Journal of Antimicrobial Chemotherapy (1999) 43, Suppl.

A, 43–48
JAC
Ciprofloxacin concentrations in lung tissue following a single
400 mg intravenous dose

Mary C. Birminghama*, Ross Guarinoa, Allen Hellerb, John H. Wiltona, Anita Shahb,
Linda Hejmanowskia, David E. Nixa and Jerome J. Schentaga
a
The Clinical Pharmacokinetics Laboratory, Millard Fillmore Health System, 3 Gates Circle, Buffalo,
NY 14209; bBayer Corporation, Pharmaceutical Division, West Haven, CT, USA

Intravenous ciprofloxacin is frequently prescribed for the treatment of infections due to noso-
comially acquired Gram-negative organisms, including those originating in the respiratory
tract. In this study, the concentrations of ciprofloxacin in serum and lung tissue were deter-
mined by HPLC in patients undergoing lung surgery. A total of 22 patients scheduled for lung
surgery received a single 400 mg iv dose of ciprofloxacin administered as a 1 h infusion. A
specimen of healthy lung tissue was obtained from resected lung from 18 of the patients for
analysis of ciprofloxacin concentration during the following time intervals after infusion (one
sample/patient): 0–2, 2–4, 4–8 and 8–12 h. Corresponding mean serum and tissue concentra-
tions were 2.37 mg/L and 3.84 mg/kg (0–2 h), 1.18 mg/L and 1.92 mg/kg (2–4 h), 0.69 mg/L and
1.77 mg/kg (4–8 h), and 0.13 mg/L and 0.67 mg/kg (8–12 h). Ciprofloxacin distributed rapidly to
lung tissue, as seen by the high concentrations in the lung tissue as early as 2 h after infusion.
Concentrations in lung tissue were generally higher than those in serum (tissue:serum ratios
ranged from 1.7 to 7.1). The mean tissue concentrations found in this study remained above the
MIC for most susceptible organisms.

Introduction have been shown to be good predictors of infection

Ciprofloxacin is a broad-spectrum fluoroquinolone antimi-
crobial agent with excellent in-vitro activity against Gram-
negative bacteria, including Pseudomonas aeruginosa, and
moderate activity against some Gram-positive organisms. 1
The availability of ciprofloxacin in both oral and iv formu-
lations has permitted the treatment of hospitalized patients
with severe infections, as well as the option of sequential
iv-to-oral administration for selected individuals. Intra-
venous ciprofloxacin has been shown to be an effective
antimicrobial option for hospitalized patients with severe
respiratory tract infections.2 Depending on the infecting
pathogen and the patient’s severity of illness, fluoro-
quinolones may often be prescribed as monotherapy,
thereby offering alternatives to standard β-lactam/amino-
glycoside or double β-lactam combinations.2
For many antimicrobials, it is important to maintain
serum inhibitory concentrations during most of the dosing
interval in order to optimize clinical and bacteriological
success. Specifically, ciprofloxacin serum concentrations
response when related to bacterial MICs.3,4 These observa-
tions, however, appear to be most valid for extracellular
bacterial infections. Patient response to intracellular bac-
terial infections may be better predicted from tissue to
serum ratios for some antimicrobials, especially for infec-
tion sites with permeability barriers (e.g. alveolar epithe-
lium).5 Furthermore, the efficacy of a newer azalide agent,
azithromycin, suggests that serum concentrations may not
be the best predictors of clinical response, since this agent
has serum concentrations below the MIC90s for many
pathogens.6,7 As such, an antimicrobial’s tissue distribution
properties are frequently investigated in order to validate
rapid and adequate tissue concentrations.
The role of fluoroquinolones in the management of
lower respiratory infections has been questioned despite
many reports documenting their penetration into saliva,
sputum, bronchial secretions and lung tissue. In general,
concentrations in sputum and bronchial secretions are
similar to those found in serum, whereas lung tissue con-
centrations are usually at least twice the serum levels.8

*Tel: 11-716-887-5163; Fax: 11-716-887-4566.

