ADVERSE REACTIONS SECTION.

6 ADVERSE REACTIONS. The most common adverse reactions (incidence >5%) are diarrhea, constipation, nausea, headache, and insomnia. (6.1)To report SUSPECTED ADVERSE REACTIONS, contact Pfizer Inc. at 1-800-438-1985 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.. 6.1Clinical Trials Experience. Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.. Clinical Trials in Adult PatientsDuring the initial clinical investigations, 2621 patients worldwide were treated with ZOSYN in phase trials. In the key North American monotherapy clinical trials (n=830 patients), 90% of the adverse events reported were mild to moderate in severity and transient in nature. However, in 3.2% of the patients treated worldwide, ZOSYN was discontinued because of adverse events primarily involving the skin (1.3%), including rash and pruritus; the gastrointestinal system (0.9%), including diarrhea, nausea, and vomiting; and allergic reactions (0.5%).Table 6: Adverse Reactions from ZOSYN Monotherapy Clinical TrialsSystem Organ Class Adverse ReactionGastrointestinal disorders Diarrhea (11.3%) Constipation (7.7%) Nausea (6.9%) Vomiting (3.3%) Dyspepsia (3.3%) Abdominal pain (1.3%)General disorders and administration site conditions Fever (2.4%) Injection site reaction (<=1%) Rigors (<=1%)Immune system disorders Anaphylaxis (<=1%)Infections and infestations Candidiasis (1.6%) Pseudomembranous colitis (<=1%)Metabolism and nutrition disorders Hypoglycemia (<=1%)Musculoskeletal and connective tissue disorders Myalgia (<=1%) Arthralgia (<=1%)Nervous system disorders Headache (7.7%)Psychiatric disorders Insomnia (6.6%)Skin and subcutaneous tissue disorders Rash (4.2%, including maculopapular, bullous, and urticarial) Pruritus (3.1%) Purpura (<=1%)Vascular disorders Phlebitis (1.3%) Thrombophlebitis (<=1%) Hypotension (<=1%) Flushing (<=1%)Respiratory, thoracic and mediastinal disorders Epistaxis (<=1%). Nosocomial Pneumonia TrialsTwo trials of nosocomial lower respiratory tract infections were conducted. In one study, 222 patients were treated with ZOSYN in dosing regimen of 4.5 every hours in combination with an aminoglycoside and 215 patients were treated with imipenem/cilastatin (500 mg/500 mg every hours) in combination with an aminoglycoside. In this trial, treatment-emergent adverse events were reported by 402 patients, 204 (91.9%) in the piperacillin/tazobactam group and 198 (92.1%) in the imipenem/cilastatin group. Twenty-five (11.0%) patients in the piperacillin/tazobactam group and 14 (6.5%) in the imipenem/cilastatin group (p 0.05) discontinued treatment due to an adverse event.The second trial used dosing regimen of 3.375 given every hours with an aminoglycoside.Table 7: Adverse Reactions from ZOSYN Plus Aminoglycoside Clinical TrialsFor adverse drug reactions that appeared in both studies the higher frequency is presented. System Organ Class Adverse ReactionBlood and lymphatic system disorders Thrombocythemia (1.4%) Anemia (<=1%) Thrombocytopenia (<=1%) Eosinophilia (<=1%)Gastrointestinal disorders Diarrhea (20%) Constipation (8.4%) Nausea (5.8%) Vomiting (2.7%) Dyspepsia (1.9%) Abdominal pain (1.8%) Stomatitis (<=1%)General disorders and administration site conditions Fever (3.2%) Injection site reaction (<=1%)Infections and infestations Oral candidiasis (3.9%) Candidiasis (1.8%)Investigations BUN increased (1.8%) Blood creatinine increased (1.8%) Liver function test abnormal (1.4%) Alkaline phosphatase increased (<=1%) Aspartate aminotransferase increased (<=1%) Alanine aminotransferase increased (<=1%)Metabolism and nutrition disorders Hypoglycemia (<=1%) Hypokalemia (<=1%)Nervous system disorders Headache (4.5%)Psychiatric disorders Insomnia (4.5%)Renal and urinary disorders Renal failure (<=1%)Skin and subcutaneous tissue disorders Rash (3.9%) Pruritus (3.2%)Vascular disorders Thrombophlebitis (1.3%) Hypotension (1.3%). Other Trials: NephrotoxicityIn randomized, multicenter, controlled trial in 1200 adult critically ill patients, piperacillin/tazobactam was found to be risk factor for renal failure (odds ratio 1.7, 95% CI 1.18 to 2.43), and associated with delayed recovery of renal function as compared to other beta-lactam antibacterial drugs1 [see Warnings and Precautions (5.5)].. Adverse Laboratory Changes (Seen During Clinical Trials)Of the trials reported, including that of nosocomial lower respiratory tract infections in which higher dose of ZOSYN was used in combination with an aminoglycoside, changes in laboratory parameters include:Hematologic--decreases in hemoglobin and hematocrit, thrombocytopenia, increases in platelet count, eosinophilia, leukopenia, neutropenia. These patients were withdrawn from therapy; some had accompanying systemic symptoms (e.g., fever, rigors, chills)Coagulation--positive direct Coombs test, prolonged prothrombin time, prolonged partial thromboplastin timeHepatic--transient elevations of AST (SGOT), ALT (SGPT), alkaline phosphatase, bilirubinRenal--increases in serum creatinine, blood urea nitrogenAdditional laboratory events include abnormalities in electrolytes (i.e., increases and decreases in sodium, potassium, and calcium), hyperglycemia, decreases in total protein or albumin, blood glucose decreased, gamma-glutamyltransferase increased, hypokalemia, and bleeding time prolonged.. Clinical Trials in Pediatric PatientsClinical studies of ZOSYN in pediatric patients suggest similar safety profile to that seen in adults.In prospective, randomized, comparative, open-label clinical trial of pediatric patients, to 12 years of age, with intra-abdominal infections (including appendicitis and/or peritonitis), 273 patients were treated with ZOSYN 112.5 mg/kg given IV every hours and 269 patients were treated with cefotaxime (50 mg/kg) plus metronidazole (7.5 mg/kg) every hours. In this trial, treatment-emergent adverse events were reported by 146 patients, 73 (26.7%) in the ZOSYN group and 73 (27.1%) in the cefotaxime/metronidazole group. Six patients (2.2%) in the ZOSYN group and patients (1.9%) in the cefotaxime/metronidazole group discontinued due to an adverse event.In retrospective, cohort study, 140 pediatric patients months to less than 18 years of age with nosocomial pneumonia were treated with ZOSYN and 267 patients were treated with comparators (which included ticarcillin-clavulanate, carbapenems, ceftazidime, cefepime, or ciprofloxacin). The rates of serious adverse reactions were generally similar between the ZOSYN and comparator groups, including patients aged months to months treated with ZOSYN 90 mg/kg IV every hours and patients older than months and less than 18 years of age treated with ZOSYN 112.5 mg/kg IV every hours.. 6.2Postmarketing Experience. In addition to the adverse drug reactions identified in clinical trials in Table and Table 7, the following adverse reactions have been identified during post-approval use of ZOSYN. Because these reactions are reported voluntarily from population of uncertain size, it is not always possible to reliably estimate their frequency or establish causal relationship to drug exposure.Hepatobiliary--hepatitis, jaundiceHematologic--hemolytic anemia, agranulocytosis, pancytopeniaImmune--hypersensitivity reactions, anaphylactic/anaphylactoid reactions (including shock)Renal--interstitial nephritisNervous system disorders--seizuresPsychiatric disorders--deliriumRespiratory--eosinophilic pneumoniaSkin and Appendages--erythema multiforme, Stevens-Johnson syndrome, toxic epidermal necrolysis, drug reaction with eosinophilia and systemic symptoms, (DRESS), acute generalized exanthematous pustulosis (AGEP), dermatitis exfoliativePostmarketing experience with ZOSYN in pediatric patients suggests similar safety profile to that seen in adults.. 6.3Additional Experience with Piperacillin. The following adverse reaction has also been reported for piperacillin for injection:Skeletal--prolonged neuromuscular blockade [see Drug Interactions (7.5)].

CARCINOGENESIS & MUTAGENESIS & IMPAIRMENT OF FERTILITY SECTION.

13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility. CarcinogenesisLong-term carcinogenicity studies in animals have not been conducted with piperacillin/tazobactam, piperacillin, or tazobactam.. MutagenesisPiperacillin/tazobactam was negative in microbial mutagenicity assays, the unscheduled DNA synthesis (UDS) test, mammalian point mutation (Chinese hamster ovary cell HPRT) assay, and mammalian cell (BALB/c-3T3) transformation assay. In vivo, piperacillin/tazobactam did not induce chromosomal aberrations in rats.. FertilityReproduction studies have been performed in rats and have revealed no evidence of impaired fertility when piperacillin/tazobactam is administered intravenously up to dose of 1280/320 mg/kg piperacillin/tazobactam, which is similar to the maximum recommended human daily dose based on body-surface area (mg/m2).

CLINICAL PHARMACOLOGY SECTION.

