Prescription Drugs

CLINICAL PHARMACOLOGY Ampicillin is bactericidal at low concentrations and is clinically effective not only against the gram-positive organisms usually susceptible to penicillin G but also against a variety of gram-negative organisms. It is stable in the presence of gastric acid and is well absorbed from the gastrointestinal tract. It diffuses readily into most body tissues and fluids; however, penetration into the cerebrospinal fluid and brain occurs only with meningeal inflammation. Ampicillin is excreted largely unchanged in the urine; its excretion can be delayed by concurrent administration of probenecid which inhibits the renal tubular secretion of ampicillin. In blood serum, ampicillin is the least bound of all the penicillins; an average of about 20 percent of the drug is bound to plasma proteins as compared to 60 to 90 percent of the other penicillins. The administration of 500 mg dose of ampicillin capsules results in an average peak blood serum level of approximately 3.0 mcg/mL; the average peak serum level for the same dose of ampicillin for oral suspension is approximately 3.4 mcg/mL. Microbiology While in vitro studies have demonstrated the susceptibility of most strains of the following organisms, clinical efficacy for infections other than those included in the INDICATIONS AND USAGE section has not been documented. Gram-Positive: strains of alpha- and beta-hemolytic streptococci, Streptococcus pneumoniae, those strains of staphylococci, which do not produce penicillinase, Clostridium sp., Bacillus anthracis, Corynebacterium xeroses, and most strains of enteracocci. Gram-Negative: Hemophilus influenzae; Neisseria gonorrhoae and N. Meningitides; Proteus mirabilis, and many strains of Salmonella (including S. typhosa), Shigella, and Escherichia coli. Note: Ampicillin is inactivated by penicillinase and therefore is ineffective against penicillinase-producing organisms including certain strains at staphylococci, Pseudomonas aeruginosa, P. Vulgaris, Klebsiella pneumoniae, Enterobacter aerogenes, and some strains of E. coli. Ampicillin is not active against Rickettsia, Mycoplasma, and "large viruses" (Miyagawanella). Testing for Susceptibility: The invading organism should be cultured and its susceptibility demonstrated as a guide to therapy. If the Kirby-Bauer method of disc susceptibility is used, a 10 mcg ampicillin disc should be used to determine the relative in vitro susceptibility.

INDICATIONS PRINCIPEN Capsules (Ampicillin Capsules) and PRINCIPEN for Oral Suspension (Ampicillin for Oral Suspension) are indicated in the treatment of infections caused by susceptible strains of the designated organism listed below; Infections of the Genitourinary Tract Including Gonorrhea: E. coli, P. mirabilis, enterococci, Shigella, S. typhosa and other Salmonella, and nonpenicillinase-producing N. gononhoeae. Infections of the Respiratory Tract: Nonpenicillinase-producing H. influenzae and staphylococci, and streptococci including streptococcus pneumoniae. Infections of the Gastrointestinal Tract: Shigella, S. typhosa and other Salmonella, E. coli, P. mirabilis, and enterococci. Meningitis: O. Meningitides. Bacteriology studies to determine the causative organisms and their sensetivity to ampicillin should be performed. Therapy may be instituted prior to the results of susceptibility testing. DOSAGE AND ADMINISTRATION Adults and Children Weight Over 20 kg. For genitourinary or gastrointestinal tract infections other than gonorrhea in men and women, the usual dose is 500 mg qid in equally spaced doses; severe or chronic infections may require larger doses. For the treatment of gonerrhea in both men and women, a single oral dose of 3.5 grams of ampicillin administered simultaneously with 1 gram of probenecid is recommended. Physicians are cautioned to use no less than the above recommended dosage for the treatment of gonorrhea. Follow-up cultures should be obtained from the original site(s) of infection 7 to 14 days after therapy. In women, it is also desirable to obtain culture test-of-cure from both the endo-cervical and anal canals. Prolonged intensive therapy is needed for complications such as proshtitis and epididymitis. For respiratory tract infections, the usual dose is 250 mg qid in equally spaced doses. Children Weighing 20 kg or Less For genitourinary or gastrointestinal tract infections, the usual dose is 100 mg/kg/day total, qid in equally divided and spaced doses. For respiratory infections, the usual dose is 50 mg/kg/day total, in equally divided and spaced doses three to four times daily. Doses for children should not exceed doses recommended for adults, All Patients, Irrespective of Age and Weight Larger doses may be required for severe or chronic infections. Although ampicillin is resistant to degradation by gastric acid, it should be administered at least one half-hour before or two hours after meals for maximal absorption. Except for the single dose regimen for gonorrhea referred to above, therapy should be continued for a minimum of 48 to 72 hours after the patient becomes asymptomatic or evidence at bacterial eradication has been obtained. In infections caused by hemolytic strains of streptococci, a minimum of 10 days treatment is recommended to guard against the risk of rheumatic fever of glomerulonephritis (see PRECAUTIONS — Laboratory Tests). In the treatment of chronic urinary or gastrointestinal infections, frequent bacteriologic and clinical appraisal is necessary during therapy and may be necessary for several months afterwards. Stubborn infections may require treatment for several weeks. Smaller doses than those indicated above should not be used. HOW SUPPLIED PRINCIPEN Capsules (Ampicillin Capsules USP): 250 mg/capsule: Size 2 capsule with a light gray body and scarlet cap. Printed in black ink with BRISTOL 7902 on both body and cap. bottles of 100 NDC 0003-0122-50 bottles of 500 NDC 0003-0122-60 Unimatic, unit dose packs of 100 NDC 0003-0122-51 500 mg/capsule: Size 0 capsule with a light gray body and scarlet cap. Printed in black ink with BRISTOL 7093 on both body and cap. bottles of 100 NDC 0003-0134-50 bottles of 500 NDC 0003-0134-60 Unimatic, unit dose packs of 100 NDC 0003-0134-51 PRINCIPEN for Oral Suspension (Ampicillin for Oral Suspension USP): Ampicilin 125: When constituted as directed on the container label, a pleasant fruit-flavored suspension containing: 125 mg per 6 mL, In bottle sizes for preparation of 100 mL NDC 0003-0969-09 150 mL NDC 0003-0969-52 200 mL NOC 0003-0969-61 Ampicilin 260: When constituted as directed on the container label, a pleasant fruit-flavored suspension containing: 250 mg per 5 mL, In bottle sizes for preparation of 100 mL NDC 0003-0972-52 200 mL NDC 0003-0972-61 Storage Capsules: Store at room temperature; avoid excessive heat; keep tightly closed. Ampicilin for oral suspension: Store at room temperature; after constitution, discard unused portion after 7 days if kept at room temperature or after 14 days if refrigerated; keep bottles tightly closed. For Rx only

