Okebo

DESCRIPTION

Doxycyclineis a broad-spectrumantibacterialsynthetically derived from oxytetracycline. Okebo (Doxycycline monohydrate USP) Capsules, 100 mg, 75 mg, and 50 mg capsules contain doxycycline monohydrate equivalent to 100 mg, 75 mg, or 50 mg of doxycycline for oral administration. The chemical designation of the light-yellow crystalline powder is alpha-6- deoxy-5-oxytetracycline.

Structural formula:

Doxycycline has a high degree of lipid solubility and a low affinity for calcium binding. It is highly stable in normal human serum. Doxycycline will not degrade into an epianhydro form.

Inert ingredients:胶体二氧化硅,硬脂酸镁,麦克风rocrystalline cellulose and sodium starch glycolate Type A Potato. Hard gelatin capsule contains black iron oxide, gelatin, red iron oxide, titanium dioxide and yellow iron oxide. The capsules are printed with edible ink containing black iron oxide, potassium hydroxide, propylene glycol, shellac and titanium dioxide.

INDICATIONS

To reduce the development of drug-resistant bacteria and maintain effectiveness of Okebo and other antibacterial drugs,

Okebo 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.

Doxycycline is indicated for the treatment of the following infections:

Rocky Mountain spotted fever, typhus fever and the typhus group, Q fever, rickettsialpox, and tick fevers caused byRickettsiae.
Respiratory tract infections caused byMycoplasma pneumoniae.
Lymphogranuloma venereum caused byChlamydia trachomatis.
Psittacosis (ornithosis) caused byChlamydophila psittaci.
Trachoma caused byChlamydia trachomatis, although the infectious agent is not always eliminated as judged by immunofluorescence.
Inclusion conjunctivitis caused byChlamydia trachomatis.
Uncomplicated urethral, endocervical or rectal infections in adults caused byChlamydia trachomatis.
Nongonococcal urethritis caused byUreaplasma urealyticum.
Relapsing fever due toBorrelia recurrentis.

Doxycycline is also indicated for the treatment of infections caused by the following gramnegative microorganisms:

Chancroid caused byHaemophilus ducreyi.
Plague due toYersinia pestis.
Tularemia due toFrancisella tularensis.
Cholera caused byVibrio cholerae.
Campylobacter fetus infections caused byCampylobacter fetus.
Brucellosis due toBrucella species(in conjunction with streptomycin).
Bartonellosis due toBartonella bacilliformis.
Granuloma inguinale caused byKlebsiella granulomatis.

Because many strains of the following groups of microorganisms have been shown to be resistant to doxycycline, culture and susceptibility testing are recommended.

Doxycycline is indicated for treatment of infections caused by the following gram-negative microorganisms, when bacteriologic testing indicates appropriate susceptibility to the drug:

大肠杆菌
Enterobacter aerogenes
Shigella species
Acinetobacter species
Respiratory tract infections caused byHaemophilus influenzae.
Respiratory tract and urinary tract infections caused byKlebsiella species.

Doxycycline is indicated for treatment of infections caused by the following gram-positive microorganisms when bacteriologic testing indicates appropriate susceptibility to the drug:

Upper respiratory infections caused byStreptococcus pneumoniae.
Anthrax due toBacillus anthracis, including inhalational anthrax (post-exposure): to reduce the incidence or progression of disease following exposure to aerosolizedBacillus anthracis.
When penicillin is contraindicated, doxycycline is an alternative drug in the treatment of the following infections:

Uncomplicated gonorrhea caused byNeisseria gonorrhoeae.
Syphilis caused byTreponema pallidum.
Yaws caused byTreponema pallidumsubspecies pertenue.
Listeriosis due toListeria monocytogenes.
Vincent's infection caused byFusobacterium fusiforme.
Actinomycosis caused by放线菌israelii.
Infections caused byClostridium species.

In acute intestinal amebiasis, doxycycline may be a useful adjunct to amebicides.

In severe acne, doxycycline may be useful adjunctive therapy.

DOSAGE AND ADMINISTRATION

THE USUAL DOSAGE AND FREQUENCY OF ADMINISTRATION OF DOXYCYCLINE DIFFERS FROM THAT OF THE OTHER TETRACYCLINES. EXCEEDING THE RECOMMENDED DOSAGE MAY RESULT IN AN INCREASED INCIDENCE OF SIDE EFFECTS.

