1. Name Of The Medicinal Product
Piperacillin/Tazobactam 2 g / 0.25 g Powder for Solution for Injection or Infusion
Piperacillin/Tazobactam 4 g / 0.5 g Powder for Solution for Injection or Infusion
2. Qualitative And Quantitative Composition
Piperacillin/Tazobactam 2 g/0.25 g Powder for Solution for Injection or Infusion
Each vial contains 2 g piperacillin (as sodium salt) and 0.25 g tazobactam (as sodium salt).
The sodium content per vial is 4.72 mmol (equivalent to 109 mg).
After reconstitution with 10 ml diluent the solution contains piperacillin 200 mg/ml and tazobactam 25 mg/ml.
Piperacillin/Tazobactam 4 g / 0.5 g Powder for Solution for Injection or Infusion
Each bottle contains 4 g piperacillin (as sodium salt) and 0.5 g tazobactam (as sodium salt).
The sodium content per bottle is 9.44 mmol (equivalent to 217 mg).
After reconstitution with 20 ml diluent the solution contains piperacillin 200 mg/ml and tazobactam 25 mg/ml.
3. Pharmaceutical Form
Powder for solution for injection or infusion.
A white to off-white powder.
4. Clinical Particulars
4.1 Therapeutic Indications
Piperacillin/Tazobactam is indicated for the treatment of moderate to severe systemic and/or local bacterial infections in which beta-lactamase producing bacteria are suspected or have been detected, such as:
Adults/adolescents and the Elderly
• Nosocomial pneumonia
• Complicated urinary tract infections (including pyelonephritis)
• Intra-abdominal infections
• Skin and soft tissue infection
• Bacterial infections in neutropenic adults
Children (2 to 12 years)
Bacterial infections in neutropenic children.
Consideration should be given to official guidance on the appropriate use of antibacterial agents.
4.2 Posology And Method Of Administration
Piperacillin/Tazobactam may be given by slow intravenous injection (over at least 3 to 5 minutes) or by slow intravenous infusion (over 20 to 30 minutes).
For reconstitution instructions, see section 6.6.
The treatment of mixed infections caused by piperacillin susceptible organisms and betalactamase producing organisms susceptible to piperacillin/tazobactam generally does not require the addition of another antibiotic.
In patients with nosocomial pneumonia and infections in neutropenic patients piperacillin/tazobactam can be used with an aminoglycoside. If the use of an aminoglycoside is needed, with piperacillin/tazobactam, both piperacillin/tazobactam and the aminoglycoside must be used in full therapeutic doses.
Neutropenic patients with signs of infection (e.g. fever) should receive immediate empirical antibiotic therapy before laboratory results are available.
Adults and children over 12 years each with normal renal function
The usual dosage for adults and children over 12 years is piperacillin/tazobactam 4000/500 mg given every 8 hours.
The total daily dose of piperacillin/tazobactam depends on the severity and localisation of the infection and can vary from piperacillin/tazobactam 2000/250 mg to piperacillin/tazobactam 4000/500 mg administered every 6 or 8 hours.
In neutropenia the recommended dose is piperacillin/tazobactam 4000/500 mg given every 6 hours in combination with an aminoglycoside.
Elderly with normal renal function
Piperacillin/tazobactam may be used at the same dose levels as adults except in cases of renal impairment (see below).
Renal Insufficiency in Adults, the Elderly and Children (over 40 kg) Receiving the Adult Dose
In patients with renal insufficiency, the intravenous dose should be adjusted to the degree of actual renal impairment. The suggested daily doses are as follows:
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For patients on haemodialysis, the maximum daily dose is piperacillin/tazobactam 8/1 g. In addition, because haemodialysis removes 30%-50% of piperacillin in 4 hours, one additional dose of piperacillin/tazobactam 2000/250 mg should be administered following each dialysis period.
For patients with renal failure and hepatic insufficiency, measurement of serum levels of piperacillin/tazobactam will provide additional guidance for adjusting dosage.
Children aged 2 - 12 years with normal renal function
Piperacillin/tazobactam is only recommended for the treatment of children with neutropenia.
Neutropenia
For children weighing less than 40 kg the dose should be adjusted to 90 mg/kg (piperacillin/tazobactam 80/10 mg), administered every 6 hours, in combination with an aminoglycoside, not exceeding piperacillin/tazobactam 4000/500 mg every 6 hours.
