Augmentin
FDA Label NDC 43598-004

To reduce the development of drug‑resistant bacteria and maintain the effectiveness of AUGMENTIN (amoxicillin/clavulanate potassium) and other antibacterial drugs, AUGMENTIN should be used only to treat infections that are proven or strongly suspected to be caused by susceptible bacteria. When culture and susceptibility information are available, they should be considered in selecting or modifying antibacterial therapy. In the absence of such data, local epidemiology and susceptibility patterns may contribute to the empiric selection of therapy.

AUGMENTIN^® is a combination penicillin-class antibacterial and beta-lactamase inhibitor indicated in the treatment of infections due to susceptible isolates of the designated bacteria in the conditions listed below*:

caused by beta‑lactamase–producing isolates of Haemophilus influenzae and Moraxella catarrhalis.

caused by beta‑lactamase–producing isolates of H. influenzae and M. catarrhalis.

caused by beta‑lactamase–producing isolates of H. influenzae and M. catarrhalis.

caused by beta‑lactamase–producing isolates of Staphylococcus aureus, Escherichia coli, and Klebsiella species.

caused by beta‑lactamase–producing isolates of E. coli, Klebsiella species, and Enterobacter species.

When susceptibility test results show susceptibility to amoxicillin, indicating no beta-lactamase production, AUGMENTIN should not be used.

AUGMENTIN may be taken without regard to meals; however, absorption of clavulanate potassium is enhanced when AUGMENTIN is administered at the start of a meal. To minimize the potential for gastrointestinal intolerance, AUGMENTIN should be taken at the start of a meal.

The usual adult dose is one 500-mg tablet of AUGMENTIN every 12 hours or one 250-mg tablet of AUGMENTIN every 8 hours. For more severe infections and infections of the respiratory tract, the dose should be one 875-mg tablet of AUGMENTIN every 12 hours or one 500-mg tablet of AUGMENTIN every 8 hours. Adults who have difficulty swallowing may be given the 125 mg/5 mL or 250 mg/5 mL suspension in place of the 500-mg tablet. The 200 mg/5 mL suspension or the 400 mg/5 mL suspension may be used in place of the 875-mg tablet.

Two 250-mg tablets of AUGMENTIN should not be substituted for one 500-mg tablet of AUGMENTIN. Since both the 250-mg and 500-mg tablets of AUGMENTIN contain the same amount of clavulanic acid (125 mg, as the potassium salt), two 250-mg tablets are not equivalent to one 500-mg tablet of AUGMENTIN.

The 250-mg tablet of AUGMENTIN and the 250-mg chewable tablet should not be substituted for each other, as they are not interchangeable. The 250-mg tablet of AUGMENTIN and the 250-mg chewable tablet do not contain the same amount of clavulanic acid (as the potassium salt). The 250-mg tablet of AUGMENTIN contains 125 mg of clavulanic acid, whereas the 250-mg chewable tablet contains 62.5 mg of clavulanic acid.

Based on the amoxicillin component, AUGMENTIN should be dosed as follows:

Neonates and Infants Aged <12 weeks (<3 months): The recommended dose of AUGMENTIN is 30 mg/kg/day divided every 12 hours, based on the amoxicillin component. Experience with the 200 mg/5 mL formulation in this age group is limited, and thus, use of the 125 mg/5 mL oral suspension is recommended.

Patients Aged 12 weeks (3 months) and Older: See dosing regimens provided in Table 1. The every 12 hour regimen is recommended as it is associated with significantly less diarrhea [see Clinical Studies (14.2)]. However, the every 12 hour suspension (200 mg/5 mL and 400 mg/5 mL) and chewable tablets (200 mg and 400 mg) contain aspartame and should not be used by phenylketonurics. [see Warnings and Precautions (5.6)]

Table 1: Dosing in Patients Aged 12 weeks (3 months) and Older

^a Each strength of suspension of AUGMENTIN is available as a chewable tablet for use by older children.

^b Duration of therapy studied and recommended for acute otitis media is 10 days.

Patients Weighing 40 kg or More: Pediatric patients weighing 40 kg or more should be dosed according to adult recommendations.

The 250-mg tablet of AUGMENTIN should not be used until the child weighs at least 40 kg,due to the different amoxicillin to clavulanic acid ratios in the 250-mg tablet of AUGMENTIN (250/125) versus the 250-mg chewable tablet of AUGMENTIN (250/62.5).

Patients with impaired renal function do not generally require a reduction in dose unless the impairment is severe. Renal impairment patients with a glomerular filtration rate of <30 mL/min should not receive the 875‑mg dose. Patients with a glomerular filtration rate of 10 to 30 mL/min should receive 500 mg or 250 mg every 12 hours, depending on the severity of the infection. Patients with a glomerular filtration rate less than 10 mL/min should receive 500 mg or 250 mg every 24 hours, depending on severity of the infection.

Hemodialysis patients should receive 500 mg or 250 mg every 24 hours,depending on severity of the infection. They should receive an additional dose both during and at the end of dialysis.

Prepare a suspension at time of dispensing as follows: Tap bottle until all the powder flows freely. Add approximately 2/3 of the total amount of water for reconstitution (see Table 2 below) and shake vigorously to suspend powder. Add remainder of the water and again shake vigorously.

Table 2: Amount of Water for Mixing Oral Suspension

Note:  Shake oral suspension well before using. Reconstituted suspension must be stored under refrigeration and discarded after 10 days.

