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SUMMARY OF PRODUCT CHARACTERISTICS

1    NAME OF THE MEDICINAL PRODUCT

Piperacillin/Tazobactam 2 g/0.25 g Powder for Solution for Infusion

2    QUALITATIVE AND QUANTITATIVE    COMPOSITION

Each vial contains 2g piperacillin (as sodium salt) and 0.25g tazobactam (as sodium salt).

One vial of powder for solution for injection or infusion contains 4.72mmol (109mg) of sodium.

For a full list of excipients see section 6.1.

3    PHARMACEUTICAL FORM

Powder for solution for infusion White to off white powder

4    CLINICAL PARTICULARS

4.1    Therapeutic indications

Piperacillin/Tazobactam is indicated for the treatment of the following infections in adults and children over 2 years of age (see sections 4.2 and 5.1):

Adults and Adolescents

-    Severe pneumonia including hospital-acquired and ventilator-associated pneumonia

-    Complicated urinary tract infections (including pyelonephritis)

-    Complicated intra-abdominal infections

-    Complicated skin and soft tissue infections (including diabetic foot infections)

Treatment of patients with bacteraemia that occurs in association with, or is suspected to be associated with, any of the infections listed above.

Piperacillin/Tazobactam may be used in the management of neutropenic patients with fever suspected to be due to a bacterial infection.

Children 2 to 12 years of age

-    Complicated intra-abdominal infections

Piperacillin/Tazobactam may be used in the management of neutropenic children with fever suspected to be due to a bacterial infection.

Consideration should be given to official guidance on the appropriate use of antibacterial agents.

4.2 Posology and method of administration Posology

The dose and frequency of Piperacillin/Tazobactam depends on the severity and localisation of the infection and expected pathogens.

Adult and adolescent patients Infections

The usual dose is 4g piperacillin/ 0.5g tazobactam given every eight hours.

For nosocomial pneumonia and bacterial infections in neutropenic patients, the recommended dose is 4g piperacillin/ 0.5g tazobactam administered every six hours. This regimen may also be applicable to treat patients with other indicated infections when particularly severe.

The following table summarises the treatment frequency and the recommended dose for adult and adolescent patients by indication or condition:

Treatment frequency	Piperacillin/Tazobactam 4g/ 0.5g
Every six hours	Severe pneumonia
	Neutropenic adults with fever suspected to be due to a bacterial infection.
Every eight hours	Complicated urinary tract infections (including pyelonephritis)
	Complicated intra-abdominal infections
	Skin and soft tissue infections (including diabetic foot infections)

Renal impairment

The intravenous dose should be adjusted to the degree of actual renal impairment (each patient must be monitored closely for signs of substance toxicity; medicinal product dose and interval should be adjusted accordingly):

Creatinine clearance (ml/min)	Piperacillin/Tazobactam (recommended dose)
>40	No dose adjustment necessary
20-40	Maximum dose suggested: 4g/ 0.5g every eight hours
<20	Maximum dose suggested: 4g/ 0.5g every 12 hours

For patients on haemodialysis, one additional dose of Piperacillin/Tazobactam 2g/0.25g should be administered following each dialysis period, because haemodialysis removes 30%-50% of piperacillin in four hours.

Hepatic Impairment

No dose adjustment is necessary (see section 5.2).

Dose in elderly patients

No dose adjustment is required for the elderly with normal renal function or creatinine clearance values above 40 ml/min.

Paediatric population (2-12 years of age)

Infections

The following table summarises the treatment frequency and the dose per body weight for paediatric patients 2-12 years of age by indication or condition:

Dose per weight and treatment frequency	Indication/ condition
80mg Piperacillin/ 10mg Tazobactam per kg body weight / every six hours	Neutropenic children with fever suspected to be due to bacterial infections*
100mg Piperacillin/ 12.5mg Tazobactam per kg body weight/ every eight hours	Complicated intra-abdominal infections*

* Not to exceed the maximum 4g/ 0.5g per dose over 30 minutes.

