Consumer medicine information

Invanz for injection [8956]

Ertapenem

BRAND INFORMATION

Brand name

Invanz

Active ingredient

Ertapenem

Schedule

S4

 

Consumer medicine information (CMI) leaflet

Please read this leaflet carefully before you start using Invanz for injection [8956].

What is in this leaflet

This leaflet answers some common questions about INVANZ. It does not contain all the available information.

It does not take the place of talking to your doctor or pharmacist.

All medicines have risks and benefits. Your doctor has weighed the risks of you using INVANZ against the benefits they expect it will have for you or your child.

If you have any concerns about being given this medicine, ask your doctor or pharmacist.

Keep this leaflet. You may need to read it again.

What INVANZ is used for

INVANZ is an antibiotic used to treat infections caused by bacteria (germs).

These infections include:

  • infections within the abdomen (stomach)
  • pelvic infections
  • diabetic foot infections in patients without osteomyelitis

INVANZ may also be used in patients not responding to, or unable to tolerate, other antibiotics.

INVANZ belongs to a class of antibiotics called carbapenems. It works by killing the bacteria causing your infection.

Your doctor may have prescribed INVANZ for another reason.

Ask your doctor if you have any questions about why INVANZ has been prescribed for you.

Before you are given INVANZ

When you or your child must not be given it

Do not use INVANZ if:

  • you have an allergy to INVANZ or any of the ingredients listed at the end of this leaflet
  • you have an allergy to other antibiotics in the same class as INVANZ
  • you have had a serious allergic reaction (anaphylaxis) to beta-lactam antibiotics, including penicillins or cephalosporins
  • the vial cap shows signs of tampering
  • the expiry date printed on the pack has passed
    If you use this medicine after the expiry date has passed, it may not work.

Do not use INVANZ by injection into a muscle if:

  • you have an allergy to amide-type local anaesthetics, particularly lignocaine
  • you are in severe shock
  • you have heart block

Do not use INVANZ in children under 3 months of age The safety and effectiveness in children younger than 3 months of age have not been established.

Before you or your child are given it

Tell your doctor if:

  1. you have or have had any medical conditions, especially the following:
  • seizures or fits, or a predisposition to seizures (eg brain scarring)
  • kidney disease, or are undergoing dialysis
  • bowel problems while using antibiotics or after finishing them, including severe abdominal or stomach cramps, or watery and severe diarrhoea
  1. you have allergies to other antibiotics, in particular penicillins and cephalosporins.
    If you are allergic to any of these you may be allergic to INVANZ.
  2. you are pregnant or intend to become pregnant
    Like most medicines, INVANZ is generally not recommended during pregnancy. However, if there is a need to consider using INVANZ during pregnancy, your doctor will discuss the possible risks and benefits to you and your unborn baby.
  3. you are breast-feeding or intend to breast-feed
    Like most medicines, the use of INVANZ is generally not recommended while breast-feeding. INVANZ is secreted into human milk.
  4. you have any allergies to any other medicines or any other substances, such as foods, preservatives or dyes
  5. you are taking a medicine containing valproic acid

If you have not told your doctor about any of the above, tell them before you are given INVANZ.

Taking other medicines

Tell your doctor if you or your child are taking any other medicines, including medicines that you buy without a prescription from your pharmacy, supermarket or health food shop.

Some medicines and INVANZ may interfere with each other. These include:

  • Sodium valproate (Epilim*), used to control different types of epilepsy and mania

These medicines may be affected by INVANZ, or may affect how well it works. You may need different amounts of your medicine, or you may need to take different medicines. Your doctor will decide whether you should use INVANZ in combination with this medicine.

Make sure your doctor and pharmacist know about all of the medicines you are taking, as they have more information on medicines to be careful with or avoid while taking INVANZ.

How INVANZ is given

INVANZ can be given in two ways:

  • as a slow injection into a vein, known as an intravenous infusion
  • as a deep injection into a large muscle, known as an intramuscular injection.

INVANZ must only be given by a doctor or nurse.

Your doctor will decide what dose and how long you or your child will receive INVANZ. This depends on your condition and other factors, such as your kidney function. No dose adjustment is necessary if you are elderly.

When preparing INVANZ for use, do not reconstitute or dilute in solutions containing dextrose (α-d-glucose). INVANZ is not compatible with dextrose.

If you receive too much (overdose)

If you are concerned that you or your child have received too much INVANZ, tell your doctor, nurse or pharmacist immediately.