12 CLINICAL PHARMACOLOGY. 12.1 Mechanism of Action. ZOSYN is an antibacterial drug [see Microbiology (12.4)].. 12.2 Pharmacodynamics. The pharmacodynamic parameter for piperacillin/tazobactam that is most predictive of clinical and microbiological efficacy is time above MIC.. 12.3 Pharmacokinetics. The mean and coefficients of variation (CV%) for the pharmacokinetic parameters of piperacillin and tazobactam after multiple intravenous doses are summarized in Table 9.Table 9: Mean (CV%) Piperacillin and Tazobactam PK ParametersCmax maximum observed concentration, AUC: Area under the curve, CL=clearance, CLR= Renal clearance V=volume of distribution, T1/2 elimination half-lifePiperacillinPiperacillin/Tazobactam DosePiperacillin and tazobactam were given in combination, infused over 30 minutes. Cmax (mcg/mL)AUCNumbers in []parentheses are coefficients of variation [CV%]. (mcgh/mL)CL (mL/min)V(L)T1/2 (h)CLR (mL/min)2.25 g134131 [14]25717.40.79--3.375 g242242 [10]20715.10.841404.5 g298322 [16]21015.40.84--TazobactamPiperacillin/Tazobactam Dose Cmax (mcg/mL)AUC (mcgh/mL)CL (mL/min)V(L)T1/2 (h)CLR (mL/min)2.25 g1516.0 [21]25817.00.77--3.375 g2425.0 [8]25114.80.681664.5 g3439.8 [15]20614.70.82--Peak plasma concentrations of piperacillin and tazobactam are attained immediately after completion of an intravenous infusion of ZOSYN. Piperacillin plasma concentrations, following 30-minute infusion of ZOSYN, were similar to those attained when equivalent doses of piperacillin were administered alone. Steady-state plasma concentrations of piperacillin and tazobactam were similar to those attained after the first dose due to the short half-lives of piperacillin and tazobactam.. DistributionBoth 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 and tazobactam are widely distributed into tissues and body fluids including intestinal mucosa, gallbladder, lung, female reproductive tissues (uterus, ovary, and fallopian tube), interstitial fluid, and bile. Mean tissue concentrations are generally 50% to 100% of those in plasma. Distribution of piperacillin and tazobactam into cerebrospinal fluid is low in subjects with non-inflamed meninges, as with other penicillins (see Table 10).Table 10: Piperacillin/Tazobactam Concentrations in Selected Tissues and Fluids after Single g/0.5 30-min IV Infusion of ZOSYNTissue or FluidNEach subject provided single sample. Sampling periodTime from the start of the infusion (h)Mean PIP Concentration Range(mg/L)Tissue:Plasma RangeTazo Concentration Range(mg/L)Tazo Tissue:Plasma RangeSkin350.5 4.534.8 94.20.60 1.14.0 7.70.49 0.93Fatty Tissue370.5 4.54.0 10.10.097 0.1150.7 1.50.10 0.13Muscle360.5 4.59.4 23.30.29 0.181.4 2.70.18 0.30Proximal Intestinal Mucosa71.5 2.531.40.5510.31.15Distal Intestinal Mucosa71.5 2.531.20.5914.52.1Appendix220.5 2.526.5 64.10.43 0.539.1 18.60.80 1.35. MetabolismPiperacillin is metabolized to minor microbiologically active desethyl metabolite. Tazobactam is metabolized to single metabolite that lacks pharmacological and antibacterial activities.. ExcretionFollowing single or multiple ZOSYN doses to healthy subjects, the plasma half-life of piperacillin and of tazobactam ranged from 0.7 to 1.2 hours and was unaffected by dose or duration of infusion.Both piperacillin and tazobactam are eliminated via the kidney by glomerular filtration and tubular secretion. Piperacillin is excreted rapidly as unchanged drug with 68% of the administered dose excreted in the urine. Tazobactam and its metabolite are eliminated primarily by renal excretion with 80% of the administered dose excreted as unchanged drug and the remainder as the single metabolite. Piperacillin, tazobactam and desethyl piperacillin are also secreted into the bile.. Specific Populations. Renal ImpairmentAfter the administration of single doses of piperacillin/tazobactam to subjects with renal impairment, the half-life of piperacillin and of tazobactam increases with decreasing creatinine clearance. At creatinine clearance below 20 mL/min, the increase in half-life is twofold for piperacillin and fourfold for tazobactam compared to subjects with normal renal function. Dosage adjustments for ZOSYN are recommended when creatinine clearance is below 40 mL/min in patients receiving the usual recommended daily dose of ZOSYN. See Dosage and Administration (2) for specific recommendations for the treatment of patients with renal -impairment.Hemodialysis removes 30% to 40% of piperacillin/tazobactam dose 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 16% of the tazobactam dose removed as the tazobactam metabolite. For dosage recommendations for patients undergoing hemodialysis [see Dosage and Administration (2)].. Hepatic ImpairmentThe half-life of piperacillin and of tazobactam increases by approximately 25% and 18%, respectively, in patients with hepatic cirrhosis compared to healthy subjects. However, this difference does not warrant dosage adjustment of ZOSYN due to hepatic cirrhosis.. PediatricsPiperacillin and tazobactam pharmacokinetics were studied in pediatric patients months of age and older. The clearance of both compounds is slower in the younger patients compared to older children and adults.In population PK analysis, estimated clearance for month-old to 12 year-old patients was comparable to adults, with population mean (SE) value of 5.64 (0.34) mL/min/kg. The piperacillin clearance estimate is 80% of this value for pediatric patients - months old. In patients younger than months of age, clearance of piperacillin is slower compared to older children; however, it is not adequately characterized for dosing recommendations. The population mean (SE) for piperacillin volume of distribution is 0.243 (0.011) L/kg and is independent of age.. GeriatricsThe impact of age on the pharmacokinetics of piperacillin and tazobactam was evaluated in healthy male subjects, aged 18 35 years (n=6) and aged 65 to 80 years (n=12). Mean half-life for piperacilln and tazobactam was 32% and 55% higher, respectively, in the elderly compared to the younger subjects. This difference may be due to age-related changes in creatinine clearance.. RaceThe effect of race on piperacillin and tazobactam was evaluated in healthy male volunteers. No difference in piperacillin or tazobactam pharmacokinetics was observed between Asian (n=9) and Caucasian (n=9) healthy volunteers who received single 4/0.5 doses.. Drug InteractionsThe potential for pharmacokinetic drug interactions between ZOSYN and aminoglycosides, probenecid, vancomycin, heparin, vecuronium, and methotrexate has been evaluated [see Drug Interactions (7)].. 12.4 Microbiology. Mechanism of ActionPiperacillin sodium exerts bactericidal activity by inhibiting septum formation and cell wall synthesis of susceptible bacteria. In vitro, piperacillin is active against variety of Gram-positive and Gram-negative aerobic and anaerobic bacteria. Tazobactam sodium has little clinically relevant in vitro activity against bacteria due to its reduced affinity to penicillin-binding proteins. It is, however, beta-lactamase inhibitor of the Molecular class enzymes, including Richmond-Sykes class III (Bush class 2b 2b) penicillinases and cephalosporinases. It varies in its ability to inhibit class II and IV (2a 4) penicillinases. Tazobactam does not induce chromosomally-mediated beta-lactamases at tazobactam concentrations achieved with the recommended dosage regimen.. Antimicrobial ActivityZOSYN has been shown to be active against most isolates of the following microorganisms both in vitro and in clinical infections [see Indications and Usage (1)]:Aerobic bacteriaGram-positive bacteriaStaphylococcus aureus (methicillin susceptible isolates only)Gram-negative bacteriaAcinetobacter baumanniiEscherichia coliHaemophilus influenzae (excluding beta-lactamase negative, ampicillin-resistant isolates) Klebsiella pneumoniaePseudomonas aeruginosa (given in combination with an aminoglycoside to which the isolate is susceptible)Anaerobic bacteriaBacteroides fragilis group (B. fragilis, B. ovatus, B. thetaiotaomicron, and B. vulgatus)The following in vitro data are available, but their clinical significance is unknown.At least 90 percent of the following bacteria exhibit an in vitro minimum inhibitory concentration (MIC) less than or equal to the susceptible breakpoint for piperacillin/tazobactam against isolates of similar genus or organism group.However, the efficacy of ZOSYN in treating clinical infections caused by these bacteria has not been established in adequate and well-controlled clinical trials.Aerobic bacteriaGram-positive bacteriaEnterococcus faecalis (ampicillin or penicillin-susceptible isolates only) Staphylococcus epidermidis (methicillin susceptible isolates only)Streptococcus agalactiaeThese are not beta-lactamase producing bacteria and, therefore, are susceptible to piperacillin alone.Streptococcus pneumoniae (penicillin-susceptible isolates only) Streptococcus pyogenes Viridans group streptococci Gram-negative bacteria Citrobacter koseriMoraxella catarrhalisMorganella morganiiNeisseria gonorrhoeaeProteus mirabilisProteus vulgarisSerratia marcescensProvidencia stuartiiProvidencia rettgeriSalmonella entericaAnaerobic bacteriaClostridium perfringensBacteroides distasonisPrevotella melaninogenica. Susceptibility TestingFor specific information regarding susceptibility test interpretive criteria and associated test methods and quality control standards recognized by FDA for this drug, please see: https://www.fda.gov/STIC.

CONTRAINDICATIONS SECTION.

4 CONTRAINDICATIONS. ZOSYN is contraindicated in patients with history of allergic reactions to any of the penicillins, cephalosporins, or beta-lactamase inhibitors.. Patients with history of allergic reactions to any of the penicillins, cephalosporins, or beta-lactamase inhibitors. (4).

PEDIATRIC USE SECTION.

8.4 Pediatric Use. The safety and effectiveness of ZOSYN for intra-abdominal infections, and nosocomial pneumonia have been established in pediatric patients months of age and older.Use of ZOSYN in pediatric patients months of age and older with intra-abdominal infections including appendicitis and/or peritonitis is supported by evidence from well-controlled studies and pharmacokinetic studies in adults and in pediatric patients. This includes prospective, randomized, comparative, open-label clinical trial with 542 pediatric patients to 12 years of age with intra-abdominal infections (including appendicitis and/or peritonitis), in which 273 pediatric patients received piperacillin/tazobactam [see Adverse Reactions (6.1) and Clinical Pharmacology (12.3)].Use of ZOSYN in pediatric patients months of age and older with nosocomial pneumonia is supported by evidence from well-controlled studies in adults with nosocomial pneumonia, simulation study performed with population pharmacokinetic model, and retrospective, cohort study of pediatric patients with nosocomial pneumonia in which 140 pediatric patients were treated with ZOSYN and 267 patients treated with comparators (which included ticarcillin-clavulanate, carbapenems, ceftazidime, cefepime, or ciprofloxacin) [see Adverse Reactions (6.1) and Clinical Pharmacology (12.3)]. Because of the limitations of the available strengths and administration requirements (i.e., administration of fractional doses is not recommended) of ZOSYN Injection supplied in GALAXY Containers, and to avoid unintentional overdose, this product is not recommended for use if dose of ZOSYN Injection in GALAXY Containers that does not equal 2.25 g, 3.375 g, or 4.5 is required and an alternative formulation of ZOSYN should be considered [see Dosage and Administration (2.1, 2.5, and 2.7)].The safety and effectiveness of ZOSYN have not been established in pediatric patients less than months of age [see Clinical Pharmacology (12) and Dosage and Administration (2)].Dosage of ZOSYN in pediatric patients with renal impairment has not been determined.

DESCRIPTION SECTION.

