EPICEPHIN 250 mg I.M.

Dry substance: Ceftriaxone disodium hemi heptahydrate 298.2 mg equivalent to 250 mg ceftriaxone per vial.

Solvent: Lidocaine hydrochloride monohydrate 21.33 mg equivalent to 20 mg lidocaine hydrochloride, water for injection q.s. 2 ml of solution.

EPICEPHIN 250 mg I.V.

Dry substance: Ceftriaxone disodium hemi heptahydrate 298.2 mg equivalent to 250 mg ceftriaxone per vial.

Solvent: Water for injection 5 ml.

EPICEPHIN 500 mg I.M.

Dry substance: Ceftriaxone disodium hemi heptahydrate 596.5 mg equivalent to 500 mg ceftriaxone per vial.

Solvent: Lidocaine hydrochloride monohydrate 21.33 mg equivalent to 20 mg lidocaine hydrochloride, water for injection q.s. 2 ml of solution.

EPICEPHIN 500 mg I.V.

Dry substance: Ceftriaxone disodium hemi heptahydrate 596.5 mg equivalent to 500 mg ceftriaxone per vial.

Solvent: Water for injection 5 ml.

EPICEPHIN 1 g I.M.

Dry substance: Ceftriaxone 1 g as disodium hemi heptahydrate per vial.

Solvent: Lidocaine hydrochloride monohydrate 37.3 mg equivalent to 35 mg lidocaine hydrochloride, water for injection q.s. 3.5 ml of solution.

EPICEPHIN 1 g I.V.

Dry substance: Ceftriaxone 1 g as disodium hemi heptahydrate per vial.

Solvent: Water for injection 10 ml.

EPICEPHIN 2 g I.V.

Dry substance: Ceftriaxone disodium hemi heptahydrate 2386.0 mg equivalent to 2000 mg ceftriaxone per vial.

Solvent: Water for injection 10 ml.

EPICEPHIN is indicated for the treatment of the following infections in Adults and Children including term neonates (from birth):

Bacterial meningitis.

Community acquired pneumonia.

Hospital acquired pneumonia.

Acute otitis media.

Intra-abdominal infections.

Complicated urinary tract infections (including pyelonephritis).

Infections of bones and joints.

Complicated skin and soft tissue infections.

Gonorrhoea.

Syphilis.

Bacterial endocarditis.

EPICEPHIN may be used:

For treatment of acute exacerbations of chronic obstructive pulmonary disease in adults.

For treatment of disseminated Lyme borreliosis (early [Stage II] and late [Stage III]) in adults and children including neonates from 15 days of age. 

For Pre-operative prophylaxis of surgical site infections.

In the management of neutropenic patients with fever that is suspected to be due to a bacterial infection.

In the treatment of patients with bacteraemia that occurs in association with, or is suspected to be associated with, any of the infections listed above. 

EPICEPHIN should be co-administered with other antibacterial agents whenever the possible range of causative bacteria would not fall within its spectrum. (see Warnings and Precaution).

Consideration should be given to official guidelines on the appropriate use of antibacterial agents.

Dosage:                                

The dose depends on the severity, susceptibility, site and type of infection and on the age and hepato-renal function of the patient.

The doses recommended in the tables below are the generally recommended doses in these indications. In particularly severe cases, doses at the higher end of the recommended range should be considered.

Adults and Children over 12 years of age (≥ 50 kg):

^* In documented bacteraemia, the higher end of the recommended dose range should be considered.

^** Twice daily (12 hourly) administration may be considered where doses greater than 2 g daily are administered.

Indications for Adults and Children over 12 years of age (≥ 50 kg) that require specific dosage schedules:

Acute otitis media:

A single intramuscular dose of EPICEPHIN 1-2 g can be given.

Limited data suggest that in cases where the patient is severely ill or previous therapy has failed, EPICEPHIN may be effective when given as an intramuscular dose of 1-2 g daily for 3 days.

Pre-operative prophylaxis of surgical site infections:

2 g as a single pre-operative dose.

Gonorrhoea:

500 mg as a single intramuscular dose.

Syphilis:

The generally recommended doses are 500 mg-1 g once daily increased to 2 g once daily for neurosyphilis for 10-14 days. The dose recommendations in syphilis, including neurosyphilis, are based on limited data. National or local guidance should be taken into consideration.

Disseminated Lyme borreliosis (early [Stage II] and late [Stage III]):

2 g once daily for 14-21 days. The recommended treatment durations vary and national or local guidelines should be taken into consideration.

Pediatric population:

Neonates, Infants and Children 15 days to 12 years of age (< 50 kg):

For children with bodyweight of 50 kg or more, the usual adult dosage should be given.

