Data from FDA - Curated by EPG Health - Last updated 21 December 2016

Indication(s)

1 INDICATIONS AND USAGE Ceftriaxone for Injection and Dextrose Injection is indicated for the treatment of the following infections when caused by susceptible bacteria.

Ceftriaxone for Injection and Dextrose Injection is a cephalosporin antibacterial indicated for the treatment of the following infections caused by susceptible isolates of the designated bacteria: Lower Respiratory Tract Infections (1.1); Skin and Skin Structure Infections (1.2); Complicated and Uncomplicated Urinary Tract Infections (1.3); Pelvic Inflammatory Disease (1.4); Bacterial Septicemia (1.5); Bone and Joint Infections (1.6); Intra-abdominal Infections (1.7); Meningitis (1.8); and Surgical Prophylaxis (1.9).

To reduce the development of drug-resistant bacteria and maintain the effectiveness of Ceftriaxone for Injection and Dextrose Injection and other antibacterial drugs, Ceftriaxone for Injection and Dextrose Injection should be used only to treat or prevent infections that are proven or strongly suspected to be caused by susceptible bacteria.

(1.10) 1.1 Lower Respiratory Tract Infections Lower respiratory tract infections caused by Streptococcus pneumoniae, Staphylococcus aureus, Haemophilus influenzae, Haemophilus parainfluenzae, Klebsiella pneumoniae, Escherichia coli, Enterobacter aerogenes, Proteus mirabilis or Serratia marcescens.

1.2 Skin and Skin Structure Infections Skin and skin structure infections caused by Staphylococcus aureus, Staphylococcus epidermidis, Streptococcus pyogenes, Viridans group streptococci, Escherichia coli, Enterobacter cloacae, Klebsiella oxytoca, Klebsiella pneumoniae, Proteus mirabilis, Morganella morganii The efficacy for these organisms in this organ system were studied in fewer than ten infections., Pseudomonas aeruginosa, Serratia marcescens, Acinetobacter calcoaceticus, Bacteroides fragilis or Peptostreptococcus species.

1.3 Complicated and Uncomplicated Urinary Tract Infections Complicated and uncomplicated urinary tract infections caused by Escherichia coli, Proteus mirabilis, Proteus vulgaris, Morganella morganii or Klebsiella pneumoniae.

1.4 Pelvic Inflammatory Disease Pelvic inflammatory disease caused by Neisseria gonorrhoeae.

Ceftriaxone sodium, like other cephalosporins, has no activity against Chlamydia trachomatis.

Therefore, when cephalosporins are used in the treatment of patients with pelvic inflammatory disease and Chlamydia trachomatis is one of the suspected pathogens, appropriate antichlamydial coverage should be added.

1.5 Bacterial Septicemia Bacterial septicemia caused by Staphylococcus aureus, Streptococcus pneumoniae, Escherichia coli, Haemophilus influenzae or Klebsiella pneumoniae.

1.6 Bone and Joint Infections Bone and joint infections caused by Staphylococcus aureus, Streptococcus pneumoniae, Escherichia coli, Proteus mirabilis, Klebsiella pneumoniae or Enterobacter species.

1.7 Intra-abdominal Infections Intra-abdominal infections caused by Escherichia coli, Klebsiella pneumoniae, Bacteroides fragilis, Clostridium species or Peptostreptococcus species.

1.8 Meningitis Meningitis caused by Haemophilus influenzae, Neisseria meningitidis or Streptococcus pneumoniae.

Ceftriaxone sodium has also been used successfully in a limited number of cases of meningitis and shunt infection caused by Staphylococcus epidermidis and Escherichia coli, however, the efficacy for these organisms in this organ system were studied in fewer than ten infections.

1.9 Surgical Prophylaxis The preoperative administration of a single 1 g dose of Ceftriaxone for Injection and Dextrose Injection may reduce the incidence of postoperative infections in patients undergoing surgical procedures classified as contaminated or potentially contaminated (e.g., vaginal or abdominal hysterectomy or cholecystectomy for chronic calculous cholecystitis in high-risk patients, such as those over 70 years of age, with acute cholecystitis not requiring therapeutic antimicrobials, obstructive jaundice or common duct bile stones) and in surgical patients for whom infection at the operative site would present serious risk (e.g., during coronary artery bypass surgery).