11 DESCRIPTION. ZOSYN (piperacillin and tazobactam) for Injection and ZOSYN (piperacillin and tazobactam) Injection are injectable antibacterial combination products consisting of the semisynthetic antibacterial piperacillin sodium and the beta-lactamase inhibitor tazobactam sodium for intravenous administration.Piperacillin sodium is derived from D(-)--aminobenzyl-penicillin. The chemical name of piperacillin sodium is sodium (2S,5R,6R)-6-[(R)-2-(4-ethyl-2,3-dioxo-1-piperazine-carboxamido)-2-phenylacetamido]-3,3-dimethyl-7-oxo-4-thia-1-azabicyclo[3.2.0]heptane-2-carboxylate. The chemical formula is C23H26N5NaO7S and the molecular weight is 539.5. The chemical structure of piperacillin sodium is:Tazobactam sodium, derivative of the penicillin nucleus, is penicillanic acid sulfone. Its chemical name is sodium (2S,3S,5R)-3-methyl-7-oxo-3-(1H-1,2,3-triazol-1-ylmethyl)-4-thia-1-azabicyclo[3.2.0]heptane-2-carboxylate-4,4-dioxide. The chemical formula is C10H11N4NaO5S and the molecular weight is 322.3. The chemical structure of tazobactam sodium is:ZOSYN Injection in the GALAXY Container is frozen iso-osmotic sterile non-pyrogenic premixed solution. The components and dosage formulations are given in the table below:Table 8: ZOSYN In GALAXY Containers Premixed Frozen SolutionComponentPiperacillin and tazobactam are present in the formulation as sodium salts. Dextrose hydrous, sodium citrate dihydrate, and edetate disodium dihydrate amounts are approximate. FunctionDosage Formulations2.25 g/50 mL3.375 g/50 mL4.5 g/100 mLPiperacillinactive ingredient2 g3 g4 gTazobactambeta-lactamase inhibitor250 mg375 mg500 mgDextrose Hydrousosmolality adjusting agent1 g350 mg2 gSodium Citrate Dihydratebuffering agent100 mg150 mg200 mgEdetate Disodium Dihydratemetal chelator0.5 mg0.75 mg1 mgWater for Injectionsolventq.s. 50 mLq.s. 50 mLq.s. 100 mLZOSYN contains total of 2.84 mEq (65 mg) of sodium (Na+) per gram of piperacillin in the combination product.ZOSYN (piperacillin and tazobactam) for Injection, is white to off-white sterile, cryodesiccated powder consisting of piperacillin and tazobactam as their sodium salts packaged in glass vials.Zosyn for Injection vials are not manufactured or distributed by Pfizer Inc. The formulation also contains edetate disodium dihydrate (EDTA) and sodium citrate.Each ZOSYN 2.25 single-dose vial contains an amount of drug sufficient for withdrawal of piperacillin sodium equivalent to grams of piperacillin and tazobactam sodium equivalent to 0.25 of tazobactam. The product also contains 0.5 mg of EDTA per vial.Each ZOSYN 3.375 single-dose vial contains an amount of drug sufficient for withdrawal of piperacillin sodium equivalent to grams of piperacillin and tazobactam sodium equivalent to 0.375 of tazobactam. The product also contains 0.75 mg of EDTA per vial.Each ZOSYN 4.5 single-dose vial contains an amount of drug sufficient for withdrawal of piperacillin sodium equivalent to grams of piperacillin and tazobactam sodium equivalent to 0.5 of tazobactam. The product also contains mg of EDTA per vial.Each Zosyn 40.5 pharmacy bulk vial contains piperacillin sodium equivalent to 36 grams of piperacillin and tazobactam sodium equivalent to 4.5 of tazobactam sufficient for delivery of multiple doses.. Each ZOSYN 2.25 single-dose vial contains an amount of drug sufficient for withdrawal of piperacillin sodium equivalent to grams of piperacillin and tazobactam sodium equivalent to 0.25 of tazobactam. The product also contains 0.5 mg of EDTA per vial.. Each ZOSYN 3.375 single-dose vial contains an amount of drug sufficient for withdrawal of piperacillin sodium equivalent to grams of piperacillin and tazobactam sodium equivalent to 0.375 of tazobactam. The product also contains 0.75 mg of EDTA per vial.. Each ZOSYN 4.5 single-dose vial contains an amount of drug sufficient for withdrawal of piperacillin sodium equivalent to grams of piperacillin and tazobactam sodium equivalent to 0.5 of tazobactam. The product also contains mg of EDTA per vial.. Each Zosyn 40.5 pharmacy bulk vial contains piperacillin sodium equivalent to 36 grams of piperacillin and tazobactam sodium equivalent to 4.5 of tazobactam sufficient for delivery of multiple doses.. Chemical Structure. Chemical Structure.

DOSAGE & ADMINISTRATION SECTION.