Renal impairment

The intravenous dose should be adjusted to the degree of actual renal impairment as follows (each patient must be monitored closely for signs of substance toxicity; medicinal product dose and interval should be adjusted accordingly):

Creatinine clearance (ml/min)	Piperacillin/Tazobactam (recommended dose)
>50	No dose adjustment needed.
<50	70mg piperacillin/ 8.75mg tazobactam/ kg every eight hours.

For children on haemodialysis, one additional dose of 40mg piperacillin/ 5mg tazobactam/ kg should be administered following each dialysis period.

Use in children aged below 2 years

The safety and efficacy of Piperacillin/Tazobactam in children 0-2 years of age has not been established.

No data from controlled clinical studies are available.

Treatment duration

The usual duration of treatment for most indications is in the range of 5-14 days. However, the duration of treatment should be guided by the severity of the infection, the pathogen(s) and the patient's clinical and bacteriological progress.

Route of administration

Piperacillin/Tazobactam 2g/0.25g is administered by intravenous infusion (over 30 minutes).

Piperacillin/Tazobactam 4g/0.5g is administered by intravenous infusion (over 30 minutes).

For reconstitution instructions, see section 6.6.

4.3 Contraindications

Hypersensitivity to the active substances, any other penicillin-antibacterial agent or to any of the excipients.

History of acute severe allergic reaction to any other beta-lactam active substances (e.g. cephalosporin, monobactam or carbapenem).

4.4 Special warnings and precautions for use

The selection of Piperacillin/Tazobactam to treat an individual patient should take into account the appropriateness of using a broad-spectrum semi-synthetic penicillin based on factors such as the severity of the infection and the prevalence of resistance to other suitable antibacterial agents.

Before initiating therapy with Piperacillin/Tazobactam, careful inquiry should be made concerning previous hypersensitivity reactions to penicillins, other beta-lactam agents (e.g. cephalosporin, monobactam or carbapenem) and other allergens. Serious and occasionally fatal hypersensitivity (anaphylactic/ anaphylactoid [including shock]) reactions have been reported in patients receiving therapy with penicillins, including Piperacillin/Tazobactam. These reactions are more likely to occur in persons with a history of sensitivity to multiple allergens. Serious hypersensitivity reactions require the discontinuation of the antibiotic, and may require administration of epinephrine and other emergency measures.

Serious skin reactions, such as Stevens-Johnson syndrome and toxic epidermal necrolysis, have been reported in patients receiving Piperacillin/Tazobactam (see section 4.8). If patients develop a skin rash they should be monitored closely and Piperacillin/Tazobactam discontinued if lesions progress.

Antibiotic-induced pseudomembranous colitis may be manifested by severe, persistent diarrhoea which may be life-threatening. The onset of pseudomembranous colitis symptoms may occur during or after antibacterial treatment. In these cases Piperacillin/Tazobactam, should be discontinued.

Therapy with Piperacillin/Tazobactam may result in the emergence of resistant organisms, which might cause super-infections.

Bleeding manifestations have occurred in some patients receiving beta-lactam antibiotics. These reactions sometimes have been associated with abnormalities of coagulation tests, such as clotting time, platelet aggregation and prothrombin time, and are more likely to occur in patients with renal failure. If bleeding manifestations occur, the antibiotic should be discontinued and appropriate therapy instituted.

Leukopenia and neutropenia may occur, especially during prolonged therapy. Therefore, periodic assessment of a full blood count should be performed.

As with treatment with other penicillins, neurological complications in the form of convulsions may occur when high doses are administered, especially in patients with impaired renal function.

This medicinal product contains 4.72mmol (109mg) of sodium per vial of powder for solution for infusion. To be taken into account by patients on a controlled sodium diet.

Hypokalaemia may occur in patients with low potassium reserves or those receiving concomitant medicinal products that may lower potassium levels; periodic electrolyte determinations may be advisable in such patients.

4.5 Interaction with other medicinal products and other forms of interaction Non-depolarising muscle relaxants

Piperacillin when used concomitantly with vecuronium has been implicated in the prolongation of the neuromuscular blockade of vecuronium. Due to their similar mechanisms of action, it is expected that the neuromuscular blockade produced by any of the non-depolarising muscle relaxants could be prolonged in the presence of piperacillin.

