Dicloxal Ox

Dicloxal Ox (Dicloxal Ox (Dicloxal Ox for injection) for injection) is indicated in the treatment of infections caused by penicillinase producing staphylococci which have demonstrated susceptibility to the drug. Cultures and susceptibility tests should be performed initially to determine the causative organism and its susceptibility to the drug. (See CLINICAL PHARMACOLOGY - Susceptibility Tests).

Dicloxal Ox (Dicloxal Ox (Dicloxal Ox for injection) for injection) may be used to initiate therapy in suspected cases of resistant staphylococcal infections prior to the availability of susceptibility test results. Dicloxal Ox (Dicloxal Ox (Dicloxal Ox for injection) for injection) should not be used in infections caused by organisms susceptible to penicillin G. If the susceptibility tests indicate that the infection is due to an organism other than a resistant Staphylococcus, therapy should not be continued with Dicloxal Ox (Dicloxal Ox (Dicloxal Ox for injection) for injection).

To reduce the development of drug-resistant bacteria and maintain the effectiveness of Dicloxal Ox Injection, USP and other antibacterial drugs, Dicloxal Ox (Dicloxal Ox (Dicloxal Ox for injection) for injection) Injection, USP 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.

Dicloxal Ox (Dicloxal Ox (Dicloxal Ox for injection) for injection) Injection, USP supplied as a premixed frozen solution is to be administered as a continuous or intermittent intravenous infusion. The usual dose recommendation is as follows:

This container system may be inappropriate for the dosage requirements for children, infants and neonates. Other dosage forms may be more appropriate.

Bacteriologic studies to determine the causative organisms and their susceptibility to Dicloxal Ox (Dicloxal Ox (Dicloxal Ox for injection) for injection) should always be performed. Duration of therapy varies with the type of severity of infection as well as the overall condition of the patient; therefore, it should be determined by the clinical and bacteriological response of the patient. In severe staphylococcal infections, therapy with Dicloxal Ox (Dicloxal Ox (Dicloxal Ox for injection) for injection) should be continued for at least 14 days. Therapy should be continued for at least 48 hours after the patient has become afebrile, asymptomatic, and cultures are negative. Treatment of endocarditis and osteomyelitis may require a longer duration of therapy.

Concurrent administration of Dicloxal Ox (Dicloxal Ox (Dicloxal Ox for injection) for injection) and probenecid increases and prolongs serum penicillin levels. Probenecid decreases the apparent volume of distribution and slows the rate of excretion by competitively inhibiting renal tubular secretion of penicillin. Penicillin-probenecid therapy is generally limited to those infections where very high serum levels of penicillin are necessary.

With intravenous administration, particularly in elderly patients, care should be taken because of the possibility of thrombophlebitis.

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

Do not add supplementary medication to Dicloxal Ox (Dicloxal Ox (Dicloxal Ox for injection) for injection) Injection, USP.

Store in a freezer capable of maintaining a temperature of -20°C/-4°F or less.

Directions for Use of GALAXY Plastic Container

Thaw at room temperature (25°C/77°F) or under refrigeration (5°C/41°F). [DO NOT FORCE THAW BY IMMERSION IN WATER BATHS OR BY MICROWAVE IRRADIATION]. Components of the solution may precipitate in the frozen state and will dissolve upon reaching room temperature with little or no agitation. Potency is not affected. Mix after solution has reached room temperature. Check for minute leaks by squeezing bag firmly. If leaks are found, discard solution as sterility may be impaired. Do not use if the solution is cloudy or precipitated or if seals are not intact. The thawed solution is stable for 21 days under refrigeration or 48 hours at room temperature. Do not refreeze.

Use sterile equipment.

Caution: Do not use plastic containers in series connections. Such use could 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.

Preparation for intravenous administration

1. Suspend container from eyelet support.
2. Remove protector from outlet port at bottom of container.
3. Attach administration set. Refer to complete directions accompanying set.

A history of a hypersensitivity (anaphylactic) reaction to any penicillin is a contraindication. Solutions containing dextrose may be contraindicated in patients with known allergy to corn or corn products.

WARNINGS

SERIOUS AND OCCASIONALLY FATAL HYPERSENSITIVITY (ANAPHYLACTIC SHOCK WITH COLLAPSE) REACTIONS HAVE OCCURRED IN PATIENTS RECEIVING PENICILLIN. THE INCIDENCE OF ANAPHYLACTIC SHOCK IN ALL PENICILLIN-TREATED PATIENTS IS BETWEEN 0.015 AND 0.04 PERCENT. ANAPHYLACTIC SHOCK RESULTING IN DEATH HAS OCCURRED IN APPROXIMATELY 0.002 PERCENT OF THE PATIENTS TREATED. ALTHOUGH ANAPHYLAXIS IS MORE FREQUENT FOLLOWING PARENTERAL ADMINISTRATION, IT HAS OCCURRED IN PATIENTS RECEIVING ORAL PENICILLINS.

