Atack L

Uses

Cefpodoxime is used for the treatment of patients infected with susceptible strains of micro-organisms which include a wide range of gram-positive & gram-negative bacteria. As it is highly stable in presence of b-lactamase enzyme, so it is more effective against gram-positive bacteria than other 3rd generation oral Cephalosporins.

The susceptible organisms include gram-positive bacteria eg. S. aureus (including penicillinase producing strains), S. saprophyticus, S. pneumoniae, S. pyogenes, S. agalactiae, P. magnus and gram-negative bacteria eg. E. coli, K. pneumoniae, H. influenzae (including b-lactamase producer & Ampicillin resistant strains), M. catarrhalis, N. gonorrhoeae (including penicillinase producing strains), P. mirabillis, C. diversus, H. parainfluenzae, K. oxytoca, P. vulgaris, P. rettgeri.

Ximeprox is used for the following diseases:-

(1) Lower respiratory tract infection: Acute community-acquired pneumonia, Acute bacterial exacerbation of chronic bronchitis; (2) Upper respiratory tract infection: Acute otitis media, Acute maxillary sinusitis, Pharyngitis, Tonsillitis; (3) Sexually transmitted diseases: Acute uncomplicated urethral & cervical gonorrhea, Acute ano-rectal infection in woman caused by N. gonorrhoeae; (4) Uncomplicated urinary tract infection: Cystitis, Pyuria; (5) Skin & soft tissue infections: Furuncle, Cellulitis, Subcutaneous abscess, infectious atheroma & periproctal abscess (6) Enteric fever.

Levofloxacin Tablet is used for Acute maxillary sinusitis , Acute bacterial exacerbation of chronic bronchitis , Nosocomial pneumonia Community acquired pneumonia, Uncomplicated urinary tract infections Complicated urinary tract infections, Acute pyelonephritis, Uncomplicated & complicated skin and skin structure infections, Chronic bacterial prostatitis

Levofloxacin Injection is used to treat Acute maxillary sinusitis, acute bacterial exacerbation of chronic bronchitis, nosocomial pneumonia, community acquired pneumonia, uncomplicated urinary tract infections, complicated urinary tract infections, acute pyelonephritis, uncomplicated & complicated skin and skin structure infections including abscesses, cellulitis, furuncles, impetigo, pyoderma, wound infections, chronic bacterial prostatitis and typhoid fever.

Levofloxacin Injection has

• Proven clinical success in hospital infections
• Reaches high concentrations in lung, urine, skin and prostate
• Ensures excellent gram-positive and gram-negative bacterial coverage, Offers better option for switch therapy

Levofloxacin Eye drops is used for the treatment of corneal ulcer caused by susceptible strains of the following bacteria:

• Gram-positive Bacteria: Corynebacterium species, Staphylococcus aureus, Staphylococcus epidermidis, Streptococcus pneumoniae, Viridans group streptococci
• Gram-negative Bacteria: Pseudomonas aeruginosa, Serratia marcescens.

