Silver sulfadiazine

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# Overview
Silver sulfadiazine is an antimicrobial agent that is FDA approved for the treatment of wound sepsis in patients with second and third degree burns.   Common adverse reactions include burning sensation and rashes.

# Adult Indications and Dosage

## FDA-Labeled Indications and Dosage (Adult)
- Silver sulfadiazine cream, is a topical antimicrobial drug indicated as an adjunct for the prevention and treatment of wound sepsis in patients with second and third degree burns.
- Prompt institution of appropriate regimens for care of the burned patient is of prime importance and includes the control of shock and pain. The burn wounds are then cleansed and debrided, silver sulfadiazine cream, is then applied under sterile conditions. The burn areas should be covered with silver sulfadiazine cream, at all times. The cream should be applied once to twice daily to a thickness of approximately one sixteenth of an inch. Whenever necessary, the cream should be reapplied to any areas from which it has been removed by patient activity. Administration may be accomplished in minimal time because dressings are not required. However, if individual patient requirements make dressings necessary, they may be used.
- Reapply immediately after hydrotherapy. Treatment with silver sulfadiazine cream, should be continued until satisfactory healing has occurred or until the burn site is ready for grafting. The drug should not be withdrawn from the therapeutic regimen while there remains the possibility of infection except if a significant adverse reaction occurs.

## Off-Label Use and Dosage (Adult)

### Guideline-Supported Use
There is limited information regarding Off-Label Guideline-Supported Use of Silver sulfadiazine in adult patients.

### NonGuideline-Supported Use
There is limited information regarding Off-Label NonGuideline-Supported Use of Silver sulfadiazine in adult patients.

# Pediatric Indications and Dosage

## FDA-Labeled Indications and Dosage (Pediatric)
There is limited information regarding FDA-Labeled Use of Silver sulfadiazine in pediatric patients.

## Off-Label Use and Dosage (Pediatric)

### Guideline-Supported Use
There is limited information regarding Off-Label Guideline-Supported Use of Silver sulfadiazine in pediatric patients.

### NonGuideline-Supported Use
There is limited information regarding Off-Label NonGuideline-Supported Use of Silver sulfadiazine in pediatric patients.

# Contraindications
- Silver sulfadiazine cream, USP 1% is contraindicated in patients who are hypersensitive to silver sulfadiazine or any of the other ingredients in the preparation.
- Because sulfonamide therapy is known to increase the possibility of kernicterus, silver sulfadiazine cream, should not be used on pregnant women approaching or at term, on premature infants, or on newborn infants during the first 2 months of life.

# Warnings
- Absorption of silver sulfadiazine varies depending upon the percent of body surface area and the extent of the tissue damage. Although few have been reported, it is possible that any adverse reaction associated with sulfonamides may occur. Some of the reactions which have been associated with sulfonamides are as follows: blood dyscrasias including agranulocytosis, aplastic anemia, thrombocytopenia, leukopenia, and hemolytic anemia; dermatologic and allergic reactions, including life-threatening cutaneous reactions Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN) and exfoliative dermatitis; gastrointestinal reactions, hepatitis and hepatocellular necrosis; CNS reactions; and toxic nephrosis.
- There is a potential cross-sensitivity between silver sulfadiazine and other sulfonamides.  If allergic reactions attributable to treatment with silver sulfadiazine occur, continuation of therapy must be weighed against the potential hazards of the particular allergic reaction.
- Fungal proliferation in and below the eschar may occur.  However, the incidence of clinically reported fungal superinfection is low.
- The use of silver sulfadiazine cream, in some cases of glucose-6-phosphate dehydrogenase-deficient individuals may be hazardous, as hemolysis may occur.

### Precautions
- If hepatic and renal functions become impaired and elimination of the drug decreases accumulation may occur. Discontinuation of silver sulfadiazine cream, should be weighed against the therapeutic benefit being achieved.
- In considering the use of topical proteolytic enzymes in conjunction with Silver sulfadiazine cream, the possibility should be noted that silver may inactivate such enzymes.
- In the treatment of burn wounds involving extensive areas of the body, the serum sulfa concentrations may approach adult therapeutic levels (8 to 12mg %). Therefore, in these patients it would be advisable to monitor serum sulfa concentrations. Renal function should be carefully monitored and the urine should be checked for sulfa crystals.
- Absorption of the propylene glycol vehicle has been reported to affect serum osmolality, which may affect the interpretation of laboratory tests.

# Adverse Reactions

## Clinical Trials Experience
- Several cases of transient leukopenia have been reported in patients receiving silver sulfadiazine therapy.1,2,3 Leukopenia associated with silver sulfadiazine administration is primarily characterized by decreased neutrophil count.  Maximal white blood cell depression occurs within two to four days of initiation of therapy.  Rebound to normal leukocyte levels follows onset within two to three days.  Recovery is not influenced by continuation of silver sulfadiazine therapy. An increased incidence has been seen in patients treated concurrently with cimetidine.
- Other infrequently occurring events include skin necrosis, erythema multiforme, skin discoloration, burning sensation, rashes, and interstitial nephritis.
- Reduction in bacterial growth after application of topical antibacterial agents has been reported to permit spontaneous healing of deep partial-thickness burns by preventing conversion of the partial thickness to full thickness by sepsis.  However, reduction in bacterial colonization has caused delayed separation, in some cases necessitating escharotomy in order to prevent contracture.

## Postmarketing Experience
There is limited information regarding Postmarketing Experience of Silver sulfadiazine in the drug label.