^* In documented bacteraemia, the higher end of the recommended dose range should be considered.

^** Twice daily (12 hourly) administration may be considered where doses greater than 2 g daily are administered.

Indications for Neonates, Infants and Children 15 days to 12 years (< 50 kg) that require specific dosage schedules:

Acute otitis media:

For initial treatment of acute otitis media, a single intramuscular dose of EPICEPHIN 50 mg/kg can be given. Limited data suggest that in cases where the child is severely ill or initial therapy has failed, EPICEPHIN may be effective when given as an intramuscular dose of 50 mg/kg daily for 3 days.

Pre-operative prophylaxis of surgical site infections:

50-80 mg/kg as a single pre-operative dose.

Syphilis:

The generally recommended doses are 75-100 mg/kg (max 4 g) once daily for 10-14 days. The dose recommendations in syphilis, including neurosyphilis, are based on very limited data. National or local guidance should be taken into consideration.

Disseminated Lyme borreliosis (early [Stage II] and late [Stage III]):

50-80 mg/kg once daily for 14-21 days. The recommended treatment durations vary and national or local guidelines should be taken into consideration.

Neonates 0-14 days:

EPICEPHIN is contraindicated in premature neonates up to a postmenstrual age of 41 weeks (gestational age + chronological age).

^* In documented bacteraemia, the higher end of the recommended dose range should be considered.

A maximum daily dose of 50 mg/kg should not be exceeded.

Indications for Neonates 0-14 days that require specific dosage schedules:

Acute otitis media:                                        

For initial treatment of acute otitis media, a single intramuscular dose of EPICEPHIN 50 mg/kg can be given.

Pre-operative prophylaxis of surgical site infections:

20-50 mg/kg as a single pre-operative dose.

Syphilis:

The generally recommended dose is 50 mg/kg once daily for 10-14 days. The dose recommendations in syphilis, including neurosyphilis, are based on very limited data.

National or local guidance should be taken into consideration.

Duration of therapy:

The duration of therapy varies according to the course of the disease. As with antibiotic therapy in general, administration of EPICEPHIN should be continued for 48-72 hours after the patient has become afebrile or evidence of bacterial eradication has been achieved.

Older people:

The dosages recommended for adults require no modification in older people provided that renal and hepatic function is satisfactory.

Patients with hepatic impairment:

Available data do not indicate the need for dose adjustment in mild or moderate liver function impairment provided renal function is not impaired.

There are no study data in patients with severe hepatic impairment. (See Pharmacokinetic properties)

Patients with renal impairment:

In patients with impaired renal function, there is no need to reduce the dosage of EPICEPHIN provided hepatic function is not impaired. Only in cases of preterminal renal failure (creatinine clearance < 10 ml/min) should the EPICEPHIN dosage not exceed 2 g daily.

In patients undergoing dialysis, no additional supplementary dosing is required following the dialysis. Ceftriaxone is not removed by peritoneal- or haemodialysis.

Close clinical monitoring for safety and efficacy is advised.

Patients with severe hepatic and renal impairment:

In patients with both severe renal and hepatic dysfunction, close clinical monitoring for safety and efficacy is advised.

Administration:

Intramuscular Administration:

EPICEPHIN can be administered by deep intramuscular injection. Intramuscular injections should be injected well within the bulk of a relatively large muscle and not more than 1 g should be injected at one site.

As the solvent used is lidocaine, the resulting solution should never be administered intravenously.

Intravenous Administration:

EPICEPHIN can be administered by intravenous infusion over at least 30 minutes (preferred route) or by slow intravenous injection over 5 minutes. Intravenous intermittent injection should be given over 5 minutes preferably in larger veins.

Intravenous doses of 50 mg/kg or more in infants and children up to 12 years of age should be given by infusion. In neonates, intravenous doses should be given over 60 minutes to reduce the potential risk of bilirubin encephalopathy (See Contraindications and Warnings and Precautions). Intramuscular administration should be considered when the intravenous route is not possible or less appropriate for the patient. For doses greater than 2 g, intravenous administration should be used.

EPICEPHIN is contraindicated in neonates (≤ 28 days) if they require (or are expected to require) treatment with calcium-containing intravenous solutions, including continuous calcium-containing infusions such as parenteral nutrition, because of the risk of precipitation of ceftriaxone-calcium (See Contraindications).

Diluents containing calcium, (e.g. Ringer’s solution or Hartmann’s solution), should not be used to reconstitute EPICEPHIN vials or to further dilute a reconstituted vial for intravenous administration because a precipitate can form. Precipitation of ceftriaxone-calcium can also occur when ceftriaxone is mixed with calcium-containing solutions in the same intravenous administration line. Therefore, EPICEPHIN and calcium-containing solutions must not be mixed or administered simultaneously (See Contraindications and Warnings and Precautions and Incompatibilities).