While you or your child are using INVANZ

Things you must do

If you develop severe diarrhoea, tell your doctor, pharmacist or nurse immediately. Do this even if it occurs several weeks after INVANZ has been stopped. Diarrhoea may mean that you have a serious condition affecting your bowel. You may need urgent medical care. Do not take any diarrhoea medicine without first checking with your doctor.

If you develop a severe skin reaction such as painful red areas, fluid filled bumps, large blisters, or peeling layers of skin whilst being given INVANZ, tell your doctor immediately. You may need urgent medical care.

Side Effects

Tell your doctor, nurse, or pharmacist as soon as possible if you or your child do not feel well while you are being given INVANZ.

INVANZ helps most people with infection, but it may have unwanted side-effects in a few people. All medicines can have side effects. Sometimes they are serious, most of the time they are not. You may need medical treatment if you get some of the side effects.

Ask your doctor or pharmacist to answer any questions you may have.

Do not be alarmed by this list of possible side effects. You may not experience any of them.

While being given it

Tell your doctor or nurse if you notice any of the following and they worry you:

  • discomfort of the vein where you had the injection, for example pain, tenderness, redness, swelling or firm swelling.
  • swelling, clotting, tenderness, swelling and inflammation
  • headache
  • nausea, vomiting
  • diarrhoea
  • vaginal itching or redness
  • alterations in some laboratory blood tests, and a combination of high fever, feeling unwell, and skin rash

These are the more common side effects of INVANZ. For the most part, these have been mild.

INVANZ may cause dizziness or sleepiness in some patients. Make sure you know how you react to INVANZ before you drive a car, operate machinery or do anything else that could be dangerous if you are dizzy or sleepy.

Tell your doctor or nurse immediately if you notice any of the following:

  • severe abdominal cramps or stomach cramps
  • watery and severe diarrhoea, which may also be bloody
  • high temperature, also called fever
  • seizures or fits
  • shortness of breath
  • chest pain
  • slow heart rate
  • skin rash, redness, itchiness or hives
  • severe skin reactions, such as painful red areas, fluid-filled bumps, large blisters, or peeling of layers of skin have been reported for the beta-lactam class of antibiotics
  • formation of lump and warmth at injection site
  • strange or disturbing thoughts or moods (including agitation, aggression, severe confusion, disorientation, mental status changes)
  • tremors or uncontrollable twitching, jerking or writhing movements
  • decreased consciousness

These may be serious side effects of INVANZ. You may need urgent medical attention. Serious side effects are rare.

Also, tell your doctor if you notice:

  • dizziness, light-headedness or unsteady walking
  • unusual tiredness or weakness
  • sore, creamy-yellow, raised patches in the mouth (oral thrush)
  • teeth staining

These are other side effects that have been reported with INVANZ. These side effects are rare.

A few people may be allergic to some medicines. Tell your doctor or nurse immediately if you notice any of the following. These are examples of acute allergy:

  • throat or chest tightness, difficulty breathing
  • swelling of the mouth, lips, eyes or face
  • flushing (sudden redness) of the face
  • vomiting

If you or your child have these, you may have had a serious allergic reaction to INVANZ. You may need urgent medical attention. These side effects are very rare.

After finishing it

Tell your doctor immediately if you notice any of the following side effects, particularly if they occur several weeks after stopping treatment with INVANZ:

  • severe abdominal cramps or stomach cramps
  • watery and severe diarrhoea, which may also be bloody
  • fever, in combination with one or both of the above

These are rare but serious side effects. You may have a serious condition affecting your bowel. This is because antibiotics such as INVANZ can change the type of bacteria in the bowel. As a result, this allows bacteria, normally present in the bowel and normally harmless, to multiply and cause the above symptoms. Therefore, you may need urgent medical attention. However, this side effect is rare.

Do not take any diarrhoea medicine without first checking with your doctor.

Other side effects not listed above may also occur in some patients. Tell your doctor if you notice any other effects.

Storage

INVANZ will usually be stored in the pharmacy or on the ward.

The powder for injection should be kept in a cool dry place where the temperature stays below 25°C.

Discard any unused vials containing solution of INVANZ which has been prepared but not used. Vials of INVANZ are intended for single-use only. They do not contain a preservative and there is a possibility of contamination with repeated use.

Do not freeze the solutions of INVANZ.

Intravenous Injection

Use solutions of INVANZ as soon as possible after reconstitution and further dilution. If storage is unavoidable, store the solution in the refrigerator where the temperature is kept between 2°C to 8°C, for not more than 24 hours, and use as soon as practicable within 4 hours after removal from the refrigerator.