PATIENT INFORMATION 1. The patient should inform the physician of any history of sensitivity to allergens, including previous hypersensitivity reactions to penicillins and cephalosporins (see WARNINGS). 2. The patient should discontinue ampicillin and contact the physician immediately if any side effect occurs (see WARNINGS). 3. Ampicillin should be taken with a full glass (8 oz) of water, one-half hour before or two hours after meals. 4. Diabetic patients should consult with the physician before changing diet or dosage of diabetes medication (see PRECAUTIONS — Drug/Laboratory Test Interactions).

OVERDOSE In case of overdosage, discontinue medication, treat symptomatically and institute supportive measures as required. In patients with renal function impairment, ampicillin-class antibiotics can be removed by hemodialysis but not by peritoneal dialysis. CONTRAINDICATIONS A history of a previous hypersensitivity reaction to any of the penicillins is a contraindication. Ampicillin is also contraindicated in infections caused by penicillinase-producing organisms.

SIDE EFFECTS As with other penicillins, it may be expected that untoward reactions will be essentially limited to sensitivity phenomena. They are more likely to occur in individuals who have previously demonstrated hypersensitivity to penicillin and in those with a history of allergy, asthma, hay fever, or urticaria. The following adverse reactions have been reported as associated with the use of ampicillin: Gastrointestinal: glositis, stamatitis, nausea, vomiting, enterocolitis, pseudomembranous colitis, and diarrhea. These reactions are usually associated with oral dosage forms of the drugs. Hypersensitivity Reactions: An erythematous, mildly pruritic, maculopapular skin rash has been reported fairly frequently. The rash, which usually does not develop within the first week of therapy, may cover the entire body including the soles, palms, and oral mucosa. The eruption usually disappears in three to seven days. Other hypersensitivity reactions that have been reported are: skin rash, pruritus, urticaria, erythema multiforme, and an occasional case of exfoliative dermatitis. Anaphylaxis is the most serious reaction experienced and has usually been associated with the parenteral dosage form of the drug Note: Urticaria, other skin rashes, and serum sickness-like reactions may be controlled by antihistamines, and if necessary, systemic corticosteroids. Whenever such reactions occur, ampicillin should be discontinued unless, in the opinion of the physician, the condition being treated is life-threatening, and amenable only to ampicillin therapy. Serious anaphylactoid reactions require emergency measures (see WARNINGS). Liver: Moderate elevation in serum glutamic oxalaacetic transaminase (SGOT) has been noted, but the significance of this finding is unknown. Hemic and Lymphatic Systems: Anemia, thrombocytopenia, thrombocytopenic purpura, eosinophilia, leukapenia, and agranulacytosis have been reported during therapy with penicillins. These reactions are usually reversible on discontinuation of therapy and are believed to be hypersensitivity phenomena. Other: Other adverse reactions that have been reported with the use at ampicillin are laryngeal stride and high fever. An occasional patient may complain of sore mouth or tongue as with any oral penicillin preparation. DRUG INTERACTIONS When administered concurrently, the following drugs may interact with ampicillin. Allopurinol: Increased possibility of skin rash, particularly in hyperuricemic patients may occur. Bacteriostatic Antibiotics: Chloramphenicol, erythromycins, sulfonamides, or tetracyclines may interfere with the bactericidal effect of penicillins. This has been demonstrated in view, however, the clinical significance of this interaction is not well documented. Oral Contraceptives: May be less effective and increased breakthrough bleeding may occur. Probenecid: May decrease renal tubular secretion of ampicillin resulting in increased blood levels and/or ampicillin toxicity. Drug/Laboratory Test Interaction After treatment with ampicillin, a false-positive reaction for glucose in the urine may occur with copper sulfate tests (Benedict's solution, Fehling's solution, or Clinitest tablets) but not with enzyme based tests such as Clinistix and Glucose Enzymatic Test Strip USP.

