Ampicillin (oral)

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# Overview
Ampicillin (oral) is an antibiotic that is FDA approved for the treatment of respiratory tract infections, bacterial infections, septicemia, endocarditis, urinary tract infections, and gastrointestinal infections.   Common adverse reactions include anemia, thrombocytopenia, thrombocytopenic purpura, eosinophilia, leukopenia, agranulocytosis, hypersensitivity reactions, glossitis, and stomatitis.

# Adult Indications and Dosage

## FDA-Labeled Indications and Dosage (Adult)
- Ampicillin Capsules, USP are indicated in the treatment of infections caused by susceptible strains of the designated organism listed below:
- Infections of the genitourinary tract including gonorrhea: E. coli, P. mirabilis, enterococci, Shigella, S. typhosa and other Salmonella, and nonpenicillinaseproducing N. gonorrhoeae.
- Infections of the respiratory tract: nonpenicillinase-producing H. influenzae and staphylococci, and streptococci including streptococcus pneumoniae.
- Infections of the gastrointestinal tract: Shigella, S. typhosa and other Salmonella, E. coli, P. mirabilis, and enterococci.
- Meningitis: N. Meningitides.
- To reduce the development of drug-resistant bacteria and maintain the effectiveness of ampicillin and other antibacterial drugs, ampicillin 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.
- Bacteriology studies to determine the causative organisms and their susceptibility to ampicillin should be performed. Therapy may be instituted prior to the results of susceptibility testing.
- ADULTS AND CHILDREN WEIGHING OVER 20 KG:
- For genitourinary or gastrointestinal tract infections other than gonorrhea in men and women, the usual dose is 500 mg qid in equally spaced doses; severe or chronic infections may require larger doses. For the treatment of gonorrhea in both men and women, a single oral dose of 3.5 grams of ampicillin administered simultaneously with 1 gram of probenecid is recommended. Physicians are cautioned to use no less than the above recommended dosage for the treatment of gonorrhea. Follow-up cultures should be obtained from the original site(s) of infection 7 to 14 days after therapy. In women, it is also desirable to obtain culture test-of-cure from both the endocervical and anal canals. Prolonged intensive therapy is needed for complications such as prostatitis and epididymitis.
- For respiratory tract infections, the usual dose is 250 mg qid in equally spaced doses.
- CHILDREN WEIGHING 20 KG OR LESS:
- For genitourinary or gastrointestinal tract infections, the usual dose is 100 mg/kg/day total, qid in equally divided and spaced doses. For respiratory infections, the usual dose is 50 mg/kg/day total, in equally divided and spaced doses three to four times daily. Doses for children should not exceed doses recommended for adults.
- ALL PATIENTS, IRRESPECTIVE OF AGE AND WEIGHT:
- Larger doses may be required for severe or chronic infections. Although ampicillin is resistant to degradation by gastric acid, it should be administered at least one-half hour before or two hours after meals for maximal absorption. Except for the single dose regimen for gonorrhea referred to above, therapy should be continued for a minimum of 48 to 72 hours after the patient becomes asymptomatic or evidence of bacterial eradication has been obtained. In infections caused by hemolytic strains of streptococci, a minimum of 10 days treatment is recommended to guard against the risk of rheumatic fever of glomerulonephritis. In the treatment of chronic urinary or gastrointestinal infections, frequent bacteriologic and clinical appraisal is necessary during therapy and may be necessary for several months afterwards. Stubborn infections may require treatment for several weeks. Smaller doses than those indicated above should not be used.

## Off-Label Use and Dosage (Adult)

### Guideline-Supported Use
There is limited information regarding Off-Label Guideline-Supported Use of Ampicillin (oral) in adult patients.

### NonGuideline-Supported Use
- Premature rupture of membranes 

# Pediatric Indications and Dosage

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

## Off-Label Use and Dosage (Pediatric)

### Guideline-Supported Use
There is limited information regarding Off-Label Guideline-Supported Use of Ampicillin (oral) in pediatric patients.

### NonGuideline-Supported Use
There is limited information regarding Off-Label NonGuideline-Supported Use of Ampicillin (oral) in pediatric patients.

# Contraindications
- A history of a previous hypersensitivity reaction to any of the penicillins is a contraindication. Ampicillin is also contraindicated in infections caused by penicillinase-producing organisms.