Renal Insufficiency in Children Aged 2-12 Years (or bodyweight less than 40 kg)
In children with renal insufficiency the intravenous dosage should be adjusted to the degree of actual renal impairment as follows:
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For children weighing <50 kg on haemodialysis the recommended dose is 45 mg (piperacillin/tazobactam 40/5 mg) /kg every 8 hours.
The above dosage modifications are only an approximation. Each patient must be monitored closely for signs of drug toxicity. Drug dose and interval should be adjusted accordingly.
Children under 2 years
Piperacillin/tazobactam is not recommended for use in children below 2 years old due to insufficient data on safety.
Hepatic Impairment
No dose adjustment is necessary.
Duration of Therapy
The duration of therapy should be guided by the severity of the infection and the patient's clinical and bacteriological progress.
In acute infections, treatment with Piperacillin/Tazobactam should be continued for 48 hours beyond the resolution of clinical symptoms or the fever.
4.3 Contraindications
Hypersensitivity to piperacillin or any other beta-lactam antibiotic and to tazobactam or any other beta-lactamase inhibitor.
4.4 Special Warnings And Precautions For Use
Warnings
Serious and occasionally fatal hypersensitivity (anaphylactic/anaphylactoid, including shock) reactions have been reported in patients receiving therapy with penicillins including piperacillin/tazobactam. These reactions are more likely to occur in persons with a history of sensitivity to multiple allergens.
There have been reports of patients with a history of penicillin hypersensitivity who have experienced severe reactions when treated with a cephalosporin.
If an allergic reaction occurs during therapy with piperacillin-tazobactam, the antibiotic should be discontinued. Serious hypersensitivity reactions may require adrenaline and other emergency measures.
Before initiating therapy with piperacillin-tazobactam, careful inquiry should be made concerning previous hypersensitivity reactions to penicillins, cephalosporins, and other allergens.
In case of severe, persistent diarrhoea, the possibility of antibiotic-induced, life threatening pseudomembranous colitis must be taken into consideration. The onset of pseudomembranous colitis symptoms may occur during or after antibacterial treatment. Therefore, piperacillin/tazobactam must be discontinued immediately in such cases, and suitable therapy should be initiated.
Precautions
Neutropenia and leucopenia may occur especially during prolonged therapy. Therefore, periodic assessment of a full blood count should be performed.
Periodic assessment of organ system functions including renal and hepatic during prolonged therapy is advisable.
Bleeding manifestations have occurred in some patients receiving beta-lactam antibiotics. These reactions have sometimes been associated with abnormalities of coagulation tests such as clotting time, platelet aggregation and prothrombin time, and are more likely to occur in patients with renal failure. If bleeding manifestations occur, the antibiotic should be discontinued and appropriate therapy instituted.
The possibility of the emergence of resistant organisms, which might cause superinfections should be kept in mind, particularly during prolonged treatment. Microbiological follow-up may be required to detect any important superinfection. If this occurs, appropriate measures should be taken.
Patients may experience neuromuscular excitability or convulsions if higher than recommended doses are given intravenously.
Piperacillin/Tazobactam 2 g/0.25 g Powder for Solution for Injection or Infusion contains 4.72 mmol (equivalent to 109 mg) of sodium per vial of powder for solution for injection or infusion.
Piperacillin/Tazobactam 4 g/0.5 g Powder for Solution for Injection or Infusion contains 9.44 mmol (equivalent to 217 mg) of sodium per bottle of powder for solution for injection or infusion.
To be taken into consideration by patients on a controlled sodium diet.
Hypokalaemia may occur in patients with low potassium reserves or who are receiving concomitant medications that may lower potassium levels; periodic electrolyte determinations should be performed in such patients. Modest elevation of indices of liver function may be observed.
Piperacillin therapy has been associated with an increased incidence of fever and rash in cystic fibrosis patients (see also section 4.8).
Until further experience is available, piperacillin/tazobactam should not be used in children who do not have neutropenia.
4.5 Interaction With Other Medicinal Products And Other Forms Of Interaction
Interaction with probenecid
Concurrent administration of probenecid and piperacillin/tazobactam produced a longer half-life and lower renal clearance for both piperacillin and tazobactam. However, peak plasma concentrations of either drug are unaffected.
Interaction with antibiotics
No clinically relevant adverse pharmacokinetic interaction with tobramycin or vancomycin has been observed inhealthy adults with a normal renal function.
The clearance of tobramycin and gentamicin was enhanced in patients with severe renal dysfunction using piperacillin/tazobactam. In these patients mixing of piperacillin/tazobactam formulation with tobramycin and gentamicin was excluded.
For information related to the administration of piperacillin/tazobactam with aminoglycosides please refer to section 6.2.
