Rocephin

DESCRIPTION

Rocephin is a sterile, semisynthetic, broad-spectrum cephalosporinantibioticfor intravenous orintramuscularadministration. Ceftriaxone sodium is (6R,7R)-7-[2-(2Amino-4-thiazolyl)glyoxylamido]-8-oxo-3-[[(1,2,5,6-tetrahydro-2-methyl-5,6-dioxo-astriazin-3-yl)thio]methyl]-5-thia-1-azabicyclo[4.2.0]oct-2-ene-2-carboxylic acid, 7²-(Z)(O-methyloxime), disodium salt, sesquaterhydrate.

The chemical formula of ceftriaxone sodium is C₁₈H₁₆N₈Na₂O₇S₃•3.5H₂O. It has a calculated molecular weight of 661.59 and the following structural formula:

Rocephin is a white to yellowish-orange crystalline powder which is readily soluble in water, sparingly soluble in methanol and very slightly soluble in ethanol. The pH of a 1% aqueous solution is approximately 6.7. The color of Rocephin solutions ranges from light yellow to amber, depending on the length of storage, concentration and diluent used.

Rocephin contains approximately 83 mg (3.6 mEq) of sodium per gram of ceftriaxone activity.

INDICATIONS

Before instituting treatment with Rocephin, appropriate specimens should be obtained for isolation of the causative organism and for determination of its susceptibility to the drug. Therapy may be instituted prior to obtaining results of susceptibility testing.

减少耐药bacter的发展ia and maintain the effectiveness of Rocephin and other antibacterial drugs, Rocephin 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.

Rocephin is indicated for the treatment of the following infections when caused by susceptible organisms:

LOWER RESPIRATORY TRACT INFECTIONScaused byStreptococcus pneumoniae, Staphylococcus aureus, Haemophilus influenzae, Haemophilus parainfluenzae, Klebsiella pneumoniae, Escherichia coli, Enterobacter aerogenes, Proteus mirabilis or Serratia marcescens.

ACUTE BACTERIAL OTITIS MEDIAcaused byStreptococcus pneumoniae, Haemophilus influenzae(including beta-lactamase producing strains) orMoraxella catarrhalis(including beta-lactamase producing strains).

NOTE: In one study lower clinical cure rates were observed with a single dose of Rocephin compared to 10 days of oral therapy. In a second study comparable cure rates were observed between single dose Rocephin and the comparator. The potentially lower clinical cure rate of Rocephin should be balanced against the potential advantages of parenteral therapy (seeClinical Studies).

SKIN AND SKIN STRUCTURE INFECTIONScaused byStaphylococcus aureus, Staphylococcus epidermidis, Streptococcus pyogenes,Viridans group streptococci,Escherichia coli, Enterobacter cloacae, Klebsiella oxytoca, Klebsiella pneumoniae, Proteus mirabilis, Morganella morganii,* Pseudomonas aeruginosa, Serratia marcescens, Acinetobacter calcoaceticus, Bacteroides fragilis*orPeptostreptococcusspecies.

URINARY TRACT INFECTIONS (complicated and uncomplicated)caused byEscherichia coli, Proteus mirabilis, Proteus vulgaris, Morganella morganiiorKlebsiella pneumoniae.

UNCOMPLICATED GONORRHEA (cervical/urethral and rectal)caused byNeisseria gonorrhoeae,including both penicillinase-and nonpenicillinase-producing strains, and pharyngeal gonorrhea caused by nonpenicillinase-producing strainsof Neisseria gonorrhoeae.

PELVIC INFLAMMATORY DISEASEcaused byNeisseria gonorrhoeae.Rocephin, like other cephalosporins, has no activity againstChlamydia trachomatis.Therefore, when cephalosporins are used in the treatment of patients with pelvic inflammatory disease andChlamydia trachomatisis one of the suspected pathogens, appropriate antichlamydial coverage should be added.

BACTERIAL SEPTICEMIAcaused byStaphylococcus aureus, Streptococcus pneumoniae, Escherichia coli, Haemophilus influenzaeorKlebsiella pneumoniae.

骨和关节感染caused byStaphylococcus aureus, Streptococcus pneumoniae, Escherichia coli, Proteus mirabilis, Klebsiella pneumoniaeorEnterobacterspecies.

INTRA-ABDOMINAL INFECTIONScaused byEscherichia coli, Klebsiella pneumoniae, Bacteroides fragilis, Clostridium species(Note: most strains ofClostridium difficile are resistant)orPeptostreptococcusspecies.

MENINGITIScaused byHaemophilus influenzae, Neisseria meningitidisorStreptococcus pneumoniae.Rocephin has also been used successfully in a limited number of cases of meningitis and shunt infection caused byStaphylococcus epidermidis*andEscherichia coli.*

*Efficacy for this organism in this organ system was studied in fewer than ten infections.

SURGICAL PROPHYLAXIS:The preoperative administration of a single 1 gm dose of Rocephin may reduce the incidence of postoperative infections in patients undergoing surgical procedures classified as contaminated or potentially contaminated (eg, 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 (eg, during coronary artery bypass surgery). Although Rocephin 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 antibiotic in the prevention of infection following coronary artery bypass surgery.

When administered prior to surgical procedures for which it is indicated, a single 1 gm dose of Rocephin provides protection from most infections due to susceptible organisms throughout the course of the procedure.

DOSAGE AND ADMINISTRATION

Rocephin may be administered intravenously or intramuscularly.

Do not use diluents containing calcium, such as Ringer’s solution or Hartmann’s solution, to reconstitute Rocephin vials or to further dilute a reconstituted vial for IV administration because a precipitate can form. Precipitation of ceftriaxone-calcium can also occur when Rocephin is mixed with calcium-containing solutions in the same IV administration line. Rocephin 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, Rocephin 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警告).

交互的是没有报告en ceftriaxone and oral calcium-containing products or interaction between intramuscular ceftriaxone and calcium-containing products (IV or oral).

Neonates

Hyperbilirubinemic neonates, especially prematures, should not be treated with Rocephin. Rocephin is contraindicated in premature neonates (seeCONTRAINDICATIONS).

