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Anti-Infective Agents

Anti-Infective Agents, Quinolones


Cetraxal, Cetraxal Comp, Ciflox, Ciloxan, Ciprofloxacin ACO, Ciprofloxacin Accord, Ciprofloxacin Actavis, Ciprofloxacin Amneal, Ciprofloxacin Arrow, Ciprofloxacin BMM Pharma, Ciprofloxacin Bluefish, Ciprofloxacin Copyfarm, Ciprofloxacin Fresenius Kabi, Ciprofloxacin Hexal, Ciprofloxacin Hospira, Ciprofloxacin Krka, Ciprofloxacin MDS, Ciprofloxacin Mylan, Ciprofloxacin Orion, Ciprofloxacin Ranbaxy, Ciprofloxacin STADA®, Ciprofloxacin Sandoz, Ciprofloxacin Villerton, Ciprofloxacin ratiopharm, Ciproxin, Ciproxin®


ciprofloxacin, ciprofloxacin hydrochloride, ciprofloxacin hydrochloride monohydrate, ciprofloxacin hydrogensulfate, ciprofloxacin lactate

A broad-spectrum antimicrobial carboxyfluoroquinoline. [PubChem]

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This substance is an antibiotic (also called, anti-bacterial agent). All antibiotics are suspected to cause antibiotic resistance and we should therefore try to limit releasing it to Nature via our wastewater streams.

Some key facts from WHO

  • Antibiotic resistance is one of the biggest threats to global health. food security, and development today
  • Antibiotic resistance can affect anyone, of any age, in any country.
  • Antibiotic resistance occurs naturally, but misuse of antibiotics in humans and animals is accelerating the process.
  • A growing number of infections – such as pneumonia, tuberculosis, gonorrhoea, and salmonellosis – are becoming harder to treat as the antibiotics used to treat them become less effective.
  • Antibiotic resistance leads to longer hospital stays, higher medical costs and increased mortality.
Due to the risk of ecotoxicity of ciprofloxacin in water, the substance is monitored within the framework of EU water legislation to "improve knowledge of the occurrence and spread of antimicrobials in the environment".

Measurements have shown that ciprofloxacin is present in the Swedish wastewater treatment plants at levels posing risk of selection of resistant bacteria.

The substance is included in the Stockholm County Council's table of pharmaceuticals with risk for negative environmental impact according to the environmental programme 2017-2021. Ciprofloxacin has been detected in treated wastewater in Stockholm County in the last five years (2012-2016).

Studies have shown that even low concentrations of antibiotics in the environment may trigger antibiotic resistance and therefore measures should be taken to ensure that as little as possible ends up in our environment.

Is recommended in The Wise List. Environmental classification of pharmaceuticals is taken into consideration, sometimes with other environmental aspects, when selecting pharmaceuticals for the Wise List. When comparable pharmaceuticals are equivalent to medical effects, safety and pharmaceutical efficacy, environmental impact and price are considered.

Suggestions on how to reduce the release of ciprofloxacin
Concrete proposals on how to work to reduce emissions of environmentally harmful pharmaceuticals on the list have been developed in close cooperation with the Stockholm Drug and Therapeutics Committee's expert advice. The action proposals were developed from an environmental perspective. The patient's best always goes first and several pharmaceuticals on the list are also included in the Wise List. However, for such pharmaceuticals, there may be measures that could reduce the environmental impact.

Concrete proposal for ciprofloxacin:

– Ciprofloxacin is recommended for pyelonephritis in the Wise List as alternative first-hand treatment with trimethoprim sulfamethoxazole.
– Ciprofloxacin should not be used in empirical treatment of lower urinary tract infection without fever, then nitrofurantoin is recommended (in the Wise List and is better from an environmental point of view than ciprofloxacin) or pivmecillinam (in the Wise Listan and is a reasonable alternative to ciprofloxacin from an environmental point of view). Nitrofurantoin is considered to be the lowest environmental risk of these.
– For antibiotics, the general rule is as restrictive use as possible without risking the patient's health. Relevant cultivation is important in order to choose antibiotics that have a good effect with as narrow spectrum as possible.

The risk classification, moderate according to Fass.se, is based on total sold amount (kg) of the substance in Sweden during the year 2011 and the toxicity of the substance.


  1. Europeiska unionens officiella tidning. Kommissionens genomförandebeslut (EU) 2018/840 av den 5 juni 2018.
  2. Goodpoint. Prioritering av läkemedel med miljörisk inom SLL. Stockholm: Goodpoint; 2016. Rapport LS 2016–0634.
  3. Halling-Sørensen B, Lützhøft HC, Andersen HR, Ingerslev F. Environmental risk assessment of antibiotics: comparison of mecillinam, trimethoprim and ciprofloxacin. J Antimicrob Chemother. 2000;46 Suppl 1:53-8; discussion 63-5.
  4. IVL Swedish Environmental Research Institute Ltd. Fick J, Lindberg RH, Kaj L, Brorström-Lundén E. Results from the Swedish National Screening Programme 2010. Subreport 3. Pharmaceuticals.
  5. IVL Swedish Environmental Research Institute Ltd Fick J, Lindberg RH, Fång J, Magnér J, Kaj L, Brorström-Lundén E. Screening 2014. Analysis of pharmaceuticals and hormones in samples from WWTPs and receiving waters. Rapport C 135.
  6. Bengtsson-Palme J, Larsson DG. Concentrations of antibiotics predicted to select for resistant bacteria: Proposed limits for environmental regulation. Environ Int. 2016;86:140-9.
  7. Gullberg E, Cao S, Berg OG, Ilbäck C, Sandegren L, Hughes D et al. Selection of resistant bacteria at very low antibiotic concentrations. PLoS Pathog. 2011;7:e1002158.
  8. Stockholms läns landsting. Förteckning över miljöbelastande läkemedel med åtgärdsförslag framtagen inom ramen för SLL:s miljöprogram 2017–2021.
  9. Fass.se för vårdpersonal
  10. Stockholms läns landsting. Kloka Listan 2018.
  11. Stockholm County Council. The Wise List 2015.
  12. Socialstyrelsen. Statistikdatabas för läkemedel.
  13. Stockholms läns landsting. Janusinfo: Läkemedelsuppföljning