43
© 1999 The British Society for Antimicrobial Chemotherapy
 M. C. Birmingham et al.
However, many tissue penetration studies suffer from tech-
nical and methodological difficulties. For saliva, sputum
and bronchial secretion, quinolone penetration varies
greatly between patients. Moreover, the failure rate pre-
dicted from saliva, sputum and bronchial secretion concen-
trations, as well as the marginal in-vitro activity of some
quinolones against streptococci, are inconsistent with
clinical trial data demonstrating clinical efficacy.
Ciprofloxacin has a large volume of distribution, low
plasma protein binding and good penetration into various
tissues and fluids.1 While ciprofloxacin has been reported
to penetrate into lung tissues,9–12 penetration studies with
iv ciprofloxacin have been limited to single 200 mg
doses13–15 or rapid (20 min) 400 mg iv infusions.16 Because a
1 h iv infusion of 400 mg every 12 h is recommended for
treatment of lower respiratory tract infections in the USA,
determination of lung tissue concentrations following the
longer infusion period are warranted. The purpose of this
study was to examine the adequacy of penetration and
actual concentrations of ciprofloxacin in serum and the
blood-free fraction of lung tissue after a single 400 mg iv
dose.
Materials and methods
A total of 13 males and nine females, >18 years of age,
requiring open lung biopsy or lung surgery were studied
after obtaining written informed consent. All prospective
study participants provided a medical history, underwent a
physical examination and had a chest X-ray taken (if one
was not available within 12 months of study entry) before
receiving study drug. In addition, all participants provided
blood for standard haematological and blood chemistry
studies, and urine for urinalysis and microscopic examina-
tion, before therapy and after surgery. Each patient
received a single iv dose of ciprofloxacin 400 mg (Bayer
Corporation Pharmaceutical Division, West Haven, CT,
USA) administered as a 1 h infusion before surgery.
Patients were excluded if they had a previous history of
allergy to a fluoroquinolone or a severe allergic reaction to
any medication; history of CNS disorders (e.g. convulsive
seizures); need for any chronic medication that interacts
with ciprofloxacin (e.g. theophylline, glyburide or pheny-
toin); history of recent (<6 months) head trauma, cerebral
vascular accident, transient ischaemic attack, CNS tumour
or neurosurgical procedure; history of psychiatric disorder
within the past 2 years, or need for current therapy for any
psychiatric illness; pregnancy or lactation; or presence of
renal disease (creatinine clearance ,30 mL/min) or hepatic
disease (AST or ALT .2.5 times upper range of normal
and/or serum bilirubin .2 mg/dL). Patients were permitted
to receive concomitant medications necessary for their
specific surgery, including other prophylactic antimicro-
bials. Administration of ciprofloxacin, by any route, within
44
1 week before surgery was another reason for exclusion
from the study.
In this open-label study design, patients were assigned a
specific time for collection of lung tissue and blood samples
at the discretion of the investigator. Patients were to be
divided into four equal groups from whom tissue material
was obtained following iv administration of ciprofloxacin.
The time of ciprofloxacin administration was adjusted so
that lung tissue and blood samples could be collected
during the following time intervals after completion of the
infusion: 0–2, 2–4, 4–8 and 8–12 h. A piece of healthy lung
tissue (approximately 1 g) was obtained from resected lung
for analysis of ciprofloxacin concentration. At the same
time, three blood samples (approximately 5 mL each) were
obtained. The first sample was used for a haemoglobin
determination by the laboratory. The second sample was
collected in a heparinized tube and stored at –20°C for later
determination of ciprofloxacin concentration in whole
blood. The third blood sample was collected in a non-
heparinized tube which was centrifuged within 1 h of
collection. The serum was separated and frozen at –20°C
for later analysis of ciprofloxacin concentration.
Lung tissue preparation
A portion of healthy tissue (approximately 1 g) was
removed from the resected lung tissue. The tissue sample
was handled using forceps and blotted gently with a piece
of gauze (moistened with sterile saline) to remove excess
blood. The tissue was subsequently placed in a pre-weighed
collection container and tightly sealed. The collection con-
tainer with tissue was weighed and frozen at –20°C until
later analysis.
At the time of analysis, the tissue sample was divided
into two portions. One of the subsamples was weighed
(c. 0.5–1.0 g) and approximately 5.0 mL of a 10% perchloric
acid in acetonitrile solution was added to the container.
The sample was homogenized and the resulting homo-