Adults

The usual dose of oral doxycycline is 200 mg on the first day of treatment (administered 100 mg every 12 hours or 50 mg every 6 hours) followed by a maintenance dose of 100 mg/day. The maintenance dose may be administered as a single dose or as 50 mg every 12 hours. In the management of more severe infections (particularly chronic infections of the urinary tract), 100 mg every 12 hours is recommended.

Pediatric Patients

For all pediatric patients weighing less than 45 kg with severe or life-threatening infections (e.g. anthrax, Rocky Mountain spotted fever), the recommended dosage is 2.2 mg/kg of body weight administered every 12 hours. Children weighing 45 kg or more should receive the adult dose (see警告AND PRECAUTIONS).

For pediatric patients with less severe disease (greater than 8 years of age and weighing less than 45 kg), the recommended dosage schedule is 4.4 mg per kg of body weight divided into two doses on the first day of treatment, followed by a maintenance dose of 2.2 mg per kg of body weight (given as a single daily dose or divided into twice daily doses). For pediatric patients weighing over 45 kg, the usual adult dose should be used.

The therapeutic antibacterial serum activity will usually persist for 24 hours following recommended dosage.

当用于链球菌正无穷ections, therapy should be continued for 10 days.

Administration of adequate amounts of fluid along with capsule and tablet forms of drugs in the tetracycline class is recommended to wash down the drugs and reduce the risk of esophageal irritation and ulceration. (SeeADVERSE REACTIONS)

如果胃刺激发生,建议that doxycycline be given with food or milk. The absorption of doxycycline is not markedly influenced by simultaneous ingestion of food or milk.

研究表明,管理of doxycycline at the usual recommended doses does not lead to excessive accumulation of doxycycline in patients with renal impairment.

Uncomplicated Gonococcal Infections In Adults (Except Anorectal Infections In Men)

100 mg, by mouth, twice a day for 7 days. As an alternate single visit dose, administer 300 mg stat followed in one hour by a second 300 mg dose.

Acute Epididymo-orchitis Caused byN. gonorrhoeae

100 mg, by mouth, twice a day for at least 10 days.

Primary And Secondary Syphilis

300 mg a day in divided doses for at least 10 days.

Uncomplicated Urethral, Endocervical, Or Rectal Infection In Adults Caused byChlamydia trachomatis

100 mg, by mouth, twice a day for at least 7 days.

Nongonococcal Urethritis Caused byC. trachomatisAndU. urealyticum

100 mg, by mouth, twice a day for at least 7 days.

Acute Epididymo-orchitis Caused byC. trachomatis

100 mg, by mouth, twice a day for at least 10 days.

Inhalational Anthrax (Post-Exposure)

ADULTS: 100 mg of doxycycline, by mouth, twice a day for 60 days. CHILDREN: weighing less than 45 kg 2.2 mg/kg of body weight, by mouth, twice a day for 60 days. Children weighing 45 kg or more should receive the adult dose.

HOW SUPPLIED

Okebo® (Doxycycline Monohydrate USP) Capsules, 50 mgare brown opaque cap and yellow opaque body imprinted with “LU” on cap in white ink and “M71” on the body in black ink filled with light yellow to grey colored blend.

Each capsule contains doxycycline monohydrate USP equivalent to 50 mg doxycycline. Okebo® (Doxycycline Monohydrate USP) Capsules, 50 mg is available in: Bottle of 100 capsulesNDC69482-400-99

Okebo® (Doxycycline Monohydrate USP) Capsules, 75 mgare brown opaque cap and light yellow opaque body imprinted with “LU” on cap in white ink and “M72” on the body in black ink filled with light yellow to grey colored blend.

Each capsule contains doxycycline monohydrate USP equivalent to 75 mg doxycycline. Okebo® (Doxycycline Monohydrate USP) Capsules, 75 mg is available in: Bottle of 100 capsulesNDC69482-475-99

Okebo® (Doxycycline Monohydrate USP) Capsules, 100 mgare brown opaque cap and yellow opaque body imprinted with “LU” on cap in white ink and “M73” on the body in black ink filled with light yellow to grey colored blend.