For pre-operative prophylaxis of surgical site infections, EPICEPHIN should be administered 30-90 minutes prior to surgery.

For instructions on reconstitution of the medicinal product before administration, see Special Precautions for Disposal.

Hypersensitivity to ceftriaxone, to any other cephalosporin or to any of the excipients.

Previous immediate and/or severe hypersensitivity reaction to a penicillin or to any other beta-lactam medicinal products.

EPICEPHIN is contraindicated in:

Premature neonates up to a postmenstrual age of 41 weeks (gestational age + chronological age)^*.

Full-term neonates (up to 28 days of age):

- with hyperbilirubinaemia, jaundice, or who are hypoalbuminaemic or acidotic because these are conditions in which bilirubin binding is likely to be impaired.^*

- if they require (or are expected to require) intravenous calcium treatment, or calcium-containing infusions due to the risk of precipitation of a ceftriaxone-calcium salt (see Warnings and Precautions, Undesirable Effects, Incompatibilities).

^* In vitro studies have shown that ceftriaxone can displace bilirubin from its serum albumin binding sites leading to a possible risk of bilirubin encephalopathy in these patients.

Contraindications to lidocaine must be excluded before intramuscular injection of ceftriaxone when lidocaine solution is used as a solvent (see Warnings and Precautions). See information in the Summary of Product Characteristics of lidocaine, especially contraindications.

EPICEPHIN solutions containing lidocaine should never be administered intravenously.

Hypersensitivity reactions:

Special caution is required to determine any other type of previous hypersensitivity reactions to penicillin or to other beta-lactam medicinal products because patients hypersensitive to these medicines may be hypersensitive to EPICEPHIN as well (cross- allergy).

As with all beta-lactam antibacterial agents, serious and occasionally fatal hypersensitivity reactions have been reported (see Undesirable Effects). In case of severe hypersensitivity reactions, treatment with ceftriaxone must be discontinued immediately and adequate emergency measures must be initiated. Before beginning treatment, it should be established whether the patient has a history of severe hypersensitivity reactions to ceftriaxone, to other cephalosporins or to any other type of beta-lactam agent. Caution should be used if ceftriaxone is given to patients with a history of non-severe hypersensitivity to other beta-lactam agents.

Severe cutaneous adverse reactions (Stevens Johnson syndrome or Lyell’s syndrome/toxic epidermal necrolysis) have been reported; however, the frequency of these events is not known (see Undesirable Effects).

Interaction with Calcium-containing products:

Cases of fatal reactions with calcium-ceftriaxone precipitates in lungs and kidneys in premature and full-term neonates aged less than 1 month have been described. At least one of them had received ceftriaxone and calcium at different times and through different intravenous lines. In the available scientific data, there are no reports of confirmed intravascular precipitations in patients, other than neonates, treated with ceftriaxone and calcium-containing solutions or any other calcium-containing products. In vitro studies demonstrated that neonates have an increased risk of precipitation of ceftriaxone-calcium compared to other age groups.

In patients of any age, ceftriaxone must not be mixed or administered simultaneously with any calcium-containing intravenous solutions, even via different infusion lines or at different infusion sites. However, in patients older than 28 days of age ceftriaxone and calcium-containing solutions may be administered sequentially one after another if infusion lines at different sites are used or if the infusion lines are replaced or thoroughly flushed between infusions with physiological salt-solution to avoid precipitation. In patients requiring continuous infusion with calcium-containing total parenteral nutrition (TPN) solutions, healthcare professionals may wish to consider the use of alternative antibacterial treatments which do not carry a similar risk of precipitation. If the use of ceftriaxone is considered necessary in patients requiring continuous nutrition, TPN solutions and ceftriaxone can be administered simultaneously, albeit via different infusion lines at different sites. Alternatively, infusion of TPN solution could be stopped for the period of ceftriaxone infusion and the infusion lines flushed between solutions (see Contraindications, Undesirable Effects, Pharmacokinetic properties, Incompatibilities).

Pediatric population:

Safety and effectiveness of ceftriaxone in neonates, infants and children have been established for the dosages described under Dosage and Administration  (see Dosage and Administration). Studies have shown that ceftriaxone, like some other cephalosporins, can displace bilirubin from serum albumin.

EPICEPHIN is contraindicated in premature and full-term neonates at risk of developing bilirubin encephalopathy (see Contraindications).

Immune-mediated haemolytic anaemia:

An immune-mediated haemolytic anaemia has been observed in patients receiving cephalosporin class antibacterials including EPICEPHIN (see Undesirable Effects). Severe cases of haemolytic anaemia, including fatalities, have been reported during EPICEPHIN treatment in both adults and children.