Rocephin is contraindicated in neonates (≤ 28 days) if they require (or are expected to require) treatment with calcium-containing IV solutions, including continuous calcium-containing infusions such as parenteral nutrition because of the risk of precipitation of ceftriaxone-calcium (seeCONTRAINDICATIONS).

Intravenous doses should be given over 60 minutes in neonates to reduce the risk of bilirubin encephalopathy.

Pediatric Patients

For the treatment of skin and skin structure infections, the recommended total daily dose is 50 to 75 mg/kg given once a day (or in equally divided doses twice a day). The total daily dose should not exceed 2 grams.

For the treatment of acute bacterial otitis media, a single intramuscular dose of 50 mg/kg (not to exceed 1 gram) is recommended (seeINDICATIONS). For the treatment of serious miscellaneous infections other than meningitis, the recommended total daily dose is 50 to 75 mg/kg, given in divided doses every 12 hours. The total daily dose should not exceed 2 grams.

In the treatment of meningitis, it is recommended that the initial therapeutic dose be 100 mg/kg (not to exceed 4 grams). Thereafter, a total daily dose of 100 mg/kg/day (not to exceed 4 grams daily) is recommended. The daily dose may be administered once a day (or in equally divided doses every 12 hours). The usual duration of therapy is 7 to 14 days.

Adults

通常成人每日剂量为1到2 g once a day (or in equally divided doses twice a day) depending on the type and severity of infection. The total daily dose should not exceed 4 grams.

IfChlamydia trachomatisis a suspected pathogen, appropriate antichlamydial coverage should be added, because ceftriaxone sodium has no activity against this organism.

For the treatment of uncomplicated gonococcal infections, a single intramuscular dose of 250 mg is recommended.

For preoperative use (surgical prophylaxis), a single dose of 1 gram administered intravenously 1/2 to 2 hours before surgery is recommended.

Generally, Rocephin therapy should be continued for at least 2 days after the signs and symptoms of infection have disappeared. The usual duration of therapy is 4 to 14 days; in complicated infections, longer therapy may be required.

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

No dosage adjustment is necessary for patients with impairment of renal or hepatic function (seePRECAUTIONS).

The dosages recommended for adults require no modification in elderly patients, up to 2 gm per day, provided there is no severe renal and hepatic impairment (seePRECAUTIONS).

Directions For Use

Intramuscular Administration

Reconstitute Rocephin powder with the appropriate diluent (seeCompatibility And Stability).

Inject diluent into vial, shake vial thoroughly to form solution. Withdraw entire contents of vial into syringe to equal total labeled dose.

After reconstitution, each 1 mL of solution contains approximately 250 mg or 350 mg equivalent of ceftriaxone according to the amount of diluent indicated below. If required, more dilute solutions could be utilized.

肌肉内的所有准备工作,Rocephin年代hould be injected well within the body of a relatively large muscle; aspiration helps to avoid unintentional injection into a blood vessel.

Vial Dosage Size	Amount of Diluent to be Added
	250 mg/mL	350 mg/mL
500 mg	1.8 mL	1.0 mL
1 gm	3.6 mL	2.1 mL

Intravenous Administration

Rocephin should be administered intravenously by infusion over a period of 30 minutes, except in neonates where administration over 60 minutes is recommended to reduce the risk of bilirubinencephalopathy. Concentrations between 10 mg/mL and 40 mg/mL are recommended; however, lower concentrations may be used if desired. Reconstitute vials with an appropriate IV diluent (seeCompatibility And Stability).

Vial Dosage Size	Amount of Diluent to be Added
500 mg	4.8 mL
1 gm	9.6 mL

After reconstitution, each 1 mL of solution contains approximately 100 mg equivalent of ceftriaxone. Withdraw entire contents and dilute to the desired concentration with the appropriate IV diluent.

Compatibility And Stability

Do not use diluents containing calcium, such as Ringer’s solution or Hartmann’s solution, to reconstitute Rocephin vials or to further dilute a reconstituted vial for IV administration. Particulate formation can result.

Ceftriaxone has been shown to be compatible with Flagyl^®IV (metronidazole hydrochloride). The concentration should not exceed 5 to 7.5 mg/mL metronidazole hydrochloride with ceftriaxone 10 mg/mL as an admixture. The admixture is stable for 24 hours at room temperature only in 0.9% sodium chloride injection or 5% dextrose in water (D5W). No compatibility studies have been conducted with the Flagyl^®IV RTU^®(metronidazole) formulation or using other diluents. Metronidazole at concentrations greater than 8 mg/mL will precipitate. Do not refrigerate the admixture as precipitation will occur.

Vancomycin, amsacrine, aminoglycosides, and fluconazole are 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 one of the compatible fluids) between the administrations.

Rocephin solutions shouldnotbe physically mixed with or piggybacked into solutions containing otherantimicrobialdrugs or into diluent solutions other than those listed above, due to possible incompatibility (see警告).

Rocephin sterile powder should be stored at room temperature—77°F (25°C)—or below and protected from light. After reconstitution, protection from normal light is not necessary. The color of solutions ranges from light yellow to amber, depending on the length of storage, concentration and diluent used.

Rocephinintramuscularsolutions remain stable (loss of potency less than 10%) for the following time periods:

	Storage
Diluent	Concentration mg/ml	Room Temp. (25°C)	Refrigerated (4°C)
Sterile Water for Injection	100	2 days	10 days
	250, 350	24 hours	3 days
0.9% Sodium Chloride Solution	100	2 days	10 days
	250, 350	24 hours	3 days
5% Dextrose Solution	100	2 days	10 days
	250, 350	24 hours	3 days
Bacteriostatic Water + 0.9% Benzyl Alcohol	100	24 hours	10 days
	250, 350	24 hours	3 days
1% Lidocaine Solution	100	24 hours	10 days
(without epinephrine)	250, 350	24 hours	3 days

Rocephinintravenoussolutions, at concentrations of 10, 20 and 40 mg/mL, remain stable (loss of potency less than 10%) for the following time periods stored in glass or PVC containers:

	Storage
Diluent	Room Temp. (25°C)	Refrigerated (4°C)
Sterile Water	2 days	10 days
0.9% Sodium Chloride Solution	2 days	10 days
5% Dextrose Solution	2 days	10 days
10% Dextrose Solution	2 days	10 days
5% Dextrose + 0.9% Sodium Chloride Solution*	2 days	Incompatible
5% Dextrose + 0.45% Sodium Chloride Solution	2 days	Incompatible
*Data available for 10 to 40 mg/mL concentrations in this diluent in PVC containers only.

