Ampiclox Ampicillin Cloxacillin Capsule Suspension and Oral Drops

Ampiclox™

Ampicillin-cloxacillin

 

QUALITATIVE AND COMPOSITION

AMPICLOX 500 mg Capsules: Each capsule contains 250 mg ampicillin as Ampicillin Trihydrate and 250 mg cloxacillin as Cloxacillin Sodium.

AMPICLOX 250 MG/5 ML Suspension: Each 5 ml after reconstitution contains 125 mg ampicillin as Ampicillin Trihydrate and 125 mg cloxacillin as Cloxacillin Sodium.

AMPICLOX 90 mg/0.6 ml Neonatal oral drops: Each 0.6 ml contains 60 mg ampicillin as Ampicillin Trihydrate and 30mg cloxacillin as Cloxacillin Sodium.

 

PHARMACEUTICAL FORM

AMPICLOX 500 mg capsule: Hard Gelatin Capsules filled with almost white granular powder.

AMPICLOX 250 mg/5 ml suspension: Off white free flowing granular powder, which on reconstitution becomes off white suspension having characteristic odour.

AMPICLOX 90 mg/0.6 ml Neonatal oral drops: Off white free flowing granular powder which on reconstitution becomes off white suspension having a characteristic odour.

 

CLINICAL PARTICULARS

Indications

AMPICLOX is indicated for the treatment of the following infections including mixed Gram-positive (except methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-resistant coagulase-negative staphylococcus (MRCoNS)) and Gram-negative infections:

Surgery: post-operative wound infections, post-operative pulmonary infections.

Respiratory infections: bronchopneumonia, acute exacerbations of chronic bronchitis.

Obstetrics: puerperal fever.

Other infections such as septicaemia, bone infections e.g., osteomyelitis, ear, nose and throat infections.

Appropriate culture and susceptibility tests should be performed before treatment in order to isolate and identify organisms causing infection and to determine their susceptibility to AMPICLOX. Where treatment is initiated before results are available expert advice should be sought when the local prevalence of resistance is such that the utility of AMPICLOX is questionable (see Pharmacological properties, Pharmacodynamics).

AMPICLOX Neonatal oral drops are indicated for the prophylaxis or treatment of bacterial infections in premature babies or neonates, caused by known susceptible strains of bacteria.

 

Dosage and Administration

Route Dosage
Adults and Elderly
Oral 1 to 2 g every 6 hours
Intramuscular (i.m.) injection 500 mg to 1 g every 4 to 6 hours
The dose of AMPICLOX may be increased for the treatment of severe infections.

 

Children 2 to 12 years Dosage
Oral Half adult dose: 5 to 10 mL suspension every 6 hours
Injectable Half adult dose: 250 mg every 8 hours
Neonatal to 2 years
Neonatal oral drops 0.6 ml (90 mg) of reconstituted suspension every 4 hours. Administer 0.5 to 1 hour prior to feeding

 

Renal impairment

In cases of renal failure, the dosage should be adapted in accordance with the following:
Creatinine clearance greater than 50 mL/minute: normal dose according to indication.
Creatinine clearance between 50 and 10 mL/minute:

– Dosage (oral or parenteral administration) initial dose: normal dose (according to indication).

– Dosage (oral or parenteral administration) maintenance dose: the normal unit dose (AMPICLOX 500 mg orally, up to 1 g i.m. or i.v.) three times daily.
Creatinine clearance below 10 mL/minute:

– Dosage (oral or parenteral administration) initial dose: normal dose (according to indication).

– Dosage (oral or parenteral administration) maintenance dose: the normal unit dose twice or once daily.

In cases of dialysis, an additional normal unit dose (AMPICLOX 500 mg orally, up to 1 g i.m. or i.v.) is to be administered after the procedure.

 

Hepatic Impairment

Reduce frequency of administration depending on the severity of the condition.