Oral anticoagulants

During simultaneous administration of heparin, oral anticoagulants and other drugs that may affect the blood coagulation system including thrombocyte function, appropriate coagulation tests should be performed more frequently and monitored regularly.

Methotrexate

Piperacillin may reduce the excretion of methotrexate; therefore, serum levels of methotrexate should be monitored in patients to avoid substance toxicity.

Probenecid

As with other penicillins, concurrent administration of probenecid and Piperacillin/Tazobactam produces a longer half-life and lower renal clearance for both piperacillin and tazobactam; however, peak plasma concentrations of either substances are unaffected.

Aminoglycosides

Piperacillin, either alone or with tazobactam, did not significantly alter the pharmacokinetics of tobramycin in subjects with normal renal function and with mild or moderate renal impairment. The pharmacokinetics of piperacillin, tazobactam, and the M1 metabolite were also not significantly altered by tobramycin administration.

The inactivation of tobramycin and gentamicin by piperacillin has been demonstrated in patients with severe renal impairment.

For information related to the administration of Piperacillin/Tazobactam with aminoglycosides please refer to sections 6.2 and 6.6.

Vancomycin

No pharmacokinetic interactions have been noted between Piperacillin/ Tazobactam and vancomycin.

Effects on laboratory tests

Non-enzymatic methods of measuring urinary glucose may lead to false-positive results, as with other penicillins. Therefore, enzymatic urinary glucose measurement is required under Piperacillin/Tazobactam therapy.

A number of chemical urine protein measurement methods may lead to false-positive results. Protein measurement with dip sticks is not affected.

The direct Coombs test may be positive.

Bio-Rad Laboratories Platelia Aspergillus EIA tests may lead to false-positive results for patients receiving Piperacillin/Tazobactam. Cross-reactions with non-Aspergillus polysaccharides and polyfuranoses with Bio-Rad Laboratories Platelia Aspergillus EIA test have been reported.

Positive test results for the assays listed above in patients receiving Piperacillin/Tazobactam should be confirmed by other diagnostic methods.

4.6 Fertility, pregnancy and lactation

Pregnancy

There are no or a limited amount of data from the use of Piperacillin/ Tazobactam in pregnant women.

Studies in animals have shown developmental toxicity, but no evidence of teratogenicity, at doses that are maternally toxic (see section 5.3).

Piperacillin and tazobactam cross the placenta. Piperacillin/Tazobactam should only be used during pregnancy if clearly indicated, i.e. only if the expected benefit outweighs the possible risks to the pregnant woman and foetus.

Breast-feeding

Piperacillin is excreted in low concentrations in breast milk; tazobactam concentrations in human milk have not been studied. Women who are breastfeeding should be treated only if the expected benefit outweighs the possible risks to the woman and child.

Fertility

A fertility study in rats showed no effect on fertility and mating after intraperitoneal administration of tazobactam or the combination Piperacillin/ Tazobactam (see section 5.3).

4.7 Effects on ability to drive and use machines

No studies on the effects on the ability to drive and use machines have been performed.

4.8 Undesirable effects

The most commonly reported adverse reactions (occurring in 1 to 10 patients in 100) are diarrhoea, nausea, vomiting and rash.

In the following table, adverse reactions are listed by system organ class and MedDRA-preferred term. Within each frequency grouping, undesirable effects are presented in order of decreasing seriousness.

Frequency groupings as follows: Very common (>1/10); common (>1/100 to <1/10); uncommon (>1/1 000 to <1/100); rare (>1/10 000 to <1/1 000); very rare (<1/10 000); not known (cannot be estimated from the available data).

phosphatase increased, gamma ^-glutamyltransferase increased, hepatitis

Skin and subcutaneous tissue disorders	Common	Rash including maculopapular rash
	Uncommon	Pruritus, urticaria
	Rare	Erythema multiforme, dermatitis bullous, exanthema
	Very rare	Stevens-Johnson Syndrome, toxic epidermal necrolysis
Musculoskeletal, and connective tissue disorders	Rare	Arthralgia, myalgia
Renal and urinary disorders	Uncommon	Blood creatinine increased
	Rare	Tubulointerstitial nephritis, renal failure
	Very rare	Blood urea increased
General disorders and administration site conditions	Uncommon Rare	Pyrexia, injection-site reaction Chills

Piperacillin therapy has been associated with an increased incidence of fever and rash in cystic fibrosis patients.