If a patient develops anaemia while on ceftriaxone, the diagnosis of a cephalosporin-associated anaemia should be considered and ceftriaxone discontinued until the aetiology is determined.

Long term treatment:

During prolonged treatment complete blood count should be performed at regular intervals.

Colitis/Overgrowth of non-susceptible microorganisms:

Antibacterial agent-associated colitis and pseudo-membranous colitis have been reported with nearly all antibacterial agents, including ceftriaxone, and may range in severity from mild to life-threatening. Therefore, it is important to consider this diagnosis in patients who present with diarrhoea during or subsequent to the administration of EPICEPHIN (see Undesirable Effects). Discontinuation of therapy with EPICEPHIN and the administration of specific treatment for Clostridium difficile should be considered. Medicinal products that inhibit peristalsis should not be given. 

Superinfections with non-susceptible micro-organisms may occur as with other antibacterial agents.

Severe renal and hepatic insufficiency:

In severe renal and hepatic insufficiency, close clinical monitoring for safety and efficacy is advised (see Dosage and Administration).

Interference with serological testing:

Interference with Coombs tests may occur, as EPICEPHIN may lead to false-positive test results. EPICEPHIN can also lead to false-positive test results for galactosaemia (see Undesirable Effects).

Non-enzymatic methods for the glucose determination in urine may give false-positive results. Urine glucose determination during therapy with EPICEPHIN should be done enzymatically (see Undesirable Effects).

The presence of EPICEPHIN may falsely lower estimated blood glucose values obtained with some blood glucose monitoring systems. Please refer to instructions for use for each system. Alternative testing methods should be used if necessary.

Sodium:

This should be taken into consideration in patients on a controlled sodium diet.

Antibacterial spectrum:

Ceftriaxone has a limited spectrum of antibacterial activity and may not be suitable for use as a single agent for the treatment of some types of infections unless the pathogen has already been confirmed (see Dosage and Administration).

In polymicrobial infections, where suspected pathogens include organisms resistant to ceftriaxone, administration of an additional antibiotic should be considered.

Use of lidocaine:

In case a lidocaine solution is used as a solvent, ceftriaxone solutions must only be used for intramuscular injection. Contraindications to lidocaine, warnings and other relevant information as detailed in the Summary of Product Characteristics of lidocaine must be considered before use (see Contraindications).

The lidocaine solution should never be administered intravenously.

Biliary lithiasis:

When shadows are observed on sonograms, consideration should be given to the possibility of precipitates of calcium-ceftriaxone. Shadows, which have been mistaken for gallstones, have been detected on sonograms of the gallbladder and have been observed more frequently at ceftriaxone doses of 1 g per day and above. Caution should be particularly considered in the pediatric population. Such precipitates disappear after discontinuation of ceftriaxone therapy. Rarely precipitates of calcium-ceftriaxone have been associated with symptoms. In symptomatic cases, conservative nonsurgical management is recommended and discontinuation of EPICEPHIN treatment should be considered by the physician based on specific benefit risk assessment(see Undesirable Effects).

Biliary stasis:

Cases of pancreatitis, possibly of biliary obstruction aetiology, have been reported in patients treated with ceftriaxone (see Undesirable Effects). Most patients presented with risk factors for biliary stasis and biliary sludge e.g. preceding major therapy, severe illness and total parenteral nutrition. A trigger or cofactor of EPICEPHIN-related biliary precipitation cannot be ruled out.

Renal lithiasis:

Cases of renal lithiasis have been reported, which is reversible upon discontinuation of ceftriaxone (see Undesirable Effects). In symptomatic cases, sonography should be performed. Use in patients with history of renal lithiasis or with hypercalciuria should be considered by the physician based on specific benefit risk assessment.

Special Precautions for Disposal and Other Handling:

Concentrations for the intravenous injection: 100 mg/ml.

Concentrations for the intravenous infusion: 50 mg/ml.

Preparation of Solutions for Injection:

The use of freshly prepared solutions is recommended. For storage conditions of the

reconstituted medicinal product, see Storage.

EPICEPHIN should not be mixed in the same syringe with any drug other than 1% Lidocaine hydrochloride solution (for intramuscular injection only).

The infusion line should be flushed after each administration.

For I.M. Injection:

EPICEPHIN 250 mg, 500 mg, 1 g is dissolved in 2 ml, 2 mL, 3.5 mL respectively of the provided solution, which contains 10 mg of lidocaine hydrochloride monohydrate per mL water for injections. The solution should be administered by deep intramuscular injection. Dosages greater than 1 g should be divided and injected at more than one site.