2 DOSAGE AND ADMINISTRATION. If dose of ZOSYN is required that does not equal 2.25 g, 3.375 g, or 4.5 g, ZOSYN injection in GALAXY Containers is not recommended for use and an alternative formulation of ZOSYN should be considered. (2.1)Adult Patients With Indications Other Than Nosocomial Pneumonia; The usual daily dosage of ZOSYN for adults is 3.375 every six hours totaling 13.5 (12.0 piperacillin/1.5 tazobactam). (2.2)Adult Patients with Nosocomial Pneumonia: Initial presumptive treatment of patients with nosocomial pneumonia should start with ZOSYN at dosage of 4.5 every six hours plus an aminoglycoside, totaling 18.0 (16.0 piperacillin/2.0 tazobactam). (2.3)Adult Patients with Renal Impairment: Dosage in patients with renal impairment (creatinine clearance <=40 mL/min) and dialysis patients should be reduced, based on the degree of renal impairment. (2.4)Pediatric Patients by Indication and Age: See Table below (2.5)Recommended Dosage of ZOSYN for Pediatric Patients months of Age and Older, Weighing up to 40 Kg and With Normal Renal FunctionAgeAppendicitis and /or PeritonitisNosocomial Pneumonia2 months to months90 mg/kg (80 mg piperacillin/10 mg tazobactam) every (eight) hours 90 mg/kg (80 mg piperacillin/10 mg tazobactam) every (six) hours Older than months112.5 mg/kg (100 mg piperacillin/12.5 mg tazobactam) every (eight) hours 112.5 mg/kg (100 mg piperacillin/12.5 mg tazobactam) every (six) hours Administer ZOSYN by intravenous infusion over 30 minutes to both adult and pediatric patients (2.2, 2.3, 2.4, 2.5).ZOSYN and aminoglycosides should be reconstituted, diluted, and administered separately. Co-administration via Y-site can be done under certain conditions. (2.8)See the full prescribing information for the preparation and administration instructions for ZOSYN for Injection single-dose vials, pharmacy bulk vials and ZOSYN Injection in GALAXY Containers.. If dose of ZOSYN is required that does not equal 2.25 g, 3.375 g, or 4.5 g, ZOSYN injection in GALAXY Containers is not recommended for use and an alternative formulation of ZOSYN should be considered. (2.1). Adult Patients With Indications Other Than Nosocomial Pneumonia; The usual daily dosage of ZOSYN for adults is 3.375 every six hours totaling 13.5 (12.0 piperacillin/1.5 tazobactam). (2.2). Adult Patients with Nosocomial Pneumonia: Initial presumptive treatment of patients with nosocomial pneumonia should start with ZOSYN at dosage of 4.5 every six hours plus an aminoglycoside, totaling 18.0 (16.0 piperacillin/2.0 tazobactam). (2.3). Adult Patients with Renal Impairment: Dosage in patients with renal impairment (creatinine clearance <=40 mL/min) and dialysis patients should be reduced, based on the degree of renal impairment. (2.4). Pediatric Patients by Indication and Age: See Table below (2.5). Administer ZOSYN by intravenous infusion over 30 minutes to both adult and pediatric patients (2.2, 2.3, 2.4, 2.5).. ZOSYN and aminoglycosides should be reconstituted, diluted, and administered separately. Co-administration via Y-site can be done under certain conditions. (2.8). See the full prescribing information for the preparation and administration instructions for ZOSYN for Injection single-dose vials, pharmacy bulk vials and ZOSYN Injection in GALAXY Containers.. 2.1 Important Administration Instructions. If dose of ZOSYN is required that does not equal 2.25 g, 3.375 g, or 4.5 g, ZOSYN injection in GALAXY Containers is not recommended for use and an alternative formulation of ZOSYN should be considered.. 2.2Dosage in Adult Patients With Indications Other Than Nosocomial Pneumonia. The usual total daily dosage of ZOSYN for adult patients with indications other than nosocomial pneumonia is 3.375 every six hours [totaling 13.5 (12.0 piperacillin/1.5 tazobactam)], to be administered by intravenous infusion over 30 minutes. The usual duration of ZOSYN treatment is from to 10 days.. 2.3Dosage in Adult Patients With Nosocomial Pneumonia. Initial presumptive treatment of adult patients with nosocomial pneumonia should start with ZOSYN at dosage of 4.5 every six hours plus an aminoglycoside, [totaling 18.0 (16.0 piperacillin/2.0 tazobactam)], administered by intravenous infusion over 30 minutes. The recommended duration of ZOSYN treatment for nosocomial pneumonia is to 14 days. Treatment with the aminoglycoside should be continued in patients from whom P. aeruginosa is isolated.. 2.4Dosage in Adult Patients With Renal Impairment. In adult patients with renal impairment (creatinine clearance <= 40 mL/min) and dialysis patients (hemodialysis and CAPD), the intravenous dose of ZOSYN should be reduced based on the degree of renal impairment. The recommended daily dosage of ZOSYN for patients with renal impairment administered by intravenous infusion over 30 minutes is described in Table 1.Table 1: Recommended Dosage of ZOSYN in Patients with Normal Renal Function and Renal Impairment (As total grams piperacillin/tazobactam)Administer ZOSYN by intravenous infusion over 30 minutes. Creatinine clearance, mL/minAll Indications (except nosocomial pneumonia)Nosocomial PneumoniaGreater than 40 mL/min3.375 every hours4.5 every hours20 to 40 mL/minCreatinine clearance for patients not receiving hemodialysis 2.25 every hours3.375 every hoursLess than 20 mL/min 2.25 every hours2.25 every hoursHemodialysis0.75 (0.67 piperacillin/0.08 tazobactam) should be administered following each hemodialysis session on hemodialysis days 2.25 every 12 hours2.25 every hoursCAPD2.25 every 12 hours2.25 every hoursFor patients on hemodialysis, the maximum dose is 2.25 every twelve hours for all indications other than nosocomial pneumonia and 2.25 every eight hours for nosocomial pneumonia. Since hemodialysis removes 30% to 40% of the administered dose, an additional dose of 0.75 ZOSYN (0.67 piperacillin/0.08 tazobactam) should be administered following each dialysis period on hemodialysis days. No additional dosage of ZOSYN is necessary for CAPD patients.. 2.5Dosage in Pediatric Patients With Appendicitis/Peritonitis or Nosocomial Pneumonia. The recommended dosage for pediatric patients with appendicitis and/or peritonitis or nosocomial pneumonia aged months of age and older, weighing up to 40 kg, and with normal renal function, is described in Table [see Use in Specific Populations (8.4) and Clinical Pharmacology (12.3)].Table 2: Recommended Dosage of ZOSYN in Pediatric Patients Months of Age and Older, Weighing Up to 40 kg, and With Normal Renal FunctionAdminister ZOSYN by intravenous infusion over 30 minutes If dose of ZOSYN is required that does not equal 2.25 g, 3.375 g, or 4.5 g, ZOSYN injection in GALAXY Containers is not recommended for use and an alternative formulation of ZOSYN should be considered [see Use in Specific Populations (8.4)]. AgeAppendicitis and/or PeritonitisNosocomial Pneumonia2 months to months90 mg/kg (80 mg piperacillin/10 mg tazobactam) every (eight) hours 90 mg/kg (80 mg piperacillin/10 mg tazobactam) every (six) hours Older than months of age112.5 mg/kg (100 mg piperacillin/12.5 mg tazobactam) every (eight) hours 112.5 mg/kg (100 mg piperacillin/12.5 mg tazobactam) every (six) hours Pediatric patients weighing over 40 kg and with normal renal function should receive the adult dose [see Dosage and Administration (2.2, 2.3)].Dosage of ZOSYN in pediatric patients with renal impairment has not been determined.. 2.6Reconstitution and Dilution of ZOSYN for Injection. Reconstitution of ZOSYN For Injection for Adult Patients and Pediatric Patients Weighing Over 40 kg. Pharmacy Bulk VialsReconstituted pharmacy bulk vial solution must be transferred and further diluted for intravenous infusion.The pharmacy bulk vial is for use in hospital pharmacy admixture service only under laminar flow hood. After reconstitution, entry into the vial must be made with sterile transfer set or other sterile dispensing device, and contents should be dispensed as aliquots into intravenous solution using aseptic technique. Use entire contents of pharmacy bulk vial promptly. Discard unused portion after 24 hours if stored at room temperature (20C to 25C [68F to 77F]), or after 48 hours if stored at refrigerated temperature (2C to 8C [36F to 46F]).Reconstitute the pharmacy bulk vial with exactly 152 mL of compatible reconstitution diluent, listed below, to concentration of 200 mg/mL of piperacillin and 25 mg/mL of tazobactam. Shake well until dissolved. Parenteral drug products should be inspected visually for particulate matter and discoloration prior to and during administration whenever solution and container permit.. Single-Dose VialsReconstitute ZOSYN single-dose vials with compatible reconstitution diluent from the list provided below.2.25 g, 3.375 g, and 4.5 ZOSYN should be reconstituted with 10 mL, 15 mL, and 20 mL, respectively. Swirl until dissolved. After reconstitution, the single-dose vials will have concentration of 202.5 mg/mL (180 mg/mL of piperacillin and 22.5 mg/mL of tazobactam).Compatible Reconstitution Diluents for Pharmacy Bulk Vials and Single-Dose Vials0.9% sodium chloride for injectionSterile water for injectionDextrose 5%Bacteriostatic saline/parabens Bacteriostatic water/parabensBacteriostatic saline/benzyl alcoholBacteriostatic water/benzyl alcohol. Dilution of the Reconstituted ZOSYN Solution for Adult Patients and Pediatric Patients Weighing Over 40 kgReconstituted ZOSYN solutions for both pharmacy bulk vials and single-dose vials should be further diluted (recommended volume per dose of 50 mL to 150 mL) in compatible intravenous solution listed below. Administer by infusion over period of at least 30 minutes. During the infusion it is desirable to discontinue the primary infusion solution.Compatible Intravenous Solutions for Pharmacy Bulk Vials and Single-Dose Vials0.9% sodium chloride for injectionSterile water for injection (Maximum recommended volume per dose of sterile water for injection is 50 mL)Dextran 6% in salineDextrose 5%Lactated Ringers Solution (compatible only with reformulated ZOSYN containing EDTA and is compatible for co-administration via Y-site)ZOSYN should not be mixed with other drugs in syringe or infusion bottle since compatibility has not been established.ZOSYN is not chemically stable in solutions that contain only sodium bicarbonate and solutions that significantly alter the pH.ZOSYN should not be added to blood products or albumin hydrolysates. Parenteral drug products should be inspected visually for particulate matter or discoloration prior to administration, whenever solution and container permit.. Dilution of the Reconstituted ZOSYN Solution for Pediatric Patients Weighing up to 40 kgThe volume of reconstituted solution required to deliver the dose of ZOSYN is dependent on the weight of the child [see Dosage and Administration (2.5)]. Reconstituted ZOSYN solutions for both bulk and single-dose vials should be further diluted in compatible intravenous solution listed above.Calculate patient dose as described in Table above [see Dosage and Administration (2.5)].Reconstitute vial with compatible reconstitution diluent, as listed above under the subheading Compatible Reconstitution Diluents for Pharmacy Bulk Vials and Single-Dose Vials, using the appropriate volume of diluent, as listed in tables and below. Following the addition of the diluent, swirl the single-dose vial or shake the pharmacy bulk vial until the powder is completely dissolved.Table 3: Reconstitution of Single-Dose Vials and Resulting ConcentrationStrength per Single-Dose VialVolume of Diluent to be Added to the VialConcentration of the Reconstituted Product2.25 (2 piperacillin /0.25 tazobactam)10 mL202.5 mg/mL(180 mg/mL piperacillin/22.5 mg/mL tazobactam)3.375 (3 piperacillin /0.375 tazobactam)15 mL4.5 (4 piperacillin /0.5 tazobactam)20 mLTable 4: Reconstitution of Pharmacy Bulk Vial and Resulting ConcentrationStrength per Pharmacy Bulk VialVolume of Diluent to be Added to the VialConcentration of the Reconstituted Product40.5 (36 piperacillin /4.5 tazobactam)152 mL225 mg/mL(200 mg/mL piperacillin/25 mg/mL tazobactam) Calculate the required volume (mL) of reconstituted ZOSYN solution based on the required dose. Aseptically withdraw the required volume of reconstituted ZOSYN solution from either the pharmacy bulk vial or single-dose vial. It should be further diluted to final piperacillin concentration of between 20 mg/mL to 80 mg/mL (tazobactam between 2.5 mg/mL to 10 mg/mL) in compatible intravenous solution (as listed above) in an appropriately sized syringe or IV bag. Administer the diluted ZOSYN solution by infusion over period of at least 30 minutes (a programmable syringe or infusion pump is recommended). During the infusion it is desirable to discontinue the primary infusion solution.. Calculate patient dose as described in Table above [see Dosage and Administration (2.5)].. Reconstitute vial with compatible reconstitution diluent, as listed above under the subheading Compatible Reconstitution Diluents for Pharmacy Bulk Vials and Single-Dose Vials, using the appropriate volume of diluent, as listed in tables and below. Following the addition of the diluent, swirl the single-dose vial or shake the pharmacy bulk vial until the powder is completely dissolved.Table 3: Reconstitution of Single-Dose Vials and Resulting ConcentrationStrength per Single-Dose VialVolume of Diluent to be Added to the VialConcentration of the Reconstituted Product2.25 (2 piperacillin /0.25 tazobactam)10 mL202.5 mg/mL(180 mg/mL piperacillin/22.5 mg/mL tazobactam)3.375 (3 piperacillin /0.375 tazobactam)15 mL4.5 (4 piperacillin /0.5 tazobactam)20 mLTable 4: Reconstitution of Pharmacy Bulk Vial and Resulting ConcentrationStrength per Pharmacy Bulk VialVolume of Diluent to be Added to the VialConcentration of the Reconstituted Product40.5 (36 piperacillin /4.5 tazobactam)152 mL225 mg/mL(200 mg/mL piperacillin/25 mg/mL tazobactam). Calculate the required volume (mL) of reconstituted ZOSYN solution based on the required dose.. Aseptically withdraw the required volume of reconstituted ZOSYN solution from either the pharmacy bulk vial or single-dose vial. It should be further diluted to final piperacillin concentration of between 20 mg/mL to 80 mg/mL (tazobactam between 2.5 mg/mL to 10 mg/mL) in compatible intravenous solution (as listed above) in an appropriately sized syringe or IV bag.. Administer the diluted ZOSYN solution by infusion over period of at least 30 minutes (a programmable syringe or infusion pump is recommended). During the infusion it is desirable to discontinue the primary infusion solution.. Stability of ZOSYN for Injection Following Reconstitution and DilutionZOSYN for Injection reconstituted from pharmacy bulk vials and single-dose vials is stable in glass and plastic containers (plastic syringes, IV bags and tubing) when used with compatible diluents. The pharmacy bulk vials and single-dose vials should NOT be frozen after reconstitution.Single-dose or pharmacy bulk vials should be used immediately after reconstitution. Discard any unused portion after storage for 24 hours at room temperature (20C to 25C [68F to 77F]), or after storage for 48 hours at refrigerated temperature (2C to 8C [36F to 46F]).Stability studies in the IV bags have demonstrated chemical stability (potency, pH of reconstituted solution and clarity of solution) for up to 24 hours at room temperature and up to one week at refrigerated temperature. ZOSYN for Injection contains no preservatives. Appropriate consideration of aseptic technique should be used.ZOSYN for Injection reconstituted from bulk and single-dose vials can be used in ambulatory intravenous infusion pumps. Stability of ZOSYN for Injection in an ambulatory intravenous infusion pump has been demonstrated for period of 12 hours at room temperature. Each dose was reconstituted and diluted to volume of 37.5 mL or 25 mL. One-day supply of dosing solution were aseptically transferred into the medication reservoir (IV bags or cartridge). The reservoir was fitted to preprogrammed ambulatory intravenous infusion pump per the manufacturers instructions. Stability of ZOSYN for Injection is not affected when administered using an ambulatory intravenous infusion pump.. 2.7Directions for Use of ZOSYN Injection. Important Administration Instructions for ZOSYN Injection in GALAXY ContainersAdminister ZOSYN Injection in GALAXY Containers using sterile equipment, after thawing to room temperature.ZOSYN containing EDTA is compatible for co-administration via Y-site intravenous tube with Lactated Ringers injection, USP.Do NOT add supplementary medication.Unused portions of ZOSYN Injection should be discarded.Do NOT use plastic containers in series connections. Such use could result in air embolism due to residual air being drawn from the primary container before administration of the fluid from the secondary container is complete.Handle frozen product containers with care. Product containers may be fragile in the frozen state.. Thawing of Plastic ContainerThaw frozen container at room temperature 20C to 25C [68F to 77F] or under refrigeration (2C to 8C [36F to 46F]). Do not force thaw by immersion in water baths or by microwave irradiation.Check for minute leaks by squeezing container firmly. If leaks are detected, discard solution as sterility may be impaired.The container should be visually inspected. Components of the solution may precipitate in the frozen state and will dissolve upon reaching room temperature with little or no agitation. Potency is not affected. Agitate after solution has reached room temperature. If after visual inspection, the solution remains cloudy or if an insoluble precipitate is noted or if any seals or outlet ports are not intact, the container should be discarded.. Administration Instructions for ZOSYN Injection in GALAXY Containers to Adult PatientsAdminister by infusion over period of at least 30 minutes. During the infusion it is desirable to discontinue the primary infusion solution.. Administration Instruction for ZOSYN Injection in GALAXY Containers to Pediatric Patients Weighing up to 40 kgIf dose of ZOSYN is required that does not equal 2.25 g, 3.375 g, or 4.5 g, ZOSYN injection in GALAXY Containers is not recommended for use and an alternative formulation of ZOSYN should be considered.. Storage of ZOSYN InjectionStore in freezer capable of maintaining temperature of -20C (-4F).For GALAXY Containers, the thawed solution is stable for 14 days under refrigeration (2C to 8C [36F to 46F]) or 24 hours at room temperature 20C to 25C [68F to 77F]. Do not refreeze thawed ZOSYN Injection.. 2.8Compatibility with Aminoglycosides. Due to the in vitro inactivation of aminoglycosides by piperacillin, ZOSYN and aminoglycosides are recommended for separate administration. ZOSYN and aminoglycosides should be reconstituted, diluted, and administered separately when concomitant therapy with aminoglycosides is indicated [see Drug Interactions (7.1)].In circumstances where co-administration via Y-site is necessary, ZOSYN formulations containing EDTA are compatible for simultaneous co-administration via Y-site infusion only with the following aminoglycosides under the following conditions:Table 5: Compatibility with AminoglycosidesAminoglycosideZOSYNDose(grams)ZOSYNDiluent Volume Diluent volumes apply only to single vials and bulk pharmacy containers (mL)Aminoglycoside Concentration Range The concentration ranges in Table are based on administration of the aminoglycoside in divided doses (10-15 mg/kg/day in two daily doses for amikacin and 3-5 mg/kg/day in three daily doses for gentamicin). Administration of amikacin or gentamicin in single daily dose or in doses exceeding those stated above via Y-site with ZOSYN containing EDTA has not been evaluated. See package insert for each aminoglycoside for complete Dosage and Administration instructions. (mg/mL)Acceptable DiluentsAmikacin2.253.3754.5501001501.75 7.50.9% sodium chloride or 5% dextroseGentamicin2.253.375ZOSYN 3.375 per 50 mL GALAXY Containers are NOT compatible with gentamicin for co-administration via Y-site due to the higher concentrations of piperacillin and tazobactam. 4.5501001500.7 3.320.9% sodium chloride or 5% dextroseOnly the concentration and diluents for amikacin or gentamicin with the dosages of ZOSYN listed above have been established as compatible for co-administration via Y-site infusion. Simultaneous co-administration via Y-site infusion in any manner other than listed above may result in inactivation of the aminoglycoside by ZOSYN.ZOSYN is not compatible with tobramycin for simultaneous co-administration via Y-site infusion. Compatibility of ZOSYN with other aminoglycosides has not been established.Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration, whenever solution and container permit.