genate centrifuged at 1875g. The supernatant was trans-
ferred to a volumetric flask and the resulting pellet
homogenized again and centrifuged twice more. The
resulting supernatants were combined with the first, diluted
to volume with 10% perchloric acid in acetonitrile and
assayed for ciprofloxacin. The concentration of cipro-
floxacin in tissue was estimated from the equation:
Tissue concentration (mg/kg) 5 (concentration in
supernatant (mg/L) 3 volume of supernatant (L))/weight
of tissue sample (kg)
Haemoglobin analysis
Lung tissue samples (0.1–0.3 g) for haemoglobin analysis
were prepared using the second tissue subsample by
homogenizing in 1–2 mL of saline.17 The resulting
homogenate was centrifuged at 1875g. The supernatant
 Ciprofloxacin concentrations in lung tissue
was transferred to a 5.0 mL volumetric flask, diluted to
volume with saline and analysed for haemoglobin using a
Hema Q Hemoglobin Photometer (Hewlett Packard,
Wilmington, DE, USA). Since all results were below the
lower limit of quantification of the assay method (5 g/dL 6
2%), no correction was performed for the amount of blood
contamination in the lung tissue samples.
HPLC assay
Ciprofloxacin concentrations in serum, whole blood and
lung tissue were determined using validated HPLC proce-
dures with fluorescence detection. For serum and whole
blood preparation, 0.50 mL of the sample was precipitated
with 0.30 mL of 10% HClO4 in acetonitrile. The mixture
was then cooled and centrifuged at 12,000g and 4°C; 50 mL
of the resulting supernatant was injected into the HPLC
system. For tissue homogenates, 0.90 mL of the final super-
natant solution was mixed with 0.05 mL each of water and
internal standard. The mixture was centrifuged at 400g for
5 min at 4°C and 15 mL was injected into the HPLC system.
The liquid chromatograph consisted of a pump (model 510;
Waters Corp., Milford, MA, USA), a fluorescence detector
(model 980; Kratos, Norwalk, CT, USA), an autosampler
(model 717; Waters Corp.), an integrator (model 4270;
Spectra-Physics, San Jose, CA, USA) and an HPLC
column containing 5 mm particles of C8 (Zorbax Rx C8,
4.6 mm 3 250 mm Hewlett Packard). The mobile phase
consisted of acetonitrile:methanol:0.01 M citric acid in a
volume ratio of 7:17:76 containing tetrabutylammonium
hydroxide and ammonium perchlorate, and was used at a
flow rate of 1.0 mL/min. The column temperature was
maintained at 35°C. Ciprofloxacin was detected using an
excitation wavelength of 270 nm and an emission wave-
length of 440 nm. Ciprofloxacin concentrations were
Table I. Demographic characteristics of study patients
Time of taking blood/tissue samplea
No sample 0–2 h
Gender (n)
male 2 2
female 2 3
Age (years)
mean 6 S.D. 65.5 6 17.3 64.5 6 10.9
range 42–81 52–78
Weight (kg)
mean 6 S.D. 84.2 6 12.9 73.7 6 19.5
range 69.9–101.2 52.2–99.8
Height (cm)
mean 6 S.D. 172.3 6 7.2 171.6 6 6.3
range 163–180 165–179
a
Time following completion of ciprofloxacin infusion.
45
computed from peak height response ratios using
difloxacin as the internal standard. The quantification
range for ciprofloxacin in serum was validated from 0.05
to 10.0 mg/L. The overall precision of the serum assay
is reflected by the mean variability (% relative standard
deviation (R.S.D.)) of the quality control samples which was
5.9%. The accuracy of the serum assay is reflected by an
overall mean recovery of 97.5% for the serum quality con-
trol samples. The quantification range for ciprofloxacin in
whole blood was validated from 0.0125 to 5.0 mg/L. The
overall precision and accuracy (percent recovery) of the
whole blood assay for the quality control samples was
13.1% and 89.9%, respectively. The quantification range
for ciprofloxacin in lung tissue samples was validated from
0.025 to 2.0 mg/L with overall precision and accuracy of
4.83% and 99.5%, respectively.
Results
Twenty-two patients (mean age, 62.1 years; range 30–81
years) received a single iv dose of 400 mg ciprofloxacin
(Table I). Only 18 patients were included in the pharma-
cokinetic analysis as lung specimens could not be obtained
from the remaining four patients (in one, surgery was
aborted as there were metastases to the mediastinum; for
the other three, there were scheduling problems with the
surgery). The 18 eligible patients underwent lung resection
or biopsy for abnormalities seen by chest X-ray or CT scan.
The concentrations of ciprofloxacin in serum and lung
tissue, as well as tissue:serum ratios, are summarized in
Table II. Ciprofloxacin distributed rapidly to the lung
tissue as evidenced by the high lung tissue concentrations
(mean, 3.84 mg/kg) observed 0–2 h after infusion (Table I).
In addition, ciprofloxacin concentrations in lung tissue
2–4 h 4–8 h 8–12 h
3 4 2
3 0 1
61.2 6 7.8 64.6 6 3.7 52.6 6 20.2
52–69 59–68 31–71
81.6 6 20.3 67.6 6 14.6 80.1 6 18.2
45.4–102.1 52.6–83 61.2–97.5
170.5 6 12.0 176.5 6 3.1 170.0 6 13.2
157–188 173–180 155–180
 M. C. Birmingham et al.