For I.V. Injection:

EPICEPHIN 250 mg, 500 mg, 1 g is dissolved in 2.5 ml, 5 mL, 10 ml of the provided water for injections.

The injection should be administered over 5 minutes, directly into the vein or via the tubing of an intravenous infusion.

For I.V. Infusion: 

The infusion should last at least 30 minutes. For I.V. infusion, 2 g EPICEPHIN is dissolved in 40 ml of one of the following calcium - free infusion solutions: sodium chloride 0.9%, sodium chloride 0.45% + glucose 2.5%, glucose 5%, glucose 10%, dextran 6% in glucose 5%, hydroxyethyl starch 6 – 10%, water for injection.

For I.V. infusion, 250 mg EPICEPHIN is diluted by the following solutions: sodium chloride 0.9%, sodium chloride 0.45% + glucose 2.5%, glucose 5%, glucose 10%, dextran 6% in glucose 5%, hydroxyethyl starch 6 – 10%. In neonates, intravenous doses should be given over 60 minutes to reduce the potential risk of bilirubin encephalopathy.

Any unused product or waste material should be disposed of in accordance with local requirements.

Incompatibilities:

Based on literature reports, ceftriaxone is not compatible with amsacrine, vancomycin, fluconazole and aminoglycosides and labetalol.

Solutions containing EPICEPHIN should not be mixed with or added to other agents except those mentioned in Special Precautions for Disposal. In particular, diluents containing calcium, (e.g. Ringer’s solution, Hartmann’s solution) should not be used to reconstitute EPICEPHIN vials or to further dilute a reconstituted vial for intravenous administration because a precipitate can form. EPICEPHIN must not be mixed or administered simultaneously with calcium-containing solutions including total parenteral nutrition (see Dosage and Administration, Contraindications, Warnings and Precautions, Undesirable Effects).

If treatment with a combination of another antibiotic with EPICEPHIN is intended, administration should not occur in the same syringe or in the same infusion solution.

This medicinal product must not be mixed with other medicinal products except those mentioned in Special Precautions for Disposal.

Calcium-containing diluents, such as Ringer’s solution or Hartmann’s solution, should not be used to reconstitute EPICEPHIN vials or to further dilute a reconstituted vial for intravenous administration because a precipitate can form. Precipitation of ceftriaxone-calcium can also occur when ceftriaxone is mixed with calcium-containing solutions in the same intravenous administration line. EPICEPHIN must not be administered simultaneously with calcium-containing intravenous solutions, including continuous calcium-containing infusions such as parenteral nutrition via a Y-site. However, in patients other than neonates, EPICEPHIN and calcium-containing solutions may be administered sequentially of one another if the infusion lines are thoroughly flushed between infusions with a compatible fluid. In vitro studies using adult and neonatal plasma from umbilical cord blood demonstrated that neonates have an increased risk of precipitation of ceftriaxone-calcium (see Dosage and Administration, Contraindications, Warnings and Precautions, Undesirable Effects, Incompatibilities).

Concomitant use with oral anticoagulants may increase the anti-vitamin K effect and the risk of bleeding. It is recommended that the International Normalised Ratio (INR) is monitored frequently and the posology of the anti-vitamin K drug adjusted accordingly, both during and after treatment with EPICEPHIN (see Undesirable Effects).

There is conflicting evidence regarding a potential increase in renal toxicity of aminoglycosides when used with cephalosporins. The recommended monitoring of aminoglycoside levels (and renal function) in clinical practice should be closely adhered to in such cases.

In an in vitro study, antagonistic effects have been observed with the combination of chloramphenicol and ceftriaxone. The clinical relevance of this finding is unknown.

There have been no reports of an interaction between ceftriaxone and oral calcium-containing products or interaction between intramuscular ceftriaxone and calcium-containing products (intravenous or oral).

In patients treated with ceftriaxone, the Coombs' test may lead to false-positive test results.

Ceftriaxone, like other antibiotics, may result in false-positive tests for galactosaemia.

Likewise, non-enzymatic methods for glucose determination in urine may yield false-positive results. For this reason, glucose level determination in urine during therapy with EPICEPHIN should be carried out enzymatically.

No impairment of renal function has been observed after concurrent administration of large doses of ceftriaxone and potent diuretics (e.g. furosemide).

Simultaneous administration of probenecid does not reduce the elimination of ceftriaxone.

Pregnancy:

Ceftriaxone crosses the placental barrier. There are limited amounts of data from the use of ceftriaxone in pregnant women. Animal studies do not indicate direct or indirect harmful effects with respect to embryonal/fetal, perinatal and postnatal development. EPICEPHIN should only be administered during pregnancy and in particular in the first trimester of pregnancy if the benefit outweighs the risk.