Each capsule contains doxycycline monohydrate USP equivalent to 100 mg doxycycline. Okebo® (Doxycycline Monohydrate USP) Capsules, 100 mg is available in: Bottle of 50 capsulesNDC69482-450-50

Store at 25°C (77°F); excursions permitted to 15 to 30°C (59 to 86°F) [see USP controlled room temperature]. Protect from light.

Dispense in a tight, light-resistant container as defined in the USP/NF.

Distributed by: Encore Dermatology, Inc., 5 Great Valley Parkway, Malvern, PA 19355 USA. Manufactured by: Lupin Limited, Goa 403 722, INDIA. Revised :Jun 2017

SIDE EFFECTS

由于口服强力霉素几乎完成absorption, side effects to the lower bowel, particularly diarrhea, have been infrequent. The following adverse reactions have been observed in patients receiving tetracyclines.

Gastrointestinal

Anorexia, nausea, vomiting, diarrhea, glossitis, dysphagia, enterocolitis, and inflammatory lesions (with monilial overgrowth) in the anogenital region, and pancreatitis. Hepatotoxicity has been reported. These reactions have been caused by both the oral and parenteral administration of tetracyclines. Rare instances of esophagitis and esophageal ulcerations have been reported in patients receiving capsule and tablet forms of drugs in the tetracycline class. Most of these patients took medications immediately before going to bed. (SeeDOSAGE AND ADMINISTRATION.)

Skin

Maculopapular and erythematous rashes, Stevens-Johnson syndrome, toxic epidermal necrolysis, and erythema multiforme have been reported. Exfoliative dermatitis has been reported but is uncommon. Photosensitivity is discussed above. (See警告.)

肾毒性

Rise in BUN has been reported and is apparently dose related. (See警告.)

Hypersensitivity Reactions

Urticaria, angioneurotic edema, anaphylaxis, anaphylactoid purpura, serum sickness, pericarditis, and exacerbation of systemic lupus erythematosus.

Blood

Hemolytic anemia, thrombocytopenia, neutropenia, and eosinophilia have been reported with tetracyclines.

Other

Intracranial hypertension (IH, pseudotumor cerebri) has been associated with the use of tetracyclines. (SeePRECAUTIONS,General.)

When given over prolonged periods, tetracyclines have been reported to produce brown-black microscopic discoloration of the thyroid gland. No abnormalities of thyroid function are known to occur.

DRUG INTERACTIONS

Because tetracyclines have been shown to depress plasma prothrombin activity, patients who are on anticoagulant therapy may require downward adjustment of their anticoagulant dosage.

Since bacteriostatic drugs may interfere with the bactericidal action of penicillin, it is advisable to avoid giving tetracyclines in conjunction with penicillin.

抗酸剂吸收四环素受损s containing aluminum, calcium, or magnesium, and iron-containing preparations.

Barbiturates, carbamazepine, and phenytoin decrease the half-life of doxycycline.

The concurrent use of tetracycline and methoxyflurane has been reported to result in fatal renal toxicity.

Concurrent use of tetracycline may render oral contraceptives less effective.

警告

The use of drugs of the tetracycline class, including doxycycline, during tooth development (last half of pregnancy, infancy and childhood to the age of 8 years) may cause permanent discoloration of the teeth (yellow-gray-brown). This adverse reaction is more common during long-term use of the drugs, but it has been observed following repeated short-term courses. Enamel hypoplasia has also been reported. Use of doxycycline in pediatric patients 8 years of age or less only when the potential benefits are expected to outweigh the risks in severe or lifethreatening conditions (e.g. anthrax, Rocky Mountain spotted fever), particularly when there are no alternative therapies.

Clostridium difficileassociated diarrhea (CDAD) has been reported with use of nearly all antibacterial agents, including Okebo, 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 ofC. difficile.

C. difficileproduces toxins A and B which contribute to the development of CDAD. Hypertoxin producing strains ofC. difficilecause 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 againstC. difficilemay need to be discontinued. Appropriate fluid and electrolyte management, protein supplementation, antibiotic treatment ofC. difficile, and surgical evaluation should be instituted as clinically indicated.

Intracranial hypertension (IH, pseudotumor cerebri) has been associated with the use of tetracyclines including Okebo. Clinical manifestations of IH include headache, blurred vision, diplopia, and vision loss; papilledema can be found on fundoscopy. Women of childbearing age who are overweight or have a history of IH are at greater risk for developing tetracycline associated IH. Concomitant use of isotretinoin and Okebo should be avoided because isotretinoin is also known to cause pseudotumor cerebri.