Interaction with anticoagulants
During simultaneous administration of heparin, oral anticoagulants and other agents which may affect the blood coagulation system including thrombocyte function, appropriate coagulation tests should be performed more frequently and monitored regularly.
Interaction with vecuronium
Piperacillin when used concomitantly with vecuronium has been implicated in the prolongation of the neuromuscular blockade of vecuronium. Due to their similar mechanism of action, it is expected that the neuromuscular blockade produced by any of the non-depolarizing muscle relaxants could be prolonged in the presence of piperacillin. This should be taken into account when piperacillin/tazobactam is used peri-operatively.
Interaction with methotrexate
Piperacillin may reduce the excretion of methotrexate. Serum levels of methotrexate should be monitored in patients on methotrexate therapy.
Interaction with laboratory test results
The administration of piperacillin/tazobactam may result in a false-positive reaction for glucose in the urine using a copper reduction method. It is recommended that glucose tests based on enzymatic glucose oxidase reaction be used.
There have been reports of positive test results using the Bio-Rad Laboratories Platelia Aspergillus EIA test in patients receiving piperacillin/tazobactam injection who were subsequently found to be free of Aspergillus infection. Cross-reactions with non-Aspergillus polysaccharides and polyfuranoses with Bio-Rad Laboratories Platelia Aspergillus EIA test have been reported. Therefore, positive test results in patients receiving piperacillin/tazobactam should be interpreted cautiously and confirmed by other diagnostic methods.
4.6 Pregnancy And Lactation
Pregnancy
There are no adequate and well-controlled studies with piperacillin/tazobactam in combination or with piperacillin or tazobactam alone in pregnant women. Studies in animals have shown reproductive toxicity (see section 5.3). Piperacillin and tazobactam cross the placenta. Piperacillin/tazobactam should only be used during pregnancy if clearly indicated.
Lactation
Piperacillin is excreted in low concentrations in breast milk. Tazobactam concentrations in human milk have not been studied. The effect on the suckling infant is unknown. Women who are breast-feeding should be treated only if clearly indicated. Diarrhoea and fungal infections of the mucous membranes as well as sensitisation could occur in the breast-fed infant.
4.7 Effects On Ability To Drive And Use Machines
No studies on the effects on the ability to drive and use machines have been performed.
However, side effects may occur (see also section 4.8), which may influence the ability to drive and use machines.
4.8 Undesirable Effects
Undesirable effects are listed by frequency as follows: Very common (
The most commonly reported adverse reactions are diarrhoea, nausea, vomiting, and rash, each having a frequency of
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The administration of high doses of beta-lactams, particularly in patients with renal insufficiency, can lead to encephalopathies (consciousness fluctuation, myoclonus and convulsions).
Piperacillin therapy has been associated with an increased incidence of fever and rash in cystic fibrosis patients.
4.9 Overdose
Symptoms
There have been post-marketing reports of overdose with piperacillin/tazobactam. The majority of these events experienced including nausea, vomiting and diarrhoea, have also been reported with the usual recommended dosage. Patients may experience neuromuscular excitability or convulsions if higher than recommended doses are given intravenously (particularly in the presence of renal failure).
Treatment of intoxication
In the event of an overdose, piperacillin/tazobactam treatment should be discontinued.
No specific antidote is known.
Treatment should be supportive and symptomatic according to the patient's clinical presentation. In the event of an emergency, all required intensive medical measures are indicated as in the case of piperacillin.
Excessive serum concentrations of either piperacillin or tazobactam will be reduced by haemodialysis (for more details see section 5.2).
5. Pharmacological Properties
5.1 Pharmacodynamic Properties
Pharmacotherapeutic group: Combinations of penicillins, including beta-lactamase inhibitors
ATC classification: J01CR05.
Mechanism of action
Piperacillin, a broad spectrum, semi-synthetic penicillin active against many Gram-positive and Gram-negative aerobic and anaerobic bacteria, exerts bactericidal activity by inhibition of both septum and cell wall synthesis. Tazobactam, a triazolylmethyl penicillanic acid sulphone, is a potent inhibitor of many beta-lactamases, in particular the plasmid mediated enzymes which commonly cause resistance to penicillins and cephalosporins including third-generation cephalosporins. The presence of tazobactam in the piperacillin/tazobactam formulation enhances and extends the antibiotic spectrum of piperacillin to include many beta-lactamase producing bacteria normally resistant to it and other beta-lactam antibiotics. Thus, piperacillin/tazobactam combines the properties of a broad spectrum antibiotic and a beta-lactamase inhibitor.
