SUMMARY OF PRODUCT CHARACTERISTICS

1 NAME OF THE MEDICINAL PRODUCT

Ciprofloxacin 2 mg/ml solution for infusion

2 QUALITATIVE AND QUANTITATIVE COMPOSITION 100 ml glass vials:

1 ml solution for infusion contains:

Ciprofloxacin lactate equivalent to 2 mg ciprofloxacin.

Each vial with 100 ml contains 200 mg ciprofloxacin.

200 ml plastic bags:

1 ml solution for infusion contains:

Ciprofloxacin lactate equivalent to 2 mg ciprofloxacin.

Each bag with 200 ml contains 400 mg ciprofloxacin.

Excipient with known effect: 15.4 mmol (354 mg) sodium per 100 ml of solution for infusion.

For the full list of excipients, see section 6.1.

3    PHARMACEUTICAL FORM

Solution for infusion

Clear, colourless to slightly yellow solution pH of the solution: 3.9 - 4.5

4    CLINICAL PARTICULARS

4.1 Therapeutic indications

Ciprofloxacin Hikma 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

•    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)

Ciprofloxacin 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)

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

Posology

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 intravenous 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 coadministration 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	Complicated and uncomplicated	400 mg twice daily to	7 to 21 days, it can be continued for longer

infections (see section 4.4)	pyelonephritis	400 mg three times a day	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 gastrointestinal tract and intraabdominal 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. Ciprofloxacin 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		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 postexposure 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	Serum Creatinine	Intravenous Dose
[ml/min/1.73 m2]	[pmol/l]	[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	> 169	200 - 400 mg every 24
dialysis		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

Ciprofloxacin 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 and 30 minutes for 200 mg Ciprofloxacin Hima. 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 (see section 6.6).

4.3 Contraindications

• Hypersensitivity to the active substance, to other quinolones or to any of the excipients listen in section 6.1.

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

4.4 Special warnings and precautions for use

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 Gram-positive or anaerobic pathogens. In such infections ciprofloxacin must be co-administered with other appropriate antibacterial agents.

Streptococcal Infections (including 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. For epididymo-orchitis and pelvic inflammatory diseases, empirical ciprofloxacin should only be considered in combination with another appropriate antibacterial agent (e.g. a cephalosporin) unless ciprofloxacin-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 ciprofloxacin in the treatment of post-surgical intraabdominal 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.

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 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 (see section 4.8).

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, even within the first 48 hours of treatment. Inflammation and ruptures of tendon may occur even up to several months after discontinuation of ciprofloxacin therapy.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).

Photosensitivity

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

Ciprofloxacin like other quinolones are known to trigger seizures or lower the seizure threshold. Cases of status epilepticus have been reported. 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 suicidal ideations/thoughts culminating in attempted suicide or completed suicide. In the occurrence of such 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).

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 (see section 4.8).

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. Antiperistaltic 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.

Impaired renal function

Since ciprofloxacin is largely excreted unchanged via renal pathway dose adjustment is needed in patients with impaired renal function as described in section 4.2 to avoid an increase in adverse drug reactions due to accumulation of ciprofloxacin.

Hepatobiliary 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, olanzapine, ropinirole, tizanidine, duloxetine, agomelatine). 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 with tests

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

Injection Site 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, 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.

4.5 Interaction with other medicinal products and other forms of interaction

Effects of other medicinal products on ciprofloxacin:

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).

Probenecid

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

Effects of 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 (C_max 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.

Cyclosporin

A transient rise in the concentration of serum creatinine was observed when ciprofloxacin and cyclosporin containing medicinal products were administered simultaneously. Therefore, it is frequently (twice a week) necessary to control the serum creatinine concentrations in these patients.

Vitamin K antagonists

Simultaneous administration of ciprofloxacin with a vitamin K antagonist may augment its anticoagulant effects. The risk may vary with the underlying infection, age and general status of the patient so that the contribution of ciprofloxacin to the increase in INR (international normalized ratio) is difficult to assess. The INR should be monitored frequently during and shortly after coadministration of ciprofloxacin with a vitamin K antagonist (e.g., warfarin, acenocoumarol, phenprocoumon, or fluindione).

Duloxetine

In clinical studies, it was demonstrated that concomitant use of duloxetine with strong inhibitors of the CYP450 1A2 isozyme such as fluvoxamine, may result in an increase of AUC and C_max of duloxetine. Although no clinical data are available on a possible interaction with ciprofloxacin, similar effects can be expected upon concomitant administration (see section 4.4).

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 C_max 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).

Lidocaine

It was demonstrated in healthy subjects that concomitant use of lidocaine containing medicinal products with ciprofloxacin, a moderate inhibitor of CYP450 1A2 isozyme, reduces clearance of intravenous lidocaine by 22%. Although lidocaine treatment was well tolerated, a possible interaction with ciprofloxacin associated with side effects may occur upon concomitant administration.

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 co-administration with ciprofloxacin are advised (see section 4.4).

Sildenafil

Cmax and AUC of sildenafil were increased approximately twofold in healthy subjects after an oral dose of 50 mg given concomitantly with 500 mg ciprofloxacin. Therefore, caution should be used prescribing ciprofloxacin concomitantly with sildenafil taking into consideration the risks and the benefits.

