Flagyl & Cipro

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Can somebody enlighten me about what is going on with this combination. I used to see this rarely and now every other patient is getting both. Is there a new study that shows something I don't know about or this just the latest in the continuing saga of family practice docs know less about ID than my mother....
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I happen to think Flagyl/Cipro is a great combo for certain treatment. Flagyl of course is the gold standard in treatment of anaerobes and that hasn't changed. And you hardly ever see newer antibiotic trial pitted against Flagyl.

Also, they're both dirt cheap and am certainly glad some prescribers are practicing cost effective medicine.

Maybe there's a gonorrhea/chlamydia breakout in your neighborhood.
 
Probably diverticulitis...if'n I had to guess...but could be an assortment of gut bugs and ailments. Maybe the local philly germ pool is full of mutants and they are double covering for a reason.

Or maybe they are nuts. Can we ever really know?
 
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We use it on the daily for GI stuff - diverticulitis, Crohn's flares, gastroenteritis, chole, bowel perf, ruptured appendix...
 
Dayum people......clap was a joke... I guess I forgot to put my trademark smiley.
 
Its Z said:
Dayum people......clap was a joke... I guess I forgot to put my trademark smiley.
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You should know better than trying to joke with a bunch of pharmacy students who like to prove how smart they are..
 
It's a bit out of date, but our docs have used Cipro + Flagyl for diabetic foot infections, covering off your anaerobes, Pseudomonas, gm -ves, as well as staph + strep. However, cipro is unreliable against staph + strep these days, and resistance of Pseudomonas to cipro is increasing. A more rational combo, that I am encouraging, is cipro + clinda.
 
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All4MyDaughter said:
Yeah, no FQ for clap around here for a while. Our docs have been using a 2g dose of azithromycin to cover for gonorrhea and chlamydia together. Metronidazole would be added if the patient also had something like Trich.
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2gm azithro is associated with treatment failure for gonorrhea. Cefixime FTW.
 
njac said:
2gm azithro is associated with treatment failure for gonorrhea. Cefixime FTW.
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We do 1g azithro + cefixime 400mg for the social infections.
 
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KARM12 said:
You should know better than trying to joke with a bunch of pharmacy students who like to prove how smart they are..
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:( I wasn't trying to prove anything... I just don't want anyone thinking they can pop their leftover FQ so they don't have to see the doc for their clap :smuggrin:
 
Pharmavixen said:
We do 2g azithro + cefixime 400mg for the social infections.
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"social infections" - I like that!

I think the 2gm azithro is excessive for chlamydia, but as long as they don't barf it up it really doesn't matter as long as they get at least a gram.
 
Yep, I've seen that combo a lot in diverticulitis and other GI infections. Usually when we get scripts from the hospital it is for Avelox/Levaquin + Flagyl, then the patient goes nuts about the Avelox/Levaquin copay and we end up calling the hospital, paging a doctor who has left for the day and is tired and trying to get some sleep at home and is woken up by some pesky pharmacy students page and ends up switching it to Cipro. Perhaps, they just got tired of the constant calls and decided to use Cipro before heading down the Levaquin/Avelox road.
 
This can't be an outbreak of GI infections. These are almost all from local family docs. I'm going to start paying more attention & asking the patients what the infection is. I just don't see what you gain by adding Cipro to Flagyl.
 
Umm, gram negative coverage?
 
Look, I have been at this game along time. This combination is being used with greatly increased frequency. I was looking for a solid reason why and nobody seems to have a clue. After I start asking docs & patients, I'll let you know if there is a pattern.

Thanks for the input.
 
I looked into this a bit more: cipro + flagyl is recommended in guidelines for the tx of moderate to severe intraabdominal infections as an alternative to 1st line agents. The cipro provides extensive gm -ve coverage, while the flagyl does the anaerobes. Staph & strep coverage isn't so good, however.

Has there been giardiasis in your vicinity? That would explain the flagyl, and the cipro they might add in case the pt's abdominal problems also have a bacterial etiology.
 
njac said:
"social infections" - I like that!
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And the dx is made with social swabs. Our drs are awesome.

njac said:
I think the 2gm azithro is excessive for chlamydia, but as long as they don't barf it up it really doesn't matter as long as they get at least a gram.
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Whoops! I meant 1g; we give 4 tabs of azith 250mg, not 8. (Corrected my original post).
 
Pharmavixen said:
I looked into this a bit more: cipro + flagyl is recommended in guidelines for the tx of moderate to severe intraabdominal infections as an alternative to 1st line agents. The cipro provides extensive gm -ve coverage, while the flagyl does the anaerobes. Staph & strep coverage isn't so good, however.