Tablets:

• 250‑mg/125-mg Tablets: Each white oval film-coated tablet, debossed with AUGMENTIN on one side and 250/125 on the other side, contains 250 mg of amoxicillin and 125 mg clavulanic acid as the potassium salt.
• 500‑mg/125-mg Tablets: Each white oval film-coated tablet, debossed with AUGMENTIN on one side and 500/125 on the other side, contains 500 mg amoxicillin and 125 mg of clavulanic acid as the potassium salt.
• 875‑mg/125-mg Tablets: Each scored white capsule‑shaped tablet, debossed with AUGMENTIN 875 on one side and scored on the other side, contains 875 mg amoxicillin and 125 mg clavulanic acid as the potassium salt.

Powder for Oral Suspension:

• 125 mg/31.25 mg per 5 mL: Banana-flavored powder for oral suspension (each 5 mL of reconstituted suspension contains 125 mg amoxicillin and 31.25 mg of clavulanic acid as the potassium salt).
• 200 mg/28.5 mg per 5 mL: Orange-favored powder for oral suspension (each 5 mL of reconstituted suspension contains 200 mg amoxicillin and 28.5 mg of clavulanic acid as the potassium salt).
• 250 mg/62.5 mg per 5 mL: Orange-flavored powder for oral suspension (each 5 mL of reconstituted suspension contains 250 mg amoxicillin and 62.5 mg of clavulanic acid as the potassium salt).
• 400 mg/57 mg per 5 mL Orange-flavored powder for oral suspension (each 5 mL of reconstituted suspension contains 400 mg amoxicillin and 57.0 mg of clavulanic acid as the potassium salt).

Chewable Tablets:

• 125-mg/31.25-mg Chewable Tablets:  Each mottled yellow, round, lemon-lime-flavored tablet, debossed with BMP 189 contains 125 mg amoxicillin and 31.25 mg clavulanic acid as the potassium salt.
• 200-mg/28.5 mg Chewable Tablets:  Each mottled pink, round, biconvex cherry-banana-flavored tablet, debossed with AUGMENTIN 200 contains 200 mg amoxicillin and 28.5 mg clavulanic acid as the potassium salt.
• 250-mg/62.5-mg Chewable Tablets:  Each mottled yellow, round, lemon-lime-flavored tablet, debossed with BMP 190 contains 250 mg amoxicillin and 62.5 mg clavulanic acid as the potassium salt.
• 400-mg/57-mg Chewable Tablets:  Each mottled pink, round, biconvex cherry-banana-flavored tablet, debossed with AUGMENTIN 400 contains 400 mg amoxicillin and 57.0 mg clavulanic acid as the potassium salt.

The 250-mg tablet of AUGMENTIN and the 250-mg chewable tablet should NOT be substituted for each other, as they are not interchangeable and the 250-mg tablet should not be used in children weighing less than 40 kg. The 250-mg tablet of AUGMENTIN and the 250-mg chewable tablet do not contain the same amount of clavulanic acid.  The 250-mg tablet of AUGMENTIN contains 125 mg of clavulanic acid whereas the 250-mg chewable tablet contains 62.5 mg of clavulanic acid. 

Two 250 mg tablets of AUGMENTIN should NOT be substituted for one 500 mg tablet of AUGMENTIN. Since both the 250 mg and 500 mg tablets of AUGMENTIN contain the same amount of clavulanic acid (125 mg, as the potassium salt), two 250 mg tablets of AUGMENTIN are not equivalent to one 500 mg tablet of AUGMENTIN.

AUGMENTIN is contraindicated in patients with a history of serious hypersensitivity reactions (e.g., anaphylaxis or Stevens-Johnson syndrome) to amoxicillin, clavulanate or to other beta‑lactam antibacterial drugs (e.g., penicillins and cephalosporins).

AUGMENTIN is contraindicated in patients with a previous history of cholestatic jaundice/hepatic dysfunction associated with AUGMENTIN.

Serious and occasionally fatal hypersensitivity (anaphylactic) reactions have been reported in patients receiving beta-lactam antibacterials, including AUGMENTIN. These reactions are more likely to occur in individuals with a history of penicillin hypersensitivity and/or a history of sensitivity to multiple allergens. Before initiating therapy with AUGMENTIN, careful inquiry should be made regarding previous hypersensitivity reactions to penicillins, cephalosporins, or other allergens. If an allergic reaction occurs, AUGMENTIN should be discontinued and appropriate therapy instituted.

Hepatic dysfunction, including hepatitis and cholestatic jaundice has been associated with the use of AUGMENTIN. Hepatic toxicity is usually reversible; however, deaths have been reported. Hepatic function should be monitored at regular intervals in patients with hepatic impairment.

Clostridium difficile associated diarrhea (CDAD) has been reported with use of nearly all antibacterial agents, including AUGMENTIN, 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 A and B 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 use. Careful medical history is necessary since CDAD has been reported to occur over 2 months after the administration of antibacterial agents.

If CDAD is suspected or confirmed, ongoing antibacterial 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.

A high percentage of patients with mononucleosis who receive amoxicillin develop an erythematous skin rash. Thus, AUGMENTIN should not be administered to patients with mononucleosis.

The possibility of superinfections with fungal or bacterial pathogens should be considered during therapy. If superinfection occurs, amoxicillin/clavulanate potassium should be discontinued and appropriate therapy instituted.

AUGMENTIN Chewable tablets and AUGMENTIN Powder for Oral Solution contain aspartame which contains phenylalanine.  Each 200-mg chewable tablet of AUGMENTIN contains 2.1 mg phenylalanine; each 400-mg chewable tablet contains 4.2 mg phenylalanine; each 5 mL of either the 200 mg/5 mL or 400 mg/5 mL oral suspension contains 7 mg phenylalanine.  The other formulations of AUGMENTIN do not contain phenylalanine.