As INVANZ does not contain a preservative, there is a risk that any prepared solution that has not been stored in a refrigerator may be contaminated with germs and cause an infection.

Intramuscular Injection

Use the reconstituted solution immediately. If storage is unavoidable, the solution should be kept in a refrigerator where the temperature is between 2°C to 8°C.

Do not store the solution of INVANZ for injection for more than one hour.

Product Description

What it looks like

INVANZ comes as a white to off-white powder in a glass vial.

Ingredients

Active ingredient:

  • ertapenem 1 g (1.046 g as the sodium salt) per vial

Inactive ingredients:

  • sodium bicarbonate
  • sodium hydroxide

Supplier

INVANZ is supplied in Australia by:

Merck Sharp & Dohme (Australia) Pty Limited
A.B.N. 14 000 173 508
Level 1, Building A,
26 Talavera Road
Macquarie Park NSW 2113

This leaflet was prepared in June 2019.

Australian Register Number:
AUST R 81449.

Published by MIMS August 2019

BRAND INFORMATION

Brand name

Invanz

Active ingredient

Ertapenem

Schedule

S4

 

Name of the medicine

Ertapenem sodium.

Excipients.

Sodium bicarbonate and sodium hydroxide. The sodium content is approximately 137 mg (approximately 6.0 mEq).

Description

Invanz (ertapenem sodium) is a sterile, synthetic, parenteral, 1-β methyl-carbapenem that is structurally related to beta-lactam antibiotics, such as penicillins and cephalosporins.
Invanz (ertapenem sodium is chemically described as [4R-[3(3S*,5S*), 4α, 5β, 6β (R*)]]- 3-[[5-[[(3-carboxyphenyl) amino] carbonyl]-3-pyrrolidinyl]thio]-6-(1- hydroxyethyl)- 4-methyl-7-oxo-1-azabicyclo[3.2.0] hept-2-ene- 2-carboxylic acid monosodium salt.
Its empirical formula is C22H24N3O7SNa. The CAS No is 153832-38-3.
Ertapenem sodium is a white to off-white hygroscopic, weakly crystalline powder, with a molecular weight of 497.50. It is soluble in water and 0.9% sodium chloride solution, practically insoluble in ethanol, and insoluble in isopropyl acetate and tetrahydrofuran.
Invanz is supplied as sterile lyophilized powder for intravenous infusion after reconstitution with appropriate diluent (see Dosage and Administration, Instructions for use) for transfer to 50 mL 0.9% Sodium Chloride Injection or for intramuscular injection following reconstitution with 1% lignocaine hydrochloride. Each vial contains 1.046 gram ertapenem sodium, equivalent to 1 gram ertapenem, and the inactive ingredients sodium bicarbonate and sodium hydroxide. The sodium content is approximately 137 mg (approximately 6.0 mEq).

Pharmacology

Clinical pharmacology.

Pharmacotherapeutic group: Carbapenem; ATC code: J01DHXX.

Microbiology.

Ertapenem has in vitro activity against a wide range of Gram positive and Gram negative aerobic and anaerobic bacteria. The bactericidal activity of ertapenem results from the inhibition of cell wall synthesis and is mediated through ertapenem binding to penicillin binding proteins (PBPs). In Escherichia coli, it has strong affinity toward PBPs 1a, 1b, 2, 3, 4 and 5 with preference for PBPs 2 and 3. Ertapenem has significant stability against hydrolysis by most classes of beta-lactamases, including penicillinases, and cephalosporinases and extended spectrum beta-lactamases, but not metallo-beta-lactamases.
Ertapenem has been shown to be active against most strains of the following microorganisms in vitro and in clinical infections.

Aerobic and facultative anaerobic Gram positive microorganisms.

Staphylococcus aureus (including penicillinase producing strains); Streptococcus agalactiae; Streptococcus pneumoniae; Streptococcus pyogenes.

Note.

Methicillin resistant Staphylococci are resistant to ertapenem. Many strains of Enterococcus faecalis and most strains of Enterococcus faecium are resistant.

Aerobic and facultative anaerobic Gram negative microorganisms.

Escherichia coli; Haemophilus influenzae (including beta-lactamase producing strains); Klebsiella pneumoniae; Moraxella catarrhalis; Proteus mirabilis.

Anaerobic microorganisms.

