Combicare

Uses

Amoxicillin is used for the treatment of the following bacterial infections when caused by susceptible organisms:

• Respiratory tract, ENT infections: Acute and chronic bronchitis, pneumonia, otitis media, sinusitis, tonsillitis, pharyngitis & laryngitis, lobar & bronchopneumonia, chronic bronchial sepsis.
• Urinary tract infections: Pyelonephritis, cystitis and urethritis.
• Obstetric & gynaecological infections: Bacteriuria in pregnancy, septic abortion, intra-abdominal sepsis and puerperal sepsis.
• Gastro-intestinal infections: Typhoid and paratyphoid.
• Skin & soft tissue infections: Cellulitis, infected wounds and abscesses.
• Generalized infections: Septicemia, bacterial endocarditis, meningitis, peritonitis and osteomyelitis.
• Venereal infections: Gonorrhea and syphilis. Amoxicillin may also be used as prophylactic cover for patients at risk of developing endocarditis when undergoing dental surgery.

Cloxacillin is used for the treatment of infections caused by Grampositive organisms including infections caused by β-lactamase producing Staphylococci such as :

• Skin and soft tissue infections : Boils, Abscesses, Carbuncles, Furunculosis, Cellulitis, Infected wounds, Infected burns, Otitis media and externa, Protection of skin graft and Skin infections like ulcer, eczema, acne, etc.
• Respiratory tract infections : Pneumonia, Lung abscess, Empyema, Sinusitis, Pharyngitis and Tonsillitis.
• Other infections caused by sensitive organisms : Osteomyelitis, Enteritis, Endocarditis, Urinary tract infection, Meningitis and Septicaemia.

Combicare is also used to associated treatment for these conditions: Acute Bacterial Sinusitis (ABS), Acute Otitis Media, Acute Otitis Media (AOM), Bacterial Infections, Community Acquired Pneumonia (CAP), Duodenal ulcer caused by helicobacter pylori, Genitourinary infections, Helicobacter Pylori Infection, Lower Respiratory Tract Infection (LRTI), Peptic Ulcer With H. Pylori Infection, Sinusitis, Skin and Subcutaneous Tissue Bacterial Infections, Urinary Tract Infection, Acute, uncomplicated Gonorrhea, Ear, nose, and throat infectionsInfection caused by staphylococci, Infections caused by penicillinase-producing staphylococci, Pneumococcal Infection, Streptococcal Infections

How Combicare works

Amoxicillin competitively inhibits penicillin-binding protein 1 and other high molecular weight penicillin binding proteins. Penicillin bind proteins are responsible for glycosyltransferase and transpeptidase reactions that lead to cross-linking of D-alanine and D-aspartic acid in bacterial cell walls. Without the action of penicillin binding proteins, bacteria upregulate autolytic enzymes and are unable to build and repair the cell wall, leading to bacteriocidal action.

By binding to specific penicillin-binding proteins (PBPs) located inside the bacterial cell wall, cloxacillin inhibits the third and last stage of bacterial cell wall synthesis. Cell lysis is then mediated by bacterial cell wall autolytic enzymes such as autolysins; it is possible that cloxacillin interferes with an autolysin inhibitor.

Dosage

Combicare dosage

Ear/Nose/ThroatInfection (Mild to Moderate):

• Adult:500 mg every 12 hours or 250 mg every 8 hours
• Children:25 mg/kg/day in divided doses every 12 hours or 20 mg/kg/day in divided doses every 8 hours

Ear/Nose/ThroatInfection (Severe):

• Adult: 875 mg every 12 hours or 500 mg every 8 hours
• Children: 45 mg/kg/day in divided doses every 12 hours or 40 mg/kg/day in divided doses every 8 hours

Lower respiratory tractInfection (Mild/ Moderate/Severe):

• Adult: 875 mg every 12 hours or 500 mg every 8 hours
• Children: 45 mg/kg/day in divided doses every 12 hours or 40 mg/kg/day in divided doses every 8 hours

Skin/skin structureInfection (Mild/Moderate):

• Adult: 500 mg every 12 hours or 250 mg every 8 hours
• Children: 25 mg/kg/day in divided doses every 12 hours or 20 mg/kg/day in divided doses every 8 hours

Skin/skin structureInfection (Severe):

• Adult: 875 mg every 12 hours or 500 mg every 8 hours
• Children: 45 mg/kg/day in divided doses every 12 hours or 40 mg/kg/day in divided doses every 8 hours

Genitourinary tractInfection (Mild/ Moderate):

• Adult: 500 mg every 12 hours or 250 mg every 8 hours
• Children: 25 mg/kg/day in divided doses every 12 hours or 20 mg/kg/day in divided doses every 8 hours

Genitourinary tractInfection (Severe):

• Adult: 875 mg every 12 hours or 500 mg every 8 hours
• Children: 45 mg/kg/day in divided doses every 12 hours or 40 mg/kg/day in divided doses every 8 hours

Gonorrhea, Acute, uncomplicated ano-genital, and urethral infections in males and females:

• Adult: 3 g as single oral dose
• Prepubertal children: 50 mg/Kg/Amoxycillin, combined with 25 mg/kg Probenecid as a single dose. Since Probenecid is contraindicated in children under 2 years, do not use this regimen in these cases.

Upper Respiratory Tract Infection (Adult):

• Usual Dose: 250 mg orally every 6 hours for 7 to 14 days, depending on the nature and severity of the infection.
• Maximum dose: 4 g/day.

Upper Respiratory Tract Infection (Pediatric):

• Usual Dose: The safety and efficacy of cloxacillin in children < 1 year have not been established.
• ≥ 1 year to 18 years: 50 to 100 mg/kg/day orally divided every 6 hours.
• Maximum dose: 4 g/day.