Although IH typically resolves after discontinuation of treatment, the possibility for permanent visual loss exists. If visual disturbance occurs during treatment, prompt ophthalmologic evaluation is warranted. Since intracranial pressure can remain elevated for weeks after drug cessation patients should be monitored until they stabilize.

All tetracyclines form a stable calcium complex in any bone-forming tissue. A decrease in the fibula growth rate has been observed in prematures given oral tetracycline in doses of 25 mg/kg every six hours. This reaction was shown to be reversible when the drug was discontinued.

Results of animal studies indicate that tetracyclines cross the placenta, are found in fetal tissues, and can have toxic effects on the developing fetus (often related to retardation of skeletal development). Evidence of embryo toxicity has been noted in animals treated early in pregnancy. If any tetracycline is used during pregnancy or if the patient becomes pregnant while taking these drugs, the patient should be apprised of the potential hazard to the fetus.

The antianabolic action of the tetracyclines may cause an increase in BUN. Studies to date indicate that this does not occur with the use of doxycycline in patients with impaired renal function.

Photosensitivity manifested by an exaggerated sunburn reaction has been observed in some individuals taking tetracyclines. Patients apt to be exposed to direct sunlight or ultraviolet light should be advised that this reaction can occur with tetracycline drugs, and treatment should be discontinued at the first evidence of skin erythema.

PRECAUTIONS

General

与其它抗菌制剂,使用this drug may result in overgrowth of nonsusceptible organisms, including fungi. If superinfection occurs, Okebo should be discontinued and appropriate therapy instituted.

Incision and drainage or other surgical procedures should be performed in conjunction with antibacterial therapy when indicated.

Prescribing Okebo in the absence of 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

In venereal disease when coexistent syphilis is suspected, a dark-field examination should be done before treatment is started and the blood serology repeated monthly for at least four months.

In long-term therapy, periodic laboratory evaluations of organ systems, including hematopoietic, renal, and hepatic studies should be performed.

Drug/Laboratory Test Interactions

False elevations of urinary catecholamine levels may occur due to interference with the fluorescence test.

Nonclinical Toxicology

Carcinogenesis, Mutagenesis, Impairment Of Fertility

Long-term studies in animals to evaluate the carcinogenic potential of doxycycline have not been conducted. However, there has been evidence of oncogenic activity in rats in studies with related antibacterial, oxytetracycline (adrenal and pituitary tumors) and minocycline (thyroid tumors). Likewise, although mutagenicity studies of doxycycline have not been conducted, positive results in in vitro mammalian cell assays have been reported for related antibacterial (tetracycline, oxytetracycline). Doxycycline administered orally at dosage levels as high as 250 mg/kg/day had no apparent effect on the fertility of female rats. Effect on male fertility has not been studied.

Pregnancy

Teratogenic Effects

Pregnancy Category D

There are no adequate and well-controlled studies on the use of doxycycline in pregnant shortterm, first trimester exposure. There are no human data available to assess the effects of longterm therapy of doxycycline in pregnant women such as that proposed for treatment of anthrax exposure. An expert review of published data on experiences with doxycycline use during pregnancy by TERIS -the Teratogen Information System -concluded that therapeutic doses during pregnancy are unlikely to pose a substantial teratogenic risk (the quantity and quality of data were assessed as limited to fair), but the data are insufficient to state that there is no risk.⁸

A case-control study (18,515 mothers of infants with congenital anomalies and 32,804 mothers of infants with no congenital anomalies) shows a weak but marginally statistically significant association with total malformations and use of doxycycline anytime during pregnancy. (Sixtythree [0.19%] of the controls and 56 [0.30%] of the cases were treated with doxycycline.) This association was not seen when the analysis was confined to maternal treatment during the period of organogenesis (i.e., in the second and third months of gestation) with the exception of a marginal relationship with neural tube defect based on only two exposed cases.⁹

A small prospective study of 81 pregnancies describes 43 pregnant women treated for 10 days with doxycycline during early first trimester. All mothers reported their exposed infants were normal at 1 year of age.¹⁰

Labor And Delivery

The effect of tetracyclines on labor and delivery is unknown.