Atack L is also used to associated treatment for these conditions: Acute Bacterial Exacerbation of Chronic Bronchitis (ABECB), Acute Otitis Media, Acute Sinusitis, Acute Tracheobronchitis, Acute maxillary sinusitis, Bacterial Infections, Bacterial Pneumonia, Community Acquired Pneumonia (CAP), Gonorrhea, Lower Respiratory Tract Infection (LRTI), Otitis Media (OM), Pharyngitis, Skin and Soft Tissue Infections, Streptococcal Pharyngitis, Streptococcal tonsillitis, Superinfection bacterial, Tonsillitis, Uncomplicated Urinary Tract Infections, Upper Respiratory Tract Infection, Uncomplicated Lower Respiratory Tract Infection (LRTI), Uncomplicated Upper Respiratory Tract Infection, Uncomplicated Urethritis gonococcal, Uncomplicated skin and subcutaneous tissue bacterial infectionsAbscesses caused by susceptible bacteria, Acute Bacterial Exacerbation of Chronic Bronchitis (ABECB) caused by susceptible bacteria, Acute Pyelonephritis caused by Infection Due to Escherichia Coli, Bacterial Conjunctivitis caused by susceptible bacteria, Cellulitis caused by susceptible bacteria, Community Acquired Pneumonia (CAP) caused by susceptible bacteria, Furuncle caused by susceptible bacteria, Impetigo caused by susceptible bacteria, Nosocomial Pneumonia caused by Pseudomonas Infections, Nosocomial Pneumonia caused by susceptible bacteria, Plague caused by Yersinia pestis, Pyoderma caused by susceptible bacteria, Wound Infections caused by susceptible bacteria, Acute bacterial sinusitis caused by susceptible bacteria, Chronic Bacterial prostatitis caused by susceptible bacteria, Chronic Pseudomonas Infections, Complicated Urinary Tract Infection caused by susceptible bacteria, Complicated skin and skin-structure infections caused by susceptible bacteria, Inhaled anthrax caused by Bacillus anthracis, Uncomplicated Urinary Tract Infection caused by susceptible bacteria, Uncomplicated skin and skin-structure infections caused by susceptible bacteria

How Atack L works

Cefpodoxime is active against a wide spectrum of Gram-positive and Gram-negative bacteria. Cefpodoxime is stable in the presence of beta-lactamase enzymes. As a result, many organisms resistant to penicillins and cephalosporins, due to their production of beta-lactamase, may be susceptible to cefpodoxime. Cefpodoxime is inactivated by certain extended spectrum beta-lactamases. The bactericidal activity of cefpodoxime results from its inhibition of cell wall synthesis. The active metabolite of cefpodoxime binds preferentially to penicillin binding protein 3, which inhibits production of peptidoglycan, the primary constituent of bacterial cell walls.

Levofloxacin, like other fluoroquinolone antibiotics, exerts its antimicrobial activity via the inhibition of two key bacterial enzymes: DNA gyrase and topoisomerase IV. Both targets are type II topoisomerases, but have unique functions within the bacterial cell. DNA gyrase is an enzyme found only in bacteria that introduces negative supercoils into DNA during replication - this helps to relieve torsional strain caused by the introduction of positive supercoils during replication, and these negative supercoils are essential for chromosome condensation and the promotion of transcription initiation. It is comprised of four subunits (two A subunits and two B subunits) of which the A subunits appear to be the target of fluoroquinolone antibiotics. Bacterial topoisomerase IV, in addition to contributing to the relaxation of positive supercoils, is essential at the terminal stages of DNA replication and functions to “unlink” newly replicated chromosomes to allow for the completion of cell division.

Inhibition of these enzymes by levofloxacin likely occurs via complexation with the topoisomerase enzymes. The end result is a blockade of DNA replication, thus inhibiting cell division and resulting in cell death.

Dosage

Atack L dosage

Ximeprox should be administered orally with food to enhance absorption. Ximeprox suspension may be given without regard to food.

Child :

15 days - 6 months : 4 mg/kg every 12 hours

6 months - 2 years : 40 mg every 12 hours

3 - 8 years : 80 mg every 12 hours

over 9 years : 100 mg every 12 hours

Patients with renal dysfunction: For patients with severe renal impairment (creatinine clearance <30 ml/min) the dosing intervals should be increased to 24 hourly.

Patients with liver cirrhosis: Cefpodoxime proxetil pharmacokinetics in cirrhotic patients are similar to those in healthy subjects. Dose adjustment is not necessary in this population.