# Warnings
- SERIOUS AND OCCASIONAL FATAL HYPERSENSITIVITY (ANAPHYLACTOID) REACTIONS HAVE BEEN REPORTED IN PATIENTS ON PENICILLIN THERAPY. ALTHOUGH ANAPHYLAXIS IS MORE FREQUENT FOLLOWING PARENTERAL ADMINISTRATION, IT HAS OCCURRED IN PATIENTS ON ORAL PENICILLINS. THESE REACTIONS ARE MORE LIKELY TO OCCUR IN INDIVIDUALS WITH A HISTORY OF PENICILLIN HYPERSENSITIVITY AND/OR A HISTORY OF SENSITIVITY TO MULTIPLE ALLERGENS.
- THERE HAVE BEEN REPORTS OF INDIVIDUALS WITH A HISTORY OF PENICILLIN HYPERSENSITIVITY WHO HAVE EXPERIENCED SEVERE HYPERSENSITIVITY REACTIONS WHEN TREATED WITH CEPHALOSPORINS. BEFORE INITIATING THERAPY WITH ANY PENICILLIN, CAREFUL INQUIRY SHOULD BE MADE CONCERNING PREVIOUS HYPERSENSITIVITY REACTIONS TO PENICILLINS, CEPHALOSPORINS, AND OTHER ALLERGENS. IF AN ALLERGIC REACTION OCCURS, THE DRUG SHOULD BE DISCONTINUED AND APPROPRIATE THERAPY INSTITUTED. SERIOUS ANAPHYLACTOID REACTIONS REQUIRE IMMEDIATE EMERGENCY TREATMENT WITH EPINEPHRINE. OXYGEN, INTRAVENOUS STEROIDS, AND AIRWAY MANAGEMENT, INCLUDING INTUBATION, SHOULD ALSO BE ADMINISTERED AS INDICATED.
- Pseudomembranous colitis has been reported with nearly all antibacterial agents, including ampicillin, and may range in severity from mild to life-threatening. Therefore, it is important to consider this diagnosis in patients who present with diarrhea subsequent to the administration of antibacterial agents.
- Treatment with antibacterial agents alters the normal flora of the colon and may permit overgrowth of clostridia. Studies indicate that a toxin produced by clostridium difficile, is one primary cause of antibiotic-associated colitis.
- After the diagnosis of pseudomembranous colitis has been established, therapeutic measures should be initiated. Mild cases of pseudomembranous colitis usually respond to drug discontinuation alone. In moderate to severe cases, consideration should be given to management with fluids and electrolytes, protein supplementation and treatment with an antibacterial drug clinically effective against C. difficile colitis.

# Adverse Reactions

## Clinical Trials Experience
There is limited information regarding Clinical Trial Experience of Ampicillin (oral) in the drug label.

## Postmarketing Experience
- As with other penicillins, it may be expected that untoward reactions will be essentially limited to sensitivity phenomena. They are more likely to occur in individuals who have previously demonstrated hypersensitivity to penicillin and in those with a history of allergy, asthma, hay fever, or urticaria.
- The following adverse reactions have been reported as associated with the use of ampicillin:
- GASTROINTESTINAL: glossitis, stomatitis, nausea, vomiting, enterocolitis, pseudomembranous colitis, and diarrhea. These reactions are usually associated with oral dosage forms of the drugs.
- HYPERSENSITIVITY REACTIONS: An erythematous, mildly pruritic, maculopapular skin rash has been reported fairly frequently . The rash, which usually does not develop within the first week of therapy, may cover the entire body including the soles, palms, and oral mucosa. The eruption usually disappears in three to seven days. Other hypersensitivity reactions that have been reported are: skin rash, pruritus, urticaria, erythema multiforme, and an occasional case of exfoliative dermatitis.
- Anaphylaxis is the most serious reaction experienced and has usually been associated with the parenteral dosage form of the drug.
- NOTE: Urticaria, other skin rashes, and serum sickness like reactions may be controlled by antihistamines, and, if necessary, systemic corticosteroids. - Whenever such reactions occur, ampicillin should be discontinued unless, in the opinion of the physician, the condition being treated is life-threatening, and amenable only to ampicillin therapy. Serious anaphylactoid reactions require emergency measures.
- LIVER: Moderate elevation in serum glutamic oxaloacetic transaminase (SGOT) has been noted, but the significance of this finding is unknown.
- HEMIC AND LYMPHATIC SYSTEMS: Anemia, thrombocytopenia, thrombocytopenic purpura, eosinophilia, leukopenia, and agranulocytosis have been reported during therapy with penicillins. These reactions are usually reversible on discontinuation of therapy and are believed to be hypersensitivity phenomena.
- Other adverse reactions that have been reported with the use of ampicillin are laryngeal stridor and high fever. An occasional patient may complain of sore mouth or tongue as with any oral penicillin preparation.

