AMPICLOX
Ampicillin sodium trihydrate – cloxacillin sodium monohydrate
QUALITATIVE AND QUANTITATIVE COMPOSITION
Capsules:
Capsules 250 mg (ampicillin sodium trihydrate - cloxacillin sodium monohydrate)
contain 125 mg ampicillin and 125 mg cloxacillin.
Capsules 500 mg (ampicillin sodium trihydrate - cloxacillin sodium monohydrate)
contain 250 mg ampicillin and 250 mg cloxacillin.
Neonatal Suspension:
Dry powder suspension 90 mg/0.6 ml (ampicillin sodium trihydrate - cloxacillin sodium
monohydrate) contains 60 mg ampicillin and 30 mg cloxacillin.
Syrup:
Syrup 250 mg/5 ml (ampicillin sodium trihydrate - cloxacillin sodium monohydrate)
contains 125 mg ampicillin and 125 mg cloxacillin.
Syrup 500 mg/5 ml (ampicillin sodium trihydrate - cloxacillin sodium monohydrate)
contains 250 mg ampicillin and 250 mg cloxacillin.
Injection:
Vials 75 mg (ampicillin sodium trihydrate - cloxacillin sodium monohydrate) contain 50
mg ampicillin and 25 mg cloxacillin.
Vials 250 mg (ampicillin sodium trihydrate - cloxacillin sodium monohydrate) contain
125 mg ampicillin and 125 mg cloxacillin.
Vials 500 mg (ampicillin sodium trihydrate - cloxacillin sodium monohydrate) contain
250 mg ampicillin and 250 mg cloxacillin.
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 neonatal suspension and injection are indicated for the prophylaxis or
treatment of bacterial infections in premature babies or neonates, caused by known
susceptibile 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 1g every 4 to 6 hours
Intravenous (i.v.) 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
Oral Half adult dose: 5 to 10 ml syrup
every 6 hours
Injectable Half adult dose: 250 mg every 8
hours
Neonates to 2 years
Neonatal suspension 0.6 ml (90 mg) of reconstituted
suspension every 4 hours. Administer
0/5 to 1 hour prior to feeding
Injection One quarter adult dose: 75 mg every
8 hours
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.
MODE OF ADMINISTRATION
Oral route:
AMPICLOX should be administered 0.5 to 1 hour before meals.
Parenteral route:
Administer by slow i.v. injection (3 to 4 minutes). AMPICLOX may also be added to
infusion fluids (except for aminoglycosides, amino acid solutions, fat emulsions and
blood), and can, therefore, be administered simultaneously with these forms of treatment
or injected, suitably diluted, into the drug tube over a period of 3 to 4 minutes.
Contraindications
AMPICLOX should not be given to patients with a history of hypersensitivity to betalactam 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 suspension 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 suspension and syrup 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 30.4 mg of sodium.
Each AMPICLOX 250 mg vial contains 15.2 mg of sodium.
Each AMPICLOX 75 mg vial contains 4.73 mg of sodium.
Each AMPICLOX 500 mg capsule contains 13.2 mg of sodium.
Each AMPICLOX 250 mg capsule contains 6.6 mg of sodium.
AMPICLOX syrup 500 mg contains 26.4 mg sodium per 5 ml dose.
AMPICLOX syrup 250 mg contains 13.2 mg sodium per 5 ml dose.
AMPICLOX Neonatal Suspension contains 2.5 mg sodium per 0.6 ml dose.
Interactions
Probenecid decreases the renal tubular excretion of AMPICLOX. 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 judgement, 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: Haemolytic anaemia, 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.
Hepato-biliary 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 system
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 narrowspectrum 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 act 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 infections.
AMPICLOX susceptibility rates are higher than ampicillin rates due to the cloxacillin
activity against β-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 cloxacillin is 0.5 to 1 hour and 1 to 1.5 hours 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 ExcipientsS
Capsules:
Magnesium stearate.
Neonatal Suspension:
Sodium benzoate
Xanthan gum
Sodium citrate anhydrous
Saccharin sodium.
Syrup:
Sodium benzoate
Disodium edetate
Methyl polysiloxane
Sodium citrate anhydrous
Saccharin sodium
Monoammonium glycyrrhizinate
Menthol dry flavour
Tutee Fruity dry flavour
Blood orange dry flavour
Sucrose.
Injection:
None.
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.
Shelf-Life
The expiry date is indicated on the packaging.
Special Precautions for Storage
AMPICLOX should be stored in a dry place below 25°C.
Do not use after the expiry date.
All medicines should be kept out of reach of children.
Reconstitution of AMPICLOX injections and preparation of AMPICLOX infusion
solutions must be carried out under appropriate aseptic conditions if extended storage
periods are required.
Nature and Contents of Container
Capsules:
250 mg: black and amethyst capsules
500 mg: black and amethyst capsules
Neonatal Suspension:
Neonatal drops: clear, glass bottles containing powder for reconstitution to 8 ml of
90 mg/0.6 ml
Syrup:
Clear, glass bottles containing powder for reconstitution to 100 ml of 250 mg/5 ml syrup
Injection:
1 g; 500 mg; 75 mg: white powder in clear, glass vials.
Instructions for Use/Handling
Neonatal Suspension:
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