Although ceftriaxone sodium has been shown to have been as effective as cefazolin in the prevention of infection following coronary artery bypass surgery, no placebo-controlled trials have been conducted to evaluate any cephalosporin antibacterial in the prevention of infection following coronary artery bypass surgery.

1.10 Usage To reduce the development of drug-resistant bacteria and maintain the effectiveness of Ceftriaxone for Injection and Dextrose Injection and other antibacterial drugs, Ceftriaxone for Injection and Dextrose Injection should be used only to treat or prevent infections that are proven or strongly suspected to be caused by susceptible bacteria.

When culture and susceptibility information are available, they should be considered in selecting or modifying antibacterial therapy.

In the absence of such data, local epidemiology and susceptibility patterns may contribute to the empiric selection of therapy.

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Advisory information

contraindications

4 CONTRAINDICATIONS Anaphylaxis to ceftriaxone or other cephalosporin class antibacterials, penicillins, or other beta-lactam antibacterials (4.1) 4.1 Anaphylaxis to Ceftriaxone or the Cephalosporin Class of Antibacterials, Penicillins, or Other Beta-lactam Antibacterials Ceftriaxone for Injection and Dextrose Injection is contraindicated in patients who have a history of anaphylaxis to ceftriaxone or the cephalosporin class of antibacterials, penicillins, or other beta-lactam antibacterials [see Warnings and Precautions (5.1)].

Adverse reactions

6 ADVERSE REACTIONS The following serious adverse reactions to ceftriaxone are described below and elsewhere in the labeling: Hypersensitivity reactions [see Warnings and Precautions (5.1)] Ceftriaxone-calcium precipitates [see Warnings and Precautions (5.2) and Drug Interactions (7.2)] Clostridium difficile-associated diarrhea [see Warnings and Precautions (5.3)] Hemolytic anemia [see Warnings and Precautions (5.4)] The most common adverse reactions occurring in greater than 2 % of patients receiving ceftriaxone include diarrhea, eosinophilia, thrombocytosis, leukopenia, and elevations of SGOT and SGPT.

To report SUSPECTED ADVERSE REACTIONS, contact B. Braun Medical Inc. at 1-800-227-2862 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.

6.1 Clinical Trials Experience Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug can not be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.

The following reactions occurred in less than or equal to 6 % of the patients: Local reactions-pain, induration, tenderness, and phlebitis after IV administration.

Hypersensitivity-rash, pruritus, fever or chills.

Hematologic-eosinophilia, thrombocytosis, leucopenia, anemia, hemolytic anemia, neutropenia, lymphopenia, thrombocytopenia, and prolongation of the prothrombin time.

Gastrointestinal-diarrhea, nausea or vomiting, and dysgeusia.

The onset of pseudomembranous colitis symptoms may occur during or after antibacterial treatment [see Warnings and Precautions (5.3)].

Hepatic-elevations of SGOT, SGPT, alkaline phosphatase, bilirubin.

Renal-elevations of the BUN, creatinine, and the presence of casts in the urine.

Central nervous system-headache or dizziness.

Genitourinary-moniliasis or vaginitis.

Miscellaneous-diaphoresis and flushing.

Ceftriaxone-calcium precipitates-Cases of fatal reactions with ceftriaxone-calcium precipitates in lung and kidneys in neonates have been described.

In some cases the infusion lines and times of administration of ceftriaxone and calcium-containing solutions differed [see Warnings and Precautions (5.2) and Drug Interactions (7.2)].

Other observed adverse reactions-abdominal pain, agranulocytosis, allergic pneumonitis, anaphylaxis, basophilia, biliary lithiasis, bronchospasm, colitis, dyspepsia, epistaxis, flatulence, gallbladder sludge, glycosuria, hematuria, jaundice, leukocytosis, lymphocytosis, monocytosis, nephrolithiasis, palpitations, a decrease in the prothrombin time, renal precipitations, seizures, and serum sickness.