Nursing Mothers

Tetracyclines are excreted in human milk, however, the extent of absorption of tetracyclines, including doxycycline, by the breastfed infant is not known. Short-term use by lactating women is not necessarily contraindicated; however, the effects of prolonged exposure to doxycycline in breast milk are unknown.¹¹Because of the potential for adverse reactions in nursing infants from doxycycline, a decision should be made whether to discontinue nursing or to discontinue the drug, taking into account the importance of the drug to the mother. (See警告.)

Pediatric Use

Because of the effects of drugs of the tetracycline –class, on tooth development and growth, use doxycycline in pediatric patients 8 years of age or less only when the potential benefits are expected to outweigh the risks in severe or life-threatening conditions (e.g. anthrax, Rocky Mountain spotted fever), particularly when there are no alternative therapies. (see警告andDOSAGE AND ADMINISTRATION).

REFERENCES

8. Friedman JM and Polifka JE. Teratogenic Effects of Drugs. A Resource for Clinicians (TERIS). Baltimore, MD: The Johns Hopkins University Press: 2000: 149-195.

9. Cziezel AE and Rockenbauer M. Teratogenic study of doxycycline. Obstet Gynecol 1997; 89:524-528.

10. Horne HW Jr. and Kundsin RB. The role of mycoplasma among 81 consecutive pregnancies: a prospective study. Int J Fertil 1980; 25:315-317.

11. Hale T. Medications and Mothers Milk. 9th edition. Amarillo, TX: Pharmasoft Publishing 2000; 225-226.

OVERDOSE

In case of overdosage, discontinue medication, treat symptomatically and institute supportive measures. Dialysis does not alter serum half-life, and it would not be of benefit in treating cases of overdosage.

CONTRAINDICATIONS

This drug is contraindicated in persons who have shown hypersensitivity to any of the tetracyclines.

CLINICAL PHARMACOLOGY

Tetracyclines are readily absorbed and are bound to plasma proteins in varying degrees. They are concentrated by the liver in the bile and excreted in the urine and feces at high concentrations in a biologically active form. Doxycycline is virtually completely absorbed after oral administration.

Following a 200 mg dose of doxycycline monohydrate, 24 normal adult volunteers averaged the following serum concentration values:

Time (hr):	0.5	1.0	1.5	2.0	3.0	4.0	8.0	12.0	24.0	48.0	72.0
Conc.	1.02	2.26	2.67	3.01	3.16	3.03	2.03	1.62	0.95	0.37	0.15 (mcg/mL)
Average Observed Values
Maximum Concentration	3.61 mcg/mL (± 0.9 sd)
Time of Maximum Concentration	2.60 hr (± 1.10 sd)
Elimination Rate Constant	0.049 per hr (± 0.030 sd)
Half-Life	16.33 hr (± 4.53 sd)

Excretion of doxycycline by the kidney is about 40%/72 hours in individuals with normal function (creatinine clearance about 75 mL/min). This percentage excretion may fall as low as 1 to 5%/72 hours in individuals with severe renal insufficiency (creatinine clearance below 10 mL/min). Studies have shown no significant difference in serum half-life of doxycycline (range 18 to 22 hours) in individuals with normal and severely impaired renal function.

Hemodialysisdoes not alter serum half-life.

Microbiology

Mechanism Of Action

Doxycycline inhibits bacterial protein synthesis by binding to the 30S ribosomal subunit. Doxycycline hasbacteriostaticactivity against a broad range ofGram-positive and Gramnegative bacteria.

Resistance

Cross resistance with other tetracyclines is common.

Antimicrobial Activity

Doxycycline has been shown to be active against most isolates of the following microorganisms, both in vitro and in clinical infections (seeINDICATIONS AND USAGE).

Gram-Negative Bacteria

Acinetobacterspecies
Bartonella bacilliformis
Brucellaspecies
Enterobacter aerogenes
大肠杆菌
Francisella tularensis
Haemophilus ducreyi
Haemophilus influenzae
Klebsiella granulomatis
Klebsiellaspecies
Neisseria gonorrhoeae
Shigellaspecies
Vibrio cholerae
Vibrio fetus
Yersinia pestis

Gram-Positive Bacteria

Bacillus anthracis
Listeria monocytogenes
Streptococcus pneumoniae

Anaerobes

Clostridiumspecies
Fusobacterium fusiforme
Propionibacterium acnes

Other Bacteria

Nocardiae andother aerobic放线菌species
Borrelia recurrentis
Chlamydophila psittaci
Chlamydia trachomatis
Mycoplasma pneumoniae
Rickettsiae
Treponema pallidum
Treponema pallidumsubspecies pertenue
Ureaplasma urealyticum

Parasites

Balantidium coli
Entamoebaspecies
Plasmodium falciparum*

*Doxycycline has been found to be active against the asexual erythrocytic forms ofPlasmodium falciparum, but not against the gametocytes ofP. falciparum. The precise mechanism of action of the drug is not known.

