- Approval Id
- 0b4e2b42dc51f916
- Drug Approval Emc Name
- Zavicefta 2 g/0.5g powder for concentrate for solution for infusion
- Drug Name
- Zavicefta 2 g/0.5g powder for concentrate for solution for infusion
- Company Address
- Ramsgate Road, Sandwich, Kent, CT13 9NJ
- Company Telephone
- +44 (0)1304 616 161
- Company Medical Info Direct Line
- +44 (0)1304 616161
- Atc Code
- J01DD52
- Legal Category
- Prescription only medicine
- Authorisation Holder
- Pfizer Limited
Ramsgate Road
Sandwich, Kent
CT13 9NJ
United Kingdom
- Authorisation Number
- PLGB 00057/1670
- Authorisation Date
- 01/01/2021
- Instruction Authorisation Holder
- Pfizer Limited
Ramsgate Road
Sandwich, Kent
CT13 9NJ
United Kingdom
- Instruction Authorisation Number
- PLGB 00057/1670
- Instruction Authorisation Date
- 01/01/2021
- Instruction Composition
- Each vial contains ceftazidime pentahydrate equivalent to 2 g ceftazidime and avibactam sodium equivalent to 0.5 g avibactam.
After reconstitution, 1 mL of solution contains 167.3 mg of ceftazidime and 41.8 mg of avibactam (see section 6.6).
\*\*Excipient with known effect:\*\*
Zavicefta contains approximately 146 mg sodium per vial.
For the full list of excipients, see section 6.1.
- Instruction Dosage Form
- Powder for concentrate for solution for infusion (powder for concentrate).
A white to yellow powder.
- Instruction Clinical Particulars
- 4.1 Therapeutic indications
Zavicefta is indicated in adults and paediatric patients aged 3 months and older for the treatment of the following infections (see sections 4.4 and 5.1):
• Complicated intra-abdominal infection (cIAI)
• Complicated urinary tract infection (cUTI), including pyelonephritis
• Hospital-acquired pneumonia (HAP), including ventilator associated pneumonia (VAP)
Treatment of adult patients with bacteraemia that occurs in association with, or is suspected to be associated
with, any of the infections listed above.
Zavicefta is also indicated for the treatment of infections due to aerobic Gram-negative organisms in adults and paediatric patients aged 3 months and older with limited treatment options (see sections 4.2, 4.4 and 5.1).
Consideration should be given to official guidance on the appropriate use of antibacterial agents.4.2 Posology and method of administration
It is recommended that Zavicefta should be used to treat infections due to aerobic Gram-negative organisms in adults and paediatric patients aged 3 months and older with limited treatment options only after consultation with a physician with appropriate experience in the management of infectious diseases (see section 4.4).
\*\*Posology\*\*
\*Dosage in adults with creatinine clearance (CrCL) > 50 mL/min\*
Table 1 shows the recommended intravenous dose for adults with estimated creatinine clearance (CrCL) > 50 mL/min (see sections 4.4 and 5.1).
Table 1: Recommended dose for adults with estimated CrCL > 50 mL/min1
| | | | | |
| --- | --- | --- | --- | --- |
| Type of infection | Dose of ceftazidime/avibactam | Frequency | Infusion time | Duration of treatment |
| cIAI2,3 | 2 g/0.5 g | Every 8 hours | 2 hours | 5-14 days |
| cUTI, including pyelonephritis3 | 2 g/0.5 g | Every 8 hours | 2 hours | 5-10 days4 |
| HAP/VAP3 | 2 g/0.5 g | Every 8 hours | 2 hours | 7-14 days |
| Bacteraemia associated with, or suspected to be associated with any of the above infections | 2 g/0.5 g | Every 8 hours | 2 hours | Duration of treatment should be in accordance with the site of infection. |
| Infections due to aerobic Gram-negative organisms in patients with limited treatment options2,3 | 2 g/0.5 g | Every 8 hours | 2 hours | Guided by the severity of the infection, the pathogen(s) and the patient's clinical and bacteriological progress5 |
1 CrCL estimated using the Cockcroft-Gault formula.
2 To be used in combination with metronidazole when anaerobic pathogens are known or suspected to be contributing to the infectious process.
3 To be used in combination with an antibacterial agent active against Gram-positive pathogens when these are known or suspected to be contributing to the infectious process.
4 The total duration shown may include intravenous Zavicefta followed by appropriate oral therapy.
5 There is very limited experience with the use of Zavicefta for more than 14 days.
\*Dosage in paediatric patients with creatinine clearance (CrCL) > 50 mL/min/1.73 m2\*
Table 2 shows the recommended intravenous doses for paediatric patients with estimated creatinine clearance (CrCL) > 50 mL/min/1.73 m2 (see sections 4.4 and 5.1).
Table 2: Recommended dose for paediatric patients with estimated CrCL1 > 50 mL/min/1.73 m2
| | | | | | |
| --- | --- | --- | --- | --- | --- |
| Type of infection | Age group | Dose of \*\*ceftazidime\*\*/avibactam7 | Frequency | Infusion time | Duration of treatment |
| cIAI2,3 OR cUTI including pyelonephritis3 OR HAP/VAP3 OR Infections due to aerobic Gram-negative organisms in patients with limited treatment options (LTO)2,3 | 6 months to <18 years | \*\*50 mg/kg\*\*/12.5 mg/kg \*\*to a maximum of\*\* \*\*2 g\*\*/0.5 g | Every 8 hours | 2 hours | cIAI: 5 – 14 days cUTI4: 5 – 14 days HAP/VAP: 7 – 14 days LTO: Guided by the severity of the infection, the pathogen(s) and the patient's clinical and bacteriological progress5 |
| Every 8 hours | 2 hours |
| 3 months to <6 months6 | \*\*40 mg/kg\*\*/10 mg/kg | Every 8 hours | 2 hours |
1 CrCL estimated using the Schwartz bedside formula.
2 To be used in combination with metronidazole when anaerobic pathogens are known or suspected to be contributing to the infectious process.
3 To be used in combination with an antibacterial agent active against Gram-positive pathogens when these are known or suspected to be contributing to the infectious process.
4 The total treatment duration shown may include intravenous Zavicefta followed by appropriate oral therapy.
5 There is very limited experience with the use of Zavicefta for more than 14 days.
6 There is limited experience with the use of Zavicefta in paediatric patients 3 months to < 6 months (see section 5.2).
7 Ceftazidime/avibactam is a combination product in a fixed 4:1 ratio and dosage recommendations are based on the ceftazidime component only (see section 6.6).
\*\*Special populations\*\*
\*Elderly\*
No dosage adjustment is required in elderly patients (see section 5.2).
\*Renal impairment\*
No dosage adjustment is required in patients with mild renal impairment (estimated CrCL > 50 - ≤ 80 mL/min) (see section 5.2).
Table 3 shows the recommended dose adjustments for adults with estimated CrCL ≤ 50 mL/min (see sections 4.4 and 5.2).
\*Dosage in adults with CrCL ≤ 50 mL/min\*
Table 3: Recommended dose for adults with estimated CrCL1 ≤ 50 mL/min
| | | | | |
| --- | --- | --- | --- | --- |
| Age Group | Estimated CrCL (mL/min) | Dose of \*\*ceftazidime\*\*/avibactam2,4 | Frequency | Infusion time |
| Adults | 31-50 | \*\*1 g\*\*/0.25 g | Every 8 hours | 2 hours |
| 16-30 | \*\*0.75 g\*\*/0.1875 g | Every 12 hours |
| 6-15 | Every 24 hours |
| End Stage Renal Disease including on haemodialysis3 | Every 48 hours |
1 CrCL estimated using the Cockcroft-Gault formula.
2 Dose recommendations are based on pharmacokinetic modelling (see section 5.2).
3 Ceftazidime and avibactam are removed by haemodialysis (see sections 4.9 and 5.2). Dosing of Zavicefta on haemodialysis days should occur after completion of haemodialysis.
4 Ceftazidime/avibactam is a combination product in a fixed 4:1 ratio and dosage recommendations are based on the ceftazidime component only (see section 6.6).
Table 4 and Table 5 show the recommended dose adjustments for paediatric patients with estimated CrCL ≤ 50 mL/min/1.73 m2 according to different age groups (see sections 4.4 and 5.2).
\*Dosage in paediatric patients ≥ 2 years of age with CrCl ≤ 50 mL/min/1.73 m2\*
Table 4: Recommended dose for paediatric patients with estimated CrCL1 ≤ 50 mL/min/1.73 m2
| | | | | |
| --- | --- | --- | --- | --- |
| Age Group | Estimated CrCL (mL/min/1.73 m2) | Dose of \*\*ceftazidime\*\*/avibactam2,4 | Frequency | Infusion time |
| Paediatric patients aged 2 years to <18 years | 31-50 | \*\*25 mg/kg\*\*/6.25 mg/kg \*\*to a maximum of\*\* \*\*1 g\*\*/0.25 g | Every 8 hours | 2 hours |
| 16-30 | \*\*18.75 mg/kg\*\*/4.7 mg/kg \*\*to a maximum of\*\* \*\*0.75 g\*\*/0.1875 g | Every 12 hours |
| 6-15 | Every 24 hours |
| End Stage Renal Disease including on haemodialysis3 | Every 48 hours |
1 CrCL estimated using the Schwartz bedside formula.
2 Dose recommendations are based on pharmacokinetic modelling (see section 5.2).
3 Ceftazidime and avibactam are removed by haemodialysis (see sections 4.9 and 5.2). Dosing of Zavicefta on haemodialysis days should occur after completion of haemodialysis.
4 Ceftazidime/avibactam is a combination product in a fixed 4:1 ratio and dosage recommendations are based on the ceftazidime component only (see section 6.6).
\*Dosage in paediatric patients <2 years of age with CrCl ≤ 50 mL/min/1.73 m2\*
Table 5: Recommended dose for paediatric patients with estimated CrCL1 ≤ 50 mL/min/1.73 m2
| | | | | |
| --- | --- | --- | --- | --- |
| Age Group | Estimated CrCL (mL/min/1.73 m2) | Dose of \*\*ceftazidime\*\*/avibactam2,3 | Frequency | Infusion time |
| 3 to < 6 months | 31 to 50 | \*\*20 mg/kg\*\*/5 mg/kg | Every 8 hours | 2 hours |
| 6 months to < 2 years | \*\*25 mg/kg\*\*/6.25 mg/kg | Every 8 hours |
| 3 to < 6 months | 16 to 30 | \*\*15 mg/kg\*\*/3.75 mg/kg | Every 12 hours |
| 6 months to < 2 years | \*\*18.75 mg/kg\*\*/4.7 mg/kg | Every 12 hours |
| 1 Calculated using the Schwartz bedside formula 2 Dose recommendations are based on pharmacokinetic modelling (see section 5.2). 3 Ceftazidime/avibactam is a combination product in a fixed 4:1 ratio and dosage recommendations are based on the ceftazidime component only (see section 6.6). | | | | |
There is insufficient information to recommend a dosage regimen for paediatric patients < 2 years of age that have a CrCL \*<\* 16 mL/min/1.73 m2.
\*Hepatic impairment\*
No dosage adjustment is required in patients with hepatic impairment (see section 5.2).
\*Paediatric population\*
The safety and efficacy of Zavicefta in paediatric patients < 3 months old have not been established. No data are available.
\*\*Method of administration\*\*
Intravenous use.
Zavicefta is administered by intravenous infusion over 120 minutes in an appropriate infusion volume (see section 6.6).
For instructions on reconstitution and dilution of the medicinal product before administration see section 6.6.4.3 Contraindications
Hypersensitivity to the active substances or to any of the excipients listed in section 6.1.
Hypersensitivity to any cephalosporin antibacterial agent.
Severe hypersensitivity (e.g. anaphylactic reaction, severe skin reaction) to any other type of β-lactam antibacterial agent (e.g. penicillins, monobactams or carbapenems).4.4 Special warnings and precautions for use
\*\*Hypersensitivity reactions\*\*
Serious and occasionally fatal hypersensitivity reactions are possible (see sections 4.3 and 4.8). In case of hypersensitivity reactions, treatment with Zavicefta must be discontinued immediately and adequate emergency measures must be initiated.
There have been reports of hypersensitivity reactions which progressed to Kounis syndrome (acute allergic coronary arteriospasm that can result in myocardial infarction, see section 4.8).