WHEN PENICILLIN THERAPY IS INDICATED, IT SHOULD BE INITIATED ONLY AFTER A COMPREHENSIVE PATIENT DRUG AND ALLERGY HISTORY HAS BEEN OBTAINED. IF AN ALLERGIC REACTION OCCURS, THE DRUG SHOULD BE DISCONTINUED AND THE PATIENT SHOULD RECEIVE SUPPORTIVE TREATMENT, E.G., ARTIFICIAL MAINTENANCE OF VENTILATION, PRESSOR AMINES, ANTIHISTAMINES, AND CORTICOSTEROIDS. INDIVIDUALS WITH A HISTORY OF PENICILLIN HYPERSENSITIVITY MAY ALSO EXPERIENCE ALLERGIC REACTIONS WHEN TREATED WITH A CEPHALOSPORIN.

Clostridium difficile associated diarrhea (CDAD) has been reported with use of nearly all antibacterial agents, including Dicloxal Ox (Dicloxal Ox (Dicloxal Ox for injection) for injection) Injection, USP, and may range in severity from mild diarrhea to fatal colitis. Treatment with antibacterial agents alters the normal flora of the colon leading to overgrowth of C. difficile.

C. difficile produces toxins A and B which contribute to the development of CDAD. Hypertoxin producing strains of C. difficile cause increased morbidity and mortality, as these infections can be refractory to antimicrobial therapy and may require colectomy. CDAD must be considered in all patients who present with diarrhea following antibiotic use. Careful medical history is necessary since CDAD has been reported to occur over two months after the administration of antibacterial agents.

If CDAD is suspected or confirmed, ongoing antibiotic use not directed against C. difficile may need to be discontinued. Appropriate fluid and electrolyte management, protein supplementation, antibiotic treatment of C. difficile, and surgical evaluation should be instituted as clinically indicated.

PRECAUTIONS

General

Dicloxal Ox (Dicloxal Ox (Dicloxal Ox for injection) for injection) should generally not be administered to patients with a history of sensitivity to any penicillin. Penicillin should be used with caution in individuals with histories of significant allergies and/or asthma. Whenever allergic reactions occur, penicillin should be withdrawn unless, in the opinion of the physician, the condition being treated is life-threatening and amenable only to penicillin therapy. The use of antibiotics may result in overgrowth of nonsusceptible organisms. If new infections due to bacteria or fungi occur, the drug should be discontinued and appropriate measures taken.

Prescribing Dicloxal Ox (Dicloxal Ox (Dicloxal Ox for injection) for injection) Injection, USP in the absence of a proven or strongly suspected bacterial infection or a prophylactic indication is unlikely to provide benefit to the patient and increases the risk of the development of drug-resistant bacteria.

Laboratory Tests

Bacteriologic studies to determine the causative organisms and their susceptibility to Dicloxal Ox should be performed. (See CLINICAL PHARMACOLOGY - Microbiology). In the treatment of suspected staphylococcal infections, therapy should be changed to another active agent if culture tests fail to demonstrate the presence of staphylococci.

Periodic assessment of organ system function including renal, hepatic, and hematopoietic should be made during prolonged therapy with Dicloxal Ox (Dicloxal Ox (Dicloxal Ox for injection) for injection).

Blood cultures, white blood cell, and differential cell counts should be obtained prior to initiation of therapy and at least weekly during therapy with Dicloxal Ox (Dicloxal Ox (Dicloxal Ox for injection) for injection).

Periodic urinalysis, blood urea nitrogen, and creatinine determinations should be performed during therapy with Dicloxal Ox (Dicloxal Ox (Dicloxal Ox for injection) for injection) and dosage alterations should be considered if these values become elevated. If any impairment of renal function is suspected or known to exist, a reduction in the total dosage should be considered and blood levels monitored to avoid possible neurotoxic reactions. AST (SGOT) and ALT (SGPT) values should be obtained periodically during therapy to monitor for possible liver function abnormalities.

Carcinogenesis and Mutagenesis and Impairment of Fertility

No long-term animal studies have been conducted with these drugs. Studies on reproduction (nafcillin) in rats and rabbits reveal no fetal or maternal abnormalities before conception and continuously through weaning (one generation).