# Drug Interactions
There is limited information regarding Drug nteractions of Silver sulfadiazine in the drug label.

# Use in Specific Populations

### Pregnancy
Pregnancy Category (FDA): B
- A reproductive study has been performed in rabbits at doses up to three to ten times the concentration of silver sulfadiazine in silver sulfadiazine cream, USP 1% and has revealed no evidence of harm to the fetus due to silver sulfadiazine.  There are, however, no adequate and well-controlled studies in pregnant women.  Because animal reproduction studies are not always predictive of human response, this drug should be used during pregnancy only if clearly justified, especially in pregnant women approaching or at term.
Pregnancy Category (AUS):
- Australian Drug Evaluation Committee (ADEC) Pregnancy Category
There is no Australian Drug Evaluation Committee (ADEC) guidance on usage of Silver sulfadiazine in women who are pregnant.

### Labor and Delivery
There is no FDA guidance on use of Silver sulfadiazine during labor and delivery.

### Nursing Mothers
- It is not known whether silver sulfadiazine cream, USP 1% is excreted in human milk. However, sulfonamides are known to be excreted in human milk and all sulfonamides derivatives are known to increase the possibility of kernicterus. Because of the possibility for serious adverse reactions in nursing infants from sulfonamides, a decision should be made whether to discontinue nursing or to discontinue the drug, taking into account the importance of the drug to the mother.

### Pediatric Use
There is no FDA guidance on the use of Silver sulfadiazine with respect to pediatric patients.

### Geriatic Use
- Of the total number of subjects in clinical studies of silver sulfadiazine cream, seven percent were 65 years of age 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.

### Gender
There is no FDA guidance on the use of Silver sulfadiazine with respect to specific gender populations.

### Race
There is no FDA guidance on the use of Silver sulfadiazine with respect to specific racial populations.

### Renal Impairment
There is no FDA guidance on the use of Silver sulfadiazine in patients with renal impairment.

### Hepatic Impairment
There is no FDA guidance on the use of Silver sulfadiazine in patients with hepatic impairment.

### Females of Reproductive Potential and Males
There is no FDA guidance on the use of Silver sulfadiazine in women of reproductive potentials and males.

### Immunocompromised Patients
There is no FDA guidance one the use of Silver sulfadiazine in patients who are immunocompromised.

# Administration and Monitoring

### Administration
- Topical

### Monitoring
There is limited information regarding Monitoring of Silver sulfadiazine in the drug label.
- Description

# IV Compatibility
There is limited information regarding IV Compatibility of Silver sulfadiazine in the drug label.

# Overdosage
There is limited information regarding Chronic Overdose of Silver sulfadiazine in the drug label.

# Pharmacology

## Mechanism of Action
- It is bactericidal for many gram-negative and gram-positive bacteria as well as being effective against yeast.

## Structure
- Silver sulfadiazine cream, USP 1% is a soft, white, water dispersible cream containing the antimicrobial agent silver sulfadiazine in micronized form for topical application.  Each gram of silver sulfadiazine cream contains 10mg of micronized silver sulfadiazine.
- This active agent has the following structural formula:

## Pharmacodynamics

### Microbiology
- Silver sulfadiazine has broad antimicrobial activity. It is bactericidal for many gram-negative and gram-positive bacteria as well as being effective against yeast. Results from in vitro testing are listed below.
- Sufficient data have been obtained to demonstrate that silver sulfadiazine will inhibit bacteria that are resistant to other antimicrobial agents and that the compound is superior to sulfadiazine.
- Studies utilizing radioactive micronized silver sulfadiazine, electron microscopy, and biochemical techniques have revealed that the mechanism of action of silver sulfadiazine on bacteria differs from silver nitrate and sodium sulfadiazine. Silver sulfadiazine acts only on the cell membrane and cell wall to produce its bactericidal effect.
- Silver sulfadiazine is not a carbonic anhydrase inhibitor and may be useful in situations where such agents are contraindicated.

## Pharmacokinetics
There is limited information regarding Pharmacokinetics of Silver sulfadiazine in the drug label.

## Nonclinical Toxicology
There is limited information regarding Nonclinical Toxicology of Silver sulfadiazine in the drug label.

# Clinical Studies
- Impairment of Fertility. Long-term dermal toxicity studies of 24 months duration in rats and 18 months in mice with concentrations of silver sulfadiazine three to ten times the concentration in silver sulfadiazine cream, USP 1% revealed no evidence of carcinogenicity.

# How Supplied
Silver sulfadiazine cream, USP 1% - white to off-white cream
NDC Number                                  Size
67877-124-20                                20g tube
67877-124-25                                25g tube
67877-124-05                                50g tube
67877-124-85                                85g tube
67877-124-50                                50g jar
67877-124-40                                400g jar
67877-124-10                                1000g jar
Manufactured for:
Ascend Laboratories, LLC
Montvale, NJ 07645
Manufactured by:
Crown Laboratories, Inc.
Johnson City, TN 37604
Product information: 1-877-272-7901
P1840.01
PRINCIPAL DISPLAY PANEL - 25g
NDC 67877-124-25
Ascend                                                              Rx
Laboratories, LLC                                              ONLY
Silver Sulfadiazine Cream, USP 1%                       Net Wt. 25g

## Storage
Store at room temperature. 15-30C (56-86F).

# Images

## Drug Images

## Package and Label Display Panel

# Patient Counseling Information
There is limited information regarding Patient Counseling Information of Silver sulfadiazine in the drug label.

# Precautions with Alcohol
- Alcohol-Silver sulfadiazine interaction has not been established. Talk to your doctor about the effects of taking alcohol with this medication.

# Brand Names
SILVER SULFADIAZENE

# Look-Alike Drug Names
There is limited information regarding Silver sulfadiazine Look-Alike Drug Names in the drug label.

# Drug Shortage Status

# Price