Bacteroides fragilis and other species in the B. fragilis group; Clostridium species (excluding C. difficile); Eubacterium species; Peptostreptococcus species; Porphyromonas asaccharolytica; Prevotella species.
The following in vitro data are available, but their clinical significance is unknown.
Ertapenem exhibits in vitro minimum inhibitory concentrations (MICs) of ≤ 1 microgram/mL against most (≥ 90%) strains of Streptococcus species including Streptococcus pneumoniae, ≤ 0.5 microgram/mL against most (≥ 90%) strains of Haemophilus species, ≤ 2 microgram/mL against most (≥ 90%) strains of the other aerobic and facultative anaerobic microorganisms and ≤ 4 microgram/mL against most (≥ 90%) strains of the strict anaerobic microorganisms in the following list; however, the safety and effectiveness of ertapenem in treating clinical infections due to these microorganisms have not been established in adequate and well controlled clinical studies.

Aerobic and facultative anaerobic Gram positive microorganisms.

Staphylococcus species, coagulase negative, methicillin susceptible; Streptococcus pneumoniae, penicillin resistant; Viridans streptococci.

Note.

Methicillin resistant staphylococci are resistant to ertapenem. Many strains of Enterococcus faecalis and most strains of Enterococcus faecium are resistant.

Aerobic and facultative anaerobic Gram negative microorganisms.

Citrobacter freundii; Enterobacter aerogenes; Enterobacter cloacae; Escherichia coli producing ESBLs; Haemophilus parainfluenzae; Klebsiella oxytoca; Klebsiella pneumoniae producing ESBLs; Morganella morganii; Proteus vulgaris; Serratia marcescens.

Note.

Many strains of the above organisms that are multiply resistant to other antibiotics, e.g. penicillins, cephalosporins (including third generation) and aminoglycosides, are susceptible to ertapenem.

Anaerobic microorganisms.

Fusobacterium species.

Pharmacokinetics.

Absorption.

Ertapenem, reconstituted with 1% Lignocaine HCl Injection, USP (in saline without adrenaline), is well absorbed following IM administration at the recommended dose of 1 g. The mean bioavailability is approximately 92%. Following 1 g daily IM administration, mean peak plasma concentrations (Cmax) are reached in approximately 2 hours (Tmax).
Average plasma concentrations (microgram/mL) of ertapenem following a single 30 minute IV infusion of a 1 g dose and IM administration of a single 1 g dose in healthy young adults are presented in Table 1.
Area under the plasma concentration curve (AUC) of ertapenem in adults increases nearly dose proportionally over the 0.5 to 2 g dose range.
There is no accumulation of ertapenem in adults following multiple IV doses ranging from 0.5 to 2 g daily or IM doses of 1 g daily.
Average plasma concentrations (microgram/mL) of ertapenem in paediatric patients are presented in Table 2.

Distribution.

Ertapenem is highly bound to human plasma proteins. In healthy young adults, the protein binding of ertapenem decreases as plasma concentrations increase, from approximately 95% bound at an approximate plasma concentration of < 100 microgram/mL to approximately 85% bound at an approximate plasma concentration of 300 microgram/mL.
The volume of distribution (Vdss) of ertapenem in adults is approximately 8 litres (0.11 litre/kg), approximately 0.2 litre/kg in paediatric patients 3 months to 12 years of age and approximately 0.16 litre/kg in paediatric patients 13 to 17 years of age.
Ertapenem penetrates into suction induced skin blisters. Concentrations of ertapenem achieved in skin blister fluid at each sampling point on the third day of 1 g once daily IV doses are presented in Table 3. The ratio of AUC in skin blister fluid to AUC in plasma is 0.61.
The level of ertapenem in breast milk of 5 lactating women was measured at random time points daily for 5 consecutive days following the last 1 g dose of intravenous therapy. The measured concentration of ertapenem in breast milk on the last day of therapy (5 to 14 days postpartum) in all 5 women was < 0.38 microgram/mL; peak concentrations were not assessed. By day 5 after discontinuation of therapy, the level of ertapenem was undetectable in the breast milk of 4 women and was detected at trace levels (< 0.13 microgram/mL) in 1 woman.
In vitro studies indicate that ertapenem does not inhibit P-glycoprotein mediated transport of digoxin or vinblastine and that ertapenem is not a substrate for P-glycoprotein mediated transport (see Interactions with Other Medicines).

Metabolism.

In healthy young adults, after IV infusion of radiolabelled 1 g ertapenem, the plasma radioactivity consists predominantly (94%) of ertapenem. The major metabolite of ertapenem is the ring opened derivative formed by hydrolysis of the beta-lactam ring.
In vitro studies in human liver microsomes indicate that ertapenem does not inhibit metabolism mediated by any of the six major cytochrome P450 (CYP) isoforms: 1A2, 2C9, 2C19, 2D6, 2E1 and 3A4 (see Interactions with Other Medicines).