Susceptibility Testing Methods

When available, the clinical microbiology laboratory should provide cumulative reports of in vitro susceptibility test results for antimicrobial drugs used in local hospitals and practice areas as periodic reports that describe the susceptibility profile of nosocomial and communityacquired pathogens. These reports should aid the physician in selecting the most effective antimicrobial.

Dilution Techniques

Quantitative methods are used to determine antimicrobial minimum inhibitory concentrations (MICs). These MICs provide estimates of the susceptibility of bacteria to antimicrobial compounds. The MICs should be determined using a standardized test method (broth and/or agar).^1,2,4,6,7The MIC values should be interpreted according to criteria provided in Table 1.

Diffusion Techniques

Quantitative methods that require measurement of zone diameters can also provide reproducible estimates of the susceptibility of bacteria to antimicrobial compounds. The zone size should be determined using a standard test method.^1,3,4This procedure uses paper disks impregnated with 30 mcg doxycycline to test the susceptibility of bacteria to doxycycline. The disk diffusion interpretive criteria are provided in Table 1.

Anaerobic Techniques

For anaerobic bacteria, the susceptibility to doxycycline can be determined by a standardized test method.^{1, 5}The MIC values obtained should be interpreted according to the criteria provided in Table 1.

Table 1: Susceptibility Test Interpretive Criteria for Doxycycline and Tetracycline

Bacteria*	Minimal Inhibitory Concentration (mcg/mL)			Zone Diameter (mm)			Agar Dilution (mcg/mL)
	S	I	R	S	I	R	S	I	R
Acinetobacterspp.
Doxycycline	≤4	8	≥16	≥13	10 to 12	≤9	-	-	-
Tetracycline	≤4	8	≥16	≥15	12 to 14	≤11	-	-	-
Anaerobes
Tetracycline	-	-	-	-	-	-	≤4	8	≥16
Bacillus anthracis†
Doxycycline	≤1	-	-	-	-	-	-	-	-
Tetracycline	≤1	-	-	-	-	-	-	-	-
Brucella species†
Doxycycline	≤1	_	-	-	-	-	-	-	-
Tetracycline	≤1	-	-	-	-	-	-	-	-
Enterobacteriaceae
Doxycycline	≤4	8	≥16	≥14	11 to 13	≤10	-	-	-
Tetracycline	≤4	8	≥16	≥15	12 to 14	≤11	-	-	-
Franciscella tularensis†
Doxycycline	≤4	-	-	-	-	-	-	-	-
Tetracycline	≤4	-	-	-	-	-	-	-	-
Haemophilus influenzae
Tetracycline	≤2	4	≥8	≥29	26 to 28	≤25	-	-	-
Mycoplasma pneumoniae†
Tetracycline	-	-	-	-	-	-	≤2	-	-
Neisseria gonorrhoeae‡
Tetracycline	-	-	-	≥38	31 to 37	≤30	≤0.25	0.5 to 1	-
Norcardiae and other aerobic Actinomyces species
Doxycycline	≤1	2 to 4	≥8	-	-	-	-	-	-
Streptococcus pneumoniae
Doxycycline	≤0.25	0.5	> 1	> 28	25 to 27	< 24	-	-	-
Tetracycline	<1	2	> 4	> 28	25 to 27	< 24	-	-	-
Vibrio cholerae
Doxycycline	≤4	8	≥16	-	-	-	-	-	-
Tetracycline	≤4	8	≥16	-	-	-	-	-	-
Yersinia pestis
Doxycycline	≤4	8	≥16	-	-	-	-	-	-
Tetracycline	≤4	8	≤16	-	-	-	-	-	-
Ureaplasma urealyticum
Tetracycline	-	-	-	-	-	-	≤1	-	≤2
* Organisms susceptible to tetracycline are also considered susceptible to doxycycline. However, some organisms that are intermediate or resistant to tetracycline may be susceptible to doxycycline. † The current absence of resistance isolates precludes defining any results other than “Susceptible”. If isolates yielding MIC results other than susceptible, they should be submitted to a reference laboratory for further testing. ‡ Gonococci with 30 mcg tetracycline disk zone diameters of <19 mm usually indicate a plasmid-mediated tetracycline resistantNeisseria gonorrhoeaeisolate. Resistance in these strains should be confirmed by a dilution test (MIC ≥ 16 mcg/mL).