– AMPICLOX should not be given to patients with a history of hypersensitivity to beta-lactam antibiotics (e.g., penicillins, cephalosporins) or excipients (See List of Excipients).

– AMPICLOX is contraindicated for ocular administration.

 

Warnings and Precautions

Caution should be observed when administering AMPICLOX Neonatal oral drops to babies whose mothers are hypersensitive to penicillin.

Before initiating therapy with AMPICLOX, careful inquiry should be made concerning previous hypersensitivity reactions to beta-lactams.

Cross-sensitivity between penicillins and cephalosporins is well documented. Serious and occasionally fatal hypersensitivity reactions (anaphylaxis) have been reported in patients receiving beta-lactam antibiotics. Although anaphylaxis is more frequent following parenteral therapy, it has occurred in patients on oral penicillins. These reactions are more likely to occur in individuals with a history of beta-lactam hypersensitivity.

If an allergic reaction occurs, AMPICLOX should be discontinued and the appropriate alternative therapy instituted. All adverse reactions should be treated symptomatically.
AMPICLOX should be avoided if infectious mononucleosis and/or acute or chronic leukaemia of lymphoid origin are suspected. The occurrence of a skin rash has been associated with these conditions following the administration of ampicillin.

Prolonged use may occasionally result in overgrowth of non-susceptible organisms.

Pseudomembranous colitis has been reported with the use of antibiotics and may range in severity from mild to life-threatening. Therefore, it is important to consider its diagnosis in patients who develop diarrhoea during or after antibiotic use. If prolonged or significant diarrhoea occurs or the patient experiences abdominal cramps, treatment should be discontinued immediately and the patient investigated further.

Dosage should be adjusted in patients with renal impairment (See Dosage and Administration, Renal impairment).

Cloxacillin can displace bilirubin from protein-binding sites. Normal caution should therefore be exercised in the treatment of jaundiced neonates.

AMPICLOX Neonatal oral drops and suspension contain sodium benzoate which is a mild irritant to the skin, eyes and mucous membrane. It may increase the risk of jaundice in newborn babies.

The sodium content of the formulation must be included in the daily allowance of patients on sodium restricted diets.

Each AMPICLOX 500 mg vial contains 29.63 mg of sodium.

Each AMPICLOX 500 mg capsule contains 13.17 mg of sodium.

AMPICLOX suspension 250 mg contains 12.14 mg sodium per 5 mL dose.

AMPICLOX Neonatal Oral drops contains 2.46 mg sodium per 0.6 mL dose.

 

Interactions

Probenecid decreases the renal tubular excretion of AMPlCLOX. Concurrent use with AMPICLOX may result in increased and prolonged blood levels of AMPICLOX.

In common with other antibiotics, AMPICLOX may affect the gut flora, leading to lower oestrogen reabsorption and reduced efficacy of combined oral contraceptives.

Sulphonamides and acetylsalicylic acid inhibit serum protein binding of cloxacillin in vitro. This may result in increased levels of free cloxacillin in serum in vivo.

Bacteriostatic drugs may interfere with the bactericidal action of AMPICLOX. Concurrent administration of allopurinol during treatment with AMPICLOX can increase the likelihood of allergic skin reactions.

 

Pregnancy and Lactation

Adequate human data on use during pregnancy are not available. However, animal studies have not identified any risk to pregnancy or embryo-foetal development.

Adequate human and animal data on use during lactation are not available.

 

Ability to perform tasks that require judgment, motor or cognitive skills

No adverse effects on the ability to drive or operate machinery have been observed.

 

Adverse Reactions

The following statements reflect the information available on the adverse reaction profile of the individual constituents (ampicillin and cloxacillin) and/or the combination in AMPICLOX. The majority of the adverse reactions listed below are not unique to ampicillin – cloxacillin and may occur when using other penicillins.