Elimination.

Ertapenem is eliminated primarily by the kidneys. The mean plasma half-life in healthy young adults and patients 13 to 17 years of age is approximately 4 hours and approximately 2.5 hours in paediatric patients 3 months to 12 years of age.
Following administration of a 1 g radiolabelled IV dose of ertapenem to healthy young adults, approximately 80% is recovered in urine and 10% in faeces. Of the 80% recovered in urine, approximately 38% is excreted as unchanged drug and approximately 37% as the ring opened metabolite.
In healthy young adults given a 1 g IV dose, average concentrations of ertapenem in urine exceed 984 microgram/mL during the period 0 to 2 hours postdose and exceed 52 microgram/mL during the period 12 to 24 hours postdose.

Gender.

Following administration of a 1 g IV dose over 30 minutes, the plasma concentrations (AUC) of ertapenem, both total and unbound, were similar in healthy male and female subjects (total drug AUC was 570.0 microgram.hr/mL for men vs 566.8 microgram.hr/mL for women).

Elderly.

Following a 1 g IV dose of ertapenem, AUC increases by approximately 39% in elderly subjects (≥ 65 years) relative to young adults (< 65 years). No dosage adjustment is necessary in elderly patients.

Paediatric patients.

Plasma concentrations of ertapenem are comparable in paediatric patients 13 to 17 years of age and adults following a 1 g once daily IV dose.
Following the 20 mg/kg dose (up to a maximum dose of 1 g), the pharmacokinetic parameter values in patients 13 to 17 years of age were generally comparable to those in healthy young adults. Three out of six patients 13 to 17 years of age received less than a 1 g dose. To provide an estimate of the pharmacokinetic data if all patients in this age group were to receive a 1 g dose, the pharmacokinetic data were calculated adjusting for a 1 g dose, assuming linearity. A comparison of results shows that a 1 g once daily dose of ertapenem achieves a pharmacokinetic profile in patients 13 to 17 years of age comparable to that of adults. The ratios (13 to 17 years/ adults) for AUC, the end of infusion concentration and the concentration at the midpoint of the dosing interval were 0.99, 1.20 and 0.84, respectively.
Plasma concentrations at the midpoint of the dosing interval following a single 15 mg/kg IV dose of ertapenem in patients 3 months to 12 years of age are comparable to plasma concentrations at the midpoint of the dosing interval following a 1 g once daily IV dose in adults (see Distribution). The plasma clearance (mL/min/kg) of ertapenem in patients 3 months to 12 years of age is approximately 2-fold higher as compared to that in adults. At the 15 mg/kg dose, the AUC value (doubled to model a twice daily dosing regimen, i.e. 30 mg/kg/day exposure) in patients 3 months to 12 years of age was comparable to the AUC value in young healthy adults receiving a 1 g IV dose of ertapenem.

Hepatic insufficiency.

The pharmacokinetics of ertapenem in patients with hepatic insufficiency have not been established. Due to the limited extent of hepatic metabolism of ertapenem, its pharmacokinetics are not expected to be affected by hepatic impairment. Therefore, no dosage adjustment is necessary in patients with hepatic impairment.

Renal insufficiency.

Following a single 1 g IV dose of ertapenem in adults, AUC is similar in patients with mild renal insufficiency (ClCr) 60-90 mL/min/1.73 m2) compared with healthy subjects (ages 25 to 82 years). AUC is increased in patients with moderate renal insufficiency (ClCr 31-59 mL/min/1.73 m2) approximately 1.5-fold compared with healthy subjects. AUC is increased in patients with advanced renal insufficiency (ClCr 5-30 mL/min/1.73 m2) approximately 2.6-fold compared with healthy subjects. AUC is increased in patients with endstage renal insufficiency (ClCr < 10 mL/min/1.73 m2) approximately 2.9-fold compared with healthy subjects. Following a single 1 g IV dose given immediately prior to a haemodialysis session, approximately 30% of the dose is recovered in the dialysate. There are no data in paediatric patients with renal insufficiency.
A dosage adjustment is recommended for adult patients with advanced or endstage renal insufficiency (see Dosage and Administration).

Clinical Trials

Note.

Reported cure rates are based on assessable subjects (excludes indeterminate and missing values).

Adult patients.

Complicated intra-abdominal infections.