The following intravenous Rocephin solutions are stable at room temperature (25°C) for 24 hours, at concentrations between 10 mg/mL and 40 mg/mL: Sodium Lactate (PVC container), 10% Invert Sugar (glass container), 5% Sodium Bicarbonate (glass container), Freamine III (glass container), Normosol-M in 5% Dextrose (glass and PVC containers), Ionosol-B in 5% Dextrose (glass container), 5% Mannitol (glass container), 10% Mannitol (glass container).

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

Note

Parenteral drug products should be inspected visually for particulate matter before administration.

Rocephin reconstituted with 5% Dextrose or 0.9% Sodium Chloride solution at concentrations between 10 mg/mL and 40 mg/mL, and then stored in frozen state (-20°C) in PVC or polyolefin containers, remains stable for 26 weeks.

Frozen solutions of Rocephin should be thawed at room temperature before use. After thawing, unused portions should be discarded.DO NOT REFREEZE.

HOW SUPPLIED

Rocephinis supplied as a sterile crystalline powder in glass vials. The following packages are available:

Vials containing 500 mg equivalent of ceftriaxone. Box of 1 (NDC0004-1963-02) and box of 10 (NDC0004-1963-01).

Vials containing 1 gm equivalent of ceftriaxone. Box of 1 (NDC0004-1964-04) and box of 10 (NDC0004-1964-01).

Note

Rocephin sterile powder should be stored at room temperature, 77°F (25°C) or below, and protected from light.

Distributed by:Genentech USA, Inc.A Member of the Roche Group, 1 DNA Way, South San Francisco, CA 94080-4990. Revised: July 2018

SIDE EFFECTS

Rocephin is generally well tolerated. In clinical trials, the following adverse reactions, which were considered to be related to Rocephin therapy or of uncertain etiology, were observed:

Local Reactions-pain, induration and tenderness was 1% overall. Phlebitis was reported in <1% after IV administration. The incidence of warmth, tightness or induration was 17% (3/17) after IM administration of 350 mg/mL and 5% (1/20) after IM administration of 250 mg/mL.

General Disorders And Administration Site Conditions-injection site pain (0.6%).

Hypersensitivity-rash (1.7%). Less frequently reported (<1%) were pruritus, fever or chills.

Infections And Infestations-genital fungal infection (0.1%).

Hematologic-eosinophilia (6%), thrombocytosis (5.1%) and leukopenia (2.1%). Less frequently reported (<1%) were anemia, hemolytic anemia, neutropenia, lymphopenia, thrombocytopenia and prolongation of the prothrombin time.

Blood And Lymphatic Disorders-granulocytopenia (0.9%), coagulopathy (0.4%).

Gastrointestinal-diarrhea/loose stools (2.7%). Less frequently reported (<1%) were nausea or vomiting, and dysgeusia. The onset of pseudomembranous colitis symptoms may occur during or after antibacterial treatment (see警告).

Hepatic-海拔的天冬氨酸转氨酶(AST)(3。1%) or alanine aminotransferase (ALT) (3.3%). Less frequently reported (<1%) were elevations of alkaline phosphatase and bilirubin.

Renal-elevations of the BUN (1.2%). Less frequently reported (<1%) were elevations of creatinine and the presence of casts in the urine.

Central Nervous System-headache or dizziness were reported occasionally (<1%).

Genitourinary-moniliasis or vaginitis were reported occasionally (<1%).

Miscellaneous-diaphoresis and flushing were reported occasionally (<1%).

Investigations-blood creatinine increased (0.6%).

Other rarely observed adverse reactions (<0.1%) include 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.

Postmarketing Experience

In addition to the adverse reactions reported during clinical trials, the following adverse experiences have been reported during clinical practice in patients treated with Rocephin. Data are generally insufficient to allow an estimate of incidence or to establish causation.

A small number of cases of fatal outcomes in which a crystalline material was observed in the lungs and kidneys at autopsy have been reported in neonates receiving Rocephin and calcium-containing fluids. In some of these cases, the same intravenous infusion line was used for both Rocephin and calcium-containing fluids and in some a precipitate was observed in the intravenous infusion line. At least one fatality has been reported in a neonate in whom Rocephin and calcium-containing fluids were administered at different time points via different intravenous lines; no crystalline material was observed at autopsy in this neonate. There have been no similar reports in patients other than neonates.

Gastrointestinal–pancreatitis, stomatitis and glossitis.

Genitourinary–oliguria, ureteric obstruction, post-renal acute renal failure.

Dermatologic–疹、过敏性皮炎、荨麻疹、水肿;acute generalized exanthematous pustulosis (AGEP) and isolated cases of severe cutaneous adverse reactions (erythema multiforme, Stevens-Johnson syndrome or Lyell’s syndrome/toxic epidermal necrolysis) have been reported.

Hematological Changes

Isolated cases of agranulocytosis (< 500/mm³) have been reported, most of them after 10 days of treatment and following total doses of 20 g or more.

Nervous System Disorders

convulsion

Other, Adverse Reactions

symptomatic precipitation of ceftriaxone calcium salt in the gallbladder, kernicterus, oliguria, and anaphylactic or anaphylactoid reactions.

Cephalosporin Class Adverse Reactions

In addition to the adverse reactions listed above which have been observed in patients treated with ceftriaxone, the following adverse reactions and altered laboratory test results have been reported for cephalosporin class antibiotics:

Adverse Reactions

Allergic reactions, drug fever, serum sickness-like reaction, renal dysfunction, toxic nephropathy, reversible hyperactivity, hypertonia, hepatic dysfunction including cholestasis, aplastic anemia, hemorrhage, and superinfection.

Altered Laboratory Tests

Positive direct Coombs’ test, false-positive test for urinary glucose, and elevated LDH (seePRECAUTIONS).

Several cephalosporins have been implicated in triggering seizures, particularly in patients with renal impairment when the dosage was not reduced (seeDOSAGE AND ADMINISTRATION). If seizures associated with drug therapy occur, the drug should be discontinued. Anticonvulsant therapy can be given if clinically indicated.