Agomelatine

In clinical studies, it was demonstrated that fluvoxamine, as a strong inhibitor of the CYP450 1A2 isoenzyme, markedly inhibits the metabolism of agomelatine resulting in a 60-fold increase of agomelatine exposure. Although no clinical data are available for a possible interaction with ciprofloxacin, a moderate inhibitor of CYP450 1A2, similar effects can be expected upon concomitant administration (‘Cytochrome P450’ in section ‘Special warnings and precautions for use).

Zolpidem

Co-administration ciprofloxacin may increase blood levels of zolpidem, concurrent use is not recommended.

4.6 Fertility, 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 and diarrhea, vomiting, transient increase in transaminases, rash, and injection and infusion site reactions. ADRs derived from clinical studies and post-marketing surveillance with ciprofloxacin (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.

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 Thrombocytopeni a 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) (see section 4.4) Serum sicknesslike reaction
Metabolism and nutrition disorders		Decreased appetite	Hyperglycaemia Hypoglycaemia (see section 4.4)
Psychiatric disorders		Psychomotor hyperactivity / agitation	Confusion and disorientation Anxiety reaction Abnormal dreams Depression (potentially culminating in suicidal ideations/thoug hts or suicide attempts and completed suicide) (see	Psychotic reactions (potentially culminating in suicidal ideations/thoug hts or suicide attempts and completed suicide) (see section 4.4)	Mania, hypomania

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)
			section 4.4) Hallucinations
Nervous system disorders		Headache Dizziness Sleep disorders Taste disorders	Par- and dysaesthesia Hypoaesthesia Tremor Seizures (incl. status epilepticus see section 4.4) Vertigo	Migraine disturbed coordination Gait disturbance Olfactory nerve disorders Intracranial hypertension and pseudotumor cerebri	Peripheral neuropathy (see section 4.4)
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 (see section 4.4 and 4.9)
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) (see section 4.4)	Pancreatitis
Hepatobiliary disorders		Increase in transaminases Increased bilirubin	Hepatic impairment Cholestatic icterus Hepatitis	Liver necrosis (very rarely progressing to life-threatening hepatic failure) (see section 4.4)
Skin and subcutaneous tissue disorders		Rash Pruritus Urticaria	Photosensitivity reactions (see section 4.4)	Petechia Erythema multiforme Erythema nodosum Stevens-Johnson	Acute generalised exanthematous pustulosis (AGEP),

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)
				syndrome (potentially life-threatening) Toxic epidermal necrolysis (potencially life-threatening)	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) (see section 4.4) Exacerbation of symptoms of myasthenia gravis (see section 4.4)
Renal and urinary disorders		Renal impairment	Renal failure Haematuria Crystalluria (see section 4.4) 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 (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: Yellow Card Scheme - Website: www.mhra.gov.uk/yellowcard.

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.

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 ciprofloxacin in overdoses.

Only a small quantity of ciprofloxacin (< 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.

5 PHARMACOLOGICAL 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.

Pharmacokinetic/pharmacodynamic relationship

Efficacy mainly depends on the relation between the maximum concentration in serum (C_max) 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

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 ciprofloxacin re	ate 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)

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 C_max 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 non-ionised 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.

Biotransformation

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.

Elimination

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

Excretion of ciprofloxacin (% of dose)
	Intravenous administration
	Urine	Faeces
Ciprofloxacin	61.5	15.2
Metabolites (Mj - 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. 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 population

The pharmacokinetic data in paediatric patients are limited.

In a study in children C_max and AUC were not age-dependent (above one year of age). No notable increase in C_max and AUC upon multiple dosing (10 mg/kg three times daily) was observed.

In 10 children with severe sepsis C_max 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 mgh/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%.

5.3 Preclinical safety data

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, 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 (E 270)

Sodium chloride

Hydrochloric acid (E 507) for pH adjustment Water for injections

6.2    Incompatibilities

This medicinal product must not be mixed with other medicinal products except those mentioned in section 6.6.

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 ciprofloxacin solutions: 3.9 - 4.5).

6.3    Shelf life

Glass vials: 3 years Plastic bags: 2 years

6.4    Special precautions for storage

Do not refrigerate or freeze.

Keep the vial/bag in the outer carton/aluminium overpouch until time of use in order to protect from light

6.5    Nature and contents of container

Glass vials:

Type I or II, clear glass vial, fitted with a bromobutyl or chlorobutyl rubber stopper and aluminium flip-off caps.

Pack sizes: 100 ml vials (200 mg ciprofloxacin) in packs of 1, 5 or 10 vials. Plastic bags:

Polypropylene infusion bag assembled with spike-port.

Pack size: 200 ml bags (400 mg ciprofloxacin) in packs of 1 bag.

6.6 Special precautions for disposal

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.

Ciprofloxacin 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 ciprofloxacin 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:

Ciprofloxacin 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.

7 MARKETING AUTHORISATION HOLDER

Hikma Farmaceutica (Portugal), S.A.

Estrada do Rio da Mo n.° 8, 8A e 8B - Ferven?a

2705-906 Terrugem SNT

Portugal

Tel.: +351 219 608 410 Fax: +351 219 615 102 e-mail: geral@hikma.pt

8    MARKETING AUTHORISATION NUMBER(S)

PL 15413/0014

9 DATE OF FIRST AUTHORISATION/RENEWAL OF THE AUTHORISATION

12/04/2010

10 DATE OF REVISION OF THE TEXT

14/07/2016