6.2 Postmarketing Experience The following adverse reactions have been reported during postapproval use of ceftriaxone.

Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to readily estimate their frequency or establish a causal relationship to drug exposure.

Gastrointestinal-stomatitis and glossitis.

Genitourinary-oliguria, ureteric obstruction, post-renal acute renal failure Hepatic-hepatitis.

Dermatologic - severe cutaneous adverse reactions (erythema multiforme, Stevens-Johnson syndrome or Lyell 's syndrome/toxic epidermal necrolysis), exanthema, allergic dermatitis, urticaria, and edema.

Immunologic - Anaphylaxis (anaphylactic shock, transient leucopenia, neutropenia, agranulocytosis and thrombocytopenia).

6.3 Cephalosporin-class Adverse Reactions In addition to the adverse reactions listed above that have been observed in patients treated with ceftriaxone, the following adverse reactions and altered laboratory tests have been reported for cephalosporin-class antibacterials: Adverse Reactions: Allergic reactions, drug fever, serum sickness-like reaction, renal dysfunction, toxic nephropathy, reversible hyperactivity, hypertonia, hepatic dysfunction including hepatitis, cholestasis, aplastic anemia, hemorrhage, and superinfection.

Altered Laboratory Tests: Positive direct Coombs ' test, false-positive test for urinary glucose, and elevated lactic acid dehydrogenase (LDH).

Usage information

Dosing and administration

2 DOSAGE AND ADMINISTRATION For intravenous use only over approximately 30 minutes.

(2) Use this formulation of ceftriaxone only in patients who require the entire 1 or 2 gram dose and not any fraction thereof.

(2.1) Recommended Dosing Schedule for Ceftriaxone for Injection and Dextrose Injection Site and Type of Infection Dose Frequency Total Daily Dose Usual Adult Dose 1 g to 2 g once a day or in equally divided doses every 12 hours should not exceed 4 g Patients with hepatic impairment and significant renal impairment should not receive more than 2 grams per day of ceftriaxone.

Surgical Prophylaxis 1 gram IV once 1/2 to 2 hours before surgery Meningitis 100 mg/kg once a day or in equally divided doses every 12 hours Should not exceed 4 g Skin and Skin Structure Infections 50 mg/kg to 75 mg/kg once a day or in equally divided doses every 12 hours should not exceed 2 g Serious Infections other than Meningitis 50 mg/kg to 75 mg/kg every 12 hours should not exceed 2 g 2.1 Adult

Population Ceftriaxone for Injection and Dextrose Injection in the DUPLEX® Container should be used only in patients who require the entire 1 or 2 gram dose and not any fraction thereof.

The recommended adult dosages are outlined in Table 1.

Ceftriaxone for Injection and Dextrose Injection should be administered intravenously (IV) over approximately 30 minutes.

The usual duration of therapy is 4 to 14 days; in complicated infections, longer therapy may be required.

When treating infections caused by Streptococcus pyogenes, therapy should be continued for at least 10 days.

Table 1: Recommended Dosing Schedule for Ceftriaxone for Injection and Dextrose Injection Site and Type of Infection Dose Frequency Total Daily Dose Usual Adult Dose 1 g to 2 g once a day or in equally divided doses every 12 hours should not exceed 4 gPatients with hepatic impairment and significant renal impairment should not receive more than 2 grams per day of ceftriaxone.

Surgical Prophylaxis 1 gram IV once 1/2 to 2 hours before surgery Skin and Skin Structure Infections 50 to 75 mg per kg once a day or in equally divided doses every 12 hours should not exceed 2 g Meningitis 100 mg per kg once a day or in equally divided doses every 12 hours should not exceed 4 g Serious Infections other than Meningitis 50 to 75 mg per kg every 12 hours should not exceed 2 g 2.2 Pediatric Patients Ceftriaxone for Injection and Dextrose Injection in the DUPLEX® Container is designed to deliver a 1 g or 2 g dose of ceftriaxone.