DOSAGE FORMS & STRENGTHS SECTION.

3 DOSAGE FORMS AND STRENGTHS. ZOSYN(R) (piperacillin and tazobactam) Injection is supplied in GALAXY Containers as frozen, iso-osmotic, sterile, non-pyrogenic solution in single-dose plastic containers:2.25 (piperacillin sodium equivalent to g piperacillin and tazobactam sodium equivalent to 0.25 tazobactam) in 50 mL.3.375 (piperacillin sodium equivalent to g piperacillin and tazobactam sodium equivalent to 0.375 tazobactam) in 50 mL.4.5 (piperacillin sodium equivalent to g piperacillin and tazobactam sodium equivalent to 0.5 tazobactam) in 100 mL.ZOSYN(R) (piperacillin and tazobactam) for Injection is white to off-white powder in vialsZosyn for Injection vials are not manufactured or distributed by Pfizer Inc.:2.25 single-dose vial (piperacillin sodium equivalent to grams of piperacillin and tazobactam sodium equivalent to 0.25 of tazobactam).3.375 single-dose vial (piperacillin sodium equivalent to grams of piperacillin and tazobactam sodium equivalent to 0.375 of tazobactam).4.5 single-dose vial (piperacillin sodium equivalent to grams of piperacillin and tazobactam sodium equivalent to 0.5 of tazobactam).40.5 pharmacy bulk vial (piperacillin sodium equivalent to 36 grams of piperacillin and tazobactam sodium equivalent to 4.5 grams tazobactam).. 2.25 single-dose vial (piperacillin sodium equivalent to grams of piperacillin and tazobactam sodium equivalent to 0.25 of tazobactam).. 3.375 single-dose vial (piperacillin sodium equivalent to grams of piperacillin and tazobactam sodium equivalent to 0.375 of tazobactam).. 4.5 single-dose vial (piperacillin sodium equivalent to grams of piperacillin and tazobactam sodium equivalent to 0.5 of tazobactam).. 40.5 pharmacy bulk vial (piperacillin sodium equivalent to 36 grams of piperacillin and tazobactam sodium equivalent to 4.5 grams tazobactam).. ZOSYN(R) for Injection: 2.25 g, 3.375 g, and 4.5 lyophilized powder for reconstitution in single-dose vials and 40.5 lyophilized powder for reconstitution in pharmacy bulk vials. (3)ZOSYN(R) Injection: 2.25 in 50 mL, 3.375 in 50 mL, and 4.5 in 100 mL frozen solution in single-dose GALAXY Containers. (3, 16). ZOSYN(R) for Injection: 2.25 g, 3.375 g, and 4.5 lyophilized powder for reconstitution in single-dose vials and 40.5 lyophilized powder for reconstitution in pharmacy bulk vials. (3). ZOSYN(R) Injection: 2.25 in 50 mL, 3.375 in 50 mL, and 4.5 in 100 mL frozen solution in single-dose GALAXY Containers. (3, 16).

DRUG INTERACTIONS SECTION.

7 DRUG INTERACTIONS. ZOSYN administration can significantly reduce tobramycin concentrations in hemodialysis patients. Monitor tobramycin concentrations in these patients. (7.1)Probenecid prolongs the half-lives of piperacillin and tazobactam and should not be co-administered with ZOSYN unless the benefit outweighs the risk. (7.2)Co-administration of ZOSYN with vancomycin may increase the incidence of acute kidney injury. Monitor kidney function in patients receiving ZOSYN and vancomycin. (7.3)Monitor coagulation parameters in patients receiving ZOSYN and heparin or oral anticoagulants. (7.4)ZOSYN may prolong the neuromuscular blockade of vecuronium and other non-depolarizing neuromuscular blockers. Monitor for adverse reactions related to neuromuscular blockade. (7.5). ZOSYN administration can significantly reduce tobramycin concentrations in hemodialysis patients. Monitor tobramycin concentrations in these patients. (7.1). Probenecid prolongs the half-lives of piperacillin and tazobactam and should not be co-administered with ZOSYN unless the benefit outweighs the risk. (7.2). Co-administration of ZOSYN with vancomycin may increase the incidence of acute kidney injury. Monitor kidney function in patients receiving ZOSYN and vancomycin. (7.3). Monitor coagulation parameters in patients receiving ZOSYN and heparin or oral anticoagulants. (7.4). ZOSYN may prolong the neuromuscular blockade of vecuronium and other non-depolarizing neuromuscular blockers. Monitor for adverse reactions related to neuromuscular blockade. (7.5). 7.1Aminoglycosides Piperacillin may inactivate aminoglycosides by converting them to microbiologically inert amides.. In vivo inactivation:When aminoglycosides are administered in conjunction with piperacillin to patients with end-stage renal disease requiring hemodialysis, the concentrations of the aminoglycosides (especially tobramycin) may be significantly reduced and should be monitored.Sequential administration of ZOSYN and tobramycin to patients with either normal renal function or mild to moderate renal impairment has been shown to modestly decrease serum concentrations of tobramycin but no dosage adjustment is considered necessary.. In vitro inactivation:Due to the in vitro inactivation of aminoglycosides by piperacillin, ZOSYN and aminoglycosides are recommended for separate administration. ZOSYN and aminoglycosides should be reconstituted, diluted, and administered separately when concomitant therapy with aminoglycosides is indicated. ZOSYN, which contains EDTA, is compatible with amikacin and gentamicin for simultaneous Y-site infusion in certain diluents and at specific concentrations. ZOSYN is not compatible with tobramycin for simultaneous Y-site infusion [see Dosage and Administration (2.8)].. 7.2Probenecid. Probenecid administered concomitantly with ZOSYN prolongs the half-life of piperacillin by 21% and that of tazobactam by 71% because probenecid inhibits tubular renal secretion of both piperacillin and tazobactam. Probenecid should not be co-administered with ZOSYN unless the benefit outweighs the risk.. 7.3Vancomycin. Studies have detected an increased incidence of acute kidney injury in patients concomitantly administered piperacillin/tazobactam and vancomycin as compared to vancomycin alone [see Warnings and Precautions (5.5)].Monitor kidney function in patients concomitantly administered with piperacillin/tazobactam and vancomycin.No pharmacokinetic interactions have been noted between piperacillin/tazobactam and vancomycin.. 7.4Anticoagulants Coagulation parameters should be tested more frequently and monitored regularly during simultaneous administration of high doses of heparin, oral anticoagulants, or other drugs that may affect the blood coagulation system or the thrombocyte function [see Warnings and Precautions (5.3)].. 7.5Vecuronium. Piperacillin when used concomitantly with vecuronium has been implicated in the prolongation of the neuromuscular blockade of vecuronium. ZOSYN could produce the same phenomenon if given along with vecuronium. Due to their similar mechanism of action, it is expected that the neuromuscular blockade produced by any of the non-depolarizing neuromuscular blockers could be prolonged in the presence of piperacillin. Monitor for adverse reactions related to neuromuscular blockade (see package insert for vecuronium bromide).. 7.6Methotrexate. Limited data suggests that co-administration of methotrexate and piperacillin may reduce the clearance of methotrexate due to competition for renal secretion. The impact of tazobactam on the elimination of methotrexate has not been evaluated. If concurrent therapy is necessary, serum concentrations of methotrexate as well as the signs and symptoms of methotrexate toxicity should be frequently monitored.. 7.7Effects on Laboratory Tests There have been reports of positive test results using the Bio-Rad Laboratories Platelia Aspergillus EIA test in patients receiving piperacillin/tazobactam injection who were subsequently found to be free of Aspergillus infection. Cross-reactions with non-Aspergillus polysaccharides and polyfuranoses with the Bio-Rad Laboratories Platelia Aspergillus EIA test have been reported. Therefore, positive test results in patients receiving piperacillin/tazobactam should be interpreted cautiously and confirmed by other diagnostic methods.As with other penicillins, the administration of ZOSYN may result in false-positive reaction for glucose in the urine using copper-reduction method (CLINITEST(R)). It is recommended that glucose tests based on enzymatic glucose oxidase reactions be used.

GERIATRIC USE SECTION.

8.5 Geriatric Use. Patients over 65 years are not at an increased risk of developing adverse effects solely because of age. However, dosage should be adjusted in the presence of renal impairment [see Dosage and Administration (2)].In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy.ZOSYN contains 65 mg (2.84 mEq) of sodium per gram of piperacillin in the combination product. At the usual recommended doses, patients would receive between 780 and 1040 mg/day (34.1 and 45.5 mEq) of sodium. The geriatric population may respond with blunted natriuresis to salt loading. This may be clinically important with regard to such diseases as congestive heart failure.This drug is known to be substantially excreted by the kidney, and the risk of toxic reactions to this drug may be greater in patients with impaired renal function. Because elderly patients are more likely to have decreased renal function, care should be taken in dose selection, and it may be useful to monitor renal function.

HOW SUPPLIED SECTION.

16 HOW SUPPLIED/STORAGE AND HANDLING. ZOSYN (piperacillin and tazobactam) Injection in GALAXY Containers are supplied as frozen, iso-osmotic, sterile, nonpyrogenic solution in single-dose plastic containers as follows:2.25 (piperacillin sodium equivalent to g piperacillin/tazobactam sodium equivalent to 0.25 tazobactam) in 50 mL. Each container has 5.58 mEq (128 mg) of sodium. Supplied 24/box--NDC 0206-8860-023.375 (piperacillin sodium equivalent to g piperacillin/tazobactam sodium equivalent to 0.375 tazobactam) in 50 mL. Each container has 8.38 mEq (192 mg) of sodium. Supplied 24/box--NDC 0206-8861-024.5 (piperacillin sodium equivalent to g piperacillin/tazobactam sodium equivalent to 0.5 tazobactam) in 100 mL. Each container has 11.17 mEq (256 mg) of sodium. Supplied 12/box--NDC 0206-8862-02ZOSYN Injection in GALAXY Containers should be stored at or below -20C (-4F) [see Dosage and Administration (2.7)]. Handle frozen product containers with care. Product containers may be fragile in the frozen state.. 2.25 (piperacillin sodium equivalent to g piperacillin/tazobactam sodium equivalent to 0.25 tazobactam) in 50 mL. Each container has 5.58 mEq (128 mg) of sodium. Supplied 24/box--NDC 0206-8860-02. 3.375 (piperacillin sodium equivalent to g piperacillin/tazobactam sodium equivalent to 0.375 tazobactam) in 50 mL. Each container has 8.38 mEq (192 mg) of sodium. Supplied 24/box--NDC 0206-8861-02. 4.5 (piperacillin sodium equivalent to g piperacillin/tazobactam sodium equivalent to 0.5 tazobactam) in 100 mL. Each container has 11.17 mEq (256 mg) of sodium. Supplied 12/box--NDC 0206-8862-02.

INDICATIONS & USAGE SECTION.