Ertapenem was evaluated in adults for the treatment of complicated intra-abdominal infections in a randomised, multicentre, double blind, controlled clinical trial. This study compared ertapenem (1 g IV once a day) with piperacillin/ tazobactam (3.375 g IV every 6 hours) for 5 to 14 days and enrolled 665 patients. In this study, complicated intra-abdominal infections were defined as those requiring surgical intervention and which extend beyond the hollow viscus into the peritoneal space. Patients were stratified at baseline into two groups: localised complicated appendicitis (stratum 1) and any other complicated intra-abdominal infection including colonic, small intestinal, and biliary infections and generalised peritonitis (stratum 2). At 1 to 2 weeks post-therapy, the clinical and microbiological success rates were 89.6% (190/212) for ertapenem and 82.7% (162/196) for piperacillin/ tazobactam; at 4 to 6 weeks post-therapy (test of cure) success rates were 86.7% (176/203) for ertapenem and 81.3% (157/193) for piperacillin/ tazobactam. At the test of cure for patients in stratum 1 the success rates were 90.4% (85/94) for ertapenem and 90.1% (82/91) for piperacillin/ tazobactam, and for patients in stratum 2 the success rates were 83.5% (91/109) for ertapenem and 73.5% (75/102) for piperacillin/ tazobactam. The clinical success rates at the test of cure by pathogen in the microbiologically evaluable patients are presented in Table 4.
In patients with E. coli bacteraemia, 100% (3/3) were treated successfully with ertapenem.

Acute pelvic infections including postpartum endomyometritis, septic abortion and postsurgical gynaecologic infections.

Ertapenem was evaluated in adults for the treatment of acute pelvic infections in a randomised, multicentre, double blind, controlled clinical trial. This study compared ertapenem (1 g IV once a day) with piperacillin/ tazobactam (3.375 g IV every 6 hours) for 3 to 10 days and enrolled 412 patients including 350 patients with obstetric/ postpartum infections and 45 patients with septic abortion. The clinical success rates at 2 to 4 weeks post-therapy (test of cure) were 93.9% (153/163) for ertapenem and 91.5% (140/153) for piperacillin/ tazobactam. The clinical success rates at the test of cure by pathogen in the microbiologically evaluable patients are presented in Table 5.
In patients with E. coli bacteraemia, 100% (6/6) were treated successfully with ertapenem.

Bacterial septicaemia.

In a composite analysis of data from pivotal and supportive studies 172 evaluable patients were bacteremic. Overall, 69/86 (80.2%) patients in the ertapenem group and 72/86 (83.7%) patients in the combined ceftriaxone and piperacillin/ tazobactam groups had a favourable response assessment (test of cure). The primary efficacy response rates at the test of cure by pathogen in the evaluable patients are presented in Table 6.

Diabetic foot infections.

Ertapenem was evaluated in adults for the treatment of diabetic foot infections in a randomized, multicenter, double blind, controlled clinical trial. This study compared ertapenem (1 g IV once a day) with piperacillin/ tazobactam (3.375 g IV every 6 hours) and enrolled 586 patients. Both regimens allowed the option to switch to oral amoxicillin/ clavulanate for a total of 5 to 28 days of treatment (parenteral and oral). Adults with type I or type II diabetes with moderate to severe diabetic foot infections requiring parenteral antibiotic therapy were enrolled. Subjects with suspected osteomyelitis were excluded. Efficacy analyses took into consideration the investigator's assessment of the severity of the baseline wound. For the primary analysis, 94.2% of patients in the ertapenem group and 92.2% of patients in the piperacillin/ tazobactam group had a favourable response assessment at the discontinuation of IV therapy assessment (DCIV) visit. The clinical success rates at 10 days post-therapy were 87.4% (180/206) for ertapenem and 82.7% (162/196) for piperacillin/ tazobactam. The clinical success rates for both the DCIV assessment and 10 day post-treatment follow up assessment (FUA) are presented in Table 7.
The clinical success rates at the post-therapy visit by pathogen in the clinically evaluable patients are presented in Table 8.

Paediatric patients.