Before beginning treatment, it should be established whether the patient has a history of hypersensitivity reactions to ceftazidime, to other cephalosporins or to any other type of β-lactam antibacterial agent. Caution should be used if ceftazidime/avibactam is given to patients with a history of non-severe hypersensitivity to penicillins, monobactams or carbapenems.
Severe cutaneous adverse reactions (SCARs) including Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), drug reaction with eosinophilia and systemic symptoms (DRESS), and acute generalised exanthematous pustulosis (AGEP), which can be life‑threatening or fatal, have been reported with unknown frequency in association with ceftazidime treatment (see section 4.8).
Patients should be advised of the signs and symptoms and monitored closely for skin reactions.
If signs and symptoms suggestive of these reactions appear, Zavicefta should be withdrawn immediately, and an alternative treatment considered.
If the patient has developed a serious reaction such as SJS, TEN, DRESS or AGEP with the use of ceftazidime, treatment with Zavicefta must not be restarted in this patient at any time.
\*\*\*Clostridioides difficile -\* associated diarrhoea\*\*
\*Clostridioides difficile -\* associated diarrhoea has been reported with ceftazidime/avibactam, and can range in severity from mild to life-threatening. This diagnosis should be considered in patients who present with diarrhoea during or subsequent to the administration of Zavicefta (see section 4.8). Discontinuation of therapy with Zavicefta and the administration of specific treatment for \*Clostridioides difficile\* should be considered. Medicinal products that inhibit peristalsis should not be given.
\*\*Renal impairment\*\*
Ceftazidime and avibactam are eliminated via the kidneys, therefore, the dose should be reduced according to the degree of renal impairment (see section 4.2). Neurological sequelae, including tremor, myoclonus, non-convulsive status epilepticus, convulsion, encephalopathy and coma, have occasionally been reported with ceftazidime when the dose has not been reduced in patients with renal impairment.
In patients with renal impairment, close monitoring of estimated creatinine clearance is advised. In some patients, the creatinine clearance estimated from serum creatinine can change quickly, especially early in the course of treatment for the infection.
\*\*Nephrotoxicity\*\*
Concurrent treatment with high doses of cephalosporins and nephrotoxic medicinal products such as aminoglycosides or potent diuretics (e.g. furosemide) may adversely affect renal function.
\*\*Direct antiglobulin test (DAGT or Coombs test) seroconversion and potential risk of haemolytic anaemia\*\*
Ceftazidime/avibactam use may cause development of a positive direct antiglobulin test (DAGT\*\*\*,\*\*\* or Coombs test), which may interfere with the cross-matching of blood and/or may cause drug induced immune haemolytic anaemia (see section 4.8). While DAGT seroconversion in patients receiving Zavicefta was very common in clinical studies (the estimated range of seroconversion across Phase 3 studies was 3.2% to 20.8% in patients with a negative Coombs test at baseline and at least one follow-up test), there was no evidence of haemolysis in patients who developed a positive DAGT on treatment. However, the possibility that haemolytic anaemia could occur in association with Zavicefta treatment cannot be ruled out. Patients experiencing anaemia during or after treatment with Zavicefta should be investigated for this possibility.
\*\*Limitations of the clinical data\*\*
Clinical efficacy and safety studies of Zavicefta have been conducted in cIAI, cUTI and HAP (including VAP).
\*Complicated intra-abdominal infections in adults\*
In two studies in patients with cIAI, the most common diagnosis (approximately 42%) was appendiceal perforation or peri-appendiceal abscess. Approximately 87% of patients had APACHE II scores of ≤ 10 and 4% had bacteraemia at baseline. Death occurred in 2.1% (18/857) of patients who received Zavicefta and metronidazole and in 1.4% (12/863) of patients who received meropenem.
Among a subgroup with baseline CrCL 30 to 50 mL/min death occurred in 16.7% (9/54) of patients who received Zavicefta and metronidazole and 6.8% (4/59) of patients who received meropenem. Patients with CrCL 30 to 50 mL/min received a lower dose of Zavicefta than is currently recommended for patients in this sub-group.
\*Complicated urinary tract infections in adults\*
In two studies in patients with cUTI, 381/1091 (34.9%) patients were enrolled with cUTI without pyelonephritis while 710 (65.1%) were enrolled with acute pyelonephritis (mMITT population). A total of 81 cUTI patients (7.4%) had bacteraemia at baseline.
\*Hospital-acquired pneumonia (including ventilator-associated pneumonia) in adults\*
In a single study in patients with nosocomial pneumonia 280/808 (34.7%) had VAP and 40/808 (5%) were bacteraemic at baseline.
\*Patients with limited treatment options\*
The use of ceftazidime/avibactam to treat patients with infections due to Gram-negative aerobic pathogens who have limited treatment options is based on experience with ceftazidime alone and on analyses of the pharmacokinetic-pharmacodynamic relationship for ceftazidime/avibactam (see section 5.1).
\*\*Spectrum of activity of ceftazidime/avibactam\*\*
Ceftazidime has little or no activity against the majority of Gram-positive organisms and anaerobes (see sections 4.2 and 5.1). Additional antibacterial agents should be used when these pathogens are known or suspected to be contributing to the infectious process.
The inhibitory spectrum of avibactam includes many of the enzymes that inactivate ceftazidime, including Ambler class A β-lactamases and class C β-lactamases. Avibactam does not inhibit class B enzymes (metallo-β-lactamases) and is not able to inhibit many of the class D enzymes (see section 5.1).
\*\*Non-susceptible organisms\*\*
Prolonged use may result in the overgrowth of non-susceptible organisms (e.g. enterococci, fungi), which may require interruption of treatment or other appropriate measures.
\*\*Interference with laboratory tests\*\*
Ceftazidime may interfere with copper reduction methods (Benedict's, Fehling's, Clinitest) for detection of glycosuria leading to false positive results. Ceftazidime does not interfere with enzyme-based tests for glycosuria.
\*\*Controlled sodium diet\*\*
This medicinal product contains approximately 146 mg sodium per vial, equivalent to 7.3% of the WHO recommended maximum daily intake (RDI) of 2 g sodium for an adult.
The maximum daily dose of this product is equivalent to 22% of the WHO recommended maximum daily intake for sodium. Zavicefta is considered high in sodium.
This should be considered when administering Zavicefta to patients who are on a controlled sodium diet.
Zavicefta may be diluted with sodium-containing solutions (see section 6.6) and this should be considered in relation to the total sodium from all sources that will be administered to the patient.
\*\*Paediatric population\*\*
There is a potential risk of overdosing, particularly for paediatric patients aged from 3 to less than 12 months of age. Care should be taken when calculating the volume of administration of the dose (see sections 4.9 and 6.6).4.5 Interaction with other medicinal products and other forms of interaction
\*In vitro\*, avibactam is a substrate of OAT1 and OAT3 transporters which might contribute to the active uptake of avibactam from the blood compartment and, therefore, affect its excretion. Probenecid (a potent OAT inhibitor) inhibits this uptake by 56% to 70% \*in vitro\* and, therefore, has the potential to alter the elimination of avibactam. Since a clinical interaction study of avibactam and probenecid has not been conducted, co-administration of avibactam with probenecid is not recommended.
Avibactam showed no significant inhibition of cytochrome P450 enzymes \*in vitro\*. Avibactam and ceftazidime showed no \*in vitro\* cytochrome P450 induction at clinically relevant concentrations. Avibactam and ceftazidime do not inhibit the major renal or hepatic transporters in the clinically relevant exposure range, therefore the interaction potential via these mechanisms is considered to be low.
Clinical data have demonstrated that there is no interaction between ceftazidime and avibactam, and between ceftazidime/avibactam and metronidazole.
\*Other types of interaction\*
Concurrent treatment with high doses of cephalosporins and nephrotoxic medicinal products such as aminoglycosides or potent diuretics (e.g. furosemide) may adversely affect renal function (see section 4.4).
Chloramphenicol is antagonistic \*in vitro\* with ceftazidime and other cephalosporins. The clinical relevance of this finding is unknown, but due to the possibility of antagonism \*in vivo\* this drug combination should be avoided.4.6 Fertility, pregnancy and lactation
\*\*Pregnancy\*\*
Animal studies with ceftazidime do not indicate direct or indirect harmful effects with respect to pregnancy, embryonal/foetal development, parturition or postnatal development. Animal studies with avibactam have shown reproductive toxicity without evidence of teratogenic effects (see section 5.3).
Ceftazidime/avibactam should only be used during pregnancy if the potential benefit outweighs the possible risk.
\*\*Breast-feeding\*\*
Ceftazidime is excreted in human milk in small quantities. It is unknown whether avibactam is excreted in human milk. A risk to newborns/infants cannot be excluded. A decision must be made whether to discontinue breast feeding or to discontinue/abstain from ceftazidime/avibactam therapy taking into account the benefit of breast feeding for the child and the benefit of therapy for the woman.
\*\*Fertility\*\*
The effects of ceftazidime/avibactam on fertility in humans have not been studied. No data are available on animal studies with ceftazidime. Animal studies with avibactam do not indicate harmful effects with respect to fertility (see section 5.3).4.7 Effects on ability to drive and use machines
Undesirable effects may occur (e.g. dizziness), which may influence the ability to drive and use machines following administration of Zavicefta (see section 4.8).4.8 Undesirable effects
\*\*Summary of the safety profile\*\*
In seven Phase 2 and Phase 3 clinical trials, 2024 adults were treated with Zavicefta. The most common adverse reactions occurring in ≥5% of patients treated with Zavicefta were Coombs direct test positive, nausea, and diarrhoea. Nausea and diarrhoea were usually mild or moderate in intensity.
\*\*Tabulated list of adverse reactions\*\*
The following adverse reactions have been reported with ceftazidime alone and/or identified during the Phase 2 and Phase 3 trials with Zavicefta. Adverse reactions are classified according to frequency and System Organ Class. Frequency categories are derived from adverse reactions and/or potentially clinically significant laboratory abnormalities, and are defined according to the following conventions:
Very common (≥1/10)
Common (≥1/100 and <1/10)
Uncommon (≥1/1,000 and <1/100)
Rare (≥1/10,000 and <1/1,000)
Very rare (<1/10,000)
not known (cannot be estimated from the available data)
Table 6: Frequency of adverse reactions by system organ class
| | | | | | |
| --- | --- | --- | --- | --- | --- |
| \*\*System Organ Class\*\* | \*\*Very common\*\* | \*\*Common\*\* | \*\*Uncommon\*\* | \*\*Very rare\*\* | \*\*not known\*\* |
| Infections and infestations | | Candidiasis (including Vulvovaginal candidiasis and Oral candidiasis) | Clostridioides difficile colitis Pseudomembranous colitis | | |
| Blood and lymphatic system disorders | Coombs direct test positive | Eosinophilia Thrombocytosis Thrombocytopenia | Neutropenia Leukopenia Lymphocytosis | | Agranulocytosis Haemolytic anaemia |
| Immune system disorders | | | | | Anaphylactic reaction |
| Nervous system disorders | | Headache Dizziness | Paraesthesia | | |
| Cardiac disorders | | | | | Kounis syndromea,\\* |
| Gastrointestinal disorders | | Diarrhoea Abdominal pain Nausea Vomiting | Dysgeusia | | |
| Hepatobiliary disorders | | Alanine aminotransferase increased Aspartate aminotransferase increased Blood alkaline phosphatase increased Gamma-glutamyltransferase increased Blood lactate dehydrogenase Increased | | | Jaundice |
| Skin and subcutaneous tissue disorders | | Rash maculopapular Urticaria Pruritus | | | Toxic epidermal necrolysis Stevens-Johnson syndrome Erythema multiforme Angioedema Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) Acute generalised exanthematous pustulosis (AGEP)\\* |
| Renal and urinary disorders | | | Blood creatinine increased Blood urea increased Acute kidney injury | Tubulointerstitial nephritis | |
| General disorders and administration site conditions | | Infusion site thrombosis Infusion site phlebitis Pyrexia | | | |
\\* ADR identified post-marketing.
a Acute coronary syndrome associated with an allergic reaction.
\*\*Paediatric population\*\*
The safety assessment in paediatric patients is based on the safety data from two trials in which 61 patients (aged from 3 years to less than 18 years) with cIAI and 67 patients with cUTI (aged from 3 months to less than 18 years) received Zavicefta. Overall, the safety profile in these 128 paediatric patients was similar to that observed in the adult population with cIAI and cUTI.