Lactation:

Ceftriaxone is excreted into human milk in low concentrations but at therapeutic doses of ceftriaxone, no effects on the breastfed infants are anticipated. However, a risk of diarrhoea and fungal infection of the mucous membranes cannot be excluded.

The possibility of sensitisation should be taken into account. A decision must be made whether to discontinue breastfeeding or to discontinue/abstain from EPICEPHIN therapy, taking into account the benefit of breastfeeding for the child and the benefit of therapy for the woman. 

Fertility:

Reproductive studies have shown no evidence of adverse effects on male or female

fertility.

During treatment with ceftriaxone, undesirable effects may occur (e.g. dizziness), which may influence the ability to drive and use machines (see Undesirable Effects). Patients should be cautious when driving or operating machinery.

The most frequently reported adverse reactions for ceftriaxone are eosinophilia, leucopenia, thrombocytopenia, diarrhoea, rash, and increased hepatic enzymes.

Data to determine the frequency of ceftriaxone ADRs was derived from clinical trials.

The following convention has been used for the classification of frequency:

Common (≥ 1/100-< 1/10); Uncommon (≥ 1/1000-< 1/100); Rare (≥ 1/10000-< 1/1000); Not known^a (cannot be estimated from the available data).

Infections and Infestations:

Uncommon: Genital fungal infection.

Rare: Pseudomembranous colitis^b.

Not known: Superinfection^b.

Blood and Lymphatic system disorders:

Common: Eosinophilia, leucopenia, thrombocytopenia.

Uncommon: Granulocytopenia, anaemia, coagulopathy.

Not known: Haemolytic anaemia^b, agranulocytosis.

Immune system disorders:

Not known: Anaphylactic shock, anaphylactic reaction, anaphylactoid reaction, hypersensitivity^b.

Nervous system disorders:

Uncommon: Headache, dizziness.

Not known: Convulsion.

Ear and Labyrinth disorders:

Not known: Vertigo.

Respiratory, Thoracic and Mediastinal disorders:

Rare: Bronchospasm.

Gastrointestinal disorders:

Common: Diarrhoea^b, loose stools.

Uncommon: Nausea, vomiting.

Not known: Pancreatitis^b, stomatitis, glossitis.

Hepatobiliary disorders:

Common: Increased hepatic enzyme.

Not known: Gall bladder precipitation^b, kernicterus.

Skin and Subcutaneous tissue disorders:

Common: Rash. 

Uncommon: Pruritus.

Rare: Urticaria.

Not known: Stevens Johnson Syndrome^b, toxic epidermal necrolysis^b, erythema multiforme, acute generalised exanthematous pustulosis.

Renal and Urinary disorders:

Rare: Haematuria, glycosuria.

Not known: Oliguria, renal precipitation (reversible).

General disorders and Administration site conditions:

Uncommon: Phlebitis, injection site pain, pyrexia.

Rare: Oedema, chills.

Investigations: 

Uncommon: Increased blood creatinine.

Not known: False positive coombs test^b, false positive galactosaemia test^b, false positive non enzymatic methods for glucose determination^b.

^a Based on post-marketing reports. Since these reactions are reported voluntarily from a population of uncertain size, it is not possible to reliably estimate their frequency which is therefore categorised as not known.

^b See Warnings and Precautions.

Description of selected adverse reactions:

Infections and Infestations:

Reports of diarrhoea following the use of ceftriaxone may be associated with Clostridium difficile. Appropriate fluid and electrolyte management should be instituted (See Warnings and Precautions).

Ceftriaxone-Calcium salt precipitation:

Rarely, severe, and in some cases, fatal, adverse reactions have been reported in pre-term and full-term neonates (aged < 28 days) who had been treated with intravenous ceftriaxone and calcium. Precipitations of ceftriaxone-calcium salt have been observed in lung and kidneys post-mortem. The high risk of precipitation in neonates is a result of their low blood volume and the longer half-life of ceftriaxone compared with adults (See Warnings and Precautions, Contraindications, Pharmacokinetic properties).

Cases of ceftriaxone precipitation in the urinary tract have been reported, mostly in children treated with high doses (e.g. ≥ 80 mg/kg/day or total doses exceeding 10 grams) and who have other risk factors (e.g. dehydration, confinement to bed). This event may be asymptomatic or symptomatic, and may lead to ureteric obstruction and postrenal acute renal failure, but is usually reversible upon discontinuation of ceftriaxone (See Warnings and Precautions).

Precipitation of ceftriaxone calcium salt in the gallbladder has been observed, primarily in patients treated with doses higher than the recommended standard dose. 