Reporting of suspected adverse reactions

Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the Yellow Card Scheme at www.mhra.gov.uk/yellowcard.

4.9 Overdose Symptoms

There have been post-marketing reports of overdose with Piperacillin/ Tazobactam. The majority of those events experienced including nausea, vomiting, and diarrhoea have also been reported with the usual recommended dose. Patients may experience neuromuscular excitability or convulsions if higher than recommended doses are given intravenously (particularly in the presence of renal failure).

Treatment

In the event of an overdose, Piperacillin/Tazobactam treatment should be discontinued. No specific antidote is known.

Treatment should be supportive and symptomatic according to the patient's clinical presentation.

Excessive serum concentrations of either piperacillin or tazobactam may be reduced by haemodialysis (see section 4.4).

5    PHARMACOLOGICAL PROPERTIES

5.1    Pharmacodynamic properties

Pharmacotherapeutic group: Antibacterials for systemic use, Combinations of penicillins, including beta-lactamase inhibitors.

ATC code: J01C R05

Mechanism of action

Piperacillin, a broad spectrum, semisynthetic penicillin exerts bactericidal activity by inhibition of both septum and cell wall synthesis.

Tazobactam, a beta-lactam structurally related to penicillins, is an inhibitor of many beta-lactamases, which commonly cause resistance to penicillins and cephalosporins but it does not inhibit AmpC enzymes or metallo beta-lactamases.

Tazobactam extends the antibiotic spectrum of piperacillin to include many beta-lactamase-producing bacteria that have acquired resistance to piperacillin alone.

Pharmacokinetic/ Pharmacodynamic relationship

The time above the minimum inhibitory concentration (T>MIC) is considered to be the major pharmacodynamic determinant of efficacy for piperacillin.

Mechanism of resistance

The two main mechanisms of resistance to Piperacillin/Tazobactam are:

•    Inactivation of the piperacillin component by those beta-lactamases that are not inhibited by tazobactam: beta-lactamases in the Molecular class B, C and D. In addition, tazobactam does not provide protection against extended-spectrum beta-lactamases (ESBLs) in the Molecular class A and D enzyme groups.

•    Alteration of penicillin-binding proteins (PBPs), which results in the reduction of the affinity of piperacillin for the molecular target in bacteria.

Additionally, alterations in bacterial membrane permeability, as well as expression of multi-drug efflux pumps, may cause or contribute to bacterial resistance to piperacillin/tazobactam, especially in Gram-negative bacteria.

Breakpoints

EUCAST clinical MIC breakpoints 2009 (2009-12-02, v 1):

For susceptibility testing purposes, the concentration of tazobactam is fixed at 4mg/L

Pathogen	Species-related breakpoints (S</R>)
Enterobacteriaceae	8/16
Pseudomonas	16/16
Gram-negative and Gram-positive anaerobes	8/16
Non-species related breakpoints	4/16

The susceptibility of streptococci is inferred from the penicillin susceptibility.

The susceptibility of staphylococci is inferred from the oxacillin susceptibility. Susceptibility

The prevalence of acquired resistance may vary geographically and with time for selected species and local information on resistance is desirable, particularly when treating severe infections. As necessary, expert advice should be sought when the local prevalence of resistance is such that the utility of the agent in at least some types of infections is questionable.

Groupings of relevant species according to piperacillin/ tazobactam susceptibility

Commonly susceptible species

Gram positive aerobes Enterococcus faecalis Listeria monocytogenes

Staphylococcus aureus, methicillin susceptible^£

Staphylococcus species, coagulase negative, methicillin-susceptible Streptococcus pyogenes Group B streptococci

Gram negative aerobes

Citrobacter koseri Haemophilus influenzae

Moraxella catarrhalis

Proteus mirabilis

Gram positive anaerobes Clostridium spp.

Eubacterium spp.

Peptostreptococcus spp.

Gram negative anaerobes Bacteroides fragilis group Fusobacterium spp.

Porphyromonas spp.

Prevotella spp.