DRUG INTERACTIONS

Patients that are administered local anesthetics may be at increased risk of developing methemoglobinemia when concurrently exposed to the following oxidizing agents:

Class	Examples
Nitrates/Nitrites	Nitroglycerin, nitroprusside, nitric oxide, nitrous oxide
Local anesthetics	Benzocaine, lidocaine, bupivacaine, mepivacaine, tetracaine, prilocaine, procaine, articaine
Antineoplastic agents	cyclophosphamide, flutamide, rasburicase, isofamide, hydroxyurea
Antibiotics	dapsone, sulfonamides, nitrofurantoin, paraaminosalicylic acid
Antimalarials	chloroquine, primaquine
Anticonvulsants	phenytoin, sodium valproate, phenobarbital
Other drugs	acetaminophen, metoclopramide, sulfa drugs (i.e., sulfasalazine), quinine

警告

Hypersensitivity Reactions

Before therapy with Rocephin is instituted, careful inquiry should be made to determine whether the patient has had previous hypersensitivity reactions to cephalosporins, penicillins and other beta-lactam agents or other drugs. This product should be given cautiously topenicillinand other beta-lactam agent-sensitive patients.Antibacterialdrugs should be administered with caution to any patient who has demonstrated some form ofallergy, particularly to drugs. Serious acute hypersensitivity reactions may require the use of subcutaneousepinephrineand other emergency measures.

As with all beta-lactam antibacterial agents, serious and occasionally fatal hypersensitivity reactions (i.e.,anaphylaxis) have been reported. In case of severe hypersensitivity reactions, treatment with ceftriaxone must be discontinued immediately and adequate emergency measures must be initiated.

Methemoglobinemia

Cases ofmethemoglobinemiahave been reported in association with localanestheticuse (e.g. lidocaine). Although all patients are at risk for methemoglobinemia, patients withglucose-6-phosphate dehydrogenasedeficiency,congenitaloridiopathicmethemoglobinemia, cardiac or pulmonary compromise, infants under 6 months of age, and concurrent exposure to oxidizing agents or their metabolites are more susceptible to developing clinical manifestations of the condition. If local anesthetics must be used in these patients, close monitoring for symptoms and signs of methemoglobinemia is recommended.

Signs and symptoms of methemoglobinemia may occur immediately or may be delayed some hours after exposure, and are characterized by acyanoticskin discoloration and abnormal coloration of the blood.Methemoglobinlevels may continue to rise; therefore, immediate treatment is required to avert more seriouscentral nervous systemandcardiovascularadverse effects, including seizures, coma, arrhythmias, and death. Discontinue Rocephin Kit and any other oxidizing agents. Depending on the severity of the symptoms, patients may respond tosupportive care, i.e., oxygen therapy, hydration. More severe symptoms may require treatment with methylene blue, exchangetransfusion, orhyperbaricoxygen.

Interaction With Calcium-Containing Products

Do not use diluents containing calcium, such as Ringer’s solution or Hartmann’s solution, to reconstitute Rocephin vials or to further dilute a reconstituted vial for IV administration because a precipitate can form. Precipitation of ceftriaxone-calcium can also occur when Rocephin is mixed with calcium-containing solutions in the same IV administration line. Rocephin must not be administered simultaneously with calcium-containing IV solutions, including continuous calcium-containing infusions such asparenteral nutritionvia a Y-site. However, in patients other than neonates, Rocephin and calcium-containing solutions may be administered sequentially of one another if the infusion lines are thoroughly flushed between infusions with a compatible fluid.In vitrostudies using adult andneonatalplasma fromumbilical cordblood demonstrated that neonates have an increased risk of precipitation of ceftriaxone-calcium (seeCLINICAL PHARMACOLOGY,CONTRAINDICATIONSandDOSAGE AND ADMINISTRATION).

Clostridium Difficile

Associated Diarrhea

Clostridium difficileassociated diarrhea (CDAD) has been reported with use of nearly all antibacterial agents, including Rocephin, and may range in severity from mild diarrhea to fatalcolitis. Treatment with antibacterial agents alters the normalfloraof thecolonleading 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 berefractoryto antimicrobial therapy and may requirecolectomy. CDAD must be considered in all patients who present with diarrhea following antibiotic use. Carefulmedical historyis 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 andelectrolytemanagement, protein supplementation, antibiotic treatment ofC. difficile,and surgical evaluation should be instituted as clinically indicated.

Hemolytic Anemia

An immune mediatedhemolytic anemiahas been observed in patients receiving cephalosporin class antibacterials including Rocephin. Severe cases ofhemolyticanemia, including fatalities, have been reported during treatment in both adults and children. If a patient develops anemia while on ceftriaxone, the diagnosis of a cephalosporin associated anemia should be considered and ceftriaxone stopped until theetiologyis determined.

PRECAUTIONS

Development Of Drug-Resistant Bacteria

Prescribing Rocephin in the absence of a proven or strongly suspected bacterial infection or aprophylacticindication is unlikely to provide benefit to the patient and increases the risk of the development of drug-resistant bacteria. Prolonged use of Rocephin may result in overgrowth of nonsusceptible organisms. Careful observation of the patient isessential. If superinfection occurs during therapy, appropriate measures should be taken.

Patients With Renal Or Hepatic Impairment

Ceftriaxone is excreted via bothbiliaryand renal excretion (seeCLINICAL PHARMACOLOGY). Therefore, patients with renal failure normally require no adjustment in dosage when usual doses of Rocephin are administered.

Dosage adjustments should not be necessary in patients with hepatic dysfunction; however, in patients with both hepatic dysfunction and significant renal disease, caution should be exercised and the Rocephin dosage should not exceed 2 gm daily.

Ceftriaxone is not removed byperitoneal-orhemodialysis. In patients undergoingdialysisno additional supplementary dosing is required following the dialysis. In patients with both severe renal and hepatic dysfunction, close clinical monitoring for safety and efficacy is advised.

Effect On Prothrombin Time

Alterations inprothrombintimes have occurred in patients treated with Rocephin. Monitorprothrombin timeduring Rocephin treatment in patients with impairedvitamin Ksynthesis or low vitamin K stores (eg, chronic hepatic disease andmalnutrition). Vitamin K administration (10 mg weekly) may be necessary if the prothrombin time is prolonged before or during therapy.