Table II. Mean 6 S.D. concentrations in serum (mg/L) and tissue (mg/kg) of
ciprofloxacin at various time intervals after completion of 1 h 400 mg infusion of
ciprofloxacin

Concentration at the following timesa

0–2 h 2–4 h 4–8 h 8–12 h

Serum (mg/L) 2.37 6 1.40 1.18 6 0.51 0.69 6 0.13 0.13 6 0.07
Tissue (mg/kg) 3.84 6 1.87 1.92 6 0.60 1.77 6 0.55 0.67 6 0.17
Tissue:serum ratio 1.70 6 0.54 2.10 6 1.54 2.67 6 0.91 7.11 6 5.74
a
Times of blood/tissue sample following completion of ciprofloxacin infusion.

not corrected for potential blood contamination.

All 22 patients received a single iv 400 mg dose of
ciprofloxacin and were considered evaluable for safety
analysis. Twenty (91%) patients reported at least one
adverse event during the 12 h monitoring period. Despite
this high rate of adverse events, only one event (rash on
forearm) was considered to be potentially related to
ciprofloxacin.

Figure 1. Lung tissue vs serum concentrations of ciprofloxacin
after iv administration of ciprofloxacin 400 mg to 18 patients.
were higher than those in serum, with mean tissue:serum
concentration ratios ranging from 1.7 to 7.1. Mean lung
concentrations at the end of a 12 h dosing interval were
approximately 0.67 mg/kg. There was a linear correlation
(r2 5 0.71) between the individual serum concentrations
and the individual concentrations of ciprofloxacin in lung
tissue (see Figure).
It was intended that ciprofloxacin and haemoglobin con-
centrations in whole blood were to have been measured for
all patients so that the concentration of the quinolone in
lung tissue could be corrected for the amount of cipro-
floxacin present in the blood which may have contaminated
the lung specimen. However, blood concentration data
were only available in five of 18 patients, as a result of
specimen mishandling. Haemoglobin content was mea-
sured in lung tissue homogenates in an attempt to correct
for possible blood contamination. However, the haemo-
globin contents of the tissue homogenate samples were all
below the lower limit of quantification of the assay and
ciprofloxacin concentrations in the lung specimens were
Discussion
In this study, ciprofloxacin concentrations were detected in
healthy lung tissue within 2 h (mean peak tissue concentra-
tions 5 3.84 mg/kg) following a 1 h infusion of a single 400
mg iv dose, thus supporting other studies which have
demonstrated excellent respiratory tract penetration.9–16 In
a similar study, mean lung tissue concentrations were 9.72
and 9.1 mg/kg at 1 and 2 h respectively, following a 20 min
infusion of 400 mg iv ciprofloxacin.16 The higher lung
concentrations observed in the latter study were probably
the result of a shorter infusion time and shorter time to lung
tissue excision. Lung tissue concentrations of ciprofloxacin
in our trial were higher than concomitant serum levels as
reflected by mean tissue:serum ratios exceeding 1.7
throughout the 12 h study period. These relatively high
ratios suggest that ciprofloxacin achieves high intracellular
penetration.
Ciprofloxacin has been reported to undergo extensive
extravascular distribution, including penetration into most
body fluids and tissues.1,9,16 It is an amphoteric substance
with two pKs. Its isoelectric point, 7.4, is the same as the pH
of serum so, at this pH, ciprofloxacin is minimally ionized
and rapidly crosses cell membranes. Once inside a cell,
ciprofloxacin often becomes ionized and is subsequently
trapped intracellularly. This phenomenon is probably
responsible for the ability of ciprofloxacin to concentrate in
cells relative to serum.18
Although antimicrobials show considerable variation
in their ability to penetrate pulmonary tissues, lung pene-
tration is considered, in part, to be predictive of efficacy