Prescribing AUGMENTIN in the absence of a proven or strongly suspected bacterial infection is unlikely to provide benefit to the patient, and increases the risk of the development of drug‑resistant bacteria.

The following are discussed in more detail in other sections of the labeling:

• Anaphylactic reactions [see Warnings and Precautions (5.1) ]
• Hepatic Dysfunction [see Warnings and Precautions (5.2) ]
• CDAD [see Warnings and Precautions (5.3) ]

Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.

The most frequently reported adverse reactions were diarrhea/loose stools (9%), nausea (3%), skin rashes and urticaria (3%), vomiting (1%) and vaginitis (1%). Less than 3% of patients discontinued therapy because of drug‑related adverse reactions. The overall incidence of adverse reactions, and in particular diarrhea, increased with the higher recommended dose. Other less frequently reported adverse reactions (<1%) include: Abdominal discomfort, flatulence, and headache.

In pediatric patients (aged 2 months to 12 years), 1 US/Canadian clinical trial was conducted which compared 45/6.4 mg/kg/day (divided every 12 hours) of AUGMENTIN for 10 days versus 40/10 mg/kg/day (divided every 8 hours) of AUGMENTIN for 10 days in the treatment of acute otitis media. A total of 575 patients were enrolled, and only the suspension formulations were used in this trial. Overall, the adverse reactions seen were comparable to that noted above; however, there were differences in the rates of diarrhea, skin rashes/urticaria, and diaper area rashes. [See Clinical Studies (14.2)]

In addition to adverse reactions reported from clinical trials, the following have been identified during postmarketing use of AUGMENTIN.  Because they are reported voluntarily from a population of unknown size, estimates of frequency cannot be made. These events have been chosen for inclusion due to a combination of their seriousness, frequency of reporting, or potential causal connection to AUGMENTIN.

Gastrointestinal:  Indigestion, gastritis, stomatitis, glossitis, black “hairy” tongue, mucocutaneous candidiasis, enterocolitis, and hemorrhagic/pseudomembranous colitis. Onset of pseudomembranous colitis symptoms may occur during or after antibiotic treatment. [see Warnings and Precautions (5.3) ]

Hypersensitivity Reactions: Pruritus, angioedema, serum sickness–like reactions (urticaria or skin rash accompanied by arthritis, arthralgia, myalgia, and frequently fever), erythema multiforme, Stevens‑Johnson syndrome, acute generalized exanthematouspustulosis, hypersensitivity vasculitis, and cases of exfoliative dermatitis (including toxic epidermal necrolysis) have been reported. [see Warnings and Precautions (5.1) ]

Liver: Hepatic dysfunction, including hepatitis and cholestatic jaundice, increases in serum transaminases (AST and/or ALT), serum bilirubin, and/or alkaline phosphatase, has been reported with AUGMENTIN. It has been reported more commonly in the elderly, in males, or in patients on prolonged treatment. The histologic findings on liver biopsy have consisted of predominantly cholestatic, hepatocellular, or mixed cholestatic‑hepatocellular changes. The onset of signs/symptoms of hepatic dysfunction may occur during or several weeks after therapy has been discontinued. The hepatic dysfunction, which may be severe, is usually reversible. Deaths have been reported. [see Contraindications (4.2), Warnings and Precautions (5.2) ]

Renal:Interstitial nephritis, hematuria, and crystalluria have been reported. [see Overdosage (10) ]

Hemic and Lymphatic Systems: Anemia, including hemolytic anemia, thrombocytopenia, thrombocytopenic purpura, eosinophilia, leukopenia, and agranulocytosishave been reported. These reactions are usually reversible on discontinuation of therapy and are believed to be hypersensitivity phenomena. Thrombocytosis was noted in less than 1% of the patients treated with AUGMENTIN. There have been reports of increased prothrombin time in patients receiving AUGMENTIN and anticoagulant therapy concomitantly. [see Drug Interactions (7.2) ]

Central Nervous System: Agitation, anxiety, behavioral changes, confusion, convulsions, dizziness, insomnia, and reversible hyperactivity have been reported.

Miscellaneous: Tooth discoloration (brown, yellow, or gray staining) has been reported. Most reports occurred in pediatric patients. Discoloration was reduced or eliminated with brushing or dental cleaning in most cases.

The safety and effectiveness of AUGMENTIN Powder for Oral Suspension and Chewable Tablets have been established in pediatric patients. Use of AUGMENTIN in pediatric patients is supported by evidence from studies of AUGMENTIN Tablets in adults with additional data from a study of AUGMENTIN Powder for Oral Suspension in pediatric patients aged 2 months to 12 years with acute otitis media. [see Clinical Studies (14.2)]

Because of incompletely developed renal function in neonates and young infants, the elimination of amoxicillin may be delayed; clavulanate elimination is unaltered in this age group. Dosing of AUGMENTIN should be modified in pediatric patients aged <12 weeks (<3 months). [see Dosage and Administration (2.2)]

Of the 3,119 patients in an analysis of clinical studies of AUGMENTIN, 32% were ≥65 years old, and 14% were ≥75 years old. No overall differences in safety or effectiveness were observed between these subjects and younger subjects, and other reported clinical experience has not identified differences in responses between the elderly and younger patients, but greater sensitivity of some older individuals cannot be ruled out.

This drug is known to be substantially excreted by the kidney, and the risk of adverse 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.

Amoxicillin is primarily eliminated by the kidney and dosage adjustment is usually required in patients with severe renal impairment (GFR <30 mL/min). See Patients with Renal Impairment (2.3) for specific recommendations in patients with renal impairment.

