Cipro 3000 MG QID for Respiratory Infection

[Sparda29]

So we got a doctor call today for Ciprofloxacin 3000 mg by mouth 4 times a day for 4 days. This was the MA calling it in, so I immediately asked to speak to the MD and she confirmed that it was 3000 mg 4 times a day for 4 days. WTF?

Patient came in, we decided not to fill it until we talked to him. It's supposedly a respiratory tract infection that's being treated, the patient looks like he is perfectly fine, no respiratory distress, no coughing. So we call the prescriber back again and try to convince her. She insists on keeping it 4 times daily but lowers the dose to 750 mg 4 times daily for 4 days.

Anyone with ID experience or whatever, ever seen this before?

---

Members don't see this ad.

 

[Priapism321]

No.

 

[Sparda29]

No.

Exactly what I thought.

 

[KARM12]

That dose makes no sense.

 

[slimcutt]

OMFG no.

 

[rx2010]

I agree with everyone, I've never seen cipro dosed that high and frequent. 3,000 mg QID?! Even 750 mg QID is too frequent for a respiratory infection.

 

[crazybob]

So we got a doctor call today for Ciprofloxacin 3000 mg by mouth 4 times a day for 4 days. This was the MA calling it in, so I immediately asked to speak to the MD and she confirmed that it was 3000 mg 4 times a day for 4 days. WTF?

Patient came in, we decided not to fill it until we talked to him. It's supposedly a respiratory tract infection that's being treated, the patient looks like he is perfectly fine, no respiratory distress, no coughing. So we call the prescriber back again and try to convince her. She insists on keeping it 4 times daily but lowers the dose to 750 mg 4 times daily for 4 days.

Anyone with ID experience or whatever, ever seen this before?

Lexi-Comp shows 500~750 mg twice daily for 7~14 days for lower respiratory tract infections.

MedScaope from WebMD shows 500 mg PO q12h for 7~14 days for lower respiratory tract infections.

MPR (monthly prescribing reference) shows 500~750 mg every 12 hours for 7~14 days for lower respiratory tract infections.

DailyMed from US National Library of Medicine and National Institutes of HEalth also shows 500 mg q12h for 7~14 days for lower respiratory tract infections.

http://www.merck.com/mmpe/lexicomp/ciprofloxacin.html shows

Usual dosage ranges:

Adults:

Oral: 250-750 mg every 12 hours

It does state the maximum dose for children to be 1.5 g/day. It doesn't say anything about adults. But, it does say

Lower respiratory tract, skin/skin structure infections:

Oral: 500-750 mg twice daily for 7-14 days

 

[Praziquantel86]

Is this the first time treating the infection? That dose (and drug) is insane.

 

[crazybob]

Hmm... I'm starting to think:

• 3000 mg was written somewhere since it would be the total amount taken for the duration of therapy
• Then QD was written so that Cipro would be taken once a day
• it was mistaken for QID
• the 3000 mg was probably written together with the QD, so someone thought it was 3000 mg that was supposed to be given, and thought it was QID when QD was written
• Then after checking the entire therapy, it should have been 750 mg QD, but the QD was mistaken for QID again.

But it should be BID, so QD shouldn't have been written at all.

If not, then I dunno what the prescriber was thinking.

 

[Priapism321]

1.5 grams daily (in two or three divided doses) is as high as I have went in adults. Keeping in mind the adults I see typically have zero circulating neutrophils for months at a time.....

 

[WVUPharm2007]

Maybe the person is like 7'5" and 800 lbs and not human. Like a Shrek or something.

But, nah, that's weird...

 

[Praziquantel86]

The first Google result for this shows a 20 year-old paper on QID dosing for peritonitis, which somehow doesn't seem very relevant.

I've seen q8h dosing for some severe VAP cases, but that's still only 1.2 g/day. The drug, dose or duration make no sense for any sort of community acquired respiratory infection. I think you'd be justified asking for additional explanation.

 

[Pharmavixen]

QID is weird; 3000mg qid, I'd be worried about causing Tdp.

 

[GamecockPharmD]

i would tell the patient to find a new MD because that one doesn't have a clue.

 

[SELDANE]

Assuming someone needed such an outrageous dose of cipro (or any antibiotic for that matter) why would you waste time with a PO route? The entire order is ridiculous.

 

[Pharmavixen]

Assuming someone needed such an outrageous dose of cipro (or any antibiotic for that matter) why would you waste time with a PO route? The entire order is ridiculous.

True, the dose is all wrong, but in the spirit of giving PO wherever you can, cipro has near total bioavailability.

 

[Rebel78]

That dose is incorrect.

Was it dispensed?

 

[Sparda29]

That dose is incorrect.

Was it dispensed?

Nope, we managed to convince her that the dose was way too high. She was very insistent on keeping QID dosing though, so we ended up dispensing 750 mg QID, which I still think was very high. We informed the patient that the dose that he was getting for a simple respiratory infection was still very high, so we told him to start off with 750 mg every 12 hours.

 

[phathead]

Huh, around here they're real fond of writing for Cipro 250mg BID x 3 days

Nice to see they swing the other way too

 

[Praziquantel86]

Nope, we managed to convince her that the dose was way too high. She was very insistent on keeping QID dosing though, so we ended up dispensing 750 mg QID, which I still think was very high. We informed the patient that the dose that he was getting for a simple respiratory infection was still very high, so we told him to start off with 750 mg every 12 hours.