\*\*Reporting of suspected adverse reactions\*\*
Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the Yellow Card Scheme at: www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store.4.9 Overdose
Overdose with ceftazidime/avibactam can lead to neurological sequelae including encephalopathy, convulsions and coma, due to the ceftazidime component.
Serum levels of ceftazidime can be reduced by haemodialysis or peritoneal dialysis. During a 4-hour haemodialysis period, 55% of the avibactam dose was removed.
- Instruction Pharmacology
- 5.1 Pharmacodynamic properties
Pharmacotherapeutic group: Antibacterials for systemic use, other beta-lactam antibacterials, third-generation cephalosporins, ATC code: J01DD52
\*\*Mechanism of action\*\*
Ceftazidime inhibits bacterial peptidoglycan cell wall synthesis following binding to penicillin binding proteins (PBPs), which leads to bacterial cell lysis and death. Avibactam is a non β-lactam, β-lactamase inhibitor that acts by forming a covalent adduct with the enzyme that is stable to hydrolysis. It inhibits both Ambler class A and class C β-lactamases and some class D enzymes, including extended-spectrum β-lactamases (ESBLs), KPC and OXA-48 carbapenemases, and AmpC enzymes. Avibactam does not inhibit class B enzymes (metallo-β-lactamases) and is not able to inhibit many class D enzymes.
\*\*Resistance\*\*
Bacterial resistance mechanisms that could potentially affect ceftazidime/avibactam include mutant or acquired PBPs, decreased outer membrane permeability to either compound, active efflux of either compound, and β-lactamase enzymes refractory to inhibition by avibactam and able to hydrolyse ceftazidime.
\*\*Antibacterial activity in combination with other antibacterial agents\*\*
No synergy or antagonism was demonstrated in \*in vitro\* drug combination studies with ceftazidime/avibactam and metronidazole, tobramycin, levofloxacin, vancomycin, linezolid, colistin and tigecycline.
\*\*Susceptibility testing breakpoints\*\*
Minimum Inhibitory Concentration (MIC) breakpoints established by the European Committee on Antimicrobial Susceptibility Testing (EUCAST) for ceftazidime/avibactam can be viewed on the following website:
https://www.ema.europa.eu/documents/other/minimum-inhibitory-concentration-mic-breakpoints\\_en.xlsx
\*\*Pharmacokinetic/pharmacodynamic relationship\*\*
The antimicrobial activity of ceftazidime against specific pathogens has been shown to best correlate with the percent time of free-drug concentration above the ceftazidime/avibactam minimum inhibitory concentration over the dose interval (% \*f\*T >MIC of ceftazidime/avibactam). For avibactam the PK-PD index is the percent time of the free drug concentration above a threshold concentration over the dose interval (% \*f\*T >CT).
\*\*Clinical efficacy against specific pathogens\*\*
Efficacy has been demonstrated in clinical studies against the following pathogens that were susceptible to ceftazidime/avibactam \*in vitro\*.
\*\*Complicated intra-abdominal infections\*\*
Gram-negative micro-organisms
• \*Citrobacter freundii\*
• \*Enterobacter cloacae\*
• \*Escherichia coli\*
• \*Klebsiella oxytoca\*
• \*Klebsiella pneumoniae\*
• \*Pseudomonas aeruginosa\*
\*\*Complicated urinary-tract infections\*\*
Gram-negative micro-organisms
• \*Escherichia coli\*
• \*Klebsiella pneumoniae\*
• \*Proteus mirabilis\*
• \*Enterobacter cloacae\*
• \*Pseudomonas aeruginosa\*
\*\*Hospital-acquired pneumonia including ventilator-associated pneumonia\*\*
Gram-negative micro-organisms
• \*Enterobacter cloacae\*
• \*Escherichia coli\*
• \*Klebsiella pneumoniae\*
• \*Proteus mirabilis\*
• \*Serratia marcescens\*
• \*Pseudomonas aeruginosa\*
Clinical efficacy has not been established against the following pathogens that are relevant to the approved indications although \*in vitro\* studies suggest that they would be susceptible to ceftazidime/avibactam in the absence of acquired mechanisms of resistance.
Gram-negative micro-organisms
• \*Citrobacter koseri\*
• \*Enterobacter aerogenes\*
• \*Morganella morganii\*
• \*Proteus vulgaris\*
• \*Providencia rettgeri\*
\*In-vitro\* data indicate that the following species are not susceptible to ceftazidime/avibactam.
• \*Staphylococcus aureus\* (methicillin-susceptible and methicillin-resistant)
• Anaerobes
• \*Enterococcus\* spp.
• \*Stenotrophomonas maltophilia\*
• \*Acinetobacter\* spp.
\*\*Paediatric population\*\*
Zavicefta has been evaluated in paediatric patients aged 3 months to < 18 years in two Phase 2 single-blind, randomised, comparative clinical studies, one in patients with cIAI and one in patients with cUTI. The primary objective in each study was to assess safety and tolerability of ceftazidime-avibactam (+/- metronidazole). Secondary objectives included assessment of pharmacokinetics and efficacy; efficacy was a descriptive endpoint in both studies. Clinical cure rate at TOC (ITT) was 91.8% (56/61) for Zavicefta compared to 95.5% (21/22) for meropenem in paediatric patients with cIAI. Microbiological eradication rate at TOC (micro-ITT) was 79.6% (43/54) for Zavicefta compared to 60.9% (14/23) for cefepime in paediatric patients with cUTI.
The licensing authority has deferred the obligation to submit the results of studies with Zavicefta in one or more subsets of the paediatric population in the treatment of cIAI, cUTI, pneumonia and Gram-negative bacterial infections (see section 4.2 for information on paediatric use).5.2 Pharmacokinetic properties
\*\*Distribution\*\*
The human protein binding of both ceftazidime and avibactam is approximately 10% and 8%, respectively. The steady-state volumes of distribution of ceftazidime and avibactam were about 17 L and 22 L, respectively in healthy adults following multiple doses of 2 g/0.5 g ceftazidime/avibactam infused over 2 hours every 8 hours. Both ceftazidime and avibactam penetrate into human bronchial epithelial lining fluid (ELF) to the same extent with concentrations around 30% of those in plasma. The concentration time profiles are similar for ELF and plasma.
Penetration of ceftazidime into the intact blood-brain barrier is poor. Ceftazidime concentrations of 4 to 20 mg/L or more are achieved in the CSF when the meninges are inflamed. Avibactam penetration of the blood brain barrier has not been studied clinically; however, in rabbits with inflamed meninges, CSF exposures of ceftazidime and avibactam were 43% and 38% of plasma AUC, respectively. Ceftazidime crosses the placenta readily, and is excreted in the breast milk.
\*\*Biotransformation\*\*
Ceftazidime is not metabolised. No metabolism of avibactam was observed in human liver preparations (microsomes and hepatocytes). Unchanged avibactam was the major drug-related component in human plasma and urine following dosing with [14C]-avibactam.
\*\*Elimination\*\*
The terminal half-life (t½) of both ceftazidime and avibactam is about 2 h after intravenous administration. Ceftazidime is excreted unchanged into the urine by glomerular filtration; approximately 80-90% of the dose is recovered in the urine within 24 h. Avibactam is excreted unchanged into the urine with a renal clearance of approximately 158 mL/min, suggesting active tubular secretion in addition to glomerular filtration. Approximately 97% of the avibactam dose is recovered in the urine, 95% within 12 h. Less than 1% of ceftazidime is excreted via the bile and less than 0.25% of avibactam is excreted into faeces.
\*\*Linearity/non-linearity\*\*
The pharmacokinetics of both ceftazidime and avibactam are approximately linear across the dose range studied (0.5 g to 2 g for ceftazidime and 0.05 g to 2 g for avibactam) for a single intravenous administration. No appreciable accumulation of ceftazidime or avibactam was observed following multiple intravenous infusions of 2 g/0.5 g of ceftazidime/avibactam administered every 8 hours for up to 11 days in healthy adults with normal renal function.
\*\*Special populations\*\*
\*Renal impairment\*
Elimination of ceftazidime and avibactam is decreased in patients with moderate or severe renal impairment. The average increases in avibactam AUC are 3.8-fold and 7-fold in subjects with moderate and severe renal impairment, see section 4.2.
\*Hepatic impairment\*
Mild to moderate hepatic impairment had no effect on the pharmacokinetics of ceftazidime in individuals administered 2 g intravenously every 8 hours for 5 days, provided renal function was not impaired. The pharmacokinetics of ceftazidime in patients with severe hepatic impairment has not been established. The pharmacokinetics of avibactam in patients with any degree of hepatic impairment has not been studied.
As ceftazidime and avibactam do not appear to undergo significant hepatic metabolism, the systemic clearance of either active substance is not expected to be significantly altered by hepatic impairment.
\*Elderly patients (≥65 years)\*
Reduced clearance of ceftazidime was observed in elderly patients, which was primarily due to age-related decrease in renal clearance of ceftazidime. The mean elimination half-life of ceftazidime ranged from 3.5 to 4 hours following intravenous bolus dosing with 2 g every 12 hours in elderly patients aged 80 years or older.
Following a single intravenous administration of 500 mg avibactam as a 30-minute IV infusion, the elderly had a slower terminal half-life of avibactam, which may be attributed to age related decrease in renal clearance.
\*Paediatric population\*
The pharmacokinetics of ceftazidime and avibactam were evaluated in paediatric patients from 3 months to < 18 years of age with suspected or confirmed infections following a single dose of ceftazidime 50 mg/kg and avibactam 12.5 mg/kg for patients weighing < 40 kg or Zavicefta 2 g/0.5 g (ceftazidime 2 grams and avibactam 0.5 grams) for patients weighing ≥ 40 kg. Plasma concentrations of ceftazidime and avibactam were similar across all four age cohorts in the study (3 months to < 2 years, 2 to < 6 years, 6 to < 12 years, and 12 to < 18 years). Ceftazidime and avibactam AUC0-t and Cmax values in the two older cohorts (paediatric patients from 6 to < 18 years), which had more extensive pharmacokinetic sampling, were similar to those observed in healthy adult subjects with normal renal function that received Zavicefta 2 g/0.5 g. Data from this study and the two Phase 2 paediatric studies in patients with cIAI and cUTI were pooled with PK data from adults (Phase 1 to Phase 3) to update the population PK model, which was used to conduct simulations to assess PK/PD target attainment. Results from these simulations demonstrated that the recommended dose regimens for paediatric patients with cIAI, cUTI and HAP/VAP, including dose adjustments for patients with renal impairment, result in systemic exposure and PK/PD target attainment values that are similar to those in adults at the approved Zavicefta dose of 2 g/0.5 g administered over 2 hours, every 8 hours.
There is limited experience with the use of ceftazidime plus avibactam in the paediatric groups of 3 months to < 6 months. The recommended dosing regimens are based on simulations conducted using the final population PK models. Simulations demonstrated that the recommended dose regimens result in comparable exposures to other age groups with PK/PD target attainment > 90%. Based on data from the completed paediatric clinical trials, at the recommended dose regimens, there was no evidence of over or under exposure in the subjects aged 3 months to < 6 months.
In addition, there is very limited data in paediatric patients aged 3 months to < 2 years with impaired renal function (CrCL ≤ 50 mL/min/1.73 m2), with no data in severe renal impairment from the completed paediatric clinical trials. Population PK models for ceftazidime and avibactam were used to conduct simulations for patients with impaired renal function.
\*Gender and race\*
The pharmacokinetics of ceftazidime/avibactam is not significantly affected by gender or race.5.3 Preclinical safety data
\*\*Ceftazidime\*\*
Non-clinical data reveal no special hazard for humans based on conventional studies of safety pharmacology, repeated dose toxicity, reproduction toxicity or genotoxicity. Carcinogenicity studies have not been conducted with ceftazidime.
\*\*Avibactam\*\*
Non-clinical data reveal no special hazard for humans based on conventional studies of safety pharmacology, repeated dose toxicity or genotoxicity. Carcinogenicity studies have not been conducted with avibactam.
\*\*Reproduction toxicity\*\*
In pregnant rabbits administered avibactam at 300 and 1000 mg/kg/day, there was a dose-related lower mean foetal weight and delayed ossification, potentially related to maternal toxicity. Plasma exposure levels at maternal and foetal NOAEL (100 mg/kg/day) indicate moderate to low margins of safety.