Pneumonia(Adult):

• Usual Dose: 500 mg orally every 6 hours for up to 21 days, depending on the nature and severity of the infection.
• Maximum dose: 4 g/day.

Pneumonia(Pediatric):

• Usual Dose: The safety and efficacy of cloxacillin in children < 1 year have not been established.
• ≥ 1 year to 18 years: 50 to 100 mg/kg/day orally divided every 6 hours.
• Maximum dose: 4 g/day.

Skin and Structure Infection(Adult):

• Usual Dose: 500 mg orally every 6 hours for 7 days, or until 3 days after acute inflammation resolves, depending on the nature and severity of the infection.
• Maximum dose: 4 g/day.

Skin and Structure Infection (Pediatric):

• Usual Dose: The safety and efficacy of cloxacillin in children < 1 year have not been established.
• ≥ 1 year to 18 years: 50 to 100 mg/kg/day orally divided every 6 hours.
• Maximum dose: 4 g/day.

Cystitis:

• Usual Adult Dose: 250 mg orally every 6 hours for 3 to 7 days, depending on the nature and severity of the infection. Cloxacillin is rarely indicated for the treatment of cystitis.
• Maximum dose: 4 g/day.

Suspension: Shake the bottle well before adding water. Then add 12 tea spoonful (60 ml) of boiled and cooled water to the bottle and shake well to make 100 ml suspension.

Amoxycillin 500 mg Injection:

• Intramuscular : Add 2.5 ml water for injection to Amoxycillin 500 mg injection vial.
• Intravenous : Dissolve Amoxycillin 500 mg injection in 10 ml water for injection.

Side Effects

Side effects are mild, rare and infrequent. As with other penicillins, it may induce diarrhea, indigestion or skin rashes that usually stop during treatment and rarely calls for discontinuation of therapy.

Common side effects are skin rash, transient diarrhoea, nausea, heartburn, pruritus and disturbance of blood electrolyte. Rarely anaphylactic shock.

Toxicity

Patients experiencing an overdose may present with hematuria, oliguria, abdominal pain, acute renal failure, vomiting, diarrhea, rash, hyperactivity, and drowsiness. Treat overdose with symptomatic and supportive treatment, which may include emesis or hemodialysis.

Oral LD₅₀ in rat and mouse is 5000 mg/kg. Intravenous LD₅₀ in rat is 1660 mg/kg. Symptoms of overdose include wheezing, tightness in the chest, fever, itching, bad cough, blue skin color, fits, and swelling of face, lips, tongue, or throat.

Precaution

In renal impairment, the excretion of antibiotic will be delayed and depending on the degree of impairment it may be necessary to reduce the total daily dose.

Cloxacillin should be given with caution to patients with known history of allergy.

Interaction

The simultaneous use of Amoxicillin and an oral contraceptive might cause breakthrough bleeding or pregnancy on rare occasions. Concurrent administration of probenecid delays the excretion of Amoxicillin.

May diminish the effect of BCG and typhoid vaccine. May increase risk of methotrexate toxicity. May diminish the therapeutic effect of Na picosulfate. May decrease serum concentrations of mycophenolate. May prolong bleeding time with anticoagulants. Increased serum concentrations with probenecid. Tetracycline may antagonise the bactericidal effect of cloxacillin.

Volume of Distribution

The central volume of distribution of amoxicillin is 27.7L.

Elimination Route

Amoxicillin is approximately 60% bioavailable. A 250mg dose of oral amoxicillin reaches a C_max 3.93±1.13mg/L with a T_max 1.31±0.33h and an AUC of 27.29±4.72mg*h/L. A 875mg dose of oral amoxicillin reaches a C_max 11.21±3.42mg/L with a T_max 1.52±0.40h and an AUC of 55.04±12.68mg*h/L.

Well absorbed from the gastrointestinal tract.

Half Life

The half life of amoxicillin is 61.3 minutes.

Clearance

The mean clearance of amoxicillin is 21.3L/h.

Elimination Route

125mg to 1g doses of amoxicillin are 70-78% eliminated in the urine after 6 hours.

Pregnancy & Breastfeeding use

Because of its lack of teratogenicity, Amoxicillin can beused safely throughout pregnancy at the normal adult dose. The small amount of Amoxicillin secreted in maternal milk rarely causes problem in the infant. It can therefore be used safely during lactation in most instances.

Pregnancy Category B. Either animal-reproduction studies have not demonstrated a foetal risk but there are no controlled studies in pregnant women or animal-reproduction studies have shown an adverse effect (other than a decrease in fertility) that was not confirmed in controlled studies in women in the 1st trimester (and there is no evidence of a risk in later trimesters).

Contraindication

Amoxicillin is contraindicated for patients hypersensitive to penicillin, infectious mononucleosis, neonatal period or babies born of mothers hypersensitive to penicillin

Cloxacillin should not be given to patients known to be hypersensitive to penicillin.

Acute Overdose

If encountered, gastro-intestinal symptoms and disturbance of the fluid and electrolyte balance may be evident. They may be treated symptomatically and supportive with attention to the water/ electrolyte balance. In the absence of an adequate fluid intake and urinary output, crystalluria is a possibility and the antibiotic may be removed from the circulation by haemodialysis. Oral administration can cause gastro intestinal symptoms such as transient diarrhoea, nausea and colic which are dose related and a result of local irritation not toxicity.

Storage Condition

Store in a cool & dry place protected from light. Amoxicillin suspension and drops should be freshly prepared, stored in a cool dry place preferably in a refrigerator. Reconstituted suspension and drops should be used within 5 days if kept at room temperature or within 7 days if kept in a refrigerator.

Dry powder: Store below 25° C. Reconstituted solution: Store between 2-8° C (stable for 4 days); 23° C (stable for 24 hr).

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