46
 Ciprofloxacin concentrations in lung tissue
in the treatment of lower respiratory tract infections. The
bacterial pathogens responsible for acute bronchitis and
acute exacerbations of chronic bronchitis are principally
found in the sputum and bronchial mucosa.19 Epithelial
lining fluid (ELF) and alveolar macrophages appear to be
important sites of infection in pneumonia and intracellular
infections (e.g. Legionella and Mycoplasma spp.), respect-
ively. Although some have suggested that measurement of
antimicrobial concentrations in ELF and alveolar macro-
phages may be a better predictor of clinical efficacy, this
hypothesis remains to be proven.19 Although the current
study did not examine concentrations specifically in ELF or
alveolar macrophages, the methodological problems and
lack of standardization surrounding each of these measure-
ments have been described.8,19 Despite these limitations,
ciprofloxacin (250 mg bd) has been reported to penetrate
well into lung tissue, including bronchial mucosa, bronchial
ELF and alveolar macrophages, with concentrations
approximately 1.6, 2.0 and >12 times that in serum, respec-
tively.20 While concentrations derived from whole lung
specimens may be misleading because of the uneven distri-
bution of antimicrobial agents within respiratory tissue, the
relatively high lung tissue:serum ratios observed in our
study (>1.7) suggest that inhibitory concentrations are
achieved at intracellular pulmonary sites. The extensive
penetration of ciprofloxacin into respiratory tract tissues
may explain why some clinical trials have shown this drug
to be effective against various organisms such as P. aerugi -
nosa despite borderline MIC values.2
We have demonstrated that ciprofloxacin penetrates
lung tissue rapidly after a single iv dose and should provide
lung tissue concentrations that are sufficient to treat most
Gram-negative and some Gram-positive infections. Tissue
concentrations for most of the dosing interval were in
excess of the MIC90s of the common respiratory tract
pathogens (i.e. <1.0 mg/L). These findings, in part, may
explain the favourable clinical observations reported in
many respiratory trials and provide support for use of
ciprofloxacin in patients with pulmonary infections. Con-
tinued research is warranted to determine the best method
of assessing respiratory tract concentrations and prediction
of clinical response.
Acknowledgements
This work was supported by a research grant from Bayer
Corporation, Pharmaceutical Division, West Haven, CT,
USA. We thank Jonathan Harris, Teresa Tartaglione and
Joan Hinchcliffe for editorial contributions.
References
1. Davis, R., Markham, A. & Balfour, J. A. (1996). Ciprofloxacin. An
updated review of its pharmacology, therapeutic efficacy and tolera-
bility. Drugs 51, 1019–74.
2. Fink, M. P., Snydman, D. R., Niederman, M. S., Leeper, K. V.,
Johnson, R. H., Heard, S. O. et al. (1994). Treatment of severe
47
pneumonia in hospitalized patients: results of a multicenter,
randomized, double-blind trial comparing intravenous ciprofloxacin
with imipenem–cilastatin. Antimicrobial Agents and Chemotherapy
38, 547–57.
3. Forrest, A., Nix, D. E., Ballow, C. H., Goss, T. F., Birmingham, M.
C. & Schentag, J. J. (1993). Pharmacodynamics of intravenous
ciprofloxacin in seriously ill patients. Antimicrobial Agents and
Chemotherapy 37, 1073–81.
4. Nix, D. E., Sands, M. F., Peloquin, C. A., Vari, A. J., Cumbo, T. J.,
Vance, J. W. et al. (1987). Dual individualization of intravenous