Ertapenem was evaluated in paediatric patients in a study which enrolled 112 patients and compared ertapenem (15 mg/kg IV every 12 hours in patients 2 to 12 years of age, and 1 g IV once a day in patients 13 to 17 years of age) to ticarcillin/ clavulanate (50 mg/kg for patients < 60 kg or 3.0 g for patients > 60 kg, 4 or 6 times a day) up to 14 days for the treatment of complicated intra-abdominal infections (IAI) and acute pelvic infections (API). The response rates for the EPP population are presented in Table 9.
Paediatric experience in intra-abdominal infections (IAI) and acute pelvic infections (API) is limited to children 2 years and older and bacterial septicaemia has not been studied in this population.
A second study assessing the effect of ertapenem in additional infections not approved in adults included paediatric patients, recruitment criteria age range 3 months to 17 years of age. This study enrolled 404 patients and compared ertapenem (15 mg/kg IV every 12 hours in patients 3 months to 12 years of age, and 1 g IV once a day in patients 13 to 17 years of age) to ceftriaxone (50 mg/kg/day IV in two divided doses in patients 3 months to 12 years of age and 50 mg/kg/day IV as a single daily dose in patients 13 to 17 years of age) for the treatment of complicated urinary tract infection (UTI), skin and soft tissue infection (SSTI) or community acquired pneumonia (CAP). Both regimens allowed the option to switch to oral amoxicillin/ clavulanate for a total of up to 14 days of treatment (parenteral and oral).

Indications

Treatment.

Invanz is indicated for the treatment of patients, aged 3 months or more, with moderate to severe infections (except meningitis, see Precautions) caused by susceptible strains of microorganisms which are suspected or proven to be resistant to all other antibiotics, or for patients unable to tolerate other antibiotics.
Invanz is also indicated for initial empiric therapy for the treatment of complicated intra-abdominal infections and acute pelvic infections including postpartum endomyometritis, septic abortion and postsurgical gynaecological infections.
Invanz is also indicated for the treatment of diabetic foot infections which require parenteral antibiotic therapy and are caused by susceptible bacterial pathogens which are suspected or proven to be resistant to all other registered antibiotics, or for patients unable to tolerate other antibiotics.
Appropriate specimens for bacteriological examination should be obtained in order to isolate and identify the causative organisms and to determine their susceptibility to ertapenem. Therapy with Invanz may be initiated empirically before the results of these tests are known; once these results become available, antimicrobial therapy should be adjusted accordingly.

Contraindications

Invanz is contraindicated in patients with known hypersensitivity to any component of this product or to other drugs in the same class or in patients who have demonstrated anaphylactic reactions to beta-lactams.
Due to the use of lignocaine HCl as a diluent, Invanz administered intramuscularly is contraindicated in patients with a known hypersensitivity to local anaesthetics of the amide type and in patients with severe shock or heart block. See the prescribing information for lignocaine HCl.

Precautions

Serious and occasionally fatal hypersensitivity (anaphylactic) reactions have been reported in patients receiving therapy with beta-lactams. These reactions are more likely to occur in individuals with a history of sensitivity to multiple allergens. There have been reports of individuals with a history of penicillin hypersensitivity who have experienced severe hypersensitivity reactions when treated with another beta-lactam. Before initiating therapy with Invanz, careful inquiry should be made concerning previous hypersensitivity reactions to penicillins, cephalosporins, other beta-lactams and other allergens. If an allergic reaction to Invanz occurs, discontinue the drug immediately. Serious anaphylactic reactions require immediate emergency treatment.
As with other antibiotics, prolonged use of Invanz may result in overgrowth of nonsusceptible organisms. Repeated evaluation of the patient's condition is essential. If superinfection occurs during therapy, appropriate measures should be taken.
Pseudomembranous colitis has been reported with nearly all antibacterial agents, including ertapenem. A toxin produced by Clostridium difficile appears to be the primary cause. The severity of the colitis may range from mild to life threatening. Therefore, it is important to consider this diagnosis in patients who develop diarrhoea or colitis in association with ertapenem use (this may occur up to several weeks after cessation of antibiotic therapy). Mild cases usually respond to drug discontinuation alone. In moderate to severe cases appropriate therapy such as oral antibacterial agents effective against Clostridium difficile should be considered. Fluid, electrolytes and protein replacement should be provided when indicated.
Caution should be taken when administering Invanz intramuscularly, to avoid inadvertent injection into a blood vessel (see Dosage and Administration). Lignocaine HCl is the diluent for intramuscular administration of Invanz. (See the prescribing information for lignocaine HCl.)
Seizure and other central nervous system (CNS) adverse experiences have been reported during treatment with Invanz (see Adverse Effects). During clinical investigations in adult patients treated with Invanz (1 g once a day), seizures, irrespective of drug relationship, occurred in 0.5% of patients during study therapy plus 14 day follow-up period. These experiences have occurred most commonly in patients with CNS disorders (e.g. brain lesions or history of seizures) and/or compromised renal function. Close adherence to the recommended dosage regimen is urged, especially in patients with known factors that predispose to convulsive activity. Anticonvulsant therapy should be continued in patients with known seizure disorders. If focal tremors, myoclonus, or seizures occur, patients should be evaluated neurologically and the dosage of Invanz re-examined to determine whether it should be decreased or discontinued.