A report of Susceptible (S) indicates that the antimicrobial is likely to inhibit growth of the microorganism if the antimicrobial drug reaches the concentration usually achievable at the site of infection. A report of Intermediate (I) indicates that the result should be considered equivocal, and, if the microorganism is not fully susceptible to alternative, clinically feasible drugs, the test should be repeated. This category implies possible clinical applicability in body sites where the drug product is physiologically concentrated or in situations where high dosage of drug can be used. This category also provides a buffer zone that prevents small uncontrolled technical factors from causing major discrepancies in interpretation. A report of Resistant (R) indicates that the antimicrobial drug is not likely to inhibit growth of the microorganism if the antimicrobial drug reaches the concentrations usually achievable at the infection site; other therapy should be selected.

Quality Control

Standardized susceptibility test procedures require the use of laboratory controls to monitor and ensure the accuracy and precision of supplies and reagents used in the assay, and the techniques of the individuals performing the test.^{1,2,3,4,5,6,7}Standard doxycycline and tetracycline powders should provide the following range of MIC values noted in Table 2. For the diffusion technique using the 30 mcg doxycycline disk or 30 mcg tetracycline disk, the criteria in should be achieved.

Table 2: Acceptable Quality Control Ranges for Susceptibility Testing for Doxycycline and Tetracycline

QC Strain	Minimal Inhibitory Concentration (mcg/mL)	Zone Diameter (mm)	Agar Dilution (mcg/mL)
大肠杆菌ATCC 25922
Doxycycline	0.5 to 2	18 to 24	-
Tetracycline	0.5 to 2	18 to 25	-
Eggerthella lentaATCC43055
Doxycycline	2 to 16	-	-
Haemophilus influenzaeATCC 49247
Tetracycline	4 to 32	14 to 22	-
Neisseria gonorrhoeaeATCC 49226
Tetracycline	-	30 to 42	0.25 to 1
Staphylococcus aureusATCC 25923
Doxycycline	-	23 to 29	-
Tetracycline	-	24 to 30	-
Staphylococcus aureusATCC 29213
Doxycycline	0.12 to 0.5	-	-
Tetracycline	0.12 to 1	-	-
Streptococcus pneumoniaeATCC 49619
Doxycycline	0.015 to 0.12	25 to 34	-
Tetracycline	0.06 to 0.5	27 to 31	-
Bacteroides fragilisATCC 25285
Tetracycline	-	-	0.12 to 0.5
Bacteroides thetaiotaomicron写明ATCC 29741
Doxycycline	2 to 8	-	-
Tetracycline	-	-	8 to 32
Mycoplasma pneumoniaeATCC 29342
Tetracycline	0.06 to 0.5	-	0.06 to 0.5
Ureaplasma urealyticumATCC 33175
Tetracycline	-	-	≥8
*ATCC is the American Type Culture Collection

Animal Pharmacology and Animal Toxicology

Hyperpigmentationof thethyroidhas been produced by members of thetetracyclineclass in the following species: in rats by oxytetracycline, doxycycline, tetracycline PO4, and methacycline; in minipigs by doxycycline, minocycline, tetracycline PO4, and methacycline; in dogs by doxycycline and minocycline; in monkeys by minocycline.

Minocycline, tetracycline PO4, methacycline, doxycycline, tetracycline base, oxytetracycline HCl and tetracycline HCl were goitrogenic in rats fed a lowiodinediet. This goitrogenic effect was accompanied by highradioactive iodineuptake. Administration of minocycline also produced a largegoiterwith highradioiodineuptake in rats fed a relatively high iodine diet.

Treatment of various animal species with this class of drugs has also resulted in the induction of thyroidhyperplasiain the following: in rats and dogs (minocycline), in chickens (chlortetracycline) and in rats and mice (oxytetracycline).Adrenal glandhyperplasia has been observed in goats and rats treated with oxytetracycline.