Mechanism of resistance
The presence of tazobactam expands the spectrum of activity of piperacillin to include micro-organisms that would otherwise, due to the formation of beta-lactamase, be resistant to piperacillin and other beta-lactam antibiotics.
In vitro investigation has demonstrated that the type I beta-lactamase inducing ability of tazobactam is insignificant with regard to Gram-negative bacteria.
In vitro studies have demonstrated a synergetic effect of piperacillin/tazobactam and aminoglycosides against Pseudomonas aeruginosa and other bacteria, including beta-lactamase producing strains
Breakpoints
The minimum inhibitory concentration (MIC) breakpoints separating susceptible, intermediately susceptible and resistant organisms have been defined as follows:
EUCAST clinical MIC breakpoints 2008 (version 1.2):
For susceptibility testing purposes, the concentration of tazobactam is fixed at 4 mg/l
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Susceptibility
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 the agent in at least some types of infections is questionable.
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$ species showing natural intermediate susceptibility
+ species for which high resistance rates ( more than 50%) have been observed in one or more areas/countries /regions within the EU
* Clinical effectiveness against this has been demonstrated in the registered indications.
5.2 Pharmacokinetic Properties
Distribution
Peak piperacillin and tazobactam plasma concentrations are attained immediately after completion of an intravenous infusion or injection.
Piperacillin plasma levels produced when given with tazobactam are similar to those attained when equivalent doses of piperacillin are administered alone.
There is a greater proportional (approximately 28%) increase in plasma levels of piperacillin and tazobactam with increasing dose over the dosage range of piperacillin/tazobactam 2000/250 mg to piperacillin/tazobactam 4000/500 mg.
Both piperacillin and tazobactam are 20 to 30% bound to plasma proteins. The protein binding of either piperacillin or tazobactam is unaffected by the presence of the other compound. Protein binding of the tazobactam metabolite is negligible.
Piperacillin/tazobactam is widely distributed in tissue and body fluids including intestinal mucosa, gallbladder, lung, bile, and bone.
Biotransformation
Piperacillin is metabolized to a minor microbiologically active desethyl metabolite. Tazobactam is metabolised to a single metabolite, which has been found to be micro-biologically inactive.
Elimination
Piperacillin and tazobactam are eliminated by the kidney via glomerular filtration and tubular secretion.
Piperacillin is excreted rapidly as unchanged drug with 68% of the administered dose appearing in the urine. Tazobactam and its metabolite are eliminated primarily by renal excretion with 80% of the administered dose appearing as unchanged drug and the remainder as the single metabolite. Piperacillin, tazobactam, and desethyl piperacillin are also secreted into the bile.
Following single or multiple doses of piperacillin/tazobactam to healthy subjects, the plasma half-life of piperacillin and tazobactam ranged from 0.7 to 1.2 hours and was unaffected by dose or duration of infusion. The elimination half-lives of both piperacillin and tazobactam are increased with decreasing renal clearance.
There are no significant changes in piperacillin pharmacokinetics due to tazobactam. Piperacillin appears to reduce the rate of elimination of tazobactam.
Impaired renal function
Piperacillin and tazobactam are haemodialysable: 31% (piperacillin) and 39% (tazobactam) of administered doses are filtrated. During peritoneal dialysis, 5% of administered piperacillin and 12% of administered tazobactam are found in the dialysis liquid. Patients treated by chronic ambulatory peritoneal dialysis should receive the same dose as non dialysed patients with severe renal insufficiency.
Impaired liver function
Plasma concentrations of piperacillin and tazobactam are prolonged in hepatically impaired patients. The half-life of piperacillin and of tazobactam increases by approximately 25% and 18%, respectively, in patients with hepatic cirrhosis compared to healthy subjects. However, dosage adjustments in patients with hepatic impairment are not necessary.
Paediatric patients
The pharmacokinetics of piperacillin/tazobactam has been studied in paediatric patients with intra-abdominal infections and other kind of infections.
In every age group, renal fraction of elimination of piperacillin and tazobactam was approximately 70% and 80%, respectively, like in adults.
Mean pharmacokinetic parameters of piperacillin/tazobactam of paediatric patients of different age groups.
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5.3 Preclinical Safety Data
Preclinical data reveal no special hazard for humans based on conventional studies of repeated dose toxicity and genotoxicity. Carcinogenicity studies have not been conducted with piperacillin/tazobactam.