In children, prospective studies have shown a variable incidence of precipitation with intravenous application - above 30 % in some studies. The incidence appears to be lower with slow infusion (20-30 minutes). This effect is usually asymptomatic, but the precipitations have been accompanied by clinical symptoms such as pain, nausea and vomiting in rare cases. Symptomatic treatment is recommended in these cases.

Precipitation is usually reversible upon discontinuation of ceftriaxone (See Warnings and Precautions).

In overdose, the symptoms of nausea, vomiting and diarrhoea can occur. Ceftriaxone concentrations cannot be reduced by haemodialysis or peritoneal dialysis. There is no specific antidote. Treatment of overdose should be symptomatic.

Pharmacotherapeutic group: Antibacterials for systemic use; Third-generation cephalosporins.

Mode of action:

Ceftriaxone inhibits bacterial cell wall synthesis following attachment to penicillin binding proteins (PBPs). This results in the interruption of cell wall (peptidoglycan) biosynthesis, which leads to bacterial cell lysis and death.

Resistance:

Bacterial resistance to ceftriaxone may be due to one or more of the following mechanisms:

Hydrolysis by beta-lactamases, including extended-spectrum beta-lactamases (ESBLs), carbapenemases and Amp C enzymes that may be induced or stably derepressed in certain aerobic Gram-negative bacterial species.

Reduced affinity of penicillin-binding proteins for ceftriaxone.

Outer membrane impermeability in Gram-negative organisms.

Bacterial efflux pumps.

Clinical Efficacy against Specific pathogens:

The prevalence of acquired resistance may vary geographically and with time for selected species and local information on resistance is desirable, particularly when treating severe infections. As necessary, expert advice should be sought when the local prevalence of resistance is such that the utility of ceftriaxone in at least some types of infections is questionable.

Commonly susceptible species:

Gram-positive aerobes:

Staphylococcus aureus (methicillin-susceptible)^£

Staphylococci coagulase-negative (methicillin-susceptible)^£

Streptococcus pyogenes (Group A)

Streptococcus agalactiae (Group B)

Streptococcus pneumoniae

Viridans Group Streptococci

Gram-negative aerobes:

Borrelia burgdorferi

Haemophilus influenzae

Haemophilus parainfluenzae

Moraxella catarrhalis

Neisseria gonorrhoea

Neisseria meningitidis

Proteus mirabilis

Providencia spp.

Treponema pallidum

Species for which acquired resistance may be a problem:

Gram-positive aerobes:

Staphylococcus epidermidis⁺

Staphylococcus haemolyticus⁺

Staphylococcus hominis⁺

Gram-negative aerobes:

Citrobacter freundii

Enterobacter aerogenes

Enterobacter cloacae

Escherichia coli^%

Klebsiella pneumoniae^%

Klebsiella oxytoca^%

Morganella morganii

Proteus vulgaris

Serratia marcescens

Anaerobes:

Bacteroides spp.

Fusobacterium spp.

Peptostreptococcus spp.

Clostridium perfringens

Inherently resistant organisms:

Gram-positive aerobes:

Enterococcus spp.

Listeria monocytogenes

Gram-negative aerobes:

Acinetobacter baumannii

Pseudomonas aeruginosa

Stenotrophomonas maltophilia

Anaerobes:

Clostridium difficile

Others:

Chlamydia spp.

Chlamydophila spp.

Mycoplasma spp.

Legionella spp.

Ureaplasma urealyticum

^£ All methicillin-resistant staphylococci are resistant to ceftriaxone.

⁺ Resistance rates >50% in at least one region.

^% ESBL producing strains are always resistant

Pharmacokinetic properties:

Absorption:

Intramuscular Administration:

Following intramuscular injection, mean peak plasma ceftriaxone levels are approximately half those observed after intravenous administration of an equivalent dose. The maximum plasma concentration after a single intramuscular dose of 1 g is about 81 mg/l and is reached in 2-3 hours after administration.

The area under the plasma concentration-time curve after intramuscular administration is equivalent to that after intravenous administration of an equivalent dose.

Intravenous Administration:

After intravenous bolus administration of ceftriaxone 500 mg and 1 g, mean peak plasma ceftriaxone levels are approximately 120 and 200 mg/l respectively. After intravenous infusion of ceftriaxone 500 mg, 1 g and 2 g, the plasma ceftriaxone levels are approximately 80, 150 and 250 mg/l respectively.

Distribution:

The volume of distribution of ceftriaxone is 7-12 l. Concentrations well above the minimal inhibitory concentrations of most relevant pathogens are detectable in tissue including lung, heart, biliary tract/liver, tonsil, middle ear and nasal mucosa, bone, and in cerebrospinal, pleural, prostatic and synovial fluids. An 8-15 % increase in mean peak plasma concentration (C_max) is seen on repeated administration; steady state is reached in most cases within 48-72 hours depending on the route of administration.