In case of overdosage, discontinue medication, treat symptomatically, and institute supportive measures as required.  A prospective study of 51 pediatric patients at a poison-control center suggested that overdosages of less than 250 mg/kg of amoxicillin are not associated with significant clinical symptoms¹.

Interstitial nephritis resulting in oliguric renal failure has been reported in patients after overdosage with amoxicillin/clavulanate potassium.

Crystalluria, in some cases leading to renal failure, has also been reported after amoxicillin/clavulanate potassium overdosage in adult and pediatric patients. In case of overdosage, adequate fluid intake and diuresis should be maintained to reduce the risk of amoxicillin/clavulanate potassium crystalluria.

Renal impairment appears to be reversible with cessation of drug administration. High blood levels may occur more readily in patients with impaired renal function because of decreased renal clearance of amoxicillin/clavulanate potassium. Amoxicillin/clavulanate potassium may be removed from circulation by hemodialysis. [see Dosage and Administration (2.3)]

AUGMENTIN is an oral antibacterial combination consisting of amoxicillin and the beta‑lactamase inhibitor, clavulanate potassium (the potassium salt of clavulanic acid).

Amoxicillin is an analog of ampicillin, derived from the basic penicillin nucleus, 6‑aminopenicillanic acid. The amoxicillin molecular formula is C₁₆H₁₉N₃O₅S•3H₂O, and the molecular weight is 419.46. Chemically, amoxicillin is (2S,5R,6R)-6-[(R)-(-)-2-Amino-2-(p-hydroxyphenyl)acetamido]-3,3-dimethyl-7-oxo-4-thia-1-azabicyclo[3.2.0]heptane-2-carboxylic acid trihydrate and may be represented structurally as:

Image 1 (Augmentin 01)

Clavulanic acid is produced by the fermentation of Streptomyces clavuligerus. It is a beta-lactam structurally related to the penicillins and possesses the ability to inactivate some beta‑lactamases by blocking the active sites of these enzymes. The clavulanate potassium molecular formula is C₈H₈KNO₅, and the molecular weight is 237.25. Chemically, clavulanate potassium is potassium (Z)(2R,5R)-3-(2-hydroxyethylidene)-7-oxo-4-oxa-1-azabicyclo[3.2.0]-heptane-2-carboxylate and may be represented structurally as:

Image 2 (Augmentin 02)

Inactive Ingredients:

• Tablets- Colloidal silicon dioxide, hypromellose, magnesium stearate, microcrystalline cellulose, polyethylene glycol, sodium starch glycolate, and titanium dioxide. Each tablet of AUGMENTIN  contains 0.63 mEq potassium.
• Powder for Oral Suspension, 125 mg/5mL and 250 mg/5mL - Colloidal silicon dioxide, flavorings, xanthan gum, mannitol, succinic acid, silica gel and sodium saccharin.
• Powder for Suspension, 200 mg/5mL and 400 mg/5mL - Colloidal silicon dioxide, flavorings, xanthan gum, silica gel, hypromellose and aspartame [see Warnings and Precautions (5.6)]

• Chewable Tablets, 125 mg and 250 mg - Colloidal silicon dioxide, flavorings, magnesium stearate, mannitol, sodium saccharin, glycine, and D&C Yellow No.10.
  
  • Each 125-mg chewable tablet and each 5 mL of reconstituted 125/5 mL oral suspension of AUGMENTIN contains 0.16 mEq potassium

  • Each 250-mg chewable tablet and each 5 mL of reconstituted 250/5 mL oral suspension of AUGMENTIN contains 0.32 mEq potassium

  • Chewable Tablets, 200 mg and 400 mg - Colloidal silicon dioxide, flavorings, magnesium stearate, mannitol, FD&C Red No. 40 and aspartame. [see Warnings and Precautions (5.6)]

    • Each 200-mg chewable tablet and each 5 mL of reconstituted 200/5 mL oral suspension of AUGMENTIN contains 0.14 mEq potassium

    • Each 400-mg chewable tablet and each 5 mL of reconstituted 400/5 mL oral suspension of AUGMENTIN contains 0.29 mEq potassium

AUGMENTIN is an antibacterial drug. [see Microbiology 12.4]

Mean amoxicillin and clavulanate potassium pharmacokinetic parameters in normal adults following administration of AUGMENTIN Tablets are shown in Table 3 and following administration of AUGMENTIN Powder for Oral Suspension and Chewable Tablets are shown in Table 4.

Table 3: Mean (±S.D.) Amoxicillin and Clavulanate Potassium Pharmacokinetic Parameters^a,b with AUGMENTIN Tablets

^a Mean (± standard deviation) values of 14 normal adults (N=15 for clavulanate potassium in the low-dose regimens). Peak concentrations occurred approximately 1.5 hours after the dose. 

^b Amoxicillin/clavulanate potassium administered at the start of a light meal.

Table 4: Mean (±S.D.) Amoxicillin and Clavulanate Potassium Pharmacokinetic Parameters^a,b with AUGMENTIN Powder for Oral Suspension and Chewable Tablets

^a Mean (± standard deviation) values of 28 normal adults. Peak concentrations occurred approximately 1 hour after the dose. 

^b Amoxicillin/clavulanate potassium administered at the start of a light meal.

