serum concentration time curve (AUC). A 60-minute intravenous infusion of 400 mg ciprofloxacin 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 ciprofloxacin every 8 hours is equivalent with respect to AUC to 750 mg oral regimen given every 12 hours.

Distribution: Protein binding of ciprofloxacin is low (20-30%). Ciprofloxacin is present in plasma largely in a nonionised form and has a large steady state distribution volume of 2-3 L/kg body weight. Ciprofloxacin 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.

Metabolism: Low concentrations of four metabolites have been reported, which were identified as: desethyleneciprofloxacin (M 1), sulphociprofloxacin (M 2), oxociprofloxacin (M 3) and formylciprofloxacin (M 4). The metabolites display in-vitro antimicrobial activity but to a lower degree than the parent compound. Ciprofloxacin is known to be a moderate inhibitor of the CYP 450 1A2 iso-enzymes.

Renal clearance is between 180-300 mL/kg/h and the total body clearance is between 480-600 mL/kg/h. Ciprofloxacin undergoes both glomerular filtration and tubular secretion. Severely impaired renal function leads to increased half lives of ciprofloxacin of up to 12 h. Non-renal clearance of ciprofloxacin is mainly due to active trans-intestinal secretion and metabolism. 1% of the dose is excreted via the biliary route. Ciprofloxacin is present in the bile in high concentrations.

Paediatric patients: 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 mg*h/L) and 16.5 mg*h/L (range 11.0-23.8 mg*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%.

5.3 Preclinical safety data

Non-clinical data reveal no special hazards 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, ciprofloxacin is phototoxic in animals at clinically relevant exposure levels. Data on photomutagenicity/ photocarcinogenicity show a weak photomutagenic or phototumorigenic effect of ciprofloxacin in-vitro and in animal experiments. This effect was comparable to that of other gyrase inhibitors.

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

6.1    List of excipients: Lactic acid (E270), Sodium chloride, Hydrochloric Acid (E507) for pH adjustment, Water for injections.

6.2    Incompatibilities: Ciprofloxacin 2 mg/ml Solution for Infusion is incompatible with injection solutions (e.g. penicillins, heparin solutions) which are chemically or physically unstable at pH of 3.9 - 4.5. Unless compatibility is proven, the infusion should always be administered separately. This medicinal product must not be mixed with other medicinal products except those mentioned in section 6.6.

6.3    Shelf life: Unopened: Three years. Single dose container. From a microbiological point of view, the product should be used immediately once opened (see section 6.4).

6.4    Special precautions for storage:

Polypropylene bag: Unopened: Store below 25°C. Keep the bag in the outer carton in order to protect from light. Do not refrigerate or freeze.

Polypropylene bottles: Unopened: Store below 25°C. Keep the bottles in the outer carton in order to protect from light. Do not refrigerate or freeze. Since Ciprofloxacin 2 mg/ml Solution for Infusion is light-sensitive, the bags and bottles should always be stored in the cardboard outer container. No special precautions are required during the normal 60 minute infusion period. Do not refrigerate or freeze Ciprofloxacin 2 mg/ml Solution for Infusion. If the product is inadvertently refrigerated, crystals may form. Do not use if crystals are present. These crystals will, however, redissolve at room temperature and do not adversely affect the quality of the product.

6.5    Nature and contents of container:

100 ml polypropylene bags: Plastic bags of polypropylene of 100 ml, with rubber (type I) closures, and Aluminium caps with plastic flip-top covers. The bags are placed in cartons. Boxes of 10 bags.

100 ml polypropylene bottles: Plastic bottles of polypropylene of 100 ml, with a molded plastic cap, a rubber (type II) gasket and a pull ring. Each bottle is placed in a metalized plastic pouch. The bottles are placed in carton boxes. Boxes of 10 bottles.

Plastic bottles of polypropylene of 100 ml, with a molded plastic cap, a rubber (type II) gasket and a pull ring. Each bottle is enclosed in an individual carton box. Boxes of 1 bottle.

200ml polypropylene bags: Plastic bags of polypropylene of 200 ml, with rubber (type I) closures, and Aluminium caps with plastic flip-top covers. The bags are placed in cartons. Boxes of 5 bags.

200 ml polypropylene bottles: Plastic bottles of polypropylene of 200 ml, with a molded plastic cap, a rubber (type II) gasket and a pull ring. Each bottle is placed in a metalized plastic pouch. The bottles are placed in carton boxes. Boxes of 10 bottles. Plastic bottles of polypropylene of 200 ml, with a molded plastic cap, a rubber (type II) gasket and a pull ring. Each bottle is placed in a metalized plastic pouch. The bottles are placed in carton boxes. Boxes of 5 bottles. Plastic bottles of polypropylene of 200 ml, with a molded plastic cap, a rubber (type II) gasket and a pull ring. Each bottle is enclosed in an individual carton box. Boxes of 1 bottle.

6.6    Special precautions for disposal and other handling:

Intravenous infusion: Ciprofloxacin should not be mixed with other drug products which are chemically or physically unstable at pH of 3.9 - 4 .5 (see section 6.2). The solution should be clear. Do not use if particles are present. Ciprofloxacin is compatible with the following commonly used infusion fluids: Rin    5% and Dextrose

10% solutions, Fructose 10% solution Sodium chloride 0.45% + Dextrose 5% solution and Sodium chloride 0.225% + Dextrose 5% solution. All solutions are stable for 48 hours below 25°C, with the only exception of the mixture of Ciprofloxacin with Ringer solution, which is stable for 12 hours below 25°C. Unless compatibility is proven, the infusion solution should always be administered separately.

Since the infusion solution is photosensitive, the infusion bags and infusion bottles should be removed from the box only immediately before use. In daylight conditions complete efficacy is guaranteed for a period of three days. Any unused solution should be disposed of in accordance with local requirements.

Noridem Enterprises Ltd., Evagorou & Makariou, Mitsi Building 3, Office 115, 1065 Nicosia, Cyprus.

8. MARKETING AUTHORISATION NUMBER_

PL 24598/0009-001 PA 1122/005-001