Acute sinusitis: 500 mg once daily for 10-14 days or 750 mg once daily for 5 days

Exacerbation of chronic bronchitis: 500 mg once daily for 7 days

Community acquired pneumonia: 500 mg once daily for 7-14 days or750 mg once daily for 5 days

Nosocomial pneumonia: 750 mg once daily for 7-14 days

Uncomplicated urinary tract infections: 250 mg once daily for 3 days

Complicated urinary tract infections and acute pyelonephritis: 250 mg once daily for 10 days

Complicated urinary tract infections and acute pyelonephritis: 750 mg once daily for 5 days

Uncomplicated skin and skin structure infections: 500 mg once daily for 7-10 daysComplicated skin and skin structure infections: 750 mg once daily for 7-14 days

Chronic bacterial prostatitis: 500 mg once daily for 28 days

Levofloxacin solution for infusion is administered by slow intravenous infusion once or twice daily. The dosage depends on the type and severity of the infection and the sensitivity of the causative pathogen. The duration of treatment varies according to the severity of the disease.Adult:

• Community-acquired pneumonia: 500 mg once or twice daily,
• Complicated urinary tract infections (including pyelonephritis): 250 mg once daily,
• Chronic bacterial prostatitis: 500 mg once daily,
• Skin and soft tissue infections: 500 mg twice daily
• Enteric fever: 500 mg once daily.

Children:

Levofloxacin can be used in children aged as low as 6 months. The usual dose for children in community acquired pneumonia is:

• Children aged 6 months to less than 5 years: 10 mg/kg b.i.d. (up to 500 mg per day) for 10 days,
• Children aged 5 years to 16 years: 10 mg/kg q.d. (up to 500 mg per day) for 10 days.

The usual dose for children in recurrent or persistent Acute Otitis Media is:

• Children aged 6 months to less than 5 years: 10 mg/kg per day (maximum dose: 500 mg/day) given twice daily for 10 days.

Paediatric Use: Levofloxacin is not recommended for children less than 6 (six) months of age.

Levofloxacin ophthalmic solution:

• Days 1 through 3: Instill one to two drops in the affected eye(s) every 30 minutes to 2 hours while awake and approximately 4 and 6 hours after retiring.
• Day 4 through treatment completion: Instill one to two drops in the affected eye(s) every 1 to 4 hours while awake.

0.5%ophthalmic solution:

• Days 1 and 2: Instill one to two drops in the affected eye(s) every 2 hours while awake, up to 8 times per day.
• Days 3 through 7: Instill one to two drops in the affected eye(s) every 4 hours while awake, up to 4 times per day.

Direction for Reconstitution of suspension:

For 100 ml suspension : Add 50 ml (10 measuring spoonful) of boiled and cooled water to the dry mixture in the bottle. For ease of preparation add water to the bottle in two portions. Shake well after each addition until all the powder is in suspension.

For 50 ml suspension : Add 25 ml (5 measuring spoonful) of boiled and cooled water to the dry mixture in the bottle. For ease of preparation add water to the bottle in two portions. Shake well after each addition until all the powder is in suspension.

For 50 ml DS suspension : Add 25 ml (5 measuring spoonful) of boiled and cooled water to the dry mixture in the bottle. For ease of preparation add water to the bottle in two portions. Shake well after each addition until all the powder is in suspension.

Note: Shake the suspension well before each use. Keep the bottle tightly closed. The reconstituted suspension should be stored in a cool and dry place, preferably in refrigerator and unused portion should be discarded after 10 days.

Administration of Levofloxacin (solution for infusion) should be continued for a minimum of 48 to 72 hours after the patient has become febrile or evidence of bacterial eradication has been obtained. Levofloxacin solution for infusion is only intended for slow intravenous infusion; it is administered once or twice daily. The infusion time must be at least 30 minutes for 250 mg or 60 minutes for 500 mg Levofloxacin solution for infusion. It is possible to switch from an initial intravenous application to the oral route at the same dosage after a few days.

Side Effects

Cefpodoxime has very few side effects. The side effects include diarrhea, nausea, skin & vaginal fungal infection, abdominal pain, headache, chest pain, myalgia, dyspepsia, dizziness, vertigo, cough etc. In children incidence of fungal skin rash is more than adults.