1 INDICATIONS AND USAGE. ZOSYN is combination of piperacillin, penicillin-class antibacterial and tazobactam, beta-lactamase inhibitor, indicated for the treatment of:Intra-abdominal infections in adult and pediatric patients months of age and older (1.1)Nosocomial pneumonia in adult and pediatric patients months of age and older (1.2)Skin and skin structure infections in adults (1.3)Female pelvic infections in adults (1.4)Community-acquired pneumonia in adults (1.5)To reduce the development of drug-resistant bacteria and maintain the effectiveness of ZOSYN and other antibacterial drugs, ZOSYN should be used only to treat or prevent infections that are proven or strongly suspected to be caused by bacteria. (1.6). Intra-abdominal infections in adult and pediatric patients months of age and older (1.1). Nosocomial pneumonia in adult and pediatric patients months of age and older (1.2). Skin and skin structure infections in adults (1.3). Female pelvic infections in adults (1.4). Community-acquired pneumonia in adults (1.5). 1.1Intra-abdominal Infections. ZOSYN is indicated in adults and pediatric patients (2 months of age and older) for the treatment of appendicitis (complicated by rupture or abscess) and peritonitis caused by beta-lactamase producing isolates of Escherichia coli or the following members of the Bacteroides fragilis group: B. fragilis, B. ovatus, B. thetaiotaomicron, or B. vulgatus.. 1.2Nosocomial Pneumonia. ZOSYN is indicated in adults and pediatric patients (2 months of age and older) for the treatment of nosocomial pneumonia (moderate to severe) caused by beta-lactamase producing isolates of Staphylococcus aureus and by piperacillin/tazobactam-susceptible Acinetobacter baumannii, Haemophilus influenzae, Klebsiella pneumoniae, and Pseudomonas aeruginosa (Nosocomial pneumonia caused by P. aeruginosa should be treated in combination with an aminoglycoside) [see Dosage and Administration (2)]. 1.3Skin and Skin Structure Infections. ZOSYN is indicated in adults for the treatment of uncomplicated and complicated skin and skin structure infections, including cellulitis, cutaneous abscesses and ischemic/diabetic foot infections caused by beta-lactamase producing isolates of Staphylococcus aureus.. 1.4Female Pelvic Infections. ZOSYN is indicated in adults for the treatment of postpartum endometritis or pelvic inflammatory disease caused by beta-lactamase producing isolates of Escherichia coli.. 1.5Community-acquired Pneumonia. ZOSYN is indicated in adults for the treatment of community-acquired pneumonia (moderate severity only) caused by beta-lactamase producing isolates of Haemophilus influenzae. 1.6Usage. To reduce the development of drug-resistant bacteria and maintain the effectiveness of ZOSYN and other antibacterial drugs, ZOSYN should be used only to treat or prevent infections that are proven or strongly suspected to be caused by 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.

PHARMACODYNAMICS SECTION.

12.2 Pharmacodynamics. The pharmacodynamic parameter for piperacillin/tazobactam that is most predictive of clinical and microbiological efficacy is time above MIC.

PHARMACOKINETICS SECTION.

12.3 Pharmacokinetics. The mean and coefficients of variation (CV%) for the pharmacokinetic parameters of piperacillin and tazobactam after multiple intravenous doses are summarized in Table 9.Table 9: Mean (CV%) Piperacillin and Tazobactam PK ParametersCmax maximum observed concentration, AUC: Area under the curve, CL=clearance, CLR= Renal clearance V=volume of distribution, T1/2 elimination half-lifePiperacillinPiperacillin/Tazobactam DosePiperacillin and tazobactam were given in combination, infused over 30 minutes. Cmax (mcg/mL)AUCNumbers in []parentheses are coefficients of variation [CV%]. (mcgh/mL)CL (mL/min)V(L)T1/2 (h)CLR (mL/min)2.25 g134131 [14]25717.40.79--3.375 g242242 [10]20715.10.841404.5 g298322 [16]21015.40.84--TazobactamPiperacillin/Tazobactam Dose Cmax (mcg/mL)AUC (mcgh/mL)CL (mL/min)V(L)T1/2 (h)CLR (mL/min)2.25 g1516.0 [21]25817.00.77--3.375 g2425.0 [8]25114.80.681664.5 g3439.8 [15]20614.70.82--Peak plasma concentrations of piperacillin and tazobactam are attained immediately after completion of an intravenous infusion of ZOSYN. Piperacillin plasma concentrations, following 30-minute infusion of ZOSYN, were similar to those attained when equivalent doses of piperacillin were administered alone. Steady-state plasma concentrations of piperacillin and tazobactam were similar to those attained after the first dose due to the short half-lives of piperacillin and tazobactam.. DistributionBoth 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 and tazobactam are widely distributed into tissues and body fluids including intestinal mucosa, gallbladder, lung, female reproductive tissues (uterus, ovary, and fallopian tube), interstitial fluid, and bile. Mean tissue concentrations are generally 50% to 100% of those in plasma. Distribution of piperacillin and tazobactam into cerebrospinal fluid is low in subjects with non-inflamed meninges, as with other penicillins (see Table 10).Table 10: Piperacillin/Tazobactam Concentrations in Selected Tissues and Fluids after Single g/0.5 30-min IV Infusion of ZOSYNTissue or FluidNEach subject provided single sample. Sampling periodTime from the start of the infusion (h)Mean PIP Concentration Range(mg/L)Tissue:Plasma RangeTazo Concentration Range(mg/L)Tazo Tissue:Plasma RangeSkin350.5 4.534.8 94.20.60 1.14.0 7.70.49 0.93Fatty Tissue370.5 4.54.0 10.10.097 0.1150.7 1.50.10 0.13Muscle360.5 4.59.4 23.30.29 0.181.4 2.70.18 0.30Proximal Intestinal Mucosa71.5 2.531.40.5510.31.15Distal Intestinal Mucosa71.5 2.531.20.5914.52.1Appendix220.5 2.526.5 64.10.43 0.539.1 18.60.80 1.35. MetabolismPiperacillin is metabolized to minor microbiologically active desethyl metabolite. Tazobactam is metabolized to single metabolite that lacks pharmacological and antibacterial activities.. ExcretionFollowing single or multiple ZOSYN doses to healthy subjects, the plasma half-life of piperacillin and of tazobactam ranged from 0.7 to 1.2 hours and was unaffected by dose or duration of infusion.Both piperacillin and tazobactam are eliminated via the kidney by glomerular filtration and tubular secretion. Piperacillin is excreted rapidly as unchanged drug with 68% of the administered dose excreted in the urine. Tazobactam and its metabolite are eliminated primarily by renal excretion with 80% of the administered dose excreted as unchanged drug and the remainder as the single metabolite. Piperacillin, tazobactam and desethyl piperacillin are also secreted into the bile.. Specific Populations. Renal ImpairmentAfter the administration of single doses of piperacillin/tazobactam to subjects with renal impairment, the half-life of piperacillin and of tazobactam increases with decreasing creatinine clearance. At creatinine clearance below 20 mL/min, the increase in half-life is twofold for piperacillin and fourfold for tazobactam compared to subjects with normal renal function. Dosage adjustments for ZOSYN are recommended when creatinine clearance is below 40 mL/min in patients receiving the usual recommended daily dose of ZOSYN. See Dosage and Administration (2) for specific recommendations for the treatment of patients with renal -impairment.Hemodialysis removes 30% to 40% of piperacillin/tazobactam dose 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 16% of the tazobactam dose removed as the tazobactam metabolite. For dosage recommendations for patients undergoing hemodialysis [see Dosage and Administration (2)].. Hepatic ImpairmentThe half-life of piperacillin and of tazobactam increases by approximately 25% and 18%, respectively, in patients with hepatic cirrhosis compared to healthy subjects. However, this difference does not warrant dosage adjustment of ZOSYN due to hepatic cirrhosis.. PediatricsPiperacillin and tazobactam pharmacokinetics were studied in pediatric patients months of age and older. The clearance of both compounds is slower in the younger patients compared to older children and adults.In population PK analysis, estimated clearance for month-old to 12 year-old patients was comparable to adults, with population mean (SE) value of 5.64 (0.34) mL/min/kg. The piperacillin clearance estimate is 80% of this value for pediatric patients - months old. In patients younger than months of age, clearance of piperacillin is slower compared to older children; however, it is not adequately characterized for dosing recommendations. The population mean (SE) for piperacillin volume of distribution is 0.243 (0.011) L/kg and is independent of age.. GeriatricsThe impact of age on the pharmacokinetics of piperacillin and tazobactam was evaluated in healthy male subjects, aged 18 35 years (n=6) and aged 65 to 80 years (n=12). Mean half-life for piperacilln and tazobactam was 32% and 55% higher, respectively, in the elderly compared to the younger subjects. This difference may be due to age-related changes in creatinine clearance.. RaceThe effect of race on piperacillin and tazobactam was evaluated in healthy male volunteers. No difference in piperacillin or tazobactam pharmacokinetics was observed between Asian (n=9) and Caucasian (n=9) healthy volunteers who received single 4/0.5 doses.. Drug InteractionsThe potential for pharmacokinetic drug interactions between ZOSYN and aminoglycosides, probenecid, vancomycin, heparin, vecuronium, and methotrexate has been evaluated [see Drug Interactions (7)].

INFORMATION FOR PATIENTS SECTION.

17 PATIENT COUNSELING INFORMATION. Serious Hypersensitivity ReactionsAdvise patients, their families, or caregivers that serious hypersensitivity reactions, including serious allergic cutaneous reactions, could occur with use of ZOSYN that require immediate treatment. Ask them about any previous hypersensitivity reactions to ZOSYN, other beta-lactams (including cephalosporins), or other allergens [see Warnings and Precautions (5.2)]. DiarrheaAdvise patients, their families, or caregivers that diarrhea is common problem caused by antibacterial drugs, including ZOSYN, which usually ends when the drug is discontinued. Sometimes after starting treatment with antibacterial drugs, patients can develop watery and bloody stools (with or without stomach cramps and fever) even as late as two or more months after having taken the last dose of the drug. If this occurs, patients should contact their physician as soon as possible [see Warnings and Precautions (5.7)].. Antibacterial ResistancePatients should be counseled that antibacterial drugs including ZOSYN should only be used to treat bacterial infections. They do not treat viral infections (e.g., the common cold). When ZOSYN is prescribed to treat bacterial infection, patients should be told that although it is common to feel better early in the course of therapy, the medication should be taken exactly as directed. Skipping doses or not completing the full course of therapy may (1) decrease the effectiveness of the immediate treatment and (2) increase the likelihood that bacteria will develop resistance and will not be treatable by ZOSYN or other antibacterial drugs in the future.. Pregnancy and LactationPatients should be counseled that ZOSYN can cross the placenta in humans and is excreted in human milk [see Use in Specific Populations (8.1, 8.2)].

LACTATION SECTION.

8.2 Lactation. Risk SummaryPiperacillin is excreted in human milk; tazobactam concentrations in human milk have not been studied. No information is available on the effects of piperacillin and tazobactam on the breast-fed child or on milk production. The developmental and health benefits of breastfeeding should be considered along with the mothers clinical need for ZOSYN and any potential adverse effects on the breastfed child from ZOSYN or from the underlying maternal condition.

MECHANISM OF ACTION SECTION.