Concomitant use of ceftriaxone with Vitamin K antagonists may increase the risk of bleeding.Coagulationparameters should be monitored frequently, and the dose of theanticoagulantadjusted accordingly, both during and after treatment with ceftriaxone (seeADVERSE REACTIONS).

Gallbladder Pseudolithiasis

Ceftriaxone-calcium precipitates in thegallbladderhave been observed in patients receiving Rocephin. These precipitates appear on sonography as an echo without acoustical shadowing suggesting sludge or as an echo with acoustical shadowing which may be misinterpreted asgallstones. The probability of such precipitates appears to be greatest in pediatric patients. Patients may beasymptomaticor may develop symptoms of gallbladder disease. The condition appears to be reversible upon discontinuation of ceftriaxone sodium and institution of conservative management. Discontinue ceftriaxone sodium in patients who develop signs and symptoms suggestive of gallbladder disease and/or the sonographic findings described above.

Urolithiasis And Post-Renal Acute Renal Failure

Ceftriaxone-calcium precipitates in theurinary tracthave been observed in patients receiving Rocephin and may be detected as sonographic abnormalities. The probability of such precipitates appears to be greatest in pediatric patients. Patients may be asymptomatic or may develop symptoms ofurolithiasis, and ureteral obstruction and post-renalacute renal failure. The condition appears to be reversible upon discontinuation of ceftriaxone sodium and institution of appropriate management. Ensure adequate hydration in patients receiving Rocephin. Discontinue Rocephin in patients who develop signs and symptoms suggestive of urolithiasis,oliguriaor renal failure and/or the sonographic findings described above.

Pancreatitis

Cases ofpancreatitis, possibly secondary to biliary obstruction, have been reported in patients treated with Rocephin. Most patients presented with risk factors for biliarystasisandbiliary sludge(preceding major therapy, severe illness,total parenteral nutrition). A cofactor role of Rocephin-related biliary precipitation cannot be ruled out.

Carcinogenesis, Mutagenesis, Impairment Of Fertility

Carcinogenesis

Considering the maximum duration of treatment and the class of the compound, carcinogenicity studies with ceftriaxone in animals have not been performed. The maximum duration of animal toxicity studies was 6 months.

Mutagenesis

Genetictoxicologytests included theAmes test, a micronucleus test and a test for chromosomal aberrations in human lymphocytes culturedin vitrowith ceftriaxone. Ceftriaxone showed no potential for mutagenic activity in these studies.

Impairment Of Fertility

Ceftriaxone produced no impairment of fertility when given intravenously to rats at daily doses up to 586 mg/kg/day, approximately 20 times the recommended clinical dose of 2 gm/day.

Pregnancy

Teratogenic Effects

Pregnancy Category B.

Reproductive studies have been performed in mice and rats at doses up to 20 times the usual human dose and have no evidence of embryotoxicity, fetotoxicity or teratogenicity. In primates, no embryotoxicity or teratogenicity was demonstrated at a dose approximately 3 times the human dose.

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.

Nonteratogenic Effects

In rats, in the Segment I (fertility and general reproduction) and Segment III (perinataland postnatal) studies with intravenously administered ceftriaxone, no adverse effects were noted on various reproductive parameters during gestation and lactation, including postnatal growth, functional behavior and reproductive ability of the offspring, at doses of 586 mg/kg/day or less.

Nursing Mothers

Low concentrations of ceftriaxone are excreted in human milk. Caution should be exercised when Rocephin is administered to a nursing woman.

Pediatric Use

Safety and effectiveness of Rocephin in neonates, infants and pediatric patients have been established for the dosages described in theDOSAGE AND ADMINISTRATIONsection.In vitrostudies have shown that ceftriaxone, like some other cephalosporins, can displace bilirubin from serumalbumin. Rocephin should not be administered to hyperbilirubinemic neonates, especially prematures (seeCONTRAINDICATIONS).

Geriatric Use

Of the total number of subjects in clinical studies of Rocephin, 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 cannot be ruled out.

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. (seeCLINICAL PHARMACOLOGY).

Influence On Diagnostic Tests

In patients treated with Rocephin the Coombs’ test may become positive. Rocephin, like other antibacterial drugs, may result in positive test results forgalactosemia.

Nonenzymatic methods for the glucose determination in urine may give false-positive results. For this reason, urine-glucose determination during therapy with Rocephin should be done enzymatically.

The presence of ceftriaxone may falsely lower estimatedblood glucosevalues obtained with some blood glucose monitoring systems. Please refer to instructions for use for each system. Alternative testing methods should be used if necessary.

OVERDOSE

In the case of overdosage, drug concentration would not be reduced by hemodialysis orperitoneal dialysis. There is no specificantidote. Treatment of overdosage should be symptomatic.

CONTRAINDICATIONS

Hypersensitivity

Rocephin is contraindicated in patients with known hypersensitivity to ceftriaxone, any of its excipients or to any other cephalosporin. Patients with previous hypersensitivity reactions to penicillin and other beta lactam antibacterial agents may be at greater risk of hypersensitivity to ceftriaxone (see警告-Hypersensitivity).

Neonates

Premature Neonates

Rocephin is contraindicated in premature neonates up to a postmenstrual age of 41 weeks (gestational age + chronological age).

Hyperbilirubinemic Neonates

Hyperbilirubinemic neonates should not be treated with Rocephin. Ceftriaxone can displace bilirubin from its binding to serum albumin, leading to a risk of bilirubin encephalopathy in these patients.

新生儿需要钙含有四世的解决方案

Rocephin is contraindicated in neonates (≤ 28 days) if they require (or are expected to require) treatment with calcium-containing IV solutions, including continuous calcium-containing infusions such asparenteralnutritionbecause of the risk of precipitation of ceftriaxone-calcium (seeCLINICAL PHARMACOLOGY,警告andDOSAGE AND ADMINISTRATION).

Cases of fatal outcomes in which a crystalline material was observed in thelungsand kidneys atautopsyhave been reported in neonates receiving Rocephin and calcium-containing fluids.