# Drug Interactions
- When administered concurrently, the following drugs may interact with ampicillin.
- ALLOPURINOL: Increased possibility of skin rash, particularly in hyperuricemic patients may occur.
- BACTERIOSTATIC ANTIBIOTICS: Chloramphenicol, erythromycins, sulfonamides, or tetracyclines may interfere with the bactericidal effect of penicillins. This has been demonstrated in vitro; however, the clinical significance of this interaction is not well-documented.
- ORAL CONTRACEPTIVES: May be less effective and increased breakthrough bleeding may occur.
- PROBENECID: May decrease renal tubular secretion of ampicillin resulting in increased blood levels and/or ampicillin toxicity.

# Use in Specific Populations

### Pregnancy
Pregnancy Category (FDA): B
- Reproduction studies in animals have revealed no evidence of impaired fertility or harm to the fetus due to penicillin. There are, however, no adequate and well-controlled studies in pregnant women. Because animal reproduction studies are not always predictive of human response, penicillin should be used during pregnancy only if clearly needed.
Pregnancy Category (AUS):
- Australian Drug Evaluation Committee (ADEC) Pregnancy Category
There is no Australian Drug Evaluation Committee (ADEC) guidance on usage of Ampicillin (oral) in women who are pregnant.

### Labor and Delivery
- Oral ampicillin-class antibiotics are poorly absorbed during labor. Studies in guinea pigs showed that intravenous administration of ampicillin slightly decreased the uterine tone and frequency of contractions, but moderately increased the height and duration of contractions. However, it is not known whether use of these drugs in humans during labor or delivery has immediate or delayed adverse effects on the fetus, prolongs the duration of labor, or increases the likelihood that forceps delivery or other obstetrical intervention or resuscitation of the newborn will be necessary.

### Nursing Mothers
- Ampicillin-class antibiotics are excreted in milk. Ampicillin used by nursing mothers may lead to sensitization of infants; therefore, a decision should be made whether to discontinue nursing or to discontinue ampicillin, taking into account the importance of the drug to the mother.

### Pediatric Use
- Penicillins are excreted primarily unchanged by the kidney; therefore, the incompletely developed renal function in neonates and young infants will delay the excretion of penicillin. Administration to neonates and young infants should be limited to the lowest dosage compatible with an effective therapeutic regimen

### Geriatic Use
There is no FDA guidance on the use of Ampicillin (oral) with respect to geriatric patients.

### Gender
There is no FDA guidance on the use of Ampicillin (oral) with respect to specific gender populations.

### Race
There is no FDA guidance on the use of Ampicillin (oral) with respect to specific racial populations.

### Renal Impairment
There is no FDA guidance on the use of Ampicillin (oral) in patients with renal impairment.

### Hepatic Impairment
There is no FDA guidance on the use of Ampicillin (oral) in patients with hepatic impairment.

### Females of Reproductive Potential and Males
There is no FDA guidance on the use of Ampicillin (oral) in women of reproductive potentials and males.

### Immunocompromised Patients
There is no FDA guidance one the use of Ampicillin (oral) in patients who are immunocompromised.

# Administration and Monitoring

### Administration
- Oral

### Monitoring
There is limited information regarding Monitoring of Ampicillin (oral) in the drug label.

# IV Compatibility
There is limited information regarding IV Compatibility of Ampicillin (oral) in the drug label.

# Overdosage
- In case of overdosage, discontinue medication, treat symptomatically and institute supportive measures as required. In patients with renal function impairment, ampicillin-class antibiotics can be removed by hemodialysis but not by peritoneal dialysis.