The most frequently reported adverse events were headache and a taste disturbance following instillation. Other adverse events included decreased/blurred vision, diarrhea, dyspepsia, fever, infection, instillation site irritation/discomfort, ocular infection, nausea, ocular pain/discomfort, and throat irritation.

Toxicity

The LD₅₀ following oral administration in mice and rats is 1803 mg/kg and 1478 mg/kg, respectively.

Levofloxacin exhibits low potential for acute toxicity - following a single high dose of levofloxacin in several different test animals (e.g. mice, rats, monkeys) observed symptoms included ataxia, ptosis, decreased motor activity, dyspnea, tremors, and convulsions. Treatment of acute overdosage should involve stomach emptying (e.g. with activated charcoal) and general supportive measures. Consider monitoring of the patient's ECG to ensure QTc values remain within range. Levofloxacin is not efficiently removed by dialysis (peritoneal or hemodialysis) and is therefore of little benefit in cases of overdose.

Precaution

In patients with transient or persistent reduction in urinary output due to renal insufficiency, the total daily dose of cefpodoxime proxetil should be reduced. Cefpodoxime, like other cephalosporins, should be administered with caution to patients receiving concurrent treatment with potent diuretics. As with other broad spectrum antibiotics, prolonged use of cefpodoxime proxetil may result in overgrowth of non-susceptible organisms. Repeated evaluation of the patient's condition is essential.

The following measures should be taken during administration of Levofloxacin: While taking Levofloxacin adequate amount of water should be drunk to avoid risk of crystalluria. Dose adjustment should be exercised during Levofloxacin ingestion in presence of renal insufficiency & hepatic insufficiency.

While taking Levofloxacin adequate amount of water should be drunk to avoid risk of crystalluria. Dose adjustment should be exercised during Levofloxacin ingestion in presence of renal insufficiency & hepatic insufficiency.

Infusion of fluid should be immediately discontinued if rigor arises for any reason during the process. Do not use if the solution is cloudy, contains particles or after expiry date.

If an allergic reaction to levofloxacin occurs, discontinue the drug. Serious acute hypersensitivity reactions may require immediate emergency treatment. Oxygen and airway management should be administered as clinically indicated.

Prolonged use may result in overgrowth of non-susceptible organisms, including fungi. If superinfection occurs, discontinue use and institute alternative therapy. Patients should be advised not to wear contact lenses if they have signs and symptoms of corneal ulcer. Avoid contaminating the applicator tip with material from the eye, fingers or other source.

Interaction

Antacids or H2-blockers may decrease the absorption of cefpodoxime. Reduced renal excretion with probenecid.

Specific drug interaction studies have not been conducted with this drug. However, the systemic administration of some quinolones has been shown to elevate plasma concentrations of theophylline, interfere with the metabolism of caffeine, and enhance the effects of the oral anticoagulant warfarin and its derivatives, and has been associated with transient elevations in serum creatinine in patients receiving systemic cyclosporine concomitantly.

Volume of Distribution

Levofloxacin is widely distributed in the body, with an average volume of distribution following oral administration between 1.09-1.26 L/kg (~89-112 L). Concentrations in many tissues and fluids may exceed those observed in plasma. Levofloxacin is known to penetrate well into skin tissue, fluids (e.g. blisters), lung tissue, and prostatic tissue, amongst others.

Elimination Route

Cefpodoxime proxetil is a prodrug that is absorbed from the gastrointestinal tract and de-esterified to its active metabolite, cefpodoxime. Following oral administration of 100 mg of cefpodoxime proxetil to fasting subjects, approximately 50% of the administered cefpodoxime dose was absorbed systemically.