Adverse reactions are listed below by system organ class and frequency. Frequencies are defined as: very common (>1/10), common (>1/100, <1/10), uncommon (>1/1000, <1/100), rare (>1/10,000, <1/1000), very rare (<1/10,000), including isolated reports. Common and uncommon adverse reactions were generally determined from pooled safety data from a clinical trial population of 1210 treated patients. Rare and very rare adverse reactions were generally determined from more than 32 years of post-marketing experience data and refer to reporting rate rather than true frequency.

 

Blood and lymphatic system disorders

Very rare: Hemolytic anemia, leucopenia, thrombocytopenia, agranulocytosis.

 

Immune system disorders

Very rare: Anaphylaxis (See Warnings and Precautions) and other hypersensitivity reactions.

Skin disorders and interstitial nephritis have been reported as hypersensitivity reactions.

(See also Skin and subcutaneous tissue disorders and Renal and urinary disorders).

If any hypersensitivity reaction occurs, the treatment should be discontinued.

 

Nervous system disorders

Very rare: Myoclonus and convulsions.

 

Gastrointestinal disorders

Common: Diarrhoea and nausea.

Uncommon: Vomiting.

Very rare: Pseudomembranous colitis (See Warnings and Precautions) and haemorrhagic colitis.

 

Hepatobillary disorders

Very rare: Hepatitis and cholestatic jaundice. A moderate and transient increase in transaminases.

 

Skin and subcutaneous tissue disorders

Common: Skin rash, urticaria, and pruritus.

The incidence of skin rash, pruritus, and urticaria is higher in patients suffering from infectious mononucleosis and acute or chronic leukaemia of lymphoid origin.

Very rare: Bullous reactions (including erythema multiforme, Stevens- Johnson syndrome and toxic epidermal necrolysis), exfoliative dermatitis and purpura.

Skin disorders have also been reported as hypersensitivity reactions (See Immune Renal and urinary disorders).

 

Renal and urinary disorders

Very rare: interstitial nephritis.

Interstitial nephritis has also been reported as a hypersensitivity reaction (See also Immune system disorders).

 

Overdose

Overdosage with oral AMPICLOX is unlikely to cause serious reactions if renal function is normal. Very high dosage of i.v. administered ampicillin and/or high dosage of cloxacillin in renal failure may provoke neurotoxic reactions similar to those seen with benzylpenicillin in excess.

Gastrointestinal effects such as nausea, vomiting, and diarrhoea may be evident.
These symptoms should be treated symptomatically.

 

PHARMACOLOGICAL PROPERTIES

Pharmacodynamics

AMPICLOX is a combination of ampicillin and cloxacillin. Cloxacillin is a narrow-spectrum antibiotic of the isoxazolyl penicillin group; it is not inactivated by staphylococcal beta-lactamases. Ampicillin is a broad-spectrum antibiotic of the aminopenicillin group; it is not resistant to beta-lactamases.

Both ampicillin and cloxacillin are bactericidal antibiotics and by interfering with the formation of new bacterial cell wall by dividing organisms.

The prevalence of acquired resistance is geographically variable and for select species may be very high. Local information on resistance is desirable, particularly when treating severe infection.

AMPICLOX susceptibility rates are higher than ampicillin rates due to the cloxacillin activity against-lactamase producing Staphylococci. Methicillin-susceptible  Staphylococcus aureus (MSSA) and methicillin-susceptible coagulase-negative staphylococcus (MSCoNS) are commonly susceptible to AMPICLOX. MRSA and MRCoNS are resistant to AMPICLOX. For all other indicated, bacterial species, the susceptibility of AMPICLOX is similar to ampicillin including limited activity against Gram-negative organisms.

 

Pharmacokinetics

Absorption

Both ampicillin and cloxacillin are stable in the gastric environment resulting in good absorption. Neither component of the combination of ampicillin and cloxacillin interferes with the absorption or excretion of the other.

The total quantity absorbed by the oral route represents 50% (cloxacillin) and 40% (ampicillin) of the quantity administered.

The presence of food in the stomach may depress oral absorption and AMPICLOX should therefore be taken 0.5 to 1 hour before meals.