In some of these cases, the same intravenous infusion line was used for both Rocephin and calcium-containing fluids and in some a precipitate was observed in the intravenous infusion line. There have been no similar reports in patients other than neonates.

Lidocaine

Intravenous administration of ceftriaxone solutions containing lidocaine is contraindicated. When lidocaine solution is used as a solvent with ceftriaxone for intramuscular injection, exclude all contraindications to lidocaine. Refer to the prescribing information of lidocaine.

CLINICAL PHARMACOLOGY

Average plasma concentrations of ceftriaxone following a single 30-minute intravenous (IV) infusion of a 0.5, 1 or 2 gm dose and intramuscular (IM) administration of a single 0.5 (250 mg/mL or 350 mg/mL concentrations) or 1 gm dose in healthy subjects are presented in Table 1.

Table 1 Ceftriaxone Plasma Concentrations After Single Dose Administration

Dose/Route	Average Plasma Concentrations (μg/mL)
	0.5 hr	1 hr	2 hr	4 hr	6 hr	8 hr	12 hr	16 hr	24 hr
0.5 gm IV*	82	59	48	37	29	23	15	10	5
0.5 gm IM 250 mg/mL	22	33	38	35	30	26	16	ND	5
0.5 gm IM 350 mg/mL	20	32	38	34	31	24	16	ND	5
1 gm IV*	151	111	88	67	53	43	28	18	9
1 gm IM	40	68	76	68	56	44	29	ND	ND
2 gm IV*	257	192	154	117	89	74	46	31	15
*IV doses were infused at a constant rate over 30 minutes. ND = Not determined.

Ceftriaxone was completely absorbed following IM administration with mean maximum plasma concentrations occurring between 2 and 3 hours post-dose. Multiple IV or IM doses ranging from 0.5 to 2 gm at 12-to 24-hour intervals resulted in 15% to 36% accumulation of ceftriaxone above single dose values.

Ceftriaxone concentrations in urine are shown in Table 2.

Table 2 Urinary Concentrations of Ceftriaxone After Single Dose Administration

Dose/Route	Average Urinary Concentrations (μg/mL)
	0-2 hr	2-4 hr	4-8 hr	8-12 hr	12-24 hr	24-48 hr
0.5 gm IV	526	366	142	87	70	15
0.5 gm IM	115	425	308	127	96	28
1 gm IV	995	855	293	147	132	32
1 gm IM	504	628	418	237	ND	ND
2 gm IV	2692	1976	757	274	198	40
ND = Not determined.

头孢曲松钠剂量的百分之三十三到67%was excreted in the urine as unchanged drug and the remainder was secreted in the bile and ultimately found in the feces as microbiologically inactive compounds. After a 1 gm IV dose, average concentrations of ceftriaxone, determined from 1 to 3 hours after dosing, were 581 μg/mL in the gallbladder bile, 788 μg/mL in the common duct bile, 898 μg/mL in the cystic duct bile, 78.2 μg/gm in the gallbladder wall and 62.1 μg/mL in the concurrent plasma.

Over a 0.15 to 3 gm dose range in healthy adult subjects, the values of elimination half-life ranged from 5.8 to 8.7 hours; apparent volume of distribution from 5.78 to 13.5 L; plasma clearance from 0.58 to 1.45 L/hour; and renal clearance from 0.32 to 0.73 L/hour. Ceftriaxone is reversibly bound to human plasma proteins, and the binding decreased from a value of 95% bound at plasma concentrations of <25 μg/mL to a value of 85% bound at 300 μg/mL. Ceftriaxone crosses the blood placenta barrier.

The average values of maximum plasma concentration, elimination half-life, plasma clearance and volume of distribution after a 50 mg/kg IV dose and after a 75 mg/kg IV dose in pediatric patients suffering from bacterial meningitis are shown in Table 3. Ceftriaxone penetrated the inflamed meninges of infants and pediatric patients; CSF concentrations after a 50 mg/kg IV dose and after a 75 mg/kg IV dose are also shown in Table 3.

Table 3 Average Pharmacokinetic Parameters of Ceftriaxone in Pediatric Patients With Meningitis

	50 mg/kg IV	75 mg/kg IV
Maximum Plasma Concentrations (μg/mL)	216	275
Elimination Half-life (hr)	4.6	4.3
Plasma Clearance (mL/hr/kg)	49	60
Volume of Distribution (mL/kg)	338	373
CSF Concentration—inflamed meninges (μg/mL)	5.6	6.4
Range (μg/mL)	1.3-18.5	1.3-44
Time after dose (hr)	3.7 (± 1.6)	3.3 (± 1.4)

Compared to that in healthy adult subjects, the pharmacokinetics of ceftriaxone were only minimally altered in elderly subjects and in patients with renal impairment or hepatic dysfunction (Table 4); therefore, dosage adjustments are not necessary for these patients with ceftriaxone dosages up to 2 gm per day. Ceftriaxone was not removed to any significant extent from the plasma by hemodialysis; in six of 26 dialysis patients, the elimination rate of ceftriaxone was markedly reduced.

Table 4 Average Pharmacokinetic Parameters of Ceftriaxone in Humans

Subject Group	Elimination Half-Life (hr)	Plasma Clearance (L/hr)	Volume of Distribution (L)
Healthy Subjects	5.8-8.7	0.58-1.45	5.8-13.5
Elderly Subjects (mean age, 70.5 yr) Patients With Renal Impairment	8.9	0.83	10.7
Hemodialysis Patients (0-5 mL/min)*	14.7	0.65	13.7
Severe (5-15 mL/min)	15.7	0.56	12.5
Moderate (16-30 mL/min)	11.4	0.72	11.8
Mild (31-60 mL/min)	12.4	0.70	13.3
Patients With Liver Disease	8.8	1.1	13.6
*Creatinine clearance.

The elimination of ceftriaxone is not altered when Rocephin is co-administered with probenecid.