In the rat, no adverse effects were observed on embryofetal development or fertility. Following administration of avibactam throughout pregnancy and lactation in the rat, there was no effect on pup survival, growth or development, however there was an increase in incidence of dilation of the renal pelvis and ureters in less than 10% of the rat pups at maternal exposures greater than or equal to approximately 1.5 times human therapeutic exposures.
- Instruction Pharmaceutical Particulars
- 6.1 List of excipients
Sodium carbonate (anhydrous)6.2 Incompatibilities
The compatibility of Zavicefta with other medicines has not been established. Zavicefta should not be mixed with or physically added to solutions containing other medicinal products.
This medicinal product must not be mixed with other medicinal products except those mentioned in section 6.6.6.3 Shelf life
\*\*Dry powder\*\*
3 years.
\*\*After reconstitution\*\*
The reconstituted vial should be used immediately.
\*\*After dilution\*\*
\*Infusion bags\*
If the intravenous solution is prepared with diluents listed in section 6.6 (ceftazidime concentration 8 mg/mL), the chemical and physical in-use stability has been demonstrated (from initial vial puncture) for up to 12 hours at 2 - 8°C, followed by up to 4 hours at not more than 25°C.
If the intravenous solution is prepared with diluents listed in section 6.6 (ceftazidime concentration > 8 mg/mL to 40 mg/mL), the chemical and physical in-use stability has been demonstrated (from initial vial puncture) for up to 4 hours at not more than 25°C.
From a microbiological point of view, the medicinal product should be used immediately, unless reconstitution and dilution have taken place in controlled and validated aseptic conditions. If not used immediately, in-use storage times and conditions prior to use are the responsibility of the user and must not exceed those stated above.
\*Infusion syringes\*
The chemical and physical in-use stability has been demonstrated (from initial vial puncture) for up to 6 hours at not more than 25°C.
From a microbiological point of view, the medicinal product should be used immediately unless reconstitution and dilution have taken place in controlled and validated aseptic conditions. If not used immediately, in-use storage times and conditions prior to use are the responsibility of the user and must not exceed 6 hours at not more than 25°C.6.4 Special precautions for storage
This medicinal product does not require any special storage conditions.
Store in the original package in order to protect from light.
For storage conditions of the reconstituted and diluted medicinal product, see section 6.3.6.5 Nature and contents of container
20 mL glass vial (Type 1) closed with a rubber (halobutyl) stopper and aluminium seal with flip-off cap.
The medicinal product is supplied in packs of 10 vials.6.6 Special precautions for disposal and other handling
The powder must be reconstituted with water for injections and the resulting concentrate must then be immediately diluted prior to use. The reconstituted solution is a pale yellow solution and is free of particles.
Zavicefta (ceftazidime/avibactam) is a combination product; each vial contains 2 g of ceftazidime and 0.5 g of avibactam in a fixed 4:1 ratio. Dosage recommendations are based on the ceftazidime component only.
Standard aseptic techniques should be used for solution preparation and administration. Doses may be prepared in an appropriately sized infusion bag or infusion syringe.
Parenteral medicinal products should be inspected visually for particulate matter prior to administration.
Each vial is for single use only.
Any unused product or waste material should be disposed of in accordance with local requirements.
The total time interval between starting reconstitution and completing preparation of the intravenous infusion should not exceed 30 minutes.
\*\*Instructions for preparing adult and paediatric doses in INFUSION BAG or in INFUSION SYRINGE:\*\*
NOTE: The following procedure describes the steps to prepare an infusion solution with a final concentration of 8-40 mg/mL of ceftazidime. All calculations should be completed prior to initiating these steps. \*\*For paediatric patients aged 3 to 12 months\*\*, detailed steps to prepare a 20 mg/mL concentration (sufficient for most scenarios) are also provided.
1. Prepare the \*\*reconstituted solution\*\* (\*\*167.3 mg/mL\*\* of ceftazidime):
a) Insert the syringe needle through the vial closure and inject 10 mL of sterile water for injections.
b) Withdraw the needle and shake the vial to give a clear solution.
c) Insert a gas relief needle through the vial closure \*\*after\*\* the product has dissolved to relieve the internal pressure (this is important to preserve product sterility).
2. Prepare the \*\*final solution\*\* for infusion (final concentration must be \*\*8-40 mg/mL\*\* of ceftazidime):
a) Infusion bag: Further dilute the reconstituted solution by transferring an appropriately calculated volume of the reconstituted solution to an infusion bag containing any of the following: sodium chloride 9 mg/mL (0.9%) solution for injection, dextrose 50 mg/mL (5%) solution for injection, or Lactated Ringer's solution.
b) Infusion syringe: Further dilute the reconstituted solution by transferring an appropriately calculated volume of the reconstituted solution combined with a sufficient volume of diluent (sodium chloride 9 mg/mL (0.9%) solution for injection or dextrose 50 mg/mL (5%) solution for injection) to an infusion syringe.
Refer to Table 7 below.
Table 7: Preparation of Zavicefta for adult and paediatric doses in INFUSION BAG or in INFUSION SYRINGE.
| | | | |
| --- | --- | --- | --- |
| \*\*Zavicefta Dose (ceftazidime)1\*\* | \*\*Volume to withdraw from reconstituted vial\*\* | \*\*Final volume after dilution in infusion bag2\*\* | \*\*Final volume in infusion syringe\*\* |
| 2 g | Entire contents (approximately 12 mL) | 50 mL to 250 mL | 50 mL |
| 1g | 6 mL | 25 mL to 125 mL | 25 mL to 50 mL |
| 0.75 g | 4.5 mL | 19 mL to 93 mL | 19 mL to 50 mL |
| All other doses | Volume (mL) calculated based on dose required: \*\*Dose (mg ceftazidime) ÷ 167.3 mg/mL ceftazidime\*\* | Volume (mL) will vary based on infusion bag size availability and preferred final concentration (must be 8-40 mg/mL of ceftazidime) | Volume (mL) will vary based on infusion syringe size availability and preferred final concentration (must be 8-40 mg/mL of ceftazidime) |
1 Based on ceftazidime component only.
2 Dilute to final ceftazidime concentration of 8 mg/mL for in-use stability up to 12 hours at 2 - 8°C, followed by up to 4 hours at not more than 25°C (i.e. dilute 2 g dose of ceftazidime in 250 mL, 1 g dose of ceftazidime in 125 mL, 0.75 g dose of ceftazidime in 93 mL, etc.). All other ceftazidime concentrations (> 8 mg/mL to 40 mg/mL) have in-use stability up to 4 hours at not more than 25°C.
\*\*Preparation of Zavicefta for use in paediatric patients aged 3 to 12 months of age in INFUSION SYRINGE:\*\*
NOTE: The following procedure describes the steps to prepare an infusion solution with a final concentration of 20 mg/mL of ceftazidime (sufficient for most scenarios). Alternative concentrations may be prepared, but must have a final concentration range of 8-40 mg/mL of ceftazidime.
1. Prepare the \*\*reconstituted solution\*\* (\*\*167.3 mg/mL\*\* of ceftazidime):
a) Insert the syringe needle through the vial closure and inject 10 mL of sterile water for injections.
b) Withdraw the needle and shake the vial to give a clear solution.
c) Insert a gas relief needle through the vial closure \*\*after\*\* the product has dissolved to relieve the internal pressure (this is important to preserve product sterility).
2. Prepare the \*\*final solution\*\* for infusion to a final concentration of \*\*20 mg/mL\*\* of ceftazidime:
a) Further dilute the reconstituted solution by transferring an appropriately calculated volume of the reconstituted solution combined with a sufficient volume of diluent (sodium chloride 9 mg/mL (0.9%) solution for injection or dextrose 50 mg/mL (5%) solution for injection) to an infusion syringe.
b) Refer to Table 8, 9, or 10 below to confirm the calculations. Values shown are approximate as it may be necessary to round to the nearest graduation mark of an appropriately sized syringe. Note that the tables are NOT inclusive of all possible calculated doses but may be utilized to estimate the approximate volume to verify the calculation.
Table 8: Preparation of Zavicefta (final concentration of 20 mg/mL of ceftazidime) in paediatric patients 3 to 12 months of age with creatinine clearance (CrCL) > 50 mL/min/1.73 m2
| | | | | |
| --- | --- | --- | --- | --- |
| \*\*Age and Zavicefta Dose (mg/kg)1\*\* | \*\*Weight (kg)\*\* | \*\*Dose (mg ceftazidime)\*\* | \*\*Volume of reconstituted solution to be withdrawn from vial (mL)\*\* | \*\*Volume of diluent to add for mixing (mL)\*\* |
| \*\*6 months to 12 months\*\* \*\*50 mg/kg of ceftazidime\*\* | 5 | 250 | 1.5 | 11 |
| 6 | 300 | 1.8 | 13 |
| 7 | 350 | 2.1 | 15 |
| 8 | 400 | 2.4 | 18 |
| 9 | 450 | 2.7 | 20 |
| 10 | 500 | 3 | 22 |
| 11 | 550 | 3.3 | 24 |
| 12 | 600 | 3.6 | 27 |
| \*\*3 months to < 6 months\*\* \*\*40 mg/kg of ceftazidime\*\* | 4 | 160 | 1 | 7.4 |
| 5 | 200 | 1.2 | 8.8 |
| 6 | 240 | 1.4 | 10 |
| 7 | 280 | 1.7 | 13 |
| 8 | 320 | 1.9 | 14 |
| 9 | 360 | 2.2 | 16 |
| 10 | 400 | 2.4 | 18 |
1 Based on ceftazidime component only.
Table 9: Preparation of Zavicefta (final concentration of 20 mg/mL of ceftazidime) in paediatric patients 3 to 12 months of age with CrCL 31 to 50 mL/min/1.73 m2
| | | | | |
| --- | --- | --- | --- | --- |
| \*\*Age and Zavicefta Dose (mg/kg)1\*\* | \*\*Weight (kg)\*\* | \*\*Dose (mg ceftazidime)\*\* | \*\*Volume of reconstituted solution to be withdrawn from vial (mL)\*\* | \*\*Volume of diluent to add for mixing (mL)\*\* |
| \*\*6 months to 12 months\*\* \*\*25 mg/kg of ceftazidime\*\* | 5 | 125 | 0.75 | 5.5 |
| 6 | 150 | 0.9 | 6.6 |
| 7 | 175 | 1 | 7.4 |
| 8 | 200 | 1.2 | 8.8 |
| 9 | 225 | 1.3 | 9.6 |
| 10 | 250 | 1.5 | 11 |
| 11 | 275 | 1.6 | 12 |
| 12 | 300 | 1.8 | 13 |
| \*\*3 months to < 6 months\*\* \*\*20 mg/kg of ceftazidime\*\* | 4 | 80 | 0.48 | 3.5 |
| 5 | 100 | 0.6 | 4.4 |
| 6 | 120 | 0.72 | 5.3 |
| 7 | 140 | 0.84 | 6.2 |
| 8 | 160 | 1 | 7.4 |
| 9 | 180 | 1.1 | 8.1 |
| 10 | 200 | 1.2 | 8.8 |
1 Based on ceftazidime component only.
Table 10: Preparation of Zavicefta (final concentration of 20 mg/mL of ceftazidime) in paediatric patients 3 to 12 months of age with CrCL 16 to 30 mL/min/1.73 m2
| | | | | |
| --- | --- | --- | --- | --- |
| \*\*Age and Zavicefta Dose (mg/kg) 1\*\* | \*\*Weight (kg)\*\* | \*\*Dose (mg ceftazidime)\*\* | \*\*Volume of reconstituted solution to be withdrawn from vial (mL)\*\* | \*\*Volume of diluent to add for mixing (mL)\*\* |
| \*\*6 months to 12 months\*\* \*\*18.75 mg/kg of ceftazidime\*\* | 5 | 93.75 | 0.56 | 4.1 |
| 6 | 112.5 | 0.67 | 4.9 |
| 7 | 131.25 | 0.78 | 5.7 |
| 8 | 150 | 0.9 | 6.6 |
| 9 | 168.75 | 1 | 7.4 |
| 10 | 187.5 | 1.1 | 8.1 |
| 11 | 206.25 | 1.2 | 8.8 |
| 12 | 225 | 1.3 | 9.6 |
| \*\*3 months to < 6 months\*\* \*\*15 mg/kg of ceftazidime\*\* | 4 | 60 | 0.36 | 2.7 |
| 5 | 75 | 0.45 | 3.3 |
| 6 | 90 | 0.54 | 4 |
| 7 | 105 | 0.63 | 4.6 |
| 8 | 120 | 0.72 | 5.3 |
| 9 | 135 | 0.81 | 6 |
| 10 | 150 | 0.9 | 6.6 |
1 Based on ceftazidime component only.
- Instruction Content
- ## Composition
Each vial contains ceftazidime pentahydrate equivalent to 2 g ceftazidime and avibactam sodium equivalent to 0.5 g avibactam.