Oral administration of 5 mL of 250 mg/5 mL suspension of AUGMENTIN or the equivalent dose of 10 mL of 125 mg/5 mL suspension of AUGMENTIN provides average peak serum concentrations approximately 1 hour after dosing of 6.9 mcg/mL for amoxicillin and 1.6 mcg/mL for clavulanic acid. The areas under the serum concentration curves obtained during the first 4 hours after dosing were 12.6 mcg*h/mL for amoxicillin and 2.9 mcg*h/mL for clavulanic acid when 5 mL of 250 mg/5 mL suspension of AUGMENTIN or equivalent dose of 10 mL of 125 mg/5 mL suspension of AUGMENTIN were administered to normal adults. One 250-mg chewable tablet of AUGMENTIN or two 125-mg chewable tablets of AUGMENTIN are equivalent to 5 mL of 250 mg/5 mL suspension of AUGMENTIN and provide similar serum concentrations of amoxicillin and clavulanic acid.

Amoxicillin serum concentrations achieved with AUGMENTIN are similar to those produced by the oral administration of equivalent doses of amoxicillin alone. Time above the minimum inhibitory concentration of 1 mcg/mL for amoxicillin has been shown to be similar after corresponding every 12 hour and every 8 hour dosing regimens of AUGMENTIN in adults and children.

Absorption: Dosing in the fasted or fed state has minimal effect on the pharmacokinetics of amoxicillin. While AUGMENTIN can be given without regard to meals, absorption of clavulanate potassium when taken with food is greater relative to the fasted state. In one study, the relative bioavailability of clavulanate was reduced when AUGMENTIN was dosed at 30 and 150 minutes after the start of a high‑fat breakfast. 

Distribution: Neither component in AUGMENTIN is highly protein‑bound; clavulanic acid is approximately 25% bound to human serum and amoxicillin approximately 18% bound.  

Amoxicillin diffuses readily into most body tissues and fluids with the exception of the brain and spinal fluid. 

Two hours after oral administration of a single 35 mg/kg dose of suspension of AUGMENTIN to fasting children, average concentrations of 3 mcg/mL of amoxicillin and 0.5 mcg/mL of clavulanic acid were detected in middle ear effusions.

Metabolism and Excretion: The half‑life of amoxicillin after the oral administration of AUGMENTIN is 1.3 hours and that of clavulanic acid is 1 hour.

Approximately 50% to 70% of the amoxicillin and approximately 25% to 40% of the clavulanic acid are excreted unchanged in urine during the first 6 hours after administration of a single 250‑mg or 500‑mg tablet of AUGMENTIN.

Amoxicillin is a semisynthetic antibiotic with in vitro bactericidal activity against Gram-positive and Gram-negative bacteria. Amoxicillin is, however, susceptible to degradation by beta-lactamases, and therefore, the spectrum of activity does not include organisms which produce these enzymes. Clavulanic acid is a beta-lactam, structurally related to the penicillins, which possesses the ability to inactivate some beta-lactamase enzymes commonly found in microorganisms resistant to penicillins and cephalosporins. In particular, it has good activity against the clinically important plasmid-mediated beta-lactamases frequently responsible for transferred drug resistance.         

The formulation of amoxicillin and clavulanic acid in AUGMENTIN protects amoxicillin from degradation by some beta-lactamase enzymes and extends the antibiotic spectrum of amoxicillin to include many bacteria normally resistant to amoxicillin.

Amoxicillin/clavulanic acid has been shown to be active against most isolates of the following bacteria, both in vitro and in clinical infections as described in the INDICATIONS AND USAGE section.

Gram-positive bacteria

Staphylococcus aureus

Gram-negative bacteria

Enterobacter species

Escherichia coli

Haemophilus influenzae

Klebsiella species

Moraxella catarrhalis

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 amoxicillin/clavulanic acid. However, the efficacy of amoxicillin/clavulanic acid in treating clinical infections due to these bacteria has not been established in adequate and well-controlled clinical trials.

Gram-positive bacteria

Enterococcus faecalis

Staphylococcus epidermidis

Staphylococcus saprophyticus

Streptococcus pneumoniae

Streptococcus pyogenes

Viridans group Streptococcus

Gram-negative Bacteria

Eikenellacorrodens

Proteus mirabilis

Anaerobic Bacteria

Bacteroidesspecies including Bacteroides fragilis

Fusobacterium species

Peptostreptococcus species 

Susceptibility Test Methods

When available, the clinical microbiology laboratory should provide the results of in vitro susceptibility test results for antimicrobial drug products used in resident hospitals to the physician as periodic reports that describe the susceptibility profile of nosocomial and community-acquired pathogens. These reports should aid the physician in selecting an antibacterial drug product for treatment.

Dilution techniques

Quantitative methods are used to determine antimicrobial minimum inhibitory concentrations (MICs). These MICs provide estimates of the susceptibility of bacteria to antimicrobial compounds. The MICs should be determined using a standardized test method^2,3 (broth and/or agar). The MIC values should be interpreted according to criteria provided in Table 5.

Diffusion techniques:

Quantitative methods that require measurement of zone diameters can also provide reproducible estimates of the susceptibility of bacteria to antimicrobial compounds. The zone size provides an estimate of the susceptibility of bacteria to antimicrobial compounds. The zone size should be determined using a standardized test method^3,4. This procedure uses paper disks impregnated with 30 mcg amoxicillin/clavulanic acid (20 mcg amoxicillin plus 10 mcg clavulanic acid) to test the susceptibility of bacteria to amoxicillin/clavulanic acid. The disc diffusion interpretive criteria are provided in Table 5.

Table 5:Susceptibility Test Interpretive Criteria for Amoxicillin Clavulanic Acid

Quality Control:

Standardized susceptibility test procedures require the use of laboratory controls to monitor and ensure the accuracy and precision of supplies and reagents used in the assay, and the techniques of the individuals performing the test^2,3,4. Standard amoxicillin/clavulanic acid powder should provide the following range of MIC values noted in Table 6 for the diffusion technique using the 30 mcg amoxicillin/clavulanic acid (20 mcg amoxicillin plus 10 mcg clavulanic acid) disk, the criteria in Table 6 should be achieved.