ciprofloxacin in patients with nosocomial lower respiratory tract
infections. American Journal of Medicine 82, Suppl. 4A, 352–6.
5. Schentag, J. J. (1989). Clinical significance of antibiotic tissue
penetration. Clinical Pharmacokinetics 16, Suppl 1., 25–31.
6. Davies, B. I., Maesen, F. P. & Gubbelmans, R. (1989). Azithro-
mycin (CP-62,993) in acute exacerbations of chronic bronchitis: an
open clinical, microbiological and pharmacokinetic study. Journal of
Antimicrobial Chemotherapy 23, 743–51.
7. Girard, A. E., Girard, D. & Retsema, J. A. (1990). Correlation of
the extravascular pharmacokinetics of azithromycin with in-vivo
efficacy in models of localized infection. Journal of Antimicrobial
Chemotherapy 25, Suppl. A, 61–71.
8. Ritrovato, C. A. & Deeter, R. G. (1991). Respiratory tract
penetration of quinolone antimicrobials: a case in study. Pharma-
cotherapy 11, 38–49.
9. Bergogne-Bérézin, E., Berthelot, G., Even, P., Stern, M. &
Reynaud, P. (1986). Penetration of ciprofloxacin into bronchial
secretions. European Journal of Clinical Microbiology 5, 197–200.
10. Honeybourne, D., Wise, R. & Andrews, J. M. (1987). Cipro-
floxacin penetration into lungs. Lancet i, 1040.
11. Hopf, G., Bocker, R., Estler, C.-J., Radtke, H. J. & Floh, W.
(1988). Concentration of ciprofloxacin in human serum, lung and
pleural tissues and fluids during and after lung surgery. Infection 16,
29–30.
12. Reid, T. M., Gould, I. M., Golder, D., Legge, J. S., Douglas, J.
G., Friend, J. A. et al. (1989). Respiratory tract penetration of cipro-
floxacin. American Journal of Medicine 87, Suppl. 5A, 60S–61S.
13. Bacracheva, N., Scholl, H., Gerova, Z., Chervenakov, P.,
Dobrev, P. & Vlahov, V. (1991). The distribution of ciprofloxacin and
its metabolites in human plasma, pulmonary and bronchial tissues.
International Journal of Clinical Pharmacology, Therapy, and Toxi-
cology 29, 352–6.
14. Caruso, E., Castro, J. M., Chamoles, N., Galimberti, R., Jorge,
L. & Rohwedder, R. (1988). Penetration of ciprofloxacin into human
lung tissue after oral and IV dosing. Paper presented at the Sixth
Mediterranean Congress of Chemotherapy, Taormina, Italy.
15. Forst, H., Ruckdeschel, G., Unertl, K., Dieterich, H. J., Ehret, W.
& Sunder-Plassmann, L. (1989). Lung tissue concentrations of
ciprofloxacin following intravenous administration in patients.
Arzneimittel-forschung 39, 618–9.
16. Rohwedder, R., Caruso, E., Nunez, T. & Schlecker, H. (1994).
Penetration of ciprofloxacin into human respiratory tract tissues after
a single intravenous dose of 400 mg ciprofloxacin. In Proceedings of
the Sixth International Congress for Infectious Disease, Prague,
1994. Abstract 172. International Society for Infectious Diseases.
17. Lowry, O. H. & Hastings, A. B. (1942). Histochemical changes
associated with aging: methods and calculations. Journal of Bio-
logical Chemistry 143, 257–69.
 M. C. Birmingham et al.

18. Neuman, M. (1988). Clinical pharmacokinetics of the newer 20. Baldwin, D. R., Wise, R., Andrews, J. M., Gill, M. & Honey-
antibacterial 4-quinolones. Clinical Pharmacokinetics 14, 96–121 bourne, D. (1993). Comparative bronchoalveolar concentrations of
[and Erratum, ibid. 14(5), table of contents]. ciprofloxacin and lomefloxacin following oral administration. Res-
piratory Medicine 87, 595–601.
19. Baldwin, D. R., Honeybourne, D. & Wise, R. (1992). Pulmonary
disposition of antimicrobial agents: methodological considerations.
Antimicrobial Agents and Chemotherapy 36, 1171–5.

48