After reconstitution, 1 mL of solution contains 167.3 mg of ceftazidime and 41.8 mg of avibactam (see section 6.6).
\*\*Excipient with known effect:\*\*
Zavicefta contains approximately 146 mg sodium per vial.
For the full list of excipients, see section 6.1.
## Pharmaceutical Form
Powder for concentrate for solution for infusion (powder for concentrate).
A white to yellow powder.
## Clinical Particulars
4.1 Therapeutic indications
Zavicefta is indicated in adults and paediatric patients aged 3 months and older for the treatment of the following infections (see sections 4.4 and 5.1):
• Complicated intra-abdominal infection (cIAI)
• Complicated urinary tract infection (cUTI), including pyelonephritis
• Hospital-acquired pneumonia (HAP), including ventilator associated pneumonia (VAP)
Treatment of adult patients with bacteraemia that occurs in association with, or is suspected to be associated
with, any of the infections listed above.
Zavicefta is also indicated for the treatment of infections due to aerobic Gram-negative organisms in adults and paediatric patients aged 3 months and older with limited treatment options (see sections 4.2, 4.4 and 5.1).
Consideration should be given to official guidance on the appropriate use of antibacterial agents.4.2 Posology and method of administration
It is recommended that Zavicefta should be used to treat infections due to aerobic Gram-negative organisms in adults and paediatric patients aged 3 months and older with limited treatment options only after consultation with a physician with appropriate experience in the management of infectious diseases (see section 4.4).
\*\*Posology\*\*
\*Dosage in adults with creatinine clearance (CrCL) > 50 mL/min\*
Table 1 shows the recommended intravenous dose for adults with estimated creatinine clearance (CrCL) > 50 mL/min (see sections 4.4 and 5.1).
Table 1: Recommended dose for adults with estimated CrCL > 50 mL/min1
| | | | | |
| --- | --- | --- | --- | --- |
| Type of infection | Dose of ceftazidime/avibactam | Frequency | Infusion time | Duration of treatment |
| cIAI2,3 | 2 g/0.5 g | Every 8 hours | 2 hours | 5-14 days |
| cUTI, including pyelonephritis3 | 2 g/0.5 g | Every 8 hours | 2 hours | 5-10 days4 |
| HAP/VAP3 | 2 g/0.5 g | Every 8 hours | 2 hours | 7-14 days |
| Bacteraemia associated with, or suspected to be associated with any of the above infections | 2 g/0.5 g | Every 8 hours | 2 hours | Duration of treatment should be in accordance with the site of infection. |
| Infections due to aerobic Gram-negative organisms in patients with limited treatment options2,3 | 2 g/0.5 g | Every 8 hours | 2 hours | Guided by the severity of the infection, the pathogen(s) and the patient's clinical and bacteriological progress5 |
1 CrCL estimated using the Cockcroft-Gault formula.
2 To be used in combination with metronidazole when anaerobic pathogens are known or suspected to be contributing to the infectious process.
3 To be used in combination with an antibacterial agent active against Gram-positive pathogens when these are known or suspected to be contributing to the infectious process.
4 The total duration shown may include intravenous Zavicefta followed by appropriate oral therapy.
5 There is very limited experience with the use of Zavicefta for more than 14 days.
\*Dosage in paediatric patients with creatinine clearance (CrCL) > 50 mL/min/1.73 m2\*
Table 2 shows the recommended intravenous doses for paediatric patients with estimated creatinine clearance (CrCL) > 50 mL/min/1.73 m2 (see sections 4.4 and 5.1).
Table 2: Recommended dose for paediatric patients with estimated CrCL1 > 50 mL/min/1.73 m2
| | | | | | |
| --- | --- | --- | --- | --- | --- |
| Type of infection | Age group | Dose of \*\*ceftazidime\*\*/avibactam7 | Frequency | Infusion time | Duration of treatment |
| cIAI2,3 OR cUTI including pyelonephritis3 OR HAP/VAP3 OR Infections due to aerobic Gram-negative organisms in patients with limited treatment options (LTO)2,3 | 6 months to <18 years | \*\*50 mg/kg\*\*/12.5 mg/kg \*\*to a maximum of\*\* \*\*2 g\*\*/0.5 g | Every 8 hours | 2 hours | cIAI: 5 – 14 days cUTI4: 5 – 14 days HAP/VAP: 7 – 14 days LTO: Guided by the severity of the infection, the pathogen(s) and the patient's clinical and bacteriological progress5 |
| Every 8 hours | 2 hours |
| 3 months to <6 months6 | \*\*40 mg/kg\*\*/10 mg/kg | Every 8 hours | 2 hours |
1 CrCL estimated using the Schwartz bedside formula.
2 To be used in combination with metronidazole when anaerobic pathogens are known or suspected to be contributing to the infectious process.
3 To be used in combination with an antibacterial agent active against Gram-positive pathogens when these are known or suspected to be contributing to the infectious process.
4 The total treatment duration shown may include intravenous Zavicefta followed by appropriate oral therapy.
5 There is very limited experience with the use of Zavicefta for more than 14 days.
6 There is limited experience with the use of Zavicefta in paediatric patients 3 months to < 6 months (see section 5.2).
7 Ceftazidime/avibactam is a combination product in a fixed 4:1 ratio and dosage recommendations are based on the ceftazidime component only (see section 6.6).
\*\*Special populations\*\*
\*Elderly\*
No dosage adjustment is required in elderly patients (see section 5.2).
\*Renal impairment\*
No dosage adjustment is required in patients with mild renal impairment (estimated CrCL > 50 - ≤ 80 mL/min) (see section 5.2).
Table 3 shows the recommended dose adjustments for adults with estimated CrCL ≤ 50 mL/min (see sections 4.4 and 5.2).
\*Dosage in adults with CrCL ≤ 50 mL/min\*
Table 3: Recommended dose for adults with estimated CrCL1 ≤ 50 mL/min
| | | | | |
| --- | --- | --- | --- | --- |
| Age Group | Estimated CrCL (mL/min) | Dose of \*\*ceftazidime\*\*/avibactam2,4 | Frequency | Infusion time |
| Adults | 31-50 | \*\*1 g\*\*/0.25 g | Every 8 hours | 2 hours |
| 16-30 | \*\*0.75 g\*\*/0.1875 g | Every 12 hours |
| 6-15 | Every 24 hours |
| End Stage Renal Disease including on haemodialysis3 | Every 48 hours |
1 CrCL estimated using the Cockcroft-Gault formula.
2 Dose recommendations are based on pharmacokinetic modelling (see section 5.2).
3 Ceftazidime and avibactam are removed by haemodialysis (see sections 4.9 and 5.2). Dosing of Zavicefta on haemodialysis days should occur after completion of haemodialysis.
4 Ceftazidime/avibactam is a combination product in a fixed 4:1 ratio and dosage recommendations are based on the ceftazidime component only (see section 6.6).
Table 4 and Table 5 show the recommended dose adjustments for paediatric patients with estimated CrCL ≤ 50 mL/min/1.73 m2 according to different age groups (see sections 4.4 and 5.2).
\*Dosage in paediatric patients ≥ 2 years of age with CrCl ≤ 50 mL/min/1.73 m2\*
Table 4: Recommended dose for paediatric patients with estimated CrCL1 ≤ 50 mL/min/1.73 m2
| | | | | |
| --- | --- | --- | --- | --- |
| Age Group | Estimated CrCL (mL/min/1.73 m2) | Dose of \*\*ceftazidime\*\*/avibactam2,4 | Frequency | Infusion time |
| Paediatric patients aged 2 years to <18 years | 31-50 | \*\*25 mg/kg\*\*/6.25 mg/kg \*\*to a maximum of\*\* \*\*1 g\*\*/0.25 g | Every 8 hours | 2 hours |
| 16-30 | \*\*18.75 mg/kg\*\*/4.7 mg/kg \*\*to a maximum of\*\* \*\*0.75 g\*\*/0.1875 g | Every 12 hours |
| 6-15 | Every 24 hours |
| End Stage Renal Disease including on haemodialysis3 | Every 48 hours |
1 CrCL estimated using the Schwartz bedside formula.
2 Dose recommendations are based on pharmacokinetic modelling (see section 5.2).
3 Ceftazidime and avibactam are removed by haemodialysis (see sections 4.9 and 5.2). Dosing of Zavicefta on haemodialysis days should occur after completion of haemodialysis.
4 Ceftazidime/avibactam is a combination product in a fixed 4:1 ratio and dosage recommendations are based on the ceftazidime component only (see section 6.6).
\*Dosage in paediatric patients <2 years of age with CrCl ≤ 50 mL/min/1.73 m2\*
Table 5: Recommended dose for paediatric patients with estimated CrCL1 ≤ 50 mL/min/1.73 m2
| | | | | |
| --- | --- | --- | --- | --- |
| Age Group | Estimated CrCL (mL/min/1.73 m2) | Dose of \*\*ceftazidime\*\*/avibactam2,3 | Frequency | Infusion time |
| 3 to < 6 months | 31 to 50 | \*\*20 mg/kg\*\*/5 mg/kg | Every 8 hours | 2 hours |
| 6 months to < 2 years | \*\*25 mg/kg\*\*/6.25 mg/kg | Every 8 hours |
| 3 to < 6 months | 16 to 30 | \*\*15 mg/kg\*\*/3.75 mg/kg | Every 12 hours |
| 6 months to < 2 years | \*\*18.75 mg/kg\*\*/4.7 mg/kg | Every 12 hours |
| 1 Calculated using the Schwartz bedside formula 2 Dose recommendations are based on pharmacokinetic modelling (see section 5.2). 3 Ceftazidime/avibactam is a combination product in a fixed 4:1 ratio and dosage recommendations are based on the ceftazidime component only (see section 6.6). | | | | |
There is insufficient information to recommend a dosage regimen for paediatric patients < 2 years of age that have a CrCL \*<\* 16 mL/min/1.73 m2.
\*Hepatic impairment\*
No dosage adjustment is required in patients with hepatic impairment (see section 5.2).
\*Paediatric population\*
The safety and efficacy of Zavicefta in paediatric patients < 3 months old have not been established. No data are available.
\*\*Method of administration\*\*
Intravenous use.
Zavicefta is administered by intravenous infusion over 120 minutes in an appropriate infusion volume (see section 6.6).
For instructions on reconstitution and dilution of the medicinal product before administration see section 6.6.4.3 Contraindications
Hypersensitivity to the active substances or to any of the excipients listed in section 6.1.
Hypersensitivity to any cephalosporin antibacterial agent.
Severe hypersensitivity (e.g. anaphylactic reaction, severe skin reaction) to any other type of β-lactam antibacterial agent (e.g. penicillins, monobactams or carbapenems).4.4 Special warnings and precautions for use
\*\*Hypersensitivity reactions\*\*
Serious and occasionally fatal hypersensitivity reactions are possible (see sections 4.3 and 4.8). In case of hypersensitivity reactions, treatment with Zavicefta must be discontinued immediately and adequate emergency measures must be initiated.
There have been reports of hypersensitivity reactions which progressed to Kounis syndrome (acute allergic coronary arteriospasm that can result in myocardial infarction, see section 4.8).
Before beginning treatment, it should be established whether the patient has a history of hypersensitivity reactions to ceftazidime, to other cephalosporins or to any other type of β-lactam antibacterial agent. Caution should be used if ceftazidime/avibactam is given to patients with a history of non-severe hypersensitivity to penicillins, monobactams or carbapenems.
Severe cutaneous adverse reactions (SCARs) including Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), drug reaction with eosinophilia and systemic symptoms (DRESS), and acute generalised exanthematous pustulosis (AGEP), which can be life‑threatening or fatal, have been reported with unknown frequency in association with ceftazidime treatment (see section 4.8).