# Pharmacology

## Mechanism of Action
- Ampicillin is bactericidal at low concentrations and is clinically effective not only against the gram-positive organisms usually susceptible to penicillin G but also against a variety of gram-negative organisms. It is stable in the presence of gastric acid and is well absorbed from the gastrointestinal tract. It diffuses readily into most body tissues and fluids; however, penetration into the cerebrospinal fluid and brain occurs only with meningeal inflammation. Ampicillin is excreted largely unchanged in the urine; its excretion can be delayed by concurrent administration of probenecid which inhibits the renal tubular secretion of ampicillin. In blood serum, ampicillin is the least bound of all the penicillins; an average of about 20 percent of the drug is bound to plasma proteins as compared to 60 to 90 percent of the other penicillins. The administration of 500 mg dose of ampicillin capsules results in an average peak blood serum level of approximately 3.0 mcg/mL.
- Microbiology: While in vitro studies have demonstrated the susceptibility of most strains of the following organisms, clinical efficacy for infections other than those included in the INDICATIONS AND USAGE section has not been documented.
- GRAM-POSITIVE  strains of alpha- and beta-hemolytic streptococci, Streptococcus pneumoniae, those strains of staphylococci, which do not produce penicillinase, Clostridium sp., Bacillus anthracis, Corynebacterium xeroses, and most strains of enterococci.
- GRAM-NEGATIVE  Hemophilus influenzae; Neisseria gonorrhoeae and N. Meningitides; Proteus mirabilis, and many strains of Salmonella (including S. typhosa), Shigella, and Escherichia coli.
- NOTE: Ampicillin is inactivated by penicillinase and therefore is ineffective against penicillinase-producing organisms including certain strains of staphylococci, Pseudomonas aeruginosa, P. Vulgaris, Klebsiella pneumoniae, Enterobacter aerogenes, and some strains of E. coli. Ampicillin is not active against Rickettsia, Mycoplasma, and large viruses (Miyagawanella).
- TESTING FOR SUSCEPTIBILITY: The invading organism should be cultured and its susceptibility demonstrated as a guide to therapy. If the Kirby-Bauer method of disc susceptibility is used, a 10 mcg ampicillin disc should be used to determine the relative in vitro susceptibility.

## Structure
- Ampicillin trihydrate is a semisynthetic penicillin derived from the basic penicillin nucleus, 6- aminopenicillanic acid. Ampicillin is designated chemically as (2S, 5R, 6R)-6--3,3- dimethyl-7-oxo-4-thia-1-azabicyclo  heptane-2- carboxylic acid. Its structural formula is:
- Ampicillin Capsules, USP for oral administration provide ampicillin trihydrate equivalent to 250 mg and 500 mg ampicillin. Inactive ingredients: black iron oxide, gelatin, magnesium stearate and titanium dioxide.

## Pharmacodynamics
There is limited information regarding Pharmacodynamics of Ampicillin (oral) in the drug label.

## Pharmacokinetics
There is limited information regarding Pharmacokinetics of Ampicillin (oral) in the drug label.

## Nonclinical Toxicology
There is limited information regarding Nonclinical Toxicology of Ampicillin (oral) in the drug label.

# Clinical Studies
There is limited information regarding Clinical Studies of Ampicillin (oral) in the drug label.

# How Supplied
- Ampicillin Capsules, USP: Each capsule, for oral administration, contains ampicillin trihydrate equivalent to 250 mg or 500 mg ampicillin, and are supplied as:
- 250 mg: white, opaque, hard gelatin capsules, imprinted in black ink GG 850/GG 850.
- NDC 0781-2144-01 in bottles of 100.
- NDC 0781-2144-05 in bottles of 500.
- 500 mg: white, opaque, hard gelatin capsules, imprinted in black ink GG 851/GG 851.
- NDC 0781-2145-01 in bottles of 100.
- NDC 0781-2145-05 in bottles of 500.

## Storage
- Store at 20-25C (68- 77F)

# Images

## Drug Images

## Package and Label Display Panel

# Patient Counseling Information
There is limited information regarding Patient Counseling Information of Ampicillin (oral) in the drug label.

# Precautions with Alcohol
- Alcohol-Ampicillin (oral) interaction has not been established. Talk to your doctor about the effects of taking alcohol with this medication.

# Brand Names
- AMPICILLIN

# Look-Alike Drug Names
There is limited information regarding Ampicillin (oral) Look-Alike Drug Names in the drug label.

# Drug Shortage Status

# Price