CYROSEF POWDER FOR SOLUTION FOR INJECTION 2GM [SIN16113P]

Product Info

CYROSEF POWDER FOR SOLUTION FOR INJECTION 2GM

[SIN16113P]

2.1. Therapeutic Indication(s)

Infections caused by pathogens sensitive to Cyrosef, e.g.:

• Sepsis;

• Meningitis;

• Disseminated Lyme Borreliosis (early and late stages of the disease);

• Abdominal Infections (peritonitis, infections of the biliary and gastrointestinal tracts);

• Infections of the bones, joints, soft tissue, skin and of wounds;

• Infections in patients with impaired defense mechanisms;

• Renal and urinary tract infections;

• Respiratory tract infections, particularly pneumonia, and ear, nose and throat infections;

• Genital infections, including gonorrhea.

And perioperative prophylaxis of infections.

2.2. Dosage and Administration

Standard dosage
Adults and children over 12 years
The usual dosage is 1–2 g of Cyrosef once daily (every 24 hours). In severe cases or in infections caused by moderately sensitive organisms, the dosage may be raised to 4 g, once daily.

Duration of therapy
The duration of therapy varies according to the course of the disease. As with antibiotic therapy in general, administration of Cyrosef should be continued for a minimum of 48–72 hours after the patient has become afebrile or evidence of bacterial eradication has been obtained.

Combination therapy
Synergy between ceftriaxone and aminoglycosides has been demonstrated with many gram-negative bacteria under experimental conditions. Although enhanced activity of such combinations is not always predictable, it should be considered in severe, life threatening infections due to micro-organisms such as Pseudomonas aeruginosa. Due to chemical incompatibility between ceftriaxone and aminoglycosides, the two drugs must be administered separately at the recommended dosages.
Chemical incompatibility with ceftriaxone has also been observed with IV administration of amsacrine, vancomycin and fluconazole.

Method of administration
As a general rule the solutions should be used immediately after preparation.
Reconstituted solutions retain their physical and chemical stability for 2 hours when stored at or below 25°C (or 8 hours in the refrigerator at 2 – 8 °C).

Intramuscular injection
For i.m. injection, ceftriaxone 250 mg or 500 mg is dissolved in 2 ml, and ceftriaxone 1 g in 3.5 ml, of 1% lidocaine hydrochloride solution and injected well within the body of a relatively large muscle. It is recommended that not more than 1 g be injected at one site. The lidocaine solution should never be administered intravenously (see section 2.3 Contraindications).

Intravenous injection
For i.v. injection, ceftriaxone 250 mg or 500 mg is dissolved in 5 ml, and ceftriaxone 1 g in 10 ml sterile water for injections. The intravenous administration should be given over 2–4 minutes.

Intravenous infusion
The infusion should be given over at least 30 minutes. For i.v. infusion, 2 g ceftriaxone is dissolved in 40 ml of one of the following calcium-free infusion solutions: Sterile water for injection, 0.9% Sodium chloride injection, 5% Dextrose injection & 5% Dextrose and 0.9% Sodium chloride injection. Ceftriaxone solutions should not be mixed with or piggybacked into solutions containing other antimicrobial drugs or into diluent solutions other than those listed above, owing to possible incompatibility.

Do not use diluents containing calcium, such as Ringer’s solution or Hartmann’s solution, to reconstitute ceftriaxone vials or to further dilute a reconstituted vial for IV administration because a precipitate can form. Precipitation of ceftriaxone-calcium can also occur when ceftriaxone is mixed with calcium-containing solutions in the same IV administration line. Ceftriaxone must not be administered simultaneously with calcium-containing IV solutions, including continuous calcium-containing infusions such as parenteral nutrition via a Y-site. However, in patients other than neonates, ceftriaxone and calcium-containing solutions may be administered sequentially of one another if the infusion lines are thoroughly flushed between infusions with a compatible fluid (see 2.4.4 Interactions with other Medicinal Products and other Forms of Interaction – please refer to the Product Insert/Patient Information Leaflet published on HSA for the full drug information).
There have been no reports of an interaction between ceftriaxone and oral calcium-containing products or interaction between intramuscular ceftriaxone and calcium-containing products (IV or oral).

2.2.1. Special Dosage Instructions

Patients with hepatic impairment
In patients with liver damage, there is no need for the dosage to be reduced provided renal function is not impaired.

Patients with renal impairment
In patients with impaired renal function, there is no need to reduce the dosage of ceftriaxone provided hepatic function is not impaired. Only in cases of preterminal renal failure (creatinine clearance <10 ml/min) should the ceftriaxone dosage not exceed 2 g daily.
Ceftriaxone is not removed by peritoneal- or hemodialysis. In patients undergoing dialysis no additional supplementary dosing is required following the dialysis.