Pharmacokinetics In The Middle Ear Fluid

In one study, total ceftriaxone concentrations (bound and unbound) were measured inmiddle earfluid obtained during the insertion of tympanostomytubesin 42 pediatric patients withotitis media. Sampling times were from 1 to 50 hours after a single intramuscular injection of 50 mg/kg of ceftriaxone. Mean (± SD) ceftriaxone levels in the middle ear reached a peak of 35 (± 12) μg/mL at 24 hours, and remained at 19 (± 7) μg/mL at 48 hours. Based on middle ear fluid ceftriaxone concentrations in the 23 to 25 hour and the 46 to 50 hour sampling time intervals, a half-life of 25 hours was calculated. Ceftriaxone is highly bound to plasma proteins. The extent of binding to proteins in the middle ear fluid is unknown.

Interaction With Calcium

Twoin vitrostudies, one using adult plasma and the other neonatal plasma from umbilicalcord血液进行了评估交互of ceftriaxone and calcium. Ceftriaxone concentrations up to 1 mM (in excess of concentrations achievedin vivofollowing administration of 2 grams ceftriaxone infused over 30 minutes) were used in combination with calcium concentrations up to 12 mM (48 mg/dL). Recovery of ceftriaxone from plasma was reduced with calcium concentrations of 6 mM (24 mg/dL) or higher in adult plasma or 4 mM (16 mg/dL) or higher in neonatal plasma. This may be reflective of ceftriaxone-calcium precipitation.

Microbiology

Mechanism Of Action

Ceftriaxone is a bactericidal agent that acts by inhibition of bacterial cell wall synthesis. Ceftriaxone has activity in the presence of some beta-lactamases, both penicillinases and cephalosporinases, ofGram-negative andGram-positivebacteria.

Mechanism Of Resistance

Resistance to ceftriaxone is primarily through hydrolysis by beta-lactamase, alteration of penicillin-binding proteins (PBPs), and decreased permeability.

Interaction with Other Antimicrobials

In anin vitrostudy antagonistic effects have been observed with the combination of chloramphenicol and ceftriaxone.

Ceftriaxone has been shown to be active against most isolates of the following bacteria, bothin vitroand in clinical infections as described in theINDICATIONSsection:

Gram-negative Bacteria

Acinetobacter calcoaceticus
Enterobacter aerogenes
Enterobacter cloacae
Escherichia coli
Haemophilus influenzae
Haemophilus parainfluenzae
Klebsiella oxytoca
Klebsiella pneumoniae
Moraxella catarrhalis
Morganella morganii
Neisseria gonorrhoeae
Neisseria meningitidis
Proteus mirabilis
Proteus vulgaris
Pseudomonas aeruginosa
Serratia marcescens

Gram-positive Bacteria

Staphylococcus aureus
Staphylococcus epidermidis
Streptococcus pneumoniae
Streptococcus pyogenes
Viridans group streptococci

Anaerobic Bacteria

Bacteroides fragilis
Clostridium species
Peptostreptococcus species

The followingin vitrodata are available, but their clinical significance is unknown. At least 90 percent of the following microorganisms exhibit anin vitrominimum inhibitory concentration (MIC) less than or equal to the susceptible breakpoint for ceftriaxone. However, the efficacy of ceftriaxone in treating clinical infections due to these microorganisms has not been established in adequate and well-controlled clinical trials.

Gram-negative Bacteria

Citrobacter diversus
Citrobacter freundii
Providenciaspecies (includingProvidencia rettgeri)
Salmonellaspecies(includingSalmonella typhi)
Shigellaspecies

Gram-positive Bacteria

Streptococcus agalactiae

Anaerobic Bacteria

Porphyromonas (Bacteroides) melaninogenicus
Prevotella (Bacteroides) bivius

Susceptibility Test Methods

When available, the clinical microbiology laboratory should provide the results ofin vitrosusceptibility test results for antimicrobial drug products used in resident hospitals to the physician as periodic reports that describe the susceptibility profile of nosocomial and community-acquired pathogens. These reports should aid the physician in selecting an antibacterial drug product for treatment.

Dilution Techniques

Quantitative methods are used to determine antimicrobial minimal 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^1,3. The MIC values should be interpreted according to criteria provided in Table 5.

Diffusion Techniques

Quantitative methods that require measurement of zone diameters also provide reproducible estimates of the susceptibility of bacteria to antimicrobial compounds. The zone size provides an estimate of the susceptibility of bacteria to antimicrobial compounds. The zone size should be determined using a standardized test method.^2,3This procedure uses paper disks impregnated with 30 mcg ceftriaxone to test the susceptibility of microorganisms to ceftriaxone. The disk diffusion interpretive criteria are provided in Table 5.

Anaerobic Techniques

For anaerobic bacteria, the susceptibility to ceftriaxone as MICs can be determined by a standardized agar test method^3,4. The MIC values obtained should be interpreted according to the criteria provided in Table 5.

Table 5 Susceptibility Test Interpretive Criteria for Ceftriaxone

Pathogen	Minimum Inhibitory Concentrations (mcg/ml)			Disk Diffusion Zone Diameters (mm)
	(S) Susceptible	(I) Intermediate	(R) Resistant	(S) Susceptible	(I) Intermediate	(R) Resistant
Enterobacteriaceaea	≤ 1	2	≥4	≥ 23	20-22	≤19
Haemophilus influenzaeb,c	≤2	-	-	≥26	-	-
Neisseria gonorrhoeaea	≤ 0.25	-	-	≥ 35	-	-
Neisseria meningitidisc	≤ 0.12	-	-	≥ 34	-	-
Streptococcus pneumoniaed meningitis isolates	≤ 0.5	1	≥ 2	-	-	-
Streptococcus pneumoniaed non-meningitis isolates	≤1	2	≥4	-	-	-
Streptococcus species beta-hemolytic groupc	≤0.5	-	-	≥ 24	-	-
Viridans group streptococci	≤ 1	2	≥ 4	≥27	25-26	≤24
Anaerobic bacteria (agar method)	≤ 1	2	≥ 4	-	-	-
aSusceptibility interpretive criteria for Enterobacteriaceae are based on a dose of 1 gram IV q 24h. For isolates with intermediate susceptibility, use a dose of 2 grams IV q 24h in patients with normal renal function. bForHaemophilus influenzae, susceptibility interpretive criteria are based on a dose of 2 grams IV every 24 hours in patients with normal renal function. cThe current absence of data on resistant isolates precludes defining any category other than ‘Susceptible’. If isolates yield MIC results other than susceptible, they should be submitted to a reference laboratory for additional testing. d阀瓣扩散ceftriaxo解释标准ne discs againstStreptococcus pneumoniaeare not available, however, isolates of pneumococci with oxacillin zone diameters of >20 mm are susceptible (MIC ≤ 0.06 mcg/mL) to penicillin and can be considered susceptible to ceftriaxone.Streptococcus pneumoniaeisolates should not be reported as penicillin (ceftriaxone) resistant or intermediate based solely on an oxacillin zone diameter of ≤ 19 mm. The ceftriaxone MIC should be determined for those isolateswith oxacillin zone diameters ≤ 19 mm.