Patients should be advised of the signs and symptoms and monitored closely for skin reactions.
If signs and symptoms suggestive of these reactions appear, Zavicefta should be withdrawn immediately, and an alternative treatment considered.
If the patient has developed a serious reaction such as SJS, TEN, DRESS or AGEP with the use of ceftazidime, treatment with Zavicefta must not be restarted in this patient at any time.
\*\*\*Clostridioides difficile -\* associated diarrhoea\*\*
\*Clostridioides difficile -\* associated diarrhoea has been reported with ceftazidime/avibactam, and can range in severity from mild to life-threatening. This diagnosis should be considered in patients who present with diarrhoea during or subsequent to the administration of Zavicefta (see section 4.8). Discontinuation of therapy with Zavicefta and the administration of specific treatment for \*Clostridioides difficile\* should be considered. Medicinal products that inhibit peristalsis should not be given.
\*\*Renal impairment\*\*
Ceftazidime and avibactam are eliminated via the kidneys, therefore, the dose should be reduced according to the degree of renal impairment (see section 4.2). Neurological sequelae, including tremor, myoclonus, non-convulsive status epilepticus, convulsion, encephalopathy and coma, have occasionally been reported with ceftazidime when the dose has not been reduced in patients with renal impairment.
In patients with renal impairment, close monitoring of estimated creatinine clearance is advised. In some patients, the creatinine clearance estimated from serum creatinine can change quickly, especially early in the course of treatment for the infection.
\*\*Nephrotoxicity\*\*
Concurrent treatment with high doses of cephalosporins and nephrotoxic medicinal products such as aminoglycosides or potent diuretics (e.g. furosemide) may adversely affect renal function.
\*\*Direct antiglobulin test (DAGT or Coombs test) seroconversion and potential risk of haemolytic anaemia\*\*
Ceftazidime/avibactam use may cause development of a positive direct antiglobulin test (DAGT\*\*\*,\*\*\* or Coombs test), which may interfere with the cross-matching of blood and/or may cause drug induced immune haemolytic anaemia (see section 4.8). While DAGT seroconversion in patients receiving Zavicefta was very common in clinical studies (the estimated range of seroconversion across Phase 3 studies was 3.2% to 20.8% in patients with a negative Coombs test at baseline and at least one follow-up test), there was no evidence of haemolysis in patients who developed a positive DAGT on treatment. However, the possibility that haemolytic anaemia could occur in association with Zavicefta treatment cannot be ruled out. Patients experiencing anaemia during or after treatment with Zavicefta should be investigated for this possibility.
\*\*Limitations of the clinical data\*\*
Clinical efficacy and safety studies of Zavicefta have been conducted in cIAI, cUTI and HAP (including VAP).
\*Complicated intra-abdominal infections in adults\*
In two studies in patients with cIAI, the most common diagnosis (approximately 42%) was appendiceal perforation or peri-appendiceal abscess. Approximately 87% of patients had APACHE II scores of ≤ 10 and 4% had bacteraemia at baseline. Death occurred in 2.1% (18/857) of patients who received Zavicefta and metronidazole and in 1.4% (12/863) of patients who received meropenem.
Among a subgroup with baseline CrCL 30 to 50 mL/min death occurred in 16.7% (9/54) of patients who received Zavicefta and metronidazole and 6.8% (4/59) of patients who received meropenem. Patients with CrCL 30 to 50 mL/min received a lower dose of Zavicefta than is currently recommended for patients in this sub-group.
\*Complicated urinary tract infections in adults\*
In two studies in patients with cUTI, 381/1091 (34.9%) patients were enrolled with cUTI without pyelonephritis while 710 (65.1%) were enrolled with acute pyelonephritis (mMITT population). A total of 81 cUTI patients (7.4%) had bacteraemia at baseline.
\*Hospital-acquired pneumonia (including ventilator-associated pneumonia) in adults\*
In a single study in patients with nosocomial pneumonia 280/808 (34.7%) had VAP and 40/808 (5%) were bacteraemic at baseline.
\*Patients with limited treatment options\*
The use of ceftazidime/avibactam to treat patients with infections due to Gram-negative aerobic pathogens who have limited treatment options is based on experience with ceftazidime alone and on analyses of the pharmacokinetic-pharmacodynamic relationship for ceftazidime/avibactam (see section 5.1).
\*\*Spectrum of activity of ceftazidime/avibactam\*\*
Ceftazidime has little or no activity against the majority of Gram-positive organisms and anaerobes (see sections 4.2 and 5.1). Additional antibacterial agents should be used when these pathogens are known or suspected to be contributing to the infectious process.
The inhibitory spectrum of avibactam includes many of the enzymes that inactivate ceftazidime, including Ambler class A β-lactamases and class C β-lactamases. Avibactam does not inhibit class B enzymes (metallo-β-lactamases) and is not able to inhibit many of the class D enzymes (see section 5.1).
\*\*Non-susceptible organisms\*\*
Prolonged use may result in the overgrowth of non-susceptible organisms (e.g. enterococci, fungi), which may require interruption of treatment or other appropriate measures.
\*\*Interference with laboratory tests\*\*
Ceftazidime may interfere with copper reduction methods (Benedict's, Fehling's, Clinitest) for detection of glycosuria leading to false positive results. Ceftazidime does not interfere with enzyme-based tests for glycosuria.
\*\*Controlled sodium diet\*\*
This medicinal product contains approximately 146 mg sodium per vial, equivalent to 7.3% of the WHO recommended maximum daily intake (RDI) of 2 g sodium for an adult.
The maximum daily dose of this product is equivalent to 22% of the WHO recommended maximum daily intake for sodium. Zavicefta is considered high in sodium.
This should be considered when administering Zavicefta to patients who are on a controlled sodium diet.
Zavicefta may be diluted with sodium-containing solutions (see section 6.6) and this should be considered in relation to the total sodium from all sources that will be administered to the patient.
\*\*Paediatric population\*\*
There is a potential risk of overdosing, particularly for paediatric patients aged from 3 to less than 12 months of age. Care should be taken when calculating the volume of administration of the dose (see sections 4.9 and 6.6).4.5 Interaction with other medicinal products and other forms of interaction
\*In vitro\*, avibactam is a substrate of OAT1 and OAT3 transporters which might contribute to the active uptake of avibactam from the blood compartment and, therefore, affect its excretion. Probenecid (a potent OAT inhibitor) inhibits this uptake by 56% to 70% \*in vitro\* and, therefore, has the potential to alter the elimination of avibactam. Since a clinical interaction study of avibactam and probenecid has not been conducted, co-administration of avibactam with probenecid is not recommended.
Avibactam showed no significant inhibition of cytochrome P450 enzymes \*in vitro\*. Avibactam and ceftazidime showed no \*in vitro\* cytochrome P450 induction at clinically relevant concentrations. Avibactam and ceftazidime do not inhibit the major renal or hepatic transporters in the clinically relevant exposure range, therefore the interaction potential via these mechanisms is considered to be low.
Clinical data have demonstrated that there is no interaction between ceftazidime and avibactam, and between ceftazidime/avibactam and metronidazole.
\*Other types of interaction\*
Concurrent treatment with high doses of cephalosporins and nephrotoxic medicinal products such as aminoglycosides or potent diuretics (e.g. furosemide) may adversely affect renal function (see section 4.4).
Chloramphenicol is antagonistic \*in vitro\* with ceftazidime and other cephalosporins. The clinical relevance of this finding is unknown, but due to the possibility of antagonism \*in vivo\* this drug combination should be avoided.4.6 Fertility, pregnancy and lactation
\*\*Pregnancy\*\*
Animal studies with ceftazidime do not indicate direct or indirect harmful effects with respect to pregnancy, embryonal/foetal development, parturition or postnatal development. Animal studies with avibactam have shown reproductive toxicity without evidence of teratogenic effects (see section 5.3).
Ceftazidime/avibactam should only be used during pregnancy if the potential benefit outweighs the possible risk.
\*\*Breast-feeding\*\*
Ceftazidime is excreted in human milk in small quantities. It is unknown whether avibactam is excreted in human milk. A risk to newborns/infants cannot be excluded. A decision must be made whether to discontinue breast feeding or to discontinue/abstain from ceftazidime/avibactam therapy taking into account the benefit of breast feeding for the child and the benefit of therapy for the woman.
\*\*Fertility\*\*
The effects of ceftazidime/avibactam on fertility in humans have not been studied. No data are available on animal studies with ceftazidime. Animal studies with avibactam do not indicate harmful effects with respect to fertility (see section 5.3).4.7 Effects on ability to drive and use machines
Undesirable effects may occur (e.g. dizziness), which may influence the ability to drive and use machines following administration of Zavicefta (see section 4.8).4.8 Undesirable effects
\*\*Summary of the safety profile\*\*
In seven Phase 2 and Phase 3 clinical trials, 2024 adults were treated with Zavicefta. The most common adverse reactions occurring in ≥5% of patients treated with Zavicefta were Coombs direct test positive, nausea, and diarrhoea. Nausea and diarrhoea were usually mild or moderate in intensity.
\*\*Tabulated list of adverse reactions\*\*
The following adverse reactions have been reported with ceftazidime alone and/or identified during the Phase 2 and Phase 3 trials with Zavicefta. Adverse reactions are classified according to frequency and System Organ Class. Frequency categories are derived from adverse reactions and/or potentially clinically significant laboratory abnormalities, and are defined according to the following conventions:
Very common (≥1/10)
Common (≥1/100 and <1/10)
Uncommon (≥1/1,000 and <1/100)
Rare (≥1/10,000 and <1/1,000)
Very rare (<1/10,000)
not known (cannot be estimated from the available data)
Table 6: Frequency of adverse reactions by system organ class
| | | | | | |
| --- | --- | --- | --- | --- | --- |
| \*\*System Organ Class\*\* | \*\*Very common\*\* | \*\*Common\*\* | \*\*Uncommon\*\* | \*\*Very rare\*\* | \*\*not known\*\* |
| Infections and infestations | | Candidiasis (including Vulvovaginal candidiasis and Oral candidiasis) | Clostridioides difficile colitis Pseudomembranous colitis | | |
| Blood and lymphatic system disorders | Coombs direct test positive | Eosinophilia Thrombocytosis Thrombocytopenia | Neutropenia Leukopenia Lymphocytosis | | Agranulocytosis Haemolytic anaemia |
| Immune system disorders | | | | | Anaphylactic reaction |
| Nervous system disorders | | Headache Dizziness | Paraesthesia | | |
| Cardiac disorders | | | | | Kounis syndromea,\\* |
| Gastrointestinal disorders | | Diarrhoea Abdominal pain Nausea Vomiting | Dysgeusia | | |
| Hepatobiliary disorders | | Alanine aminotransferase increased Aspartate aminotransferase increased Blood alkaline phosphatase increased Gamma-glutamyltransferase increased Blood lactate dehydrogenase Increased | | | Jaundice |
| Skin and subcutaneous tissue disorders | | Rash maculopapular Urticaria Pruritus | | | Toxic epidermal necrolysis Stevens-Johnson syndrome Erythema multiforme Angioedema Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) Acute generalised exanthematous pustulosis (AGEP)\\* |
| Renal and urinary disorders | | | Blood creatinine increased Blood urea increased Acute kidney injury | Tubulointerstitial nephritis | |
| General disorders and administration site conditions | | Infusion site thrombosis Infusion site phlebitis Pyrexia | | | |
\\* ADR identified post-marketing.
a Acute coronary syndrome associated with an allergic reaction.
\*\*Paediatric population\*\*
The safety assessment in paediatric patients is based on the safety data from two trials in which 61 patients (aged from 3 years to less than 18 years) with cIAI and 67 patients with cUTI (aged from 3 months to less than 18 years) received Zavicefta. Overall, the safety profile in these 128 paediatric patients was similar to that observed in the adult population with cIAI and cUTI.
\*\*Reporting of suspected adverse reactions\*\*
Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the Yellow Card Scheme at: www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store.4.9 Overdose
Overdose with ceftazidime/avibactam can lead to neurological sequelae including encephalopathy, convulsions and coma, due to the ceftazidime component.
Serum levels of ceftazidime can be reduced by haemodialysis or peritoneal dialysis. During a 4-hour haemodialysis period, 55% of the avibactam dose was removed.