Penetration into particular tissues:

Ceftriaxone penetrates the meninges. Penetration is greatest when the meninges are inflamed. Mean peak ceftriaxone concentrations in CSF in patients with bacterial meningitis are reported to be up to 25 % of plasma levels compared to 2 % of plasma levels in patients with uninflamed meninges. Peak ceftriaxone concentrations in CSF are reached approximately 4-6 hours after intravenous injection. Ceftriaxone crosses the placental barrier and is excreted in the breast milk at low concentrations (See Pregnancy, Lactation and Fertility).

Protein binding:

Ceftriaxone is reversibly bound to albumin. Plasma protein binding is about 95 % at plasma concentrations below 100 mg/l. Binding is saturable and the bound portion decreases with rising concentration (up to 85 % at a plasma concentration of 300 mg/l).

Biotransformation:

Ceftriaxone is not metabolised systemically; but is converted to inactive metabolites by the gut flora.

Elimination:

Plasma clearance of total ceftriaxone (bound and unbound) is 10-22 ml/min. Renal clearance is 5-12 ml/min. 50-60 % of ceftriaxone is excreted unchanged in the urine, primarily by glomerular filtration, while 40-50 % is excreted unchanged in the bile. The elimination half-life of total ceftriaxone in adults is about 8 hours.

Patients with renal or hepatic impairment:

In patients with renal or hepatic dysfunction, the pharmacokinetics of ceftriaxone are only minimally altered with the half-life slightly increased (less than two fold), even in patients with severely impaired renal function.

The relatively modest increase in half-life in renal impairment is explained by a compensatory increase in non-renal clearance, resulting from a decrease in protein binding and corresponding increase in non-renal clearance of total ceftriaxone. 

In patients with hepatic impairment, the elimination half-life of ceftriaxone is not increased, due to a compensatory increase in renal clearance. This is also due to an increase in plasma free fraction of ceftriaxone contributing to the observed paradoxical increase in total drug clearance, with an increase in volume of distribution paralleling that of total clearance.

Older people:

In older people aged over 75 years the average elimination half-life is usually two to three times that of young adults.

Pediatric population:

The half-life of ceftriaxone is prolonged in neonates. From birth to 14 days of age, the levels of free ceftriaxone may be further increased by factors such as reduced glomerular filtration and altered protein binding. During childhood, the half-life is lower than in neonates or adults.

The plasma clearance and volume of distribution of total ceftriaxone are greater in neonates, infants and children than in adults.

Linearity/Non-linearity:

The pharmacokinetics of ceftriaxone are non-linear and all basic pharmacokinetic parameters, except the elimination half-life, are dose-dependent if based on total drug concentrations, increasing less than proportionally with dose. Non-linearity is due to saturation of plasma protein binding and is therefore observed for total plasma ceftriaxone but not for free (unbound) ceftriaxone.

Pharmacokinetic/Pharmacodynamic relationship:

As with other beta-lactams, the pharmacokinetic-pharmacodynamic index demonstrating the best correlation with in vivo efficacy is the percentage of the dosing interval that the unbound concentration remains above the minimum inhibitory concentration (MIC) of ceftriaxone for individual target species (i.e. %T > MIC).

Store at a temperature not exceeding 30^ºC. 

After reconstitution it should be stored at temperature 2^ºC - 8^ºC for 24 hours.

Packs for I.M. Injection:

EPICEPHIN 250 mg Vials: Box containing 1 vial + 1 ampoule (2 ml) of 1% Lidocaine hydrochloride solvent.

EPICEPHIN 500 mg Vials:  Box containing 1 vial + 1 ampoule (2 ml) of 1% Lidocaine hydrochloride solvent.

EPICEPHIN 1 g Vials:  Box containing 1 vial + 1 ampoule (3.5 ml) of 1% Lidocaine hydrochloride solvent.

Packs for I.V. Injection:

EPICEPHIN 250 mg Vials: Box containing 1 vial + 1 ampoule (5 ml) of (Sterile Water for Injection) solvent.

EPICEPHIN 500 mg Vials:  Box containing 1 vial + 1 ampoule (5 ml) of (Sterile Water for Injection) solvent.

EPICEPHIN 1 g Vials:  Box containing 1 vial + 1 ampoule (10 ml) of (Sterile Water for Injection) solvent.

Packs for I.V. Infusion:        

EPICEPHIN 2 g Vials: Box containing 1 vial + 1 ampoules (10 ml) of (Sterile Water for Injection) solvent.