So you told the patient to take a different dose than what was prescribed? I'll agree with you that the dose was ridiculous, but that's practicing medicine without a license. Good luck to you folks when the doc finds out.

You can't have it both ways - either you dispense it or you don't. I would have opted for the latter.

 

[Sparda29]

Luckily for the patient, his son and wife are also pharmacists so he has like 4 different opinions going into this.

 

[njac]

Nevermind that the Cipro was for a(presumably) community acquired resp infectioin.

Any chance they weren't able to match up the lines in a dosing guide and were looking at Unasyn dosing?

 

[Rebel78]

Nevermind that the Cipro was for a(presumably) community acquired resp infectioin.

Any chance they weren't able to match up the lines in a dosing guide and were looking at Unasyn dosing?

I can't imagine that happened, the names wouldn't be near each other, IV/PO. Though I see the 3 gram qid reasoning.

Stuff like this scares me when I'm dealing with it, just wonder what some people are thinking.

 

[Sparda29]

Well **** me, I did a Google search on the prescriber with their office #, the prescriber is a ****ing dentist.

 

[WVUPharm2007]

Ummm...dentist?

Heh. I doubt it is for a respiratory infection. (Unless they are illegally practicing medicine.) I wonder if we are talking endocarditis prophylaxis. Which would pretty much change my entire outlook on the problem.

Any of you clinical dorks know the dose for such a thing? Cause I don't. You watch it be 30mg/kg for 3-4 doses a day or some **** making us all look stupid...lmao...

 

[Priapism321]

Ummm...dentist?

Heh. I doubt it is for a respiratory infection. (Unless they are illegally practicing medicine.) I wonder if we are talking endocarditis prophylaxis. Which would pretty much change my entire outlook on the problem.

Any of you clinical dorks know the dose for such a thing? Cause I don't. You watch it be 30mg/kg for 3-4 doses a day or some **** making us all look stupid...lmao...

Fluoroquinolones are not mentioned at all in the most recent guidelines from the American Heart Association...

 

[Priapism321]

Strike that, they are mentioned once in the guideline, where the AHA recommend against the use of fluoroquinolones for IE prevention.

 

[crazybob]

Any of you clinical dorks know the dose for such a thing? Cause I don't. You watch it be 30mg/kg for 3-4 doses a day or some **** making us all look stupid...lmao...

If you assume the person weighs 200 lbs, he weights 90.9 kg, or about 91 kg.

If you take the dose of 30 mg/kg, it comes out to be 91 kg * 30 mg/kg = 2730 mg. Isn't that quite a bit for one day?

 

[WVUPharm2007]

Strike that, they are mentioned once in the guideline, where the AHA recommend against the use of fluoroquinolones for IE prevention.

lmao...well, if they made a point to not recommend it, then its been used before.

I'd bet it one of those patients that is "allergic" to everything because they got a rash back in 1967 after taking some Keflex...and the dentist is 74 years old and has never heard of Avelox...

 

[WVUPharm2007]

If you assume the person weighs 200 lbs, he weights 90.9 kg, or about 91 kg.

If you take the dose of 30 mg/kg, it comes out to be 91 kg * 30 mg/kg = 2730 mg. Isn't that quite a bit for one day?

Yeah...

...

...but whatever. Some psychiatrists use 200mg of citalopram a day, too. In weird situations, sometimes you figure out what the dose limiting toxicity is and weigh the option.

Actually, I googled it up (Google, being the prime search engine of real scientists, naturally)...check this **** out.

The efficacy of ciprofloxacin in treatment and prophylaxis of Staphylococcus aureus endocarditis in rats infected with a strain tolerant to the standard anti-staphylo-coccal antibiotics cloxacillin, vancomycin and teicoplanin was compared with its non-tolerant variant. After 5 days of treatment with ciprofloxacin 30 mg/kg subcuta-neously every 8 h bacterial densities in vegetations from animals infected with the tolerant and the non-tolerant strain were similar. Resistance to ciprofloxacin did not emerge in either strain of S. aureus during treatment.

Now, granted, this is an animal study and clearly Cipro for endocarditis prophylaxis is poorly studied and probably shouldn't be even considered without experiencing major problems in using conventional therapy and consulting an ID specialist...its just that I find it amusing that I found someone, somewhere that tried 30mg/kg q8h...

...

Of course, all of this actually being needed is incredibly unlikely. The patient would have to be legitimately at risk for anaphylaxis from multiple drugs...and be at high risk for IE...

 

[Aznfarmerboi]

Speaking of which Sparda, if that was the case... we met today. I was the asian RPH on duty.

 

[WVUPharm2007]

Speaking of which Sparda, if that was the case... we met today. I was the asian RPH on duty.

An Asian pharmacist? That really narrows it down.

 

[crazybob]

An Asian pharmacist? That really narrows it down.

In my state, it definitely does

 

[PumpkinSmasher]

Speaking of which Sparda, if that was the case... we met today. I was the asian RPH on duty.

You lucky devil...was it as fun interacting in real life as is it on SDN?

 

[Sparda29]

Speaking of which Sparda, if that was the case... we met today. I was the asian RPH on duty.

You were floating? Where was your white coat?

Oh yeah, what do you think of the mess we call our waiting bins? Absolutely ridiculous because of Readyfill.