 

Distribution

AMPICLOX diffuses well into most tissues and body fluids including, among others, bronchial secretions, sinuses, saliva, cerebrospinal fluid (variable percentage depending on the degree of meningeal inflammation), bile, serous membranes and middle ear.

Crossing the meningeal barrier: AMPICLOX diffuses in only small proportion into the cerebrospinal fluid of subjects whose meninges are not inflamed.

Crossing into breast milk: AMPICLOX is excreted in small quantities in breast milk.
Plasma half-life for cloxacilln is 0.5 to 1 hour and 1 to 1.5 hour for ampicillin.

Protein binding: the serum protein binding proportion is approximately 94% for cloxacillin and 18% for ampicillin.

 

Metabolism

In normal subjects approximately 20% (cloxacillin) and 40% (ampicillin) of the dose administered is metabolised.

 

Excretion

AMPICLOX is eliminated mainly through the kidney. Approximately 30% of the dose administered orally and over 60% of the ampicillin dose administered parenterally is eliminated in active form in the urine within 24 hours. The equivalent percentages for cloxacillin are approximately 20% and 30% respectively. A small proportion (10%) of the dose administered is excreted in bile.

 

PHARMACEUTICAL PARTICULARS

List of Excipients

AMPICLOX 500 mg Capsules

Magnesium stearate

Colloidal Anhydrous Silica

AMPICLOX 90 mg/0.6 ml Neonatal oral drops

Sodium benzoate

Xanthan gum

Sodium citrate anhydrous

Saccharin sodium

AMPICLOX 250 mg/5 ml Suspension

Xanthan gum

Disodium edetate

Sodium benzoate

Colloidal Anhydrous Silica

Sodium citrate

Peppermint dry flavour

Orange dry flavour

Sorbitol

 

Incompatibilities

AMPICLOX must not be dissolved in either protein or protein hydrolysate solutions or in lipid solutions, or in blood or plasma.

When AMPICLOX is prescribed together with an aminoglycoside, the two antibiotics should not be mixed in the same container as the one containing the infusion solution because a loss of activity may occur.

 

Special Precautions for Storage

AMPICLOX 500 mg capsules

Store in a dry place below 25°C

AMPICLOX 250 mg/5 ml Suspension

Keep tightly closed and store in a dry place below 25°C

Once dispensed the suspension should be used within 7 days. If necessary dilute with Syrup B.P.

AMPICLOX 90 mg/0.6 ml Neonatal oral drops

Keep tightly closed and store in a dry place below 25°C

Once dispensed store in a cool place; preferably a refrigerator. Do not freeze.

Pour away any medicine remaining after 5 days. Throw away bottle and pipette.

 

Shelf-life

The expiry date is indicated on the packaging.

 

Nature and Contents of Container

AMPICLOX 500mg capsule

Tropicalised blisters.

AMPICLOX 90 mg/0.6 ml Neonatal oral drops

Bottles.

AMPICLOX 250 mg/5 ml suspension

Bottles.

 

Instructions for Use and Handling

AMPICLOX 250 mg/5 ml Suspension

Preparation of the suspension: Boil water and allow it to cool, then slowly add water up to the mark on the label and shake well. Before each use, shake the bottle containing the reconstituted mixture thoroughly.

AMPICLOX 90 mg/0.6 ml Neonatal oral drops

Preparation of the suspension: Before dispensing this drug, add 7 mL of distilled water to the powder and shake well. Before each use, shake the bottle containing the reconstituted mixture thoroughly.

 

KEEP OUT OF REACH OF CHILDREN

 

Not all presentations are available in every country.

 

AMPICLOX is a trademarks of the GlaxoSmithKline group of companies.

Version number: GAO3

Version date: 25 AUG 2014

© 2014 GlaxoSmithKline

 

Manufactured under license by

MEDREICH LIMITED

Bangalore, INDIA.

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