Pregnancy

Teratogenic Effects

Pregnancy Category B

Reproduction studies performed in the mouse, rat, and rabbit have revealed no evidence of impaired fertility or harm to the fetus due to the penicillinase-resistant penicillins. Human experience with the penicillins during pregnancy has not shown any positive evidence of adverse effects on the fetus. There are, however, no adequate or well-controlled studies in pregnant women showing conclusively that harmful effects of these drugs on the fetus can be excluded. Because animal reproduction studies are not always predictive of human response, this drug should be used during pregnancy only if clearly needed.

Nursing Mothers

Penicillins are excreted in human milk. Caution should be exercised when penicillins are administered to a nursing woman.

Pediatric Use

Because of incompletely developed renal function in pediatric patients, Dicloxal Ox (Dicloxal Ox (Dicloxal Ox for injection) for injection) may not be completely excreted, with abnormally high blood levels resulting. Frequent blood levels are advisable in this group with dosage adjustments when necessary. All pediatric patients treated with penicillins should be monitored closely for clinical and laboratory evidence of toxic or adverse effects. Safety and effectiveness in pediatric patients have not been established.

The potential for toxic effects in pediatric patients from chemicals that may leach from the single dose premixed intravenous preparation in plastic containers has not been evaluated.

Geriatric Use

Clinical studies of Dicloxal Ox (Dicloxal Ox (Dicloxal Ox for injection) for injection) injection did not include sufficient number of subjects aged 65 and over to determine whether they respond differently from younger subjects. Other reported clinical experience has not identified differences in responses between the elderly and younger patients. In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy.

This drug is known to be substantially excreted by the kidney, and the risk of toxic 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.

Dicloxal Ox (Dicloxal Ox (Dicloxal Ox for injection) for injection) Injection contains 92.4 mg (4.02 mEq) of sodium per gram. At the usual recommended doses, patients would receive between 92.4 and 554 mg/day (4.02 and 24.1 mEq) of sodium. The geriatric population may respond with a blunted natriuresis to salt loading. This may be clinically important with regard to such diseases as congestive heart failure.

Body as a Whole

The reported incidence of allergic reactions to penicillin ranges from 0.7 to 10 percent (see WARNINGS). Sensitization is usually the result of treatment but some individuals have had immediate reactions when first treated. In such cases, it is thought that the patients may have had prior exposure to the drug via trace amounts present in milk and vaccines.

Two types of allergic reactions to penicillins are noted clinically, immediate and delayed.

Immediate reactions usually occur within 20 minutes of administration and range in severity from urticaria and pruritus to angioneurotic edema, laryngospasm, bronchospasm, hypotension, vascular collapse and death. Such immediate anaphylactic reactions are very rare (see WARNINGS) and usually occur after parenteral therapy but have occurred in patients receiving oral therapy. Another type of immediate reaction, an accelerated reaction, may occur between 20 minutes and 48 hours after administration and may include urticaria, pruritus, and fever. Although laryngeal edema, laryngospasm, and hypotension occasionally occur, fatality is uncommon. Delayed allergic reactions to penicillin therapy usually occur after 48 hours and sometimes as late as 2 to 4 weeks after initiation of therapy.

Manifestations of this type of reaction include serum sickness-like symptoms (i.e., fever, malaise, urticaria, myalgia, arthralgia, abdominal pain) and various skin rashes. Nausea, vomiting, diarrhea, stomatitis, black or hairy tongue, and other symptoms of gastrointestinal irritation may occur, especially during oral penicillin therapy.

Nervous System Reactions

Neurotoxic reactions similar to those observed with penicillin G may occur with large intravenous doses of Dicloxal Ox (Dicloxal Ox (Dicloxal Ox for injection) for injection) , especially with patients with renal insufficiency.

Urogenital Reactions

Renal tubular damage and interstitial nephritis have been associated infrequently with the administration of Dicloxal Ox (Dicloxal Ox (Dicloxal Ox for injection) for injection). Manifestations of this reaction may include rash, fever, eosinophilia, hematuria, proteinuria, and renal insufficiency.

Gastrointestinal Reactions

Pseudomembranous colitis has been reported with the use of Dicloxal Ox (Dicloxal Ox (Dicloxal Ox for injection) for injection). The onset of pseudomembranous colitis symptoms may occur during or after antibiotic treatment (see WARNINGS).

Metabolic Reactions

Hepatotoxicity, characterized by fever, nausea, and vomiting associated with abnormal liver function tests, mainly elevated SGOT levels, has been associated with the use of Dicloxal Ox (Dicloxal Ox (Dicloxal Ox for injection) for injection).

The signs and symptoms of Dicloxal Ox overdosage are those described in the ADVERSE REACTIONS section. If signs or symptoms occur, discontinue use of the medication, treat symptomatically, and institute appropriate supportive measures.