Species for which acquired resistance may be a problem

Gram positive aerobes

Enterococcus faecium ^$,.+

Streptococcus pneumonia

Streptococcus viridans group

Gram negative aerobes Actinobacter baumannii ^$

Burkholderia cepacia Citrobacter freundii Enterobacter spp.

Escherichia coli Klebsiella pneumonia Morganella morganii

Proteus vulgaris Providencia ssp.

Pseudomonas aeruginosa Serratia spp.

Inherently resistant organisms

Gram positive aerobes Corynebacterium jeikeium

Gram negative aerobes Legionella spp

Stenotrophomonas maltophilia ’$

Other microorganisms

Chlamydophilia pneumonia Mycoplasma pneumonia

$ Species showing natural intermediate susceptibility

+ Species for which high resistance rates (more than 50%) have been observed in one or more areas/countries/regions within the EU.

^£All methicillin-resistant staphylococci are resistant to piperacillin/ tazobactam.

5.2 Pharmacokinetic properties Absorption

The peak piperacillin and tazobactam concentrations after 4g/0.5g administered over 30 minutes by intravenous infusion are 298pg/ml and 34pg/ml respectively.

Distribution

Both piperacillin and tazobactam are approximately 30% bound to plasma proteins. The protein binding of either piperacillin or tazobactam is unaffected by the presence of the other compound. Protein binding of the tazobactam metabolite is negligible.

Piperacillin/Tazobactam is widely distributed in tissue and body fluids including intestinal mucosa, gallbladder, lung, bile and bone. Mean tissue concentrations are generally 50 to 100% of those in plasma. Distribution into cerebrospinal fluid is low in subjects with non-inflamed meninges, as with other penicillins.

Biotransformation

Piperacillin is metabolised to a minor microbiologically active desethyl metabolite. Tazobactam is metabolised to a single metabolite, which has been found to be microbiologically inactive.

Elimination

Piperacillin and tazobactam are eliminated by the kidney via glomerular filtration and tubular secretion.

Piperacillin is excreted rapidly as unchanged drug with 68% of the administered dose appearing in the urine. Tazobactam and its metabolite are eliminated primarily by renal excretion with 80% of the administered dose appearing as unchanged drug and the remainder as the single metabolite. Piperacillin, tazobactam, and desethyl piperacillin are also secreted into the bile.

Following single or multiple doses of Piperacillin/Tazobactam to healthy subjects, the plasma half-life of piperacillin and tazobactam ranged from 0.7 to 1.2 hours and was unaffected by dose or duration of infusion. The elimination half-lives of both piperacillin and tazobactam are increased with decreasing renal clearance.

There are no significant changes in piperacillin pharmacokinetics due to tazobactam. Piperacillin appears to reduce the clearance of tazobactam.

Special populations

The half-life of piperacillin and of tazobactam increases by approximately 25% and 18%, respectively, in patients with hepatic cirrhosis compared to healthy subjects.

The half-life of piperacillin and tazobactam increases with decreasing creatinine clearance. The increase in half-life is two-fold and four-fold for piperacillin and tazobactam, respectively, at creatinine clearance below 20ml/min compared to patients with normal renal function.

Haemodialysis removes 30% to 50% of piperacillin/ tazobactam, with an additional 5% of the tazobactam dose removed as the tazobactam metabolite. Peritoneal dialysis removes approximately 6% and 21% of the piperacillin and tazobactam doses, respectively, with up to 18% of the tazobactam dose removed as the tazobactam metabolite.

Paediatric population

In a population PK analysis, estimated clearance for 9 month-old to 12 year-old patients was comparable to adults, with a population mean (SE) value of 5.64 (0.34)ml/min/kg. The piperacillin clearance estimate is 80% of this value for paediatric patients 2-9 months of age. The population mean (SE) for piperacillin volume of distribution is 0.243 (0.011) l/kg and is independent of age.

Elderly patients

The mean half-life for piperacillin and tazobactam were 32% and 55% longer, respectively, in the elderly compared with younger subjects. This difference may be due to age-related changes in creatinine clearance.

Race

No difference in piperacillin or tazobactam pharmacokinetics was observed between Asian (n=9) and Caucasian (n=9) healthy volunteers who received single 4g/ 0.5g doses.