REFERENCES

1. Clinical and Laboratory Standards Institute (CLSI). Performance Standards forAntimicrobialSusceptibility Testing; Twenty-seventh Informational Supplement, CLSI document M100-S27 [2017]. Clinical and Laboratory Standards Institute, 950 West Valley Road, Suite 2500, Wayne, Pennsylvania 19087, USA.

2. Clinical and Laboratory Standards Institute. Methods for Dilution Antimicrobial Susceptibility Tests for Bacteria that Grow Aerobically; Approved Standard - Tenth Edition. CLSI document M07- A10 [2015], Clinical and Laboratory Standards Institute, 950 West Valley Road, Suite 2500, Wayne, Pennsylvania 19087, USA.

3. Clinical and Laboratory Standards Institute. Performance Standards for Antimicrobial Disk Susceptibility Tests; Approved Standard - Twelfth Edition. CLSI document M02-A12 [2015], Clinical and Laboratory Standards Institute, 950 West Valley Road, Suite 2500, Wayne, Pennsylvania 19087, USA.

4. Clinical and Laboratory Standards Institute. Methods for Antimicrobial Dilution and Disk Susceptibility Testing of Infrequently Isolated or Fastidious Bacteria; Approved Guideline - Third Edition. CLSI document M45-A3 [2015], Clinical and Laboratory Standards Institute, 950 West Valley Road, Suite 2500, Wayne, Pennsylvania 19087, USA.

5. Clinical and Laboratory Standards Institute (CLSI). Methods for Antimicrobial Susceptibility Testing ofAnaerobicBacteria; Approved Standard - Eighth Edition. CLSI document M11- A8 [2012], Clinical and Laboratory Standards Institute, 950 West Valley Road, Suite 2500, Wayne, PA 19087 USA.

6. Clinical and Laboratory Standards Institute. Susceptibility Testing ofMycobacteria, Nocardiae, and OtherAerobicActinomycetes; Approved Standard - Second Edition. CLSI document M24-A2 [2011], Clinical and Laboratory Standards Institute, 950 West Valley Road, Suite 2500, Wayne, Pennsylvania 19087, USA.

7. Clinical and Laboratory Standards Institute. Methods for Antimicrobial Susceptibility Testing for Human Mycoplasmas; Approved Guideline. CLSI document M43-A [2011], Clinical and Laboratory Standards Institute, 950 West Valley Road, Suite 2500, Wayne, Pennsylvania 19087, USA.

PATIENT INFORMATION

All patients taking doxycycline should be advised:

• to avoid excessive sunlight or artificial ultraviolet light while receiving doxycycline and to discontinue therapy if phototoxicity (e.g., skin eruptions, etc.) occurs.Sunscreenor sunblock should be considered. (See警告.)
• 对drink fluids liberally along with doxycycline to reduce the risk ofesophagealirritation andulceration. (SeeADVERSE REACTIONS.)
• that the absorption of tetracyclines is reduced when taken with foods, especially those which contain calcium. However, the absorption of doxycycline is not markedly influenced by simultaneous ingestion of food or milk. (SeeDRUG INTERACTIONS.)
• that the absorption of tetracyclines is reduced when takingbismuthsubsalicylate. (SeeDRUG INTERACTIONS.)
• not to use outdated or poorly stored doxycycline.
• that the use of doxycycline might increase the incidence of vaginalcandidiasis.

Diarrhea is a common problem caused by antibiotics which usually ends when theantibioticis discontinued. Sometimes after starting treatment with antibiotics, patients can develop watery and bloody stools (with or withoutstomach crampsand fever) even as late as two or more months after having taken the last dose of the antibiotic. If this occurs, patients should contact their physician as soon as possible.

Patients should be counseled that antibacterial drugs including Okebo should only be used to treat bacterial infections. They do not treat viral infections (e.g., thecommon cold). When Okebo is prescribed to treat a bacterial infection, patients should be told that although it is common to feel better early in the course of therapy, the medication should be taken exactly as directed. Skipping doses or not completing the full course of therapy may (1) decrease the effectiveness of the immediate treatment and (2) increase the likelihood that bacteria will develop resistance and will not be treatable by Okebo or other antibacterial drugs in the future.