12.1 Mechanism of Action. ZOSYN is an antibacterial drug [see Microbiology (12.4)].

MICROBIOLOGY SECTION.

12.4 Microbiology. Mechanism of ActionPiperacillin sodium exerts bactericidal activity by inhibiting septum formation and cell wall synthesis of susceptible bacteria. In vitro, piperacillin is active against variety of Gram-positive and Gram-negative aerobic and anaerobic bacteria. Tazobactam sodium has little clinically relevant in vitro activity against bacteria due to its reduced affinity to penicillin-binding proteins. It is, however, beta-lactamase inhibitor of the Molecular class enzymes, including Richmond-Sykes class III (Bush class 2b 2b) penicillinases and cephalosporinases. It varies in its ability to inhibit class II and IV (2a 4) penicillinases. Tazobactam does not induce chromosomally-mediated beta-lactamases at tazobactam concentrations achieved with the recommended dosage regimen.. Antimicrobial ActivityZOSYN has been shown to be active against most isolates of the following microorganisms both in vitro and in clinical infections [see Indications and Usage (1)]:Aerobic bacteriaGram-positive bacteriaStaphylococcus aureus (methicillin susceptible isolates only)Gram-negative bacteriaAcinetobacter baumanniiEscherichia coliHaemophilus influenzae (excluding beta-lactamase negative, ampicillin-resistant isolates) Klebsiella pneumoniaePseudomonas aeruginosa (given in combination with an aminoglycoside to which the isolate is susceptible)Anaerobic bacteriaBacteroides fragilis group (B. fragilis, B. ovatus, B. thetaiotaomicron, and B. vulgatus)The following in vitro data are available, but their clinical significance is unknown.At least 90 percent of the following bacteria exhibit an in vitro minimum inhibitory concentration (MIC) less than or equal to the susceptible breakpoint for piperacillin/tazobactam against isolates of similar genus or organism group.However, the efficacy of ZOSYN in treating clinical infections caused by these bacteria has not been established in adequate and well-controlled clinical trials.Aerobic bacteriaGram-positive bacteriaEnterococcus faecalis (ampicillin or penicillin-susceptible isolates only) Staphylococcus epidermidis (methicillin susceptible isolates only)Streptococcus agalactiaeThese are not beta-lactamase producing bacteria and, therefore, are susceptible to piperacillin alone.Streptococcus pneumoniae (penicillin-susceptible isolates only) Streptococcus pyogenes Viridans group streptococci Gram-negative bacteria Citrobacter koseriMoraxella catarrhalisMorganella morganiiNeisseria gonorrhoeaeProteus mirabilisProteus vulgarisSerratia marcescensProvidencia stuartiiProvidencia rettgeriSalmonella entericaAnaerobic bacteriaClostridium perfringensBacteroides distasonisPrevotella melaninogenica. Susceptibility TestingFor specific information regarding susceptibility test interpretive criteria and associated test methods and quality control standards recognized by FDA for this drug, please see: https://www.fda.gov/STIC.

NONCLINICAL TOXICOLOGY SECTION.

13 NONCLINICAL TOXICOLOGY. 13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility. CarcinogenesisLong-term carcinogenicity studies in animals have not been conducted with piperacillin/tazobactam, piperacillin, or tazobactam.. MutagenesisPiperacillin/tazobactam was negative in microbial mutagenicity assays, the unscheduled DNA synthesis (UDS) test, mammalian point mutation (Chinese hamster ovary cell HPRT) assay, and mammalian cell (BALB/c-3T3) transformation assay. In vivo, piperacillin/tazobactam did not induce chromosomal aberrations in rats.. FertilityReproduction studies have been performed in rats and have revealed no evidence of impaired fertility when piperacillin/tazobactam is administered intravenously up to dose of 1280/320 mg/kg piperacillin/tazobactam, which is similar to the maximum recommended human daily dose based on body-surface area (mg/m2).

OVERDOSAGE SECTION.

10 OVERDOSAGE. There have been postmarketing reports of overdose with piperacillin/tazobactam. The majority of those events experienced, including nausea, vomiting, and diarrhea, have also been reported with the usual recommended dosages. Patients may experience neuromuscular excitability or seizures if higher than recommended doses are given intravenously (particularly in the presence of renal failure) [see Warnings and Precautions (5.4)].Treatment should be supportive and symptomatic according the patients clinical presentation. Excessive serum concentrations of either piperacillin or tazobactam may be reduced by hemodialysis. Following single 3.375 dose of piperacillin/tazobactam, the percentage of the piperacillin and tazobactam dose removed by hemodialysis was approximately 31% and 39%, respectively [see Clinical Pharmacology (12)].

PACKAGE LABEL.PRINCIPAL DISPLAY PANEL.

PRINCIPAL DISPLAY PANEL 2.25 Container. ZOSYN(R) (Piperacillin and TazobactamInjection)2.25 gRx onlyGALAXYSingle DoseContainer50 mLIso-osmoticNDC 0206-8860-01Code 2G3575Sterile NonpyrogenicStore at or below -20C/-4F. Thaw at room temperature 20 to 25C (68 to 77F)or under refrigeration to 8C (36 to 46F). DO NOT FORCE THAW BY IMMERSIONIN WATER BATHS OR BY MICROWAVE IRRADIATION. Thawed solution remainsstable for 14 days under refrigeration or 24 hours at room temperature.Do not refreeze.Dosage and Use: For intravenous use only. As directed by physician. See Package Insert.Cautions: Do not add supplementary medication or additives. Must not be usedin series connections. Check for minute leaks and solution clarity.Each 50 mL contains: Piperacillin Sodium equivalent to g Piperacillin andTazobactam Sodium equivalent to 0.25 Tazobactam in Water for Injection.Approximately g Dextrose Hydrous added to adjust osmolality. Approximately100 mg Sodium Citrate Dihydrate added as buffer. pH adjusted with sodiumbicarbonate and hydrochloric acid. pH 5.5 6.8Each 50 mL also contains approximately 0.5 mg Edetate Disodium Dihydrate addedas metal chelator.GALAXY is registered trademark of Baxter International Inc.Distributed byWyeth Pharmaceuticals LLCA subsidiary of Pfizer IncPhiladelphia, PA 19101PL 2040 Plastic1460520007-34-00-0150Pfizer Injectables. PRINCIPAL DISPLAY PANEL 2.25 Container.

PREGNANCY SECTION.

8.1 Pregnancy. Risk SummaryPiperacillin and tazobactam cross the placenta in humans. However, there are insufficient data with piperacillin and/or tazobactam in pregnant women to inform drug-associated risk for major birth defects and miscarriage. No fetal structural abnormalities were observed in rats or mice when piperacillin/tazobactam was administered intravenously during organogenesis at doses to times and to times the human dose of piperacillin and tazobactam, respectively, based on body-surface area (mg/m2). However, fetotoxicity in the presence of maternal toxicity was observed in developmental toxicity and peri/postnatal studies conducted in rats (intraperitoneal administration prior to mating and throughout gestation or from gestation day 17 through lactation day 21) at doses less than the maximum recommended human daily dose based on body-surface area (mg/m2) [see Data ].The background risk of major birth defects and miscarriage for the indicated population is unknown. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2-4% and 15-20%, respectively.. Data. Animal DataIn embryo-fetal development studies in mice and rats, pregnant animals received intravenous doses of piperacillin/tazobactam up to 3000/750 mg/kg/day during the period of organogenesis. There was no evidence of teratogenicity up to the highest dose evaluated, which is to times and to times the human dose of piperacillin and tazobactam, in mice and rats respectively, based on body-surface area (mg/m2). Fetal body weights were reduced in rats at maternally toxic doses at or above 500/62.5 mg/kg/day, minimally representing 0.4 times the human dose of both piperacillin and tazobactam based on body-surface area (mg/m2).A fertility and general reproduction study in rats using intraperitoneal administration of tazobactam or the combination piperacillin/tazobactam prior to mating and through the end of gestation, reported decrease in litter size in the presence of maternal toxicity at 640 mg/kg/day tazobactam (4 times the human dose of tazobactam based on body-surface area), and decreased litter size and an increase in fetuses with ossification delays and variations of ribs, concurrent with maternal toxicity at >=640/160 mg/kg/day piperacillin/tazobactam (0.5 times and times the human dose of piperacillin and tazobactam, respectively, based on body-surface area).Peri/postnatal development in rats was impaired with reduced pup weights, increased stillbirths, and increased pup mortality concurrent with maternal toxicity after intraperitoneal administration of tazobactam alone at doses >=320 mg/kg/day (2 times the human dose based on body surface area) or of the combination piperacillin/tazobactam at doses >=640/160 mg/kg/day (0.5 times and times the human dose of piperacillin and tazobactam, respectively, based on body-surface area) from gestation day 17 through lactation day 21.

RECENT MAJOR CHANGES SECTION.

Dosage and Administration (2)X/2021.

REFERENCES SECTION.

15 REFERENCES. Jensen J-US, Hein L, Lundgren B, et al. BMJ Open 2012; 2:e000635. doi:10.1136.. Jensen J-US, Hein L, Lundgren B, et al. BMJ Open 2012; 2:e000635. doi:10.1136.

SPL UNCLASSIFIED SECTION.

1.1Intra-abdominal Infections. ZOSYN is indicated in adults and pediatric patients (2 months of age and older) for the treatment of appendicitis (complicated by rupture or abscess) and peritonitis caused by beta-lactamase producing isolates of Escherichia coli or the following members of the Bacteroides fragilis group: B. fragilis, B. ovatus, B. thetaiotaomicron, or B. vulgatus.

USE IN SPECIFIC POPULATIONS SECTION.