Susceptibility of staphylococci to ceftriaxone may be deduced from testing only penicillin and either cefoxitin or oxacillin.

A report ofSusceptibleindicates that the antimicrobial drug is likely to inhibit growth of the pathogen if the antimicrobial drug reaches the concentration at the site of infection. A report ofIntermediateindicates 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 is physiologically concentrated or in situations where a 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 ofResistantindicates that the antimicrobial drug is not likely to inhibit growth of the pathogen 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 individual performing the test^1,2,3,4.

Standard ceftriaxone powder should provide the following range of MIC values noted in Table 6. For the diffusion technique using the 30 mcg disk, the criteria in Table 6 should be achieved.

Table 6 Acceptable Quality Control Ranges for Ceftriaxone

QC Strain	Minimum Inhibitory Concentrations (mcg/mL)	Disk Diffusion Zone diameters (mm)
Escherichia coli ATCC25922	0.03 -0.12	29 -35
Staphylococcus aureus ATCC25923	-	22 -28
Staphylococcus aureus ATCC29213	1 – 8	-
Haemophilus influenzae ATCC49247	0.06 -0.25	31 -39
Neisseria gonorrhoeae ATCC49226	0.004 -0.015	39 -51
Pseudomonas aeruginosa ATCC27853	8-64	17-23
Streptococcus pneumoniae ATCC49619	0.03 -0.12	30 -35
Bacteroides fragilis ATCC25285 (agar method)	32 – 128	-
Bacteroides thetaiotaomicron ATCC29741 (agar method)	64 – 256	-

Clinical Studies

Clinical Trials In Pediatric Patients With Acute Bacterial Otitis Media

In two adequate and well-controlled US clinical trials a single IM dose of ceftriaxone was compared with a 10 day course of oral antibiotic in pediatric patients between the ages of 3 months and 6 years. The clinical cure rates and statistical outcome appear in the table below:

Table 7 Clinical Efficacy in Pediatric Patients with Acute Bacterial Otitis Media

Clinical Efficacy in Evaluable Population
Study Day	Ceftriaxone Single Dose	Comparator – 10 Days of Oral Therapy	95% Confidence Interval	Statistical Outcome
Study 1 – US	amoxicillin/clavulanate
14	74% (220/296)	82% (247/302)	(-14.4%, -0.5%)	Ceftriaxone is lower than control at study day 14 and 28.
28	58% (167/288)	67% (200/297)	(-17.5%, -1.2%)
Study 2 -US5	TMP-SMZ
14	54% (113/210)	60% (124/206)	(-16.4%, 3.6%)	Ceftriaxone is equivalent to control at study day 14 and 28.
28	35% (73/206)	45% (93/205)	(-19.9%, 0.0%)

An open-label bacteriologic study of ceftriaxone without a comparator enrolled 108 pediatric patients, 79 of whom had positive baseline cultures for one or more of the common pathogens. The results of this study are tabulated as follows:

Week 2 and 4 Bacteriologic Eradication Rates in the Per Protocol Analysis in the Roche Bacteriologic Study by pathogen:

Table 8 Bacteriologic Eradication Rates by Pathogen

	Study Day 13-15		Study Day 30+2
Organism	No. Analyzed	No. Erad. (%)	No. Analyzed	No. Erad. (%)
Streptococcus pneumoniae	38	32 (84)	35	25 (71)
Haemophilus influenzae	33	28 (85)	31	22 (71)
Moraxella catarrhalis	15	12 (80)	15	9 (60)

Animal Pharmacology

Concretions consisting of the precipitated calcium salt of ceftriaxone have been found in the gallbladder bile of dogs and baboons treated with ceftriaxone.

这些出现在狗的沉积物,received 100 mg/kg/day for 4 weeks. A similar phenomenon has been observed in baboons but only after a protracted dosing period (6 months) at higher dose levels (335 mg/kg/day or more). The likelihood of this occurrence in humans is considered to be low, since ceftriaxone has a greater plasma half-life in humans, the calcium salt of ceftriaxone is more soluble in human gallbladder bile and the calcium content of human gallbladder bile is relatively low.

REFERENCES

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

2. Clinical and Laboratory Standards Institute (CLSI).Performance Standards for Antimicrobial Susceptibility Testing; Twenty-fifth Informational Supplement.CLSI document M100-S25, Clinical and Laboratory Standards Institute, 950 West Valley Road, Suite 2500, Wayne, Pennsylvania 19087, USA, 2015.

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

4. Clinical and Laboratory Standards Institute (CLSI).Methods for Antimicrobial Susceptibility Testing of Anaerobic Bacteria; Approved Standard -Eight Edition.CLSI document M11-A8, Clinical and Laboratory Standards Institute, 950 West Valley Road, Suite 2500, Wayne, PA 19087 USA, 2012

Distributed by:Genentech USA, Inc.A Member of the Roche Group, 1 DNA Way, South San Francisco, CA 94080-4990. Revised: July 2018

PATIENT INFORMATION

• Inform patients that use of local anesthetics may cause methemoglobinemia, a serious condition that must be treated promptly. Advise patients or caregivers to stop use and seek immediate medical attention if they or someone in their care experience the following signs or symptoms: pale, gray, or blue colored skin (cyanosis); headache; rapid heart rate; shortness of breath;lightheadedness; or fatigue.
• Patients should be counseled that antibacterial drugs including Rocephin should only be used to treat bacterial infections. They do not treat viral infections (eg,common cold).
• When Rocephin 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 Rocephin or other antibacterial drugs in the future.
• Diarrhea is a common problem caused by antibiotics which usually ends when the antibiotic is 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.