## Pharmacological Properties
5.1 Pharmacodynamic properties
Pharmacotherapeutic group: Antibacterials for systemic use, other beta-lactam antibacterials, third-generation cephalosporins, ATC code: J01DD52
\*\*Mechanism of action\*\*
Ceftazidime inhibits bacterial peptidoglycan cell wall synthesis following binding to penicillin binding proteins (PBPs), which leads to bacterial cell lysis and death. Avibactam is a non β-lactam, β-lactamase inhibitor that acts by forming a covalent adduct with the enzyme that is stable to hydrolysis. It inhibits both Ambler class A and class C β-lactamases and some class D enzymes, including extended-spectrum β-lactamases (ESBLs), KPC and OXA-48 carbapenemases, and AmpC enzymes. Avibactam does not inhibit class B enzymes (metallo-β-lactamases) and is not able to inhibit many class D enzymes.
\*\*Resistance\*\*
Bacterial resistance mechanisms that could potentially affect ceftazidime/avibactam include mutant or acquired PBPs, decreased outer membrane permeability to either compound, active efflux of either compound, and β-lactamase enzymes refractory to inhibition by avibactam and able to hydrolyse ceftazidime.
\*\*Antibacterial activity in combination with other antibacterial agents\*\*
No synergy or antagonism was demonstrated in \*in vitro\* drug combination studies with ceftazidime/avibactam and metronidazole, tobramycin, levofloxacin, vancomycin, linezolid, colistin and tigecycline.
\*\*Susceptibility testing breakpoints\*\*
Minimum Inhibitory Concentration (MIC) breakpoints established by the European Committee on Antimicrobial Susceptibility Testing (EUCAST) for ceftazidime/avibactam can be viewed on the following website:
https://www.ema.europa.eu/documents/other/minimum-inhibitory-concentration-mic-breakpoints\\_en.xlsx
\*\*Pharmacokinetic/pharmacodynamic relationship\*\*
The antimicrobial activity of ceftazidime against specific pathogens has been shown to best correlate with the percent time of free-drug concentration above the ceftazidime/avibactam minimum inhibitory concentration over the dose interval (% \*f\*T >MIC of ceftazidime/avibactam). For avibactam the PK-PD index is the percent time of the free drug concentration above a threshold concentration over the dose interval (% \*f\*T >CT).
\*\*Clinical efficacy against specific pathogens\*\*
Efficacy has been demonstrated in clinical studies against the following pathogens that were susceptible to ceftazidime/avibactam \*in vitro\*.
\*\*Complicated intra-abdominal infections\*\*
Gram-negative micro-organisms
• \*Citrobacter freundii\*
• \*Enterobacter cloacae\*
• \*Escherichia coli\*
• \*Klebsiella oxytoca\*
• \*Klebsiella pneumoniae\*
• \*Pseudomonas aeruginosa\*
\*\*Complicated urinary-tract infections\*\*
Gram-negative micro-organisms
• \*Escherichia coli\*
• \*Klebsiella pneumoniae\*
• \*Proteus mirabilis\*
• \*Enterobacter cloacae\*
• \*Pseudomonas aeruginosa\*
\*\*Hospital-acquired pneumonia including ventilator-associated pneumonia\*\*
Gram-negative micro-organisms
• \*Enterobacter cloacae\*
• \*Escherichia coli\*
• \*Klebsiella pneumoniae\*
• \*Proteus mirabilis\*
• \*Serratia marcescens\*
• \*Pseudomonas aeruginosa\*
Clinical efficacy has not been established against the following pathogens that are relevant to the approved indications although \*in vitro\* studies suggest that they would be susceptible to ceftazidime/avibactam in the absence of acquired mechanisms of resistance.
Gram-negative micro-organisms
• \*Citrobacter koseri\*
• \*Enterobacter aerogenes\*
• \*Morganella morganii\*
• \*Proteus vulgaris\*
• \*Providencia rettgeri\*
\*In-vitro\* data indicate that the following species are not susceptible to ceftazidime/avibactam.
• \*Staphylococcus aureus\* (methicillin-susceptible and methicillin-resistant)
• Anaerobes
• \*Enterococcus\* spp.
• \*Stenotrophomonas maltophilia\*
• \*Acinetobacter\* spp.
\*\*Paediatric population\*\*
Zavicefta has been evaluated in paediatric patients aged 3 months to < 18 years in two Phase 2 single-blind, randomised, comparative clinical studies, one in patients with cIAI and one in patients with cUTI. The primary objective in each study was to assess safety and tolerability of ceftazidime-avibactam (+/- metronidazole). Secondary objectives included assessment of pharmacokinetics and efficacy; efficacy was a descriptive endpoint in both studies. Clinical cure rate at TOC (ITT) was 91.8% (56/61) for Zavicefta compared to 95.5% (21/22) for meropenem in paediatric patients with cIAI. Microbiological eradication rate at TOC (micro-ITT) was 79.6% (43/54) for Zavicefta compared to 60.9% (14/23) for cefepime in paediatric patients with cUTI.
The licensing authority has deferred the obligation to submit the results of studies with Zavicefta in one or more subsets of the paediatric population in the treatment of cIAI, cUTI, pneumonia and Gram-negative bacterial infections (see section 4.2 for information on paediatric use).5.2 Pharmacokinetic properties
\*\*Distribution\*\*
The human protein binding of both ceftazidime and avibactam is approximately 10% and 8%, respectively. The steady-state volumes of distribution of ceftazidime and avibactam were about 17 L and 22 L, respectively in healthy adults following multiple doses of 2 g/0.5 g ceftazidime/avibactam infused over 2 hours every 8 hours. Both ceftazidime and avibactam penetrate into human bronchial epithelial lining fluid (ELF) to the same extent with concentrations around 30% of those in plasma. The concentration time profiles are similar for ELF and plasma.
Penetration of ceftazidime into the intact blood-brain barrier is poor. Ceftazidime concentrations of 4 to 20 mg/L or more are achieved in the CSF when the meninges are inflamed. Avibactam penetration of the blood brain barrier has not been studied clinically; however, in rabbits with inflamed meninges, CSF exposures of ceftazidime and avibactam were 43% and 38% of plasma AUC, respectively. Ceftazidime crosses the placenta readily, and is excreted in the breast milk.
\*\*Biotransformation\*\*
Ceftazidime is not metabolised. No metabolism of avibactam was observed in human liver preparations (microsomes and hepatocytes). Unchanged avibactam was the major drug-related component in human plasma and urine following dosing with [14C]-avibactam.
\*\*Elimination\*\*
The terminal half-life (t½) of both ceftazidime and avibactam is about 2 h after intravenous administration. Ceftazidime is excreted unchanged into the urine by glomerular filtration; approximately 80-90% of the dose is recovered in the urine within 24 h. Avibactam is excreted unchanged into the urine with a renal clearance of approximately 158 mL/min, suggesting active tubular secretion in addition to glomerular filtration. Approximately 97% of the avibactam dose is recovered in the urine, 95% within 12 h. Less than 1% of ceftazidime is excreted via the bile and less than 0.25% of avibactam is excreted into faeces.
\*\*Linearity/non-linearity\*\*
The pharmacokinetics of both ceftazidime and avibactam are approximately linear across the dose range studied (0.5 g to 2 g for ceftazidime and 0.05 g to 2 g for avibactam) for a single intravenous administration. No appreciable accumulation of ceftazidime or avibactam was observed following multiple intravenous infusions of 2 g/0.5 g of ceftazidime/avibactam administered every 8 hours for up to 11 days in healthy adults with normal renal function.
\*\*Special populations\*\*
\*Renal impairment\*
Elimination of ceftazidime and avibactam is decreased in patients with moderate or severe renal impairment. The average increases in avibactam AUC are 3.8-fold and 7-fold in subjects with moderate and severe renal impairment, see section 4.2.
\*Hepatic impairment\*
Mild to moderate hepatic impairment had no effect on the pharmacokinetics of ceftazidime in individuals administered 2 g intravenously every 8 hours for 5 days, provided renal function was not impaired. The pharmacokinetics of ceftazidime in patients with severe hepatic impairment has not been established. The pharmacokinetics of avibactam in patients with any degree of hepatic impairment has not been studied.
As ceftazidime and avibactam do not appear to undergo significant hepatic metabolism, the systemic clearance of either active substance is not expected to be significantly altered by hepatic impairment.
\*Elderly patients (≥65 years)\*
Reduced clearance of ceftazidime was observed in elderly patients, which was primarily due to age-related decrease in renal clearance of ceftazidime. The mean elimination half-life of ceftazidime ranged from 3.5 to 4 hours following intravenous bolus dosing with 2 g every 12 hours in elderly patients aged 80 years or older.
Following a single intravenous administration of 500 mg avibactam as a 30-minute IV infusion, the elderly had a slower terminal half-life of avibactam, which may be attributed to age related decrease in renal clearance.
\*Paediatric population\*
The pharmacokinetics of ceftazidime and avibactam were evaluated in paediatric patients from 3 months to < 18 years of age with suspected or confirmed infections following a single dose of ceftazidime 50 mg/kg and avibactam 12.5 mg/kg for patients weighing < 40 kg or Zavicefta 2 g/0.5 g (ceftazidime 2 grams and avibactam 0.5 grams) for patients weighing ≥ 40 kg. Plasma concentrations of ceftazidime and avibactam were similar across all four age cohorts in the study (3 months to < 2 years, 2 to < 6 years, 6 to < 12 years, and 12 to < 18 years). Ceftazidime and avibactam AUC0-t and Cmax values in the two older cohorts (paediatric patients from 6 to < 18 years), which had more extensive pharmacokinetic sampling, were similar to those observed in healthy adult subjects with normal renal function that received Zavicefta 2 g/0.5 g. Data from this study and the two Phase 2 paediatric studies in patients with cIAI and cUTI were pooled with PK data from adults (Phase 1 to Phase 3) to update the population PK model, which was used to conduct simulations to assess PK/PD target attainment. Results from these simulations demonstrated that the recommended dose regimens for paediatric patients with cIAI, cUTI and HAP/VAP, including dose adjustments for patients with renal impairment, result in systemic exposure and PK/PD target attainment values that are similar to those in adults at the approved Zavicefta dose of 2 g/0.5 g administered over 2 hours, every 8 hours.
There is limited experience with the use of ceftazidime plus avibactam in the paediatric groups of 3 months to < 6 months. The recommended dosing regimens are based on simulations conducted using the final population PK models. Simulations demonstrated that the recommended dose regimens result in comparable exposures to other age groups with PK/PD target attainment > 90%. Based on data from the completed paediatric clinical trials, at the recommended dose regimens, there was no evidence of over or under exposure in the subjects aged 3 months to < 6 months.
In addition, there is very limited data in paediatric patients aged 3 months to < 2 years with impaired renal function (CrCL ≤ 50 mL/min/1.73 m2), with no data in severe renal impairment from the completed paediatric clinical trials. Population PK models for ceftazidime and avibactam were used to conduct simulations for patients with impaired renal function.
\*Gender and race\*
The pharmacokinetics of ceftazidime/avibactam is not significantly affected by gender or race.5.3 Preclinical safety data
\*\*Ceftazidime\*\*
Non-clinical data reveal no special hazard for humans based on conventional studies of safety pharmacology, repeated dose toxicity, reproduction toxicity or genotoxicity. Carcinogenicity studies have not been conducted with ceftazidime.
\*\*Avibactam\*\*
Non-clinical data reveal no special hazard for humans based on conventional studies of safety pharmacology, repeated dose toxicity or genotoxicity. Carcinogenicity studies have not been conducted with avibactam.
\*\*Reproduction toxicity\*\*
In pregnant rabbits administered avibactam at 300 and 1000 mg/kg/day, there was a dose-related lower mean foetal weight and delayed ossification, potentially related to maternal toxicity. Plasma exposure levels at maternal and foetal NOAEL (100 mg/kg/day) indicate moderate to low margins of safety.
In the rat, no adverse effects were observed on embryofetal development or fertility. Following administration of avibactam throughout pregnancy and lactation in the rat, there was no effect on pup survival, growth or development, however there was an increase in incidence of dilation of the renal pelvis and ureters in less than 10% of the rat pups at maternal exposures greater than or equal to approximately 1.5 times human therapeutic exposures.