8 USE IN SPECIFIC POPULATIONS. Dosage in patients with renal impairment (creatinine clearance <=40 mL/min) should be reduced based on the degree of renal impairment. (2.4, 8.6). 8.1 Pregnancy. Risk SummaryPiperacillin and tazobactam cross the placenta in humans. However, there are insufficient data with piperacillin and/or tazobactam in pregnant women to inform drug-associated risk for major birth defects and miscarriage. No fetal structural abnormalities were observed in rats or mice when piperacillin/tazobactam was administered intravenously during organogenesis at doses to times and to times the human dose of piperacillin and tazobactam, respectively, based on body-surface area (mg/m2). However, fetotoxicity in the presence of maternal toxicity was observed in developmental toxicity and peri/postnatal studies conducted in rats (intraperitoneal administration prior to mating and throughout gestation or from gestation day 17 through lactation day 21) at doses less than the maximum recommended human daily dose based on body-surface area (mg/m2) [see Data ].The background risk of major birth defects and miscarriage for the indicated population is unknown. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2-4% and 15-20%, respectively.. Data. Animal DataIn embryo-fetal development studies in mice and rats, pregnant animals received intravenous doses of piperacillin/tazobactam up to 3000/750 mg/kg/day during the period of organogenesis. There was no evidence of teratogenicity up to the highest dose evaluated, which is to times and to times the human dose of piperacillin and tazobactam, in mice and rats respectively, based on body-surface area (mg/m2). Fetal body weights were reduced in rats at maternally toxic doses at or above 500/62.5 mg/kg/day, minimally representing 0.4 times the human dose of both piperacillin and tazobactam based on body-surface area (mg/m2).A fertility and general reproduction study in rats using intraperitoneal administration of tazobactam or the combination piperacillin/tazobactam prior to mating and through the end of gestation, reported decrease in litter size in the presence of maternal toxicity at 640 mg/kg/day tazobactam (4 times the human dose of tazobactam based on body-surface area), and decreased litter size and an increase in fetuses with ossification delays and variations of ribs, concurrent with maternal toxicity at >=640/160 mg/kg/day piperacillin/tazobactam (0.5 times and times the human dose of piperacillin and tazobactam, respectively, based on body-surface area).Peri/postnatal development in rats was impaired with reduced pup weights, increased stillbirths, and increased pup mortality concurrent with maternal toxicity after intraperitoneal administration of tazobactam alone at doses >=320 mg/kg/day (2 times the human dose based on body surface area) or of the combination piperacillin/tazobactam at doses >=640/160 mg/kg/day (0.5 times and times the human dose of piperacillin and tazobactam, respectively, based on body-surface area) from gestation day 17 through lactation day 21.. 8.2 Lactation. Risk SummaryPiperacillin is excreted in human milk; tazobactam concentrations in human milk have not been studied. No information is available on the effects of piperacillin and tazobactam on the breast-fed child or on milk production. The developmental and health benefits of breastfeeding should be considered along with the mothers clinical need for ZOSYN and any potential adverse effects on the breastfed child from ZOSYN or from the underlying maternal condition.. 8.4 Pediatric Use. The safety and effectiveness of ZOSYN for intra-abdominal infections, and nosocomial pneumonia have been established in pediatric patients months of age and older.Use of ZOSYN in pediatric patients months of age and older with intra-abdominal infections including appendicitis and/or peritonitis is supported by evidence from well-controlled studies and pharmacokinetic studies in adults and in pediatric patients. This includes prospective, randomized, comparative, open-label clinical trial with 542 pediatric patients to 12 years of age with intra-abdominal infections (including appendicitis and/or peritonitis), in which 273 pediatric patients received piperacillin/tazobactam [see Adverse Reactions (6.1) and Clinical Pharmacology (12.3)].Use of ZOSYN in pediatric patients months of age and older with nosocomial pneumonia is supported by evidence from well-controlled studies in adults with nosocomial pneumonia, simulation study performed with population pharmacokinetic model, and retrospective, cohort study of pediatric patients with nosocomial pneumonia in which 140 pediatric patients were treated with ZOSYN and 267 patients treated with comparators (which included ticarcillin-clavulanate, carbapenems, ceftazidime, cefepime, or ciprofloxacin) [see Adverse Reactions (6.1) and Clinical Pharmacology (12.3)]. Because of the limitations of the available strengths and administration requirements (i.e., administration of fractional doses is not recommended) of ZOSYN Injection supplied in GALAXY Containers, and to avoid unintentional overdose, this product is not recommended for use if dose of ZOSYN Injection in GALAXY Containers that does not equal 2.25 g, 3.375 g, or 4.5 is required and an alternative formulation of ZOSYN should be considered [see Dosage and Administration (2.1, 2.5, and 2.7)].The safety and effectiveness of ZOSYN have not been established in pediatric patients less than months of age [see Clinical Pharmacology (12) and Dosage and Administration (2)].Dosage of ZOSYN in pediatric patients with renal impairment has not been determined.. 8.5 Geriatric Use. Patients over 65 years are not at an increased risk of developing adverse effects solely because of age. However, dosage should be adjusted in the presence of renal impairment [see Dosage and Administration (2)].In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy.ZOSYN contains 65 mg (2.84 mEq) of sodium per gram of piperacillin in the combination product. At the usual recommended doses, patients would receive between 780 and 1040 mg/day (34.1 and 45.5 mEq) of sodium. The geriatric population may respond with blunted natriuresis to salt loading. This may be clinically important with regard to such diseases as congestive heart failure.This drug is known to be substantially excreted by the kidney, and the risk of toxic reactions to this drug may be greater in patients with impaired renal function. Because elderly patients are more likely to have decreased renal function, care should be taken in dose selection, and it may be useful to monitor renal function.. 8.6Renal Impairment. In patients with creatinine clearance <= 40 mL/min and dialysis patients (hemodialysis and CAPD), the intravenous dose of ZOSYN should be reduced to the degree of renal function impairment [see Dosage and Administration (2)].. 8.7Hepatic Impairment. Dosage adjustment of ZOSYN is not warranted in patients with hepatic cirrhosis [see Clinical Pharmacology (12.3)].. 8.8Patients with Cystic Fibrosis. As with other semisynthetic penicillins, piperacillin therapy has been associated with an increased incidence of fever and rash in cystic fibrosis patients.

WARNINGS AND PRECAUTIONS SECTION.

5 WARNINGS AND PRECAUTIONS. Serious hypersensitivity reactions (anaphylactic/anaphylactoid) reactions have been reported in patients receiving ZOSYN. Discontinue ZOSYN if reaction occurs. (5.1)ZOSYN may cause severe cutaneous adverse reactions, such as Stevens-Johnson syndrome, toxic epidermal necrolysis, drug reaction with eosinophilia and systemic symptoms, and acute generalized exanthematous pustulosis. Discontinue ZOSYN for progressive rashes. (5.2)Hematological effects (including bleeding, leukopenia and neutropenia) have occurred. Monitor hematologic tests during prolonged therapy. (5.3)As with other penicillins, ZOSYN may cause neuromuscular excitability or seizures. Patients receiving higher doses, especially in the presence of renal impairment may be at greater risk. Closely monitor patients with renal impairment or seizure disorders for signs and symptoms of neuromuscular excitability or seizures. (5.4)Nephrotoxicity in critically ill patients has been observed; the use of ZOSYN was found to be an independent risk factor for renal failure and was associated with delayed recovery of renal function as compared to other beta-lactam antibacterial drugs in randomized, multicenter, controlled trial in critically ill patients. Based on this study, alternative treatment options should be considered in the critically ill population. If alternative treatment options are inadequate or unavailable, monitor renal function during treatment with ZOSYN. (5.5)Clostridioides difficile-associated diarrhea: evaluate patients if diarrhea occurs. (5.7). Serious hypersensitivity reactions (anaphylactic/anaphylactoid) reactions have been reported in patients receiving ZOSYN. Discontinue ZOSYN if reaction occurs. (5.1). ZOSYN may cause severe cutaneous adverse reactions, such as Stevens-Johnson syndrome, toxic epidermal necrolysis, drug reaction with eosinophilia and systemic symptoms, and acute generalized exanthematous pustulosis. Discontinue ZOSYN for progressive rashes. (5.2). Hematological effects (including bleeding, leukopenia and neutropenia) have occurred. Monitor hematologic tests during prolonged therapy. (5.3). As with other penicillins, ZOSYN may cause neuromuscular excitability or seizures. Patients receiving higher doses, especially in the presence of renal impairment may be at greater risk. Closely monitor patients with renal impairment or seizure disorders for signs and symptoms of neuromuscular excitability or seizures. (5.4). Nephrotoxicity in critically ill patients has been observed; the use of ZOSYN was found to be an independent risk factor for renal failure and was associated with delayed recovery of renal function as compared to other beta-lactam antibacterial drugs in randomized, multicenter, controlled trial in critically ill patients. Based on this study, alternative treatment options should be considered in the critically ill population. If alternative treatment options are inadequate or unavailable, monitor renal function during treatment with ZOSYN. (5.5). Clostridioides difficile-associated diarrhea: evaluate patients if diarrhea occurs. (5.7). 5.1Hypersensitivity Adverse Reactions. Serious and occasionally fatal hypersensitivity (anaphylactic/anaphylactoid) reactions (including shock) have been reported in patients receiving therapy with ZOSYN. These reactions are more likely to occur in individuals with history of penicillin, cephalosporin, or carbapenem hypersensitivity or history of sensitivity to multiple allergens. Before initiating therapy with ZOSYN, careful inquiry should be made concerning previous hypersensitivity reactions. If an allergic reaction occurs, ZOSYN should be discontinued and appropriate therapy instituted.. 5.2Severe Cutaneous Adverse Reactions. ZOSYN may cause severe cutaneous adverse reactions, such as Stevens-Johnson syndrome, toxic epidermal necrolysis, drug reaction with eosinophilia and systemic symptoms, and acute generalized exanthematous pustulosis. If patients develop skin rash they should be monitored closely and ZOSYN discontinued if lesions progress.. 5.3Hematologic Adverse Reactions. Bleeding manifestations have occurred in some patients receiving beta-lactam drugs, including piperacillin. These reactions have sometimes 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, ZOSYN should be discontinued and appropriate therapy instituted.The leukopenia/neutropenia associated with ZOSYN administration appears to be reversible and most frequently associated with prolonged administration.Periodic assessment of hematopoietic function should be performed, especially with prolonged therapy, i.e., >= 21 days [see Adverse Reactions (6.1)].. 5.4Central Nervous System Adverse Reactions. As with other penicillins, ZOSYN may cause neuromuscular excitability or seizures. Patients receiving higher doses, especially patients with renal impairment may be at greater risk for central nervous system adverse reactions. Closely monitor patients with renal impairment or seizure disorders for signs and symptoms of neuromuscular excitability or seizures [see Adverse Reactions (6.2)]. 5.5Nephrotoxicity in Critically Ill Patients. The use of ZOSYN was found to be an independent risk factor for renal failure and was associated with delayed recovery of renal function as compared to other beta-lactam antibacterial drugs in randomized, multicenter, controlled trial in critically ill patients [see Adverse Reactions (6.1)]. Based on this study, alternative treatment options should be considered in the critically ill population. If alternative treatment options are inadequate or unavailable, monitor renal function during treatment with ZOSYN [see Dosage and Administration (2.4)].Combined use of piperacillin/tazobactam and vancomycin may be associated with an increased incidence of acute kidney injury [see Drug Interactions (7.3)].. 5.6Electrolyte Effects. ZOSYN contains total of 2.84 mEq (65 mg) of Na+ (sodium) per gram of piperacillin in the combination product. This should be considered when treating patients requiring restricted salt intake. Periodic electrolyte determinations should be performed in patients with low potassium reserves, and the possibility of hypokalemia should be kept in mind with patients who have potentially low potassium reserves and who are receiving cytotoxic therapy or diuretics.. 5.7 Clostridioides difficile-Associated Diarrhea. Clostridioides difficile-associated diarrhea (CDAD) has been reported with use of nearly all antibacterial agents, including ZOSYN, and may range in severity from mild diarrhea to fatal colitis. Treatment with antibacterial agents alters the normal flora of the colon leading to overgrowth of C. difficile.C. difficile produces toxins and which contribute to the development of CDAD. Hypertoxin producing strains of C. difficile cause increased morbidity and mortality, as these infections can be refractory to antimicrobial therapy and may require colectomy. CDAD must be considered in all patients who present with diarrhea following antibacterial drug use. Careful medical history is necessary since CDAD has been reported to occur over two months after the administration of antibacterial agents.If CDAD is suspected or confirmed, ongoing antibacterial drug use not directed against C. difficile may need to be discontinued. Appropriate fluid and electrolyte management, protein supplementation, antibacterial treatment of C. difficile, and surgical evaluation should be instituted as clinically indicated.. 5.8Development of Drug-Resistant Bacteria. Prescribing ZOSYN in the absence of proven or strongly suspected bacterial infection or prophylactic indication is unlikely to provide benefit to the patient and increases the risk of development of drug-resistant bacteria.