5.3 Preclinical safety data

Preclinical data reveal no special hazard for humans based on conventional studies of repeated dose toxicity and genotoxicity. Carcinogenicity studies have not been conducted with Piperacillin/Tazobactam.

A fertility and general reproduction study in rats using intraperitoneal administration of tazobactam or the combination Piperacillin/Tazobactam reported a decrease in litter size and an increase in foetuses with ossification delays and variations of ribs, concurrent with maternal toxicity. Fertility of the F1 generation and embryonic development of F2 generation were not impaired.

Teratogenicity studies using intravenous administration of tazobactam or the combination Piperacillin/Tazobactam in mice and rats resulted in slight reductions in rat foetal weights at maternally toxic doses but did not show teratogenic effects.

Peri/postnatal development was impaired (reduced pup weights, increase in pup mortality, increase in stillbirths) concurrently with maternal toxicity after intraperitoneal administration of tazobactam or the combination Piperacillin/ Tazobactam in the rat.

6 PHARMACEUTICAL PARTICULARS

6.1    List of excipients

None

6.2 Incompatibilities

This medicinal product must not be mixed with other medicinal products except those mentioned in section 6.6.

Whenever Piperacillin/Tazobactam is used concurrently with another antibiotic (e.g. aminoglycosides), the substances must be administered separately. The mixing of Piperacillin/Tazobactam with an aminoglycoside in vitro can result in substantial inactivation of the aminoglycoside.

Piperacillin/Tazobactam should not be mixed with other substances in a syringe or infusion bottle since compatibility has not been established.

Because of chemical instability, Piperacillin/Tazobactam should not be used with solutions containing only sodium bicarbonate.

Lactated Ringer's solution is not compatible with Piperacillin/Tazobactam.

Piperacillin/Tazobactam should not be added to blood products or albumin hydrolysates.

6.3 Shelf life

Unopened - 3 years

When reconstituted with water for injections and saline, reconstituted solutions will remain stable for 24 hours at 25°C and for 48 hours at 4°C.

From a microbiological point of view, once opened, the product should be used immediately. If not used immediately, in-use storage times and conditions prior to use are the responsibility of the user and would normally not be longer than 24 hours at 2-8°C, unless reconstitution has taken place in controlled and validated aseptic conditions.

6.4 Special precautions for storage

Unopened: Do not store above 25°C.

After reconstitution: Store at 2-8°C (see 6.3 Shelf Life).

6.5 Nature and contents of container

Packs of one two, five and ten* Type II glass vial with butyl rubber stopper and aluminium/plastic seal

*Not all pack sizes may be marketed.

6.6 Special precautions for disposal Intravenous use

Each vial of Piperacillin/Tazobactam 2g/0.25g Powder for Solution for Infusion should be reconstituted with 10ml of one of the following diluents:

•    Sterile water for injections

•    0.9% sodium chloride for injection

To achieve effective reconstitution, invert and shake the vial thoroughly to detach any powder adhering to the walls prior to addition of the diluent. Add the solvent and shake until complete dissolution is achieved.

The reconstituted solution should be further diluted to at least 50ml with one of the reconstitution diluents, or with Dextrose 5% in Water.

Displacement Volume

Each gram of Piperacillin/Tazobactam 2g/0.25g Powder for Solution for Infusion has a displacement volume of 0.7ml.

Piperacillin/Tazobactam 2g/0.25g Powder for Solution for Infusion will displace 1.58ml.

The reconstitution/dilution is to be made under aseptic conditions. The solution is to be inspected visually for particulate matter and discoloration prior to administration. The solution should only be used if the solution is clear and free from particles.

Any unused product or waste material should be disposed of in accordance with local requirements.

7 MARKETING AUTHORISATION HOLDER

Wockhardt UK Limited Ash Road North Wrexham LL13 9UF United Kingdom

8 MARKETING AUTHORISATION NUMBER(S)

PL 29831/0329

9    DATE OF FIRST AUTHORISATION/RENEWAL OF THE AUTHORISATION

17/04/2009

10    DATE OF REVISION OF THE TEXT

11/09/2014