WARNINGS Serious and occasional fatal hypersensitivity (anaphylactoid) reactions have been reported in patients on penicillin therapy. Although anaphylaxis is more frequent following parenteral administration, it has occurred in patients on oral penicillins. These reactions are more apt to occur in individuals with a history at penicillin hypersensitivity and/or a history of sensitivity to multiple allergens. There have been well documented reports of individuals with a history of penicillin hypersensitivity who have experienced severe hypersensitivity reactions when treated with cephalosporins. Before initiating therapy with any penicillin, careful inquiry should be made concerning previous hypersensitivity reactions to penicillins, cephalosporins, and other allergens. If an allergic reaction occurs, the drug should be discontinued and appropriate therapy instituted. Serious anaphylactoid reactions require immediate emergency treatment with epinephrine. Oxygen, intravenous steroids, and airway management, including intubation, should also be administered as indicated. Pseudomembranous colitis has been reported with nearly all antibacterial agents, including ampicillin, and may range in severity from mild to life-threatening. Therefore, it is important to consider this diagnosis in patients who present with diarrhea subsequent to the administration of antibacterial agents. Treatment with antibacterial agents alters the normal flora of the colon and may permit overgrowth of clostridia. Studies indicate that a toxin produced by clostridium difficile, is one primary cause of "antibiotic-associated colitis". After the diagnosis of pseudomembranous colitis has bean established, therapeutic measures should be initiated. Mild cases of pseudomembranous colitis usually respond to drug discontinuation alone. In moderate to severe cases, consideration should be given to management with fluids and electrolytes, protein supplementation and treatment with an antibacterial drug clinically effective against C. difficile colitis. PRECAUTIONS General Prolonged use of antibiotics may promote the overgrowth of nonsusceptible organisms, including fungi. Should superinfection occur, appropriate measures should be taken. Patients with gonorrhea who also have syphilis should be given additional appropriate parenteral penicillin treatment. Treatment with ampicillin does not preclude the need for surgical procedures, particularly in staphylococcal infections. Laboratory Tests In prolonged therapy, and particularly with high dosage regimens, periodic evaluation of the renal, hepatic, and hematopoietic systems is recommended. In streptococcal infections, therapy must be sufficient to eliminate the organism (10 days minimum); otherwise the sequelae of streptococcal disease may occur. Cultures should be taken following completion of treatment to determine whether streptococci have been eradicated. Cases of gonococcal infection with a suspected lesion of syphilis should have darkfield examinations ruling out syphilis before receiving ampicillin. Patients who do not have suspected lesions of syphilis and are treated with ampicillin should have a follow- up serologic test for syphilis each month for four months to detect syphilis that may have been masked from treatment for gonorrhea. Drug Interactions See DRUG INTERACTIONS section. Carcinogenesis, Mutagenesis, Impairment of Fertility Long-term studies in animals have not been performed to evaluate carcinogenesis, mutagenesis, or impairment of fertility in males or females. Pregnancy Teratogenic Eftects: Category B: Reproduction studies in animals have revealed no evidence of impaired fertility or harm to the fetus due to penicillin. There are, however, no adequate and well-controlled studies in pregnant women. Because animal reproduction studies are not always predictive of human response, penicillin should be used during pregnancy only if clearly needed. Labor and Delivery Oral ampicillin-class antibiotics are poorly absorbed during labor. Studies in guinea pigs showed that intravenous administration of ampicillin slightly decreased the uterine tone and frequency of contractians, but moderately increased the height and duration of contractions. However, it is not known whether use of these drugs in humans during labor or delivery has immediate or delayed adverse effects on the fetus, prolongs the duration of labor, or increases the likelihood that forceps delivery or other obstetrical intervention or resuscitation of the newborn will be necessary. Nursing Mothers Ampicillin-class antibiotics are excreted in milk. Ampicillin used by nursing mothers may lead to sensitization of infants; therefore, a decision should be made whether to discontinue nursing or to discontinue ampicillin, taking into account the importance of the drug to the mother. Pediatric Use Penicillins are excreted primarily unchanged by the kidney, therefore, the incompletely developed renal functioning neonates and young infants will delay the excretion of penicillin. Administration to neonates and young infants should be limited to the lowest dosage compatible with an effective therapeutic regimen (see DOSAGE AND ADMINISTRATION).