## Pharmaceutical Particulars
6.1 List of excipients
Sodium carbonate (anhydrous)6.2 Incompatibilities
The compatibility of Zavicefta with other medicines has not been established. Zavicefta should not be mixed with or physically added to solutions containing other medicinal products.
This medicinal product must not be mixed with other medicinal products except those mentioned in section 6.6.6.3 Shelf life
\*\*Dry powder\*\*
3 years.
\*\*After reconstitution\*\*
The reconstituted vial should be used immediately.
\*\*After dilution\*\*
\*Infusion bags\*
If the intravenous solution is prepared with diluents listed in section 6.6 (ceftazidime concentration 8 mg/mL), the chemical and physical in-use stability has been demonstrated (from initial vial puncture) for up to 12 hours at 2 - 8°C, followed by up to 4 hours at not more than 25°C.
If the intravenous solution is prepared with diluents listed in section 6.6 (ceftazidime concentration > 8 mg/mL to 40 mg/mL), the chemical and physical in-use stability has been demonstrated (from initial vial puncture) for up to 4 hours at not more than 25°C.
From a microbiological point of view, the medicinal product should be used immediately, unless reconstitution and dilution have taken place in controlled and validated aseptic conditions. If not used immediately, in-use storage times and conditions prior to use are the responsibility of the user and must not exceed those stated above.
\*Infusion syringes\*
The chemical and physical in-use stability has been demonstrated (from initial vial puncture) for up to 6 hours at not more than 25°C.
From a microbiological point of view, the medicinal product should be used immediately unless reconstitution and dilution have taken place in controlled and validated aseptic conditions. If not used immediately, in-use storage times and conditions prior to use are the responsibility of the user and must not exceed 6 hours at not more than 25°C.6.4 Special precautions for storage
This medicinal product does not require any special storage conditions.
Store in the original package in order to protect from light.
For storage conditions of the reconstituted and diluted medicinal product, see section 6.3.6.5 Nature and contents of container
20 mL glass vial (Type 1) closed with a rubber (halobutyl) stopper and aluminium seal with flip-off cap.
The medicinal product is supplied in packs of 10 vials.6.6 Special precautions for disposal and other handling
The powder must be reconstituted with water for injections and the resulting concentrate must then be immediately diluted prior to use. The reconstituted solution is a pale yellow solution and is free of particles.
Zavicefta (ceftazidime/avibactam) is a combination product; each vial contains 2 g of ceftazidime and 0.5 g of avibactam in a fixed 4:1 ratio. Dosage recommendations are based on the ceftazidime component only.
Standard aseptic techniques should be used for solution preparation and administration. Doses may be prepared in an appropriately sized infusion bag or infusion syringe.
Parenteral medicinal products should be inspected visually for particulate matter prior to administration.
Each vial is for single use only.
Any unused product or waste material should be disposed of in accordance with local requirements.
The total time interval between starting reconstitution and completing preparation of the intravenous infusion should not exceed 30 minutes.
\*\*Instructions for preparing adult and paediatric doses in INFUSION BAG or in INFUSION SYRINGE:\*\*
NOTE: The following procedure describes the steps to prepare an infusion solution with a final concentration of 8-40 mg/mL of ceftazidime. All calculations should be completed prior to initiating these steps. \*\*For paediatric patients aged 3 to 12 months\*\*, detailed steps to prepare a 20 mg/mL concentration (sufficient for most scenarios) are also provided.
1. Prepare the \*\*reconstituted solution\*\* (\*\*167.3 mg/mL\*\* of ceftazidime):
a) Insert the syringe needle through the vial closure and inject 10 mL of sterile water for injections.
b) Withdraw the needle and shake the vial to give a clear solution.
c) Insert a gas relief needle through the vial closure \*\*after\*\* the product has dissolved to relieve the internal pressure (this is important to preserve product sterility).
2. Prepare the \*\*final solution\*\* for infusion (final concentration must be \*\*8-40 mg/mL\*\* of ceftazidime):
a) Infusion bag: Further dilute the reconstituted solution by transferring an appropriately calculated volume of the reconstituted solution to an infusion bag containing any of the following: sodium chloride 9 mg/mL (0.9%) solution for injection, dextrose 50 mg/mL (5%) solution for injection, or Lactated Ringer's solution.
b) Infusion syringe: Further dilute the reconstituted solution by transferring an appropriately calculated volume of the reconstituted solution combined with a sufficient volume of diluent (sodium chloride 9 mg/mL (0.9%) solution for injection or dextrose 50 mg/mL (5%) solution for injection) to an infusion syringe.
Refer to Table 7 below.
Table 7: Preparation of Zavicefta for adult and paediatric doses in INFUSION BAG or in INFUSION SYRINGE.
| | | | |
| --- | --- | --- | --- |
| \*\*Zavicefta Dose (ceftazidime)1\*\* | \*\*Volume to withdraw from reconstituted vial\*\* | \*\*Final volume after dilution in infusion bag2\*\* | \*\*Final volume in infusion syringe\*\* |
| 2 g | Entire contents (approximately 12 mL) | 50 mL to 250 mL | 50 mL |
| 1g | 6 mL | 25 mL to 125 mL | 25 mL to 50 mL |
| 0.75 g | 4.5 mL | 19 mL to 93 mL | 19 mL to 50 mL |
| All other doses | Volume (mL) calculated based on dose required: \*\*Dose (mg ceftazidime) ÷ 167.3 mg/mL ceftazidime\*\* | Volume (mL) will vary based on infusion bag size availability and preferred final concentration (must be 8-40 mg/mL of ceftazidime) | Volume (mL) will vary based on infusion syringe size availability and preferred final concentration (must be 8-40 mg/mL of ceftazidime) |
1 Based on ceftazidime component only.
2 Dilute to final ceftazidime concentration of 8 mg/mL for in-use stability up to 12 hours at 2 - 8°C, followed by up to 4 hours at not more than 25°C (i.e. dilute 2 g dose of ceftazidime in 250 mL, 1 g dose of ceftazidime in 125 mL, 0.75 g dose of ceftazidime in 93 mL, etc.). All other ceftazidime concentrations (> 8 mg/mL to 40 mg/mL) have in-use stability up to 4 hours at not more than 25°C.
\*\*Preparation of Zavicefta for use in paediatric patients aged 3 to 12 months of age in INFUSION SYRINGE:\*\*
NOTE: The following procedure describes the steps to prepare an infusion solution with a final concentration of 20 mg/mL of ceftazidime (sufficient for most scenarios). Alternative concentrations may be prepared, but must have a final concentration range of 8-40 mg/mL of ceftazidime.
1. Prepare the \*\*reconstituted solution\*\* (\*\*167.3 mg/mL\*\* of ceftazidime):
a) Insert the syringe needle through the vial closure and inject 10 mL of sterile water for injections.
b) Withdraw the needle and shake the vial to give a clear solution.
c) Insert a gas relief needle through the vial closure \*\*after\*\* the product has dissolved to relieve the internal pressure (this is important to preserve product sterility).
2. Prepare the \*\*final solution\*\* for infusion to a final concentration of \*\*20 mg/mL\*\* of ceftazidime:
a) Further dilute the reconstituted solution by transferring an appropriately calculated volume of the reconstituted solution combined with a sufficient volume of diluent (sodium chloride 9 mg/mL (0.9%) solution for injection or dextrose 50 mg/mL (5%) solution for injection) to an infusion syringe.
b) Refer to Table 8, 9, or 10 below to confirm the calculations. Values shown are approximate as it may be necessary to round to the nearest graduation mark of an appropriately sized syringe. Note that the tables are NOT inclusive of all possible calculated doses but may be utilized to estimate the approximate volume to verify the calculation.
Table 8: Preparation of Zavicefta (final concentration of 20 mg/mL of ceftazidime) in paediatric patients 3 to 12 months of age with creatinine clearance (CrCL) > 50 mL/min/1.73 m2
| | | | | |
| --- | --- | --- | --- | --- |
| \*\*Age and Zavicefta Dose (mg/kg)1\*\* | \*\*Weight (kg)\*\* | \*\*Dose (mg ceftazidime)\*\* | \*\*Volume of reconstituted solution to be withdrawn from vial (mL)\*\* | \*\*Volume of diluent to add for mixing (mL)\*\* |
| \*\*6 months to 12 months\*\* \*\*50 mg/kg of ceftazidime\*\* | 5 | 250 | 1.5 | 11 |
| 6 | 300 | 1.8 | 13 |
| 7 | 350 | 2.1 | 15 |
| 8 | 400 | 2.4 | 18 |
| 9 | 450 | 2.7 | 20 |
| 10 | 500 | 3 | 22 |
| 11 | 550 | 3.3 | 24 |
| 12 | 600 | 3.6 | 27 |
| \*\*3 months to < 6 months\*\* \*\*40 mg/kg of ceftazidime\*\* | 4 | 160 | 1 | 7.4 |
| 5 | 200 | 1.2 | 8.8 |
| 6 | 240 | 1.4 | 10 |
| 7 | 280 | 1.7 | 13 |
| 8 | 320 | 1.9 | 14 |
| 9 | 360 | 2.2 | 16 |
| 10 | 400 | 2.4 | 18 |
1 Based on ceftazidime component only.
Table 9: Preparation of Zavicefta (final concentration of 20 mg/mL of ceftazidime) in paediatric patients 3 to 12 months of age with CrCL 31 to 50 mL/min/1.73 m2
| | | | | |
| --- | --- | --- | --- | --- |
| \*\*Age and Zavicefta Dose (mg/kg)1\*\* | \*\*Weight (kg)\*\* | \*\*Dose (mg ceftazidime)\*\* | \*\*Volume of reconstituted solution to be withdrawn from vial (mL)\*\* | \*\*Volume of diluent to add for mixing (mL)\*\* |
| \*\*6 months to 12 months\*\* \*\*25 mg/kg of ceftazidime\*\* | 5 | 125 | 0.75 | 5.5 |
| 6 | 150 | 0.9 | 6.6 |
| 7 | 175 | 1 | 7.4 |
| 8 | 200 | 1.2 | 8.8 |
| 9 | 225 | 1.3 | 9.6 |
| 10 | 250 | 1.5 | 11 |
| 11 | 275 | 1.6 | 12 |
| 12 | 300 | 1.8 | 13 |
| \*\*3 months to < 6 months\*\* \*\*20 mg/kg of ceftazidime\*\* | 4 | 80 | 0.48 | 3.5 |
| 5 | 100 | 0.6 | 4.4 |
| 6 | 120 | 0.72 | 5.3 |
| 7 | 140 | 0.84 | 6.2 |
| 8 | 160 | 1 | 7.4 |
| 9 | 180 | 1.1 | 8.1 |
| 10 | 200 | 1.2 | 8.8 |
1 Based on ceftazidime component only.
Table 10: Preparation of Zavicefta (final concentration of 20 mg/mL of ceftazidime) in paediatric patients 3 to 12 months of age with CrCL 16 to 30 mL/min/1.73 m2
| | | | | |
| --- | --- | --- | --- | --- |
| \*\*Age and Zavicefta Dose (mg/kg) 1\*\* | \*\*Weight (kg)\*\* | \*\*Dose (mg ceftazidime)\*\* | \*\*Volume of reconstituted solution to be withdrawn from vial (mL)\*\* | \*\*Volume of diluent to add for mixing (mL)\*\* |
| \*\*6 months to 12 months\*\* \*\*18.75 mg/kg of ceftazidime\*\* | 5 | 93.75 | 0.56 | 4.1 |
| 6 | 112.5 | 0.67 | 4.9 |
| 7 | 131.25 | 0.78 | 5.7 |
| 8 | 150 | 0.9 | 6.6 |
| 9 | 168.75 | 1 | 7.4 |
| 10 | 187.5 | 1.1 | 8.1 |
| 11 | 206.25 | 1.2 | 8.8 |
| 12 | 225 | 1.3 | 9.6 |
| \*\*3 months to < 6 months\*\* \*\*15 mg/kg of ceftazidime\*\* | 4 | 60 | 0.36 | 2.7 |
| 5 | 75 | 0.45 | 3.3 |
| 6 | 90 | 0.54 | 4 |
| 7 | 105 | 0.63 | 4.6 |
| 8 | 120 | 0.72 | 5.3 |
| 9 | 135 | 0.81 | 6 |
| 10 | 150 | 0.9 | 6.6 |
1 Based on ceftazidime component only.
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