Table 6: Acceptable Quality Control Ranges for Amoxicillin/Clavulanic Acid

Long‑term studies in animals have not been performed to evaluate carcinogenic potential.

AUGMENTIN (4:1 ratio formulation of amoxicillin:clavulanate) was non-mutagenic in the Ames bacterial mutation assay, and the yeast gene conversion assay. AUGMENTIN was weakly positive in the mouse lymphoma assay, but the trend toward increased mutation frequencies in this assay occurred at doses that were also associated with decreased cell survival. AUGMENTIN was negative in the mouse micronucleus test, and in the dominant lethal assay in mice. Potassium clavulanate alone was tested in the Ames bacterial mutation assay and in the mouse micronucleus test, and was negative in each of these assays.

AUGMENTIN (2:1 ratio formulation of amoxicillin:clavulanate) at oral doses of up to 1,200 mg/kg/day was found to have no effect on fertility and reproductive performance in rats.  Based on body surface area, this dose of amoxicillin is approximately 4 times the maximum recommended adult human oral dose (875 mg every 12 hours).  For clavulanate, the dose multiple is approximately 9 times higher than the maximum recommended adult human oral dose (125 mg every 8 hours), also based on body surface area.

Data from 2 pivotal trials in 1,191 patients treated for either lower respiratory tract infections or complicated urinary tract infections compared a regimen of 875‑mg tablets of AUGMENTIN every 12 hours to 500‑mg tablets of AUGMENTIN dosed every 8 hours (584 and 607 patients, respectively). Comparable efficacy was demonstrated between the every 12 hours and every 8 hours dosing regimens. There was no significant difference in the percentage of adverse events in each group. The most frequently reported adverse event was diarrhea; incidence rates were similar for the 875‑mg every 12 hours and 500‑mg every 8 hours dosing regimens (15% and 14%, respectively); however, there was a statistically significant difference (p < 0.05) in rates of severe diarrhea or withdrawals with diarrhea between the regimens: 1% for 875‑mg every 12 hours regimen versus 2% for the 500‑mg every 8 hours regimen.

In one of these pivotal trials, patients with either pyelonephritis (n = 361) or a complicated urinary tract infection (i.e., patients with abnormalities of the urinary tract that predispose to relapse of bacteriuria following eradication, n = 268) were randomized (1:1) to receive either 875‑mg tablets of AUGMENTIN every 12 hours (n=308) or 500‑mg tablets of AUGMENTIN every 8 hours (n=321). 

The number of bacteriologically evaluable patients was comparable between the two dosing regimens. AUGMENTIN produced comparable bacteriological success rates in patients assessed 2 to 4 days immediately following end of therapy. The bacteriologic efficacy rates were comparable at one of the follow‑up visits (5 to 9 days post‑therapy) and at a late post‑therapy visit (in the majority of cases, this was 2 to 4 weeks post-therapy), as seen in Table 7.

Table 7: Bacteriologic efficacy rates for AUGMENTIN

As noted before, though there was no significant difference in the percentage of adverse events in each group, there was a statistically significant difference in rates of severe diarrhea or withdrawals with diarrhea between the regimens.

One US/Canadian clinical trial was conducted which compared 45/6.4 mg/kg/day (divided every 12 hours) of AUGMENTIN for 10 days versus 40/10 mg/kg/day (divided every 8 hours) of AUGMENTIN for 10 days in the treatment of acute otitis media. Only the suspension formulations were used in this trial. A total of 575 pediatric patients (aged 2 months to 12 years) were enrolled, with an even distribution among the 2 treatment groups and a comparable number of patients were evaluable (i.e., ³ 84%) per treatment group. Otitis media‑specific criteria were required for eligibility and a strong correlation was found at the end of therapy and follow‑up between these criteria and physician assessment of clinical response. The clinical efficacy rates at the end of therapy visit (defined as 2‑4 days after the completion of therapy) and at the follow‑up visit (defined as 22‑28 days post‑completion of therapy) were comparable for the 2 treatment groups, with the following cure rates obtained for the evaluable patients: At end of therapy, 87% (n = 265) and 82% (n = 260) for 45 mg/kg/day every 12 hours and 40 mg/kg/day every 8 hours, respectively. At follow‑up, 67% (n = 249) and 69% (n = 243) for 45 mg/kg/day every 12 hours and 40 mg/kg/day every 8 hours, respectively.

Diarrhea was defined as either: (a) 3 or more watery or 4 or more loose/watery stools in 1 day; OR (b) 2 watery stools per day or 3 loose/watery stools per day for 2 consecutive days. The incidence of diarrhea was significantly lower in patients who received the every 12 hours regimen compared to patients who received the every 8 hours regimen (14% and 34%, respectively). In addition, the number of patients with either severe diarrhea or who were withdrawn with diarrhea was significantly lower in the every 12 hours treatment group (3% and 8% for the every 12 hours/10 day and every 8 hours/10 day, respectively). In the every 12 hours treatment group, 3 patients (1%) were withdrawn with an allergic reaction, while 1 patient in the every 8 hours group was withdrawn for this reason. The number of patients with a candidal infection of the diaper area was 4% and 6% for the every 12 hours and every 8 hours groups, respectively.

It is not known if the finding of a statistically significant reduction in diarrhea with the oral suspensions dosed every 12 hours, versus suspensions dosed every 8 hours, can be extrapolated to the chewable tablets. The presence of mannitol in the chewable tablets may contribute to a different diarrhea profile. The every 12 hour oral suspensions (200 mg/5 mL and 400 mg/5 mL) are sweetened with aspartame.

