Drug points: Allergy associated with ciprofloxacin

British Medical Journal, March 11, 2000 by P Burke, S R Burne

Allergy associated with ciprofloxacin

Meningococcal infection can be life threatening. Most infections are sporadic, although clusters do occur, particularly in teenagers. The management of clusters includes giving antibiotics to a defined group. Vaccination has a role in clusters of meningococcal serogroup C infection. Although ciprofloxacin 500 mg orally is not licensed for prophylaxis against meningococcal disease, it is used because it reduces meningococcal carriage,[1] can be given as a single dose, and, unlike rifampicin, does not interact adversely with the contraceptive pill.[2] We report on anaphylactoid reactions to ciprofloxacin in three students and a close contact with meninogoccal infection (table).

Two cases (one fatal) of meningococcal infection occurred in first year university students within 12 days of each other. Ciprofloxacin 500 mg orally was offered to all the 4253 students in their first year at the university; around 3200 accepted.

Three cases of anaphylactoid reaction occurred--a rate of about 1:1000, much higher than the 1:100 000 quoted (12 cases in a population of 972 000)? Two of the three students had no history of atopic illness. All three students and the contact recovered. Additional adverse reactions were mild skin rashes in three students and nausea and vomiting in two.

A high rate of serious adverse events must be balanced by clear benefits to the target group. Ciprofloxacin clears meningococcal carriage so reducing transmission to a susceptible host. As carriers do not become cases the benefits from ciprofloxacin are for the community not the individual. The risk of a second case of infection among close contacts is 500 to 1000 times higher than in the general population.[4] The risk of a third case in a student population that has already had two cases is unknown.

Serious allergic reactions to ciprofloxacin

                       Age       Onset
Patient (sex)        (years)   (minutes)

Student
1 (male)               21         30
2 (female)             20        20-30
3(*) (female)          19         3t

Contact
1([dagger]) (male)     19         30

Patient (sex)        Symptoms

Student
1 (male)             Tight and hoarse throat,
                     swelling of eyes
2 (female)           Itchy rash, tight throat
3(*) (female)        Dyspnoea, tight throat,
                     swelling of eyes, cough

Contact
1([dagger]) (male)   Swelling of face and eyes

Patient (sex)        Findings

Student
1 (male)             Blood pressure 150/100 mm Hg,
                     peak flow 550 1/m
2 (female)           Blood pressure 120/80 mm Hg,
                     peak flow 450 1/m
3(*) (female)        Peak flow 300 1/m, heart rate
                     160, 100% saturation

Contact
1([dagger]) (male)   --

Patient (sex)        Treatment

Student
1 (male)             Adrenaline intramuscularly and
                      chlorpheniramine orally
2 (female)           Adrenaline intramuscularly and
                      chlorpheniramine orally
3(*) (female)        Adrenaline intramuscularly
                      Chlorpheniramine orally
                      and salbutamol by nebuhaler.
                     Admitted to hospital for 2 days
Contact
1([dagger]) (male)   Chlorpheniramine and hydrocortisone
                      intramuscularly

(*) History of asthma with inhaled steroids. ([dagger]) Hours. ([double dagger]) History of penicillin allergy.

[1] Gaunt PN, Lambert BE. Single dose ciprofloxacin for the eradication of pharyngeal carriage of Neisseria meningitidis. J Antimicrob Chemother 1988;21:489-96.

[2] Borcherding SM, Bastian TL, Self TH, Abou-Shala N, LeDuc BW, LaLonde DW. Two and four day rifampicin chemoprophylaxis regimens induce oxidative metabolism. Antimicrob Agents Chemo 1993;36:1553-8.

[3] Davis H, McGoodwin E, Greene Reed T. Anaphylactoid reactions reported after treatment with ciprofloxacin. Ann Intern Med 1989; 111:1041-3.

[4] Hastings L, Stuart J, Andrews N, Begg N. A retrospective survey of clusters of meningococcal disease in England and Wales, 1993 to 1995: estimated risks of further cases in household and educational settings. CDR Review 1997;7:R 195-200.

P Burke, S R Burne, St Bartholomew's Medical Centre, Oxford OX4 1XB, K J Cann, Department of Public Health, Oxfordshire Health Authority, Headington, Oxford OX3 7LG