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

Elderly
The dosages recommended for adults require no modification in elderly patients, provided there is no severe renal and hepatic impairment.

Children
Neonates, infants and children up to 12 years
The following dosage schedules are recommended for once daily administration:
Neonates (up to 14 days): 20–50 mg/kg bodyweight once daily. The daily dose should not exceed 50 mg/kg.
Ceftriaxone is contraindicated in premature neonates up to a postmenstrual age of 41 weeks (gestational age + chronological age) (see section 2.3 Contraindications).
Ceftriaxone is contraindicated in neonates (≤28 days) if they require (or are expected to require) treatment with calcium-containing IV solutions, including continuous calcium-containing infusions such as parenteral nutrition because of the risk of precipitation of ceftriaxone-calcium (see section 2.3 Contraindications).
For neonates, infants and children (15 days to 12 years): 20–80 mg/kg once daily.
For children with bodyweights of 50 kg or more, the usual adult dosage should be used.
Intravenous doses of ≥50 mg/kg bodyweight, in infants and children up to 12 years of age, should be given by infusion over at least 30 minutes. In neonates, intravenous doses should be given over 60 minutes to reduce the potential risk of bilirubin encephalopathy.

Meningitis
In bacterial meningitis in infants and children, treatment begins with doses of 100 mg/kg (up to a maximum of 4 g) once daily. As soon as the causative organism has been identified and its sensitivity determined, the dosage can be reduced accordingly. The following duration of therapy has shown to be effective:

Lyme borreliosis
50 mg/kg to a maximum of 2 g in children and adults, once daily for 14 days.

Gonorrhea (penicillinase-producing and non-penicillinase-producing strains)
A single i.m. dose of 250 mg.

Perioperative prophylaxis
A single dose of 1–2 g depending on the risk of infection of 30–90 minutes prior to surgery. In colorectal surgery, administration of ceftriaxone with or without a 5-nitroimidazole, e.g. ornidazole (separate administration, see 2.2 Dosage and Administration) has been proven effective.

2.3. Contraindications

Hypersensitivity
Ceftriaxone is contraindicated in patients with known hypersensitivity to ceftriaxone, any of its excipients or to any other cephalosporin. Patients with previous hypersensitivity reactions to penicillin and other beta lactam agents may be at a greater risk of hypersensitivity to ceftriaxone (see section 2.4.1 Warnings and Precaution General – Hypersensitivity – please refer to the Product Insert/Patient Information Leaflet published on HSA for the full drug information).

Lidocaine
Contraindications to lidocaine must be excluded before intramuscular injection of ceftriaxone when lidocaine solution is used as a solvent (see section 2.2 Dosage and Administration). See contraindications section in the prescribing information of lidocaine. Ceftriaxone solutions containing lidocaine should never be administered intravenously.

Premature Neonates
Ceftriaxone is contraindicated in premature neonates up to postmenstrual age of 41 weeks (gestational age + chronological age).

Hyperbilirubinemic newborns
Hyperbilirubinaemic newborns should not be treated with ceftriaxone. In vitro studies have shown that ceftriaxone can displace bilirubin from its binding to serum albumin leading to a possible risk of bilirubin encephalopathy can possibly develop in these patients.

Neonates and Calcium-Containing IV Solutions
Ceftriaxone is contraindicated in neonates (≤28 days) if they require (or are expected to require) treatment with calcium-containing IV solutions, including continuous calcium-containing infusions such as parenteral nutrition because of the risk of precipitation of ceftriaxone-calcium (see 2.2 Dosage and Administration and 2.4.4 Interactions with other Medicinal Products and other Forms of Interaction – please refer to the Product Insert/Patient Information Leaflet published on HSA for the full drug information).
A small number of cases of fatal outcomes in which a crystalline material was observed in the lungs and kidneys at autopsy have been reported in neonates receiving ceftriaxone and calcium-containing fluids. In some of these cases, the same intravenous infusion line was used for both ceftriaxone and calcium-containing fluids and in some a precipitate was observed in the intravenous infusion line. At least one fatality has been reported in a neonate in whom ceftriaxone and calcium-containing fluids were administered at different time points via different intravenous lines; no crystalline material was observed at autopsy in this neonate. There have been no similar reports in patients other than neonates (see 2.6.1 Post Marketing – please refer to the Product Insert/Patient Information Leaflet published on HSA for the full drug information).