1. Swanson-Biearman B, Dean BS, Lopez G, Krenzelok EP. The effects of penicillin and cephalosporin ingestions in children less than six years of age.Vet Hum Toxicol. 1988; 30: 66‑67.

2. Clinical and Laboratory Standards Institute (CLSI). Methods for Dilution Antimicrobial Susceptibility Tests for Bacteria that Grow Aerobically; Approved Standard – 8^th ed. CLSI Document M7-A9. CLSI, 940 West Valley Road, Suite 1400, Wayne, PA, 19087, 2012.

3. Clinical and Laboratory Standards Institute (CLSI). Performance Standard for Antimicrobial Disk Susceptibility Tests;Approved Standard – 11^th ed. CLSI Document M2-A11. CLSI, 940 West Valley Road, Suite 1400, Wayne, PA, 19087, 2012.

4.  CLSI. Performance Standards for Antimicrobial Susceptibility Testing: 22^nd Informational Supplement. CLSI document M100-S22. CLSI, Wayne, PA, 2012.

Tablets:

250‑mg/125-mg Tablets: Each white oval film-coated tablet, debossed with AUGMENTIN on one side and 250/125 on the other side, contains 250mg amoxicillin as the trihydrate and 125mg clavulanic acid as the potassium salt.

NDC 43598-018-30                bottles of 30

NDC 43598-018-78                Unit Dose (10x10) 100 tablets 

500‑mg/125-mg Tablets: Each white oval film-coated tablet, debossed with AUGMENTIN on one side and 500/125 on the other side, contains 500mg amoxicillin as the trihydrate and 125mg clavulanic acid as the potassium salt.

NDC 43598-006-14                bottles of 20

NDC 43598-006-78                Unit Dose (10x10) 100 tablets

875‑mg/125-mg Tablets: Each scored white capsule‑shaped tablet, debossed with AUGMENTIN 875 on one side and scored on the other side, contains 875mg amoxicillin as the trihydrate and 125mg clavulanic acid as the potassium salt.

NDC 43598-021-14                bottles of 20

NDC 43598-021-78                Unit Dose (10x10) 100 tablets

Powder for Oral Suspension:125 mg/31.25 mg per 5 mL: Banana-flavored powder for oral suspension (each 5 mL of reconstituted suspension contains 125 mg amoxicillin and 31.25 mg of clavulanic acid as the potassium salt).

NDC 43598-012-51                75 mL bottle

NDC 43598-012-52                100 mL bottle

NDC 43598-012-53                150 mL bottle

200 mg/28.5 mg per 5 mL: Orange-favored powder for oral suspension (each 5 mL of reconstituted suspension contains 200 mg amoxicillin and 28.5 mg of clavulanic acid as the potassium salt).

NDC 43598-013-50                50 mL bottle

NDC 43598-013-51                75 mL bottle

NDC 43598-013-52                100 mL bottle

250 mg/62.5 mg per 5 mL: Orange-flavored powder for oral suspension (each 5 mL of reconstituted suspension contains 250 mg amoxicillin and 62.5 mg of clavulanic acid as the potassium salt).

NDC 43598-004-51                75 mL bottle

NDC 43598-004-52                100 mL bottle

NDC 43598-004-53                150 mL bottle 

400 mg/57 mg per 5 mL Orange-flavored powder for oral suspension (each 5 mL of reconstituted suspension contains 400 mg amoxicillin and 57.0 mg of clavulanic acid as the potassium salt).

NDC 43598-008-50                50 mL bottle

NDC 43598-008-51                75 mL bottle

NDC 43598-008-52                100 mL bottle

Chewable Tablets:125-mg/31.25-mg Chewable Tablets:  Each mottled yellow, round, lemon-lime-flavored tablet, debossed with BMP 189, contains 125 mg amoxicillin and 31.25 mg clavulanic acid as the potassium salt.

NDC 43598-014-31                carton of 30 (5x6) tablets

200-mg/28.5 mg Chewable Tablets:  Each mottled pink, round, biconvex, cherry-banana-flavored tablet, debossed with AUGMENTIN 200, contains 200 mg amoxicillin and 28.5 mg clavulanic acid as the potassium salt.

NDC 43598-015-14                carton of 20 tablets

250-mg/62.5-mg Chewable Tablets:  Each mottled yellow, round, lemon-lime-flavored tablet, debossed with BMP 190, contains 250 mg amoxicillin and 62.5 mg clavulanic acid as the potassium salt.

NDC 43598-016-31                carton of 30 (5x6) tablets

400-mg/57-mg Chewable Tablets:  Each mottled pink, round, biconvex, cherry-banana-flavored tablet, debossed with AUGMENTIN 400, contains 400 mg amoxicillin and 57.0 mg clavulanic acid as the potassium salt.

NDC 43598-017-14    carton of 20 tablets

Dispense in original container.

Store tablets and dry powder at or below 25°C (77°F).

Store reconstituted suspension under refrigeration. Discard unused suspension after 10 days.

Keep out of the reach of children.

Patients should be informed that AUGMENTIN may be taken every 8 hours or every 12 hours, depending on the dose prescribed.  Each dose should be taken with a meal or snack to reduce the possibility of gastrointestinal upset.

Patients should be counseled that antibacterial drugs, including AUGMENTIN, should only be used to treat bacterial infections. They do not treat viral infections (e.g., the common cold). When AUGMENTIN is prescribed to treat a 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 AUGMENTIN or other antibacterial drugs in the future.

