Top 10 Common Medication Errors-Drug #7: Ciprofloxacin

In the pediatric population, medication errors can occur in both the inpatient and outpatient settings. According to one study, pediatric medication errors occur at an approximate rate of 16% in the outpatient setting.¹

In this series, I focus on 10 errors that are seen frequently in outpatient clinics. In previous cases, I focused on common errors associated with infant acetaminophen,² insulin,³ ceftriaxone,⁴ hydralazine and hydoxzyine,⁵ amoxicillin/clavulanic acid,⁶ and ketorolac.⁷Medication Error #7: Ciprofloxacin
A gastrostomy tube–dependent 5-year-old girl (weight, 20 kg) presented to the clinic with a 2-day history of fever and lethargy. Urine culture and blood culture were obtained at that time. The patient was sent home without medication because the clinician thought that the patient might only have a viral respiratory infection.

Two days later, the urine culture turned positive for Escherichia coli sensitive to only ciprofloxacin. The clinician thus called in a prescription to a local pharmacy for ciprofloxacin suspension (200 mg via G-tube bid [10 mg/kg/dose]). After the patient received 2 doses of the medication, the parents noticed that the G-tube was clogged off.

What’s the problem here?

Discussion
Ciprofloxacin usually is not the drug of choice for pediatric patients because of reported cases of tendon rupture in this population.^8,9 However, because the organism in this case is sensitive only to ciprofloxacin, the clinician has no other choice than to use this antibiotic.

Ciprofloxacin is effective in treating patients with urinary tract infection (UTI) caused by E coli. The problem is that the suspension formulation of this medication cannot be given via any kind of feeding tube because it will adhere to the tube, causing the tube to clog off.⁸

If a patient has a feeding tube as does the case patient, using the tablet formulation for administration is recommended. Clinicians can choose the nearest half or full immediate-release tablet strength (in this case, it would have been the 250-mg tablet because it would still be within the range of a 10 to 15 mg/kg/dose for uncomplicated UTI) and crush it and mix it with water. The feeding tube should be flushed with water before and after administering the medication, and tube feeds should also be held 1 hour before and 2 hours afterward.

The available strengths of the ciprofloxacin immediate-release tablets include 100 mg, 250 mg, 500 mg, and 750 mg.⁸

This error could have been easily prevented if both the clinician and the pharmacist realized that ciprofloxacin suspension cannot be given via a G-tube.

References
1. Kaushal R, Goldmann DA, Keohane CA, et al. Adverse drug events in pediatric outpatients. Ambul Pediatr. 2007;7:383-389.
2. So J. Top 10 common medication errors-and how to avoid them: Drug #1: acetaminophen. Sept 19, 2011.
3. So J. Top 10 common medication errors-and how to avoid them: Drug #2: insulin. Oct 18, 2012.
4. So J. Top 10 common medication errors-and how to avoid them: Drug #3: ceftriaxone. Nov 28, 2012.
5. So J. Top 10 common medication errors-and how to avoid them: Drug #4: hydroxyzine and hydralazine. Dec 28, 2012.
6. So J. Top 10 common medication errors-and how to avoid them: Drug #5: amoxicillin/clavulanic acid. February 1, 2013.
7. So J. Top 10 common medication errors-and how to avoid them: Drug #6: ketorolac. February 27, 2013.
8. Taketomo CK, Hodding JH, Kraus DM. Pediatric Dosage Handbook. 18th ed. Hudson, Ohio: Lexi-Comp; 2011.
9. Liu HH. Safety profile of the fluoroquinolones: focus on levofloxacin. Drug Saf. 2010;33:353-369.