Absorption of levofloxacin following oral administration is rapid and essentially complete, with an oral bioavailability of approximately 99%. Due to its nearly complete absorption, the intravenous and oral formulations of levofloxacin may be interchangeable. The T_max is generally attained 1-2 hours following administration and the C_max is proportional to the given dose - an intravenous dose of 500mg infused over 60 minutes resulted in a C_max of 6.2 ± 1.0 µg/mL whereas a 750mg dose infused over 90 minutes resulted in a C_max of 11.5 ± 4.0 µg/mL. Oral administration with food prolongs the T_max by approximately 1 hour and slightly decreases the C_max, but these changes are not likely to be clinically significant.

Systemic absorption following oral inhalation is approximately 50% lower than that observed following oral administration.

Half Life

2.09 to 2.84 hours

The average terminal elimination half-life of levofloxacin is 6-8 hours.

Clearance

The average apparent total body clearance of levofloxacin ranges from 8.64-13.56 L/h, and its renal clearance ranges from 5.76-8.52 L/h. The relative similarity of these ranges indicates a small degree of non-renal clearance.

Elimination Route

Over the recommended dosing range (100 to 400 mg), approximately 29 to 33% of the administered cefpodoxime dose was excreted unchanged in the urine in 12 hours.

The majority of administered levofloxacin is excreted unchanged in the urine. Following the administration of a single oral dose of levofloxacin, approximately 87% was eliminated unchanged in the urine within 48 hours and less than 4% was eliminated in the feces within 72 hours.

Pregnancy & Breastfeeding use

There are no adequate and well-controlled studies on Cefpodoxime proxetil use in pregnant woman, but it was found neither teratogenic nor embryocidal in animal trial. However, the drug should be used during pregnancy only if clearly needed. In nursing mother, Cefpodoxime is excreted in breast milk & there is potential risk of serious reactions in nursing infants, so a decision should be made whether to discontinue breast feeding or to discontinue the drug.

Levofloxacin is not recommended for use during pregnancy or nursing, as the effects on the unborn child or nursing infant are unknown.

Contraindication

Cefpodoxime is contraindicated in patients with known allergy to the cephalosporin class of antibiotics.

Renal Impairment: Patients with renal dysfunction: For patients with severe renal impairment (creatinine clearance <30 ml/min) the dosing intervals should be increased to 24 hourly.

Hepatic Impairment: The dosage does not require modification in cases of hepatic impairment.

Levofloxacin is contraindicated in patients with a history of hypersensitivity to Levofloxacin, quinolone antimicrobial agents, or any other components of this product.

Special Warning

Use in Children: From clinical studies, it is evident that Levofloxacin can be used in children aged as low as 6 months.The usual dose for children in community acquired pneumonia (CAP) is-

• Children aged 6 months to less than 5 years: 10 mg/kg b.i.d. (up to 500 mg per day) for 10 days.
• Children aged 5 years to 16 years: 10 mg/kg q.d. (up to 500 mg per day) for 10 days.

The usual dose for children in recurrent or persistent Acute Otitis Media (AOM) is Children aged 6 months to less than 5 years: 10 mg/kg per day (maximum dose: 500 mg/day) given twice daily for 10 days.

Acute Overdose

Symptoms: Nausea, vomiting, epigastric distress and diarrhoea.

Management: Haemodialysis or peritoneal dialysis may be useful in the event of a serious toxic reaction particularly if renal function is compromised.

Levofloxacin exhibits a low potential for acute toxicity. However, in the events of an acute overdosage, the stomach should be emptied. The patients should be kept under observation and appropriate hydration should be maintained.

Storage Condition

Capsule: Store below 30° C, protected from light and moisture.

Powder for suspension: Store below 25° C, protected from light and moisture.

After reconstitution: The suspension can be used within 7 days if be kept at room temperature and within 14 days if be kept in refrigerator (2° to 8° C). Always keep the bottle tightly closed.

Store in a cool & dry place, protected from light. Keep out of the reach of children.

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