Counsel patients that diarrhea is a common problem caused by antibacterials, and it usually ends when the antibacterial is discontinued. Sometimes after starting treatment with antibacterials, patients can develop watery and bloody stools (with or without stomach cramps and fever) even as late as 2 or more months after having taken their last dose of the antibacterial. If diarrhea is severe or lasts more than 2 or 3 days, patients should contact their physician.

Patients should be advised to keep suspension refrigerated.  Shake well before using.  When dosing a child with the suspension (liquid) of AUGMENTIN, use a dosing spoon or medicine dropper.  Be sure to rinse the spoon or dropper after each use.  Bottles of suspension of AUGMENTIN may contain more liquid than required.  Follow your doctor’s instructions about the amount to use and the days of treatment your child requires.  Discard any unused medicine.

Patients should be aware that AUGMENTIN contains a penicillin class drug product that can cause allergic reactions in some individuals.

AUGMENTIN is a registered trademark of GlaxoSmithKline and is licensed to Dr. Reddy’s Laboratories Inc.

CLINITEST is a registered trademark of Miles, Inc.

Manufactured. By:
Dr. Reddy’s Laboratories Tennessee LLC,
Bristol, TN 37620

Issued: 02/2014

NDC 43598-012-51

AUGMENTIN^®

125 mg/5 mL

AMOXICILLIN/CLAVULANATE POTASSIUM

FOR ORAL SUSPENSION

When reconstituted, each 5 mL contains:

AMOXICILLIN, 125 MG,

as the trihydrate

CLAVULANIC ACID, 31.25 MG,

as clavulanate potassium

75 mL (when reconstituted)

R_x only

Directions for mixing:

Tap bottle until all powder flows freely. Add approximately 2/3 of total water for reconstitution (total = 67 mL); shake vigorously to wet powder. Add remaining water; again shake vigorously.

Dosage: See accompanying prescribing information.

Keep tightly closed.

Shake well before using.

Must be refrigerated.

Discard after 10 days.

Use only if inner seal is intact.

Net contents: Equivalent to 1.875 g amoxicillin and 0.469 g clavulanic acid.

Store dry powder at room temperature.

Manufactured. By: Dr. Reddy’s Laboratories Tennessee LLC.
Bristol, TN 37620

I0414

150055049

Image 3 (125 mg 75 mL Label)

NDC 43598-018-30

AUGMENTIN^®

AMOXICILLIN/CLAVULANATE POTASSIUM TABLETS

AMOXICILLIN, 250 MG, as the trihydrate

CLAVULANIC ACID, 125 MG, as clavulanate potassium

30 Tablets

R_x only

Store at room temperature. Dispense in original container; advise patients to keep in closed container. Each tablet contains 250 mg amoxicillin as the trihydrate, 125 mg clavulanic acid as clavulanate potassium.

Dosage: See accompanying prescribing information.

Use only if inner seal is intact.

Manufactured. By: Dr. Reddy’s Laboratories Tennessee LLC.
Bristol, TN 37620

150055043

I0414

Aug 250mg Tab (250 mg 30 Tab Label)

NDC 43598-006-14

AUGMENTIN^®

AMOXICILLIN/CALVULANATE POTASSIUM TABLETS

AMOXICILLIN, 500 MG, as the trihydrate

CLAVULANIC ACID, 125 MG, as clavulanate potassium

20 Tablets

R_x only

Store at or below room temperature 25^oC (77^oF). Dispense in original container; advise patients to keep in closed container. Each tablet contains 500 mg amoxicillin as the trihydrate, 125 mg clavulanic acid as clavulanate potassium.

Dosage: One tablet every 12 hours. See prescribing information.

Use only if inner seal is intact.

Manufactured. By: Dr. Reddy’s Laboratories Tennessee LLC.
Bristol, TN 37620

150055047

I0414

Aug 500mg Tab (500 mg 20 Tab Label)

NDC 43598-021-14

AUGMENTIN^®

AMOXICILLIN/CALVULANATE POTASSIUM TABLETS

AMOXICILLIN, 875 MG, as the trihydrate

CLAVULANIC ACID, 125 MG, as clavulanate potassium

20 Tablets

R_x only

Store at or below room temperature 25^oC (77^oF). Dispense in original container; advise patients to keep in closed container. Each tablet contains 875 mg amoxicillin as the trihydrate, 125 mg clavulanic acid as clavulanate potassium.

Dosage: One tablet every 12 hours. See prescribing information.

Use only if inner seal is intact.

Manufactured. By: Dr. Reddy’s Laboratories Tennessee LLC.
Bristol, TN 37620

150055048

I0414

Aug 875mg Tab (875 mg 20 Tab Label)

NDC 43598-004-51

AUGMENTIN^®

250 mg/5 mL

AMOXICILLIN/CLAVULANATE POTASSIUM

FOR ORAL SUSPENSION

When reconstituted, each 5 mL contains:

AMOXICILLIN, 250 MG,

as the trihydrate

CLAVULANIC ACID, 62.5 MG,

as clavulanate potassium

75 mL (when reconstituted)

R_x only

Directions for mixing:

Tap bottle until all powder flows freely. Add approximately 2/3 of total water for reconstitution (total = 65 mL); shake vigorously to wet powder. Add remaining water; again shake vigorously.

Dosage: See accompanying prescribing information.

Keep tightly closed.

Shake well before using.

Must be refrigerated.

Discard after 10 days.

Use only if inner seal is intact.

Net contents: Equivalent to 3.75 g amoxicillin and 0.938 g clavulanic acid.

Store dry powder at room temperature.

Manufactured. By: Dr. Reddy’s Laboratories Tennessee LLC.
Bristol, TN 37620

I0414

150055044

Image 4 (250 mg 75 mL Label)