To prevent unintentional overdose, this product should not be used in pediatric patients who require less than the full adult dose of ceftriaxone.

[see Use in Specific Populations (8.4)] 2.3 Preparation for Use of Ceftriaxone for Injection and Dextrose Injection in DUPLEX® Container This reconstituted solution is for intravenous use only.

Do not use plastic containers in series connections.

Such use would result in air embolism due to residual air being drawn from the primary container before administration of the fluid from the secondary container is complete.

If administration is controlled by a pumping device, care must be taken to discontinue pumping action before the container runs dry or air embolism may result.

Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration.

Use only if solution is clear and container and seals are intact.

DUPLEX® Drug Delivery System Storage To avoid inadvertent activation, the DUPLEX® Container should remain in the folded position until activation is intended.

Patient Labeling and Drug Powder/Diluent Inspection Apply patient-specific label on foil side of container.

Use care to avoid activation.

Do not cover any portion of foil strip with patient label.

Unlatch side tab and unfold DUPLEX® Container (see Diagram 1).

Visually inspect diluent chamber for particulate matter.

Use only if container and seals are intact.

To inspect the drug powder for foreign matter or discoloration, peel foil strip from drug chamber (see Diagram 2).

Protect from light after removal of foil strip.

Note:

If foil strip is removed, the container should be re-folded and the side tab latched until ready to activate.

The product must then be used within 7 days, but not beyond the labeled expiration date.

Diagram 1 Diagram 2 Reconstitution (Activation) Do not use directly after storage by refrigeration, allow the product to equilibrate to room temperature before patient use.

Unfold the DUPLEX® container and point the set port in a downward direction.

Starting at the hanger tab end, fold the DUPLEX® Container just below the diluent meniscus trapping all air above the fold.

To activate, squeeze the folded diluent chamber until the seal between the diluent and powder opens, releasing diluent into the drug powder chamber (see Diagram 3).

Agitate the liquid-powder mixture until the drug powder is completely dissolved.

Note:

Following reconstitution (activation), product must be used within 24 hours if stored at room temperature or within 7 days if stored under refrigeration.

Diagram 3 Administration Visually inspect the reconstituted solution for particulate matter.

Point the set port in a downwards direction.

Starting at the hanger tab end, fold the DUPLEX® Container just below the solution meniscus trapping all air above the fold.

Squeeze the folded DUPLEX® Container until the seal between reconstituted drug solution and set port opens, releasing liquid to set port (see Diagram 4).

Prior to attaching the IV set, check for minute leaks by squeezing container firmly.

If leaks are found, discard container and solution as sterility may be compromised.

Using aseptic technique, peel foil cover from the set port and attach sterile administration set (see Diagram 5).

Refer to directions for use accompanying the administration set.

Diagram 4 Diagram 5 Important Administration Instructions Do not use in series connections.

Do not introduce additives into the DUPLEX®

Container.

Administer Ceftriaxone for Injection and Dextrose Injection intravenously over approximately 30 minutes.

After the indicated stability time periods, unused portions of solutions should be discarded.

Vancomycin, amsacrine, aminoglycosides, and fluconazole are physically incompatible with ceftriaxone in admixtures.

When any of these drugs are to be administered concomitantly with ceftriaxone by intermittent intravenous infusion, it is recommended that they be given sequentially, with thorough flushing of the intravenous lines (with 0.9 % sodium chloride injection or 5 % dextrose in water (D5W)) between the administrations.

Ceftriaxone for Injection and Dextrose Injection should not be physically mixed with or piggybacked into solutions containing other antimicrobial drugs due to possible incompatibility.

[see Drug Interactions (7.1)] Precipitation of ceftriaxone-calcium can also occur when Ceftriaxone for Injection and Dextrose Injection is mixed with calcium-containing solutions in the same IV administration line.

Ceftriaxone for Injection and Dextrose Injection 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 for Injection and Dextrose Injection 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 Warnings and Precautions (5.2)] 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).