A fertility study of piperacillin/ tazobactam reported a decrease in litter size and an increase in fetuses with ossification delays and variations of ribs following i.p. administration to rats. Fertility of the F1 generation and embryonic development of the F2 generation was not impaired. A teratogenicity study in rats, did not show teratogenic effects after i.v. administration. In the rat, effects on the embryonic development were observed at maternal toxic doses. Peri/postnatal development was impaired (reduced fetal weights, increase in pup mortality, increase in stillbirths) concurrently with maternal toxicity after i.p. administration in the rat.
6. Pharmaceutical Particulars
6.1 List Of Excipients
None.
6.2 Incompatibilities
This medicinal product must not be mixed with other medicinal products except those mentioned in section 6.6.
This product must not be mixed or co-administrated with any aminoglycosides. The mixing of piperacillin/tazobactam with an aminoglycoside in vitro can result in substantial inactivation of the aminoglycoside.
Piperacillin/tazobactam should not be mixed with other drugs in a syringe or infusion bottle since compatibility has not been established.
Piperacillin/tazobactam should be administered through an infusion set separately from any other drugs unless compatibility is proven.
Due to chemical instability, piperacillin/tazobactam should not be used in solutions that contain sodium hydrogen carbonate.
Lactated Ringer's (Hartmann's) solution is not compatible with piperacillin/tazobactam.
Piperacillin/tazobactam should not be added to blood products or albumin hydrolysates.
6.3 Shelf Life
Unopened:
2 years
After reconstitution (and dilution):
Chemical and physical in-use stability has been demonstrated for 24 hours at 20-25°C and for 48 hours at 2-8°C.
From a microbiological point of view, once opened, the product should be used immediately.
If not used immediately, in-use storage times and conditions prior to use are the responsibility of the user and would normally not be longer than 24 hours at 2-8°C, unless reconstitution/dilution has taken place in controlled and validated aseptic conditions.
6.4 Special Precautions For Storage
This medicinal product does not require any special storage conditions.
For storage conditions of the reconstituted/diluted medicinal product, see section 6.3.
6.5 Nature And Contents Of Container
Piperacillin/Tazobactam 2 g/0.25 g Powder for Solution for Injection or Infusion
30 ml vial glass type III, with halogenated butyl rubber stopper and aluminium overseal with grey flip-off cap.
Pack sizes of 1, 5, 10, 12 and 50 vials.
Piperacillin/Tazobactam 4 g / 0.5 g Powder for Solution for Injection or Infusion
100 ml bottle glass type II, with halogenated butyl rubber stopper and aluminium overseal with red flip-off cap.
Pack sizes of 1, 5, 10, 12 and 50 bottles.
Not all pack sizes may be marketed.
6.6 Special Precautions For Disposal And Other Handling
The reconstitution/dilution is to be made under aseptic conditions. The solution is to be inspected visually for particulate matter and discoloration prior to administration. The solution should only be used if the solution is clear and free from particles.
For single use only. Discard any unused solution.
Any unused product or waste material should be discarded in accordance with local requirements.
Reconstitution directions (to intravenous injection)
Each vial of Piperacillin/Tazobactam 2 g/0.25 g Powder for Solution for Injection or Infusion should be reconstituted with 10 ml diluent.
Each bottle of Piperacillin/Tazobactam 4 g/0.5 g Powder for Solution for Injection or Infusion should be reconstituted with 20 ml diluent.
Sterile diluents for preparation of the reconstituted solution:
• water for injection;
• sodium chloride 9 mg/ml (0.9 %) solution in water for injection;
• glucose 50 mg/ml (5 %) solution in water for injection;
• glucose 50 mg/ml (5 %) solution in sodium chloride 9 mg/ml (0.9%) solution.
Swirl until dissolved. Intravenous injection should be given over at least 3-5 minutes.
Dilution directions (to intravenous infusion)
Each vial of Piperacillin/Tazobactam 2 g/0.25 g Powder for Solution for Injection or Infusion should be reconstituted with 10 ml of the above diluents.
Each bottle of Piperacillin/Tazobactam 4 g/0.5 g Powder for Solution for Injection or Infusion should be reconstituted with 20 ml of the above diluents.
The reconstituted solution may be further diluted to 50 ml with the following sterile diluent:
• water for injection
and to 50,100 or 150 ml with one of the following sterile diluents:
• sodium chloride 9 mg/ml (0.9 %) solution in water for injection;
• glucose 50 mg/ml (5 %) solution in water for injection;
• dextran (grade 40) 60 mg/ml (6 %) solution in sodium chloride 9 mg/ml (0.9%) solution.
Intravenous infusion should b
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