Severe cutaneous adverse reactions.

Severe cutaneous adverse reactions (SCAR), such as Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), drug reaction with eosinophilia and systemic symptoms (DRESS), and acute generalised exanthematous pustulosis (AGEP) have been reported in patients taking beta-lactam antibiotics. When SCAR is suspected, Invanz should be discontinued immediately and an alternative treatment should be considered.

Carcinogenicity, mutagenicity, and impairment of fertility.

The carcinogenic potential of ertapenem has not been examined in long-term animal studies.
Ertapenem was not genotoxic, as assessed in vitro for gene mutations, chromosomal aberrations and DNA strand breaks in cultured mammalian cells. An in vivo assay of chromosomal damage (micronucleus test in mice) was also negative.
Ertapenem had no adverse effect on fertility of either male or female rats at doses up to 700 mg/kg/day IV, which was associated with a plasma AUC level similar to the anticipated human value at the clinically recommended dose.

Use in pregnancy.

(Category B3)
In mice and rats given IV doses of up to 700 mg/kg/day (for rats, similar to human exposure at the recommended dose of 1 g based on plasma AUCs; no exposure data were available for mice), there was no evidence of developmental toxicity as assessed by external, visceral and skeletal examination of the fetuses. However, in mice given 700 mg/kg/day, slight decreases in average fetal weights and an associated decrease in the average number of ossified sacrocaudal vertebrae were observed. Ertapenem crosses the placental barrier in rats.
There are no adequate and well controlled studies in pregnant women. Invanz should not be used in pregnant women, unless the expected therapeutic benefit to the mother clearly outweighs the potential risk to the mother and fetus.

Use in lactation.

Ertapenem is excreted in human milk (see Pharmacology, Distribution). In rats given IV doses of up to 700 mg/kg/day (similar to human exposure at the recommended dose of 1 g based on plasma AUCs) there was no evidence of postnatal toxicity. Invanz should not be used in a breastfeeding woman, unless the expected therapeutic benefit to the mother clearly outweighs the potential risk to the infant.

Use in CNS infections.

Invanz is not recommended in the treatment of meningitis or other CNS infections in the paediatric population due to a lack of sufficient CSF penetration to cover all relevant pathogens.

Effects on ability to drive and operate machinery.

Dizziness and somnolence can occur which may affect some patients' ability to drive and/or operate machinery.

Paediatric use.

Safety and effectiveness of Invanz in paediatric patients 3 months to 17 years of age are supported by evidence from adequate and well controlled studies in adults, pharmacokinetic data in paediatric patients and additional data from comparator controlled studies in paediatric patients 3 months to 17 years of age and 2 to 17 years of age in intra-abdominal infection (IAI) and acute pelvic infection (API)* comparator controlled studies (see Indications and Clinical Trials, Paediatric patients). There are no data in paediatric patients with renal insufficiency.
*Acute pelvic infection is not the same entity as pelvic inflammatory disease.
Invanz is not recommended in infants under 3 months of age as no data are available.

Geriatric use.

In clinical studies, the efficacy and safety of Invanz in the elderly (≥ 65 years) was comparable to that seen in younger patients (< 65 years).

Interactions

When ertapenem is administered with probenecid, probenecid competes for active tubular secretion and thus inhibits the renal excretion of ertapenem. This leads to small but statistically significant increases in the elimination half-life (19%) and in the AUC (25%). No dosage adjustment is necessary when ertapenem is given with probenecid. Because of the small effect on half-life, the coadministration with probenecid to extend the half-life of ertapenem is not recommended.
In vitro studies indicate that ertapenem does not inhibit P-glycoprotein mediated transport of digoxin or vinblastine and that ertapenem is not a substrate for P-glycoprotein mediated transport. In vitro studies in human liver microsomes indicate ertapenem does not inhibit metabolism mediated by any of the six major cytochrome P450 (CYP) isoforms: 1A2, 2C9, 2C19, 2D6, 2E1 and 3A4. Drug interactions caused by inhibition of P-glycoprotein mediated drug clearance or CYP mediated drug clearance are unlikely (see Pharmacology, Pharmacokinetics, Distribution and Metabolism.