Use in special populations

8 USE IN SPECIFIC POPULATIONS Hepatic and renal impairment Patients with both hepatic and renal impairment should not receive more than 2 grams of ceftriaxone per day (5.8) Pediatric Patients Ceftriaxone for Injection and Dextrose Injection in the DUPLEX® Container is designed to deliver a 1 g or 2 g dose of ceftriaxone.

To prevent unintentional overdose, this product should not be used in pediatric patients who require less than the full adult dose of ceftriaxone.

(2.2, 8.4) 8.1 Pregnancy Pregnancy Category B Reproductive studies have been performed in mice, rats, and primates at intravenous doses of 625, 586, and 84 mg/kg/day respectively without evidence of embryotoxicity, fetotoxicity, or teratogenicity.

These doses are approximately 1.5, 2.8, and 0.8 times the recommended clinical dose of 2 g/day based on body surface area comparisons.

There are, however, no adequate and well-controlled studies in pregnant women.

Because animal reproductive studies are not always predictive of human response, this drug should be used during pregnancy only if clearly needed.

Ceftriaxone was tested in a Segment III (pre-postnatal) study in rats at intravenous doses of up to 586 mg/kg/day approximately 2.8 times (mg/ m2 comparison) the recommended daily dose of 2 g/day.

No adverse effects were noted on various reproductive parameters during gestation and lactation, including postnatal growth, functional behavior, and reproductive ability of the offspring.

8.3 Nursing Mothers Ceftriaxone is excreted in human breast milk.

Caution should be exercised when Ceftriaxone for Injection and Dextrose Injection is administered to a nursing woman.

8.4 Pediatric Use Ceftriaxone for Injection and Dextrose Injection in the DUPLEX® Container is designed to deliver a 1 g or 2 g dose of ceftriaxone.

To prevent unintentional overdose, this product should not be used in pediatric patients who require less than the full 1 g or 2 g adult dose of ceftriaxone.

8.5 Geriatric Use Of the total number of subjects in clinical studies of ceftriaxone sodium, 32 % were 60 and over.

No overall differences in safety or effectiveness were observed between these subjects and younger subjects, and other reported clinical experience has not identified differences in responses between the elderly and younger patients, but greater sensitivity of some older individuals can not be ruled out.

Ceftriaxone is known to be substantially excreted by the kidney, and the risk of adverse reactions to this drug may be greater in patients with impaired renal function.

Because elderly patients are more likely to have decreased renal function, care should be taken in dose selection, and it may be useful to monitor renal function.

The pharmacokinetics of ceftriaxone were only minimally altered in geriatric patients compared to healthy adult subjects and dosage adjustments are not necessary for geriatric patients with ceftriaxone dosages up to 2 grams per day, provided there is no severe renal and hepatic impairment.

[see Clinical Pharmacology (12)]

Pregnancy and lactation
8.3 Nursing Mothers Ceftriaxone is excreted in human breast milk. Caution should be exercised when Ceftriaxone for Injection and Dextrose Injection is administered to a nursing woman.

Interactions

7 DRUG INTERACTIONS Vancomycin, amsacrine, aminoglycosides, and fluconazole are physically incompatible.

(7.1) Calcium-containing products: precipitation can occur.

(7.2) 7.1 Vancomycin, Amsacrine, Aminoglycosides, and Fluconazole Vancomycin, amsacrine, aminoglycosides, and fluconazole are physically incompatible with ceftriaxone in admixtures.

[see Dosage and Administration (2.3)] 7.2 Calcium-containing Products Precipitation of ceftriaxone-calcium can occur when Ceftriaxone for Injection and Dextrose Injection is mixed with calcium-containing solutions in the same IV administration line.

Ceftriaxone for Injection and Dextrose Injection must not be administered simultaneously with calcium-containing IV solutions.

Ceftriaxone for Injection and Dextrose Injection and calcium-containing solutions may be administered sequentially.

[see Warnings and Precautions (5.2)]

More information

Category Value
Authorisation number NDA050796
Orphan designation No
Product NDC 0264-3153,0264-3155
Date Last Revised 21-07-2015
Type HUMAN PRESCRIPTION DRUG
RXCUI 1665021
Marketing authorisation holder B. Braun Medical Inc.