Has there been giardiasis in your vicinity? That would explain the flagyl, and the cipro they might add in case the pt's abdominal problems also have a bacterial etiology.
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No this is a large metropolitan area, no giardia. I must have seen this combination a dozen times in the last couple of weeks. As I get more info, I'll post again.
 
Pharmavixen said:
The cipro provides extensive gm -ve coverage, while the flagyl does the anaerobes.
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I've seen a lot of cipro + flagyl lately where I work, so finally I asked one of my pharmacists about it, and this is pretty much what he said... in addition to being relatively cheap.
 
I write for cipro/flagyl for diverticultis, colitis all the time. I usually write the indication on the rx so that the pharmacist knows why I wrote for it.
 
tkim said:
I write for cipro/flagyl for diverticultis, colitis all the time. I usually write the indication on the rx so that the pharmacist knows why I wrote for it.
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:thumbup: I wish more physicians did stuff like that
 
tkim said:
I write for cipro/flagyl for diverticultis, colitis all the time. I usually write the indication on the rx so that the pharmacist knows why I wrote for it.
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Someone give this doc a medal... seriously. Pharmacy is way less of a headache with minimal amounts of reasoning shared.
 
Actually, I think I read the suggestion on the pharm forum. In NYS, the back of the script has an 'indication' box - i.e., infection, pain, etc, but nothing as specific as what I write on the front. MA doesn't have that checkbox in the back.

I also write "must fill this abx (Keflex, PCN) with pain med" when I write for people who present with monthly 'dental pain', so they have to get the abx when they fill their vicodin, though I don't know how well that works, or if it's even legal.
 
I also write "must fill this abx (Keflex, PCN) with pain med" when I write for people who present with monthly 'dental pain', so they have to get the abx when they fill their vicodin, though I don't know how well that works, or if it's even legal.
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I think its legal, after all, you don't have to right them a prescription. I always follow those requests. Actually, anytime someone brings in an ER script and they just want the pain medicine, I call the ER to ask if they are OK with that, 99% of the time they say no.


As for the OP, I am also seeing a lot of Cipro/Flagyl RX's, often from NP's. Relatively rarely, do I see this combo from a surgeon or GI doc.
 
This is a great combo to treat GI infections. Flagyl has coverage for C. diff, and cipro for e.coli, and shigella infections.
 
ask an avelox rep what they think about this combo:)
 
tkim said:
Actually, I think I read the suggestion on the pharm forum. In NYS, the back of the script has an 'indication' box - i.e., infection, pain, etc, but nothing as specific as what I write on the front. MA doesn't have that checkbox in the back.

I also write "must fill this abx (Keflex, PCN) with pain med" when I write for people who present with monthly 'dental pain', so they have to get the abx when they fill their vicodin, though I don't know how well that works, or if it's even legal.
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You are my hero. Its good to see that you are an attending and some residents and interns will learn from such simple but important suggestions. Its a good lesson in CYA (cover Yo ass). :thumbup:
 
Quiksilver said:
You are my hero. Its good to see that you are an attending and some residents and interns will learn from such simple but important suggestions. Its a good lesson in CYA (cover Yo ass). :thumbup:
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Well, I work in a community, non-academic hospital, but thanks for the kudos anyway.
 
side qq- why are doctors giving such high doses of Amoxicillin to patients.. im talking about 8 year olds taking 3000mgs per day...
 
WVUPharm2007 said:
Dose for otitis is at minimum 80 migs per kig...if we're talking about a 70 or 80 lbs kid...that's about right...
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I had thought that at 40 kgs we switched to adult doses.

Not that this is a common occurrence, but I just gave cipro-flagyl for cellulitis s/p rottweiler bite. Apparently that's recommended if they fail augmentin.
 
VA Hopeful Dr said:
I had thought that at 40 kgs we switched to adult doses.

Not that this is a common occurrence, but I just gave cipro-flagyl for cellulitis s/p rottweiler bite. Apparently that's recommended if they fail augmentin.
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Is it? I'm too lazy to look it up. I know that 4g is the max dose, I'm just trying to rationalize it. I'm sure one of our dorky "look at how smart I am" types will find out for us lickity split. I have seen a few cases of 1000mg qid in adults in my life.

Otherwise, I'm fine with being super aggressive with some antibiotics. Like amoxil. What's the worst that will happen? Epic diarrhea?
 
VA Hopeful Dr said:
I had thought that at 40 kgs we switched to adult doses.

Not that this is a common occurrence, but I just gave cipro-flagyl for cellulitis s/p rottweiler bite. Apparently that's recommended if they fail augmentin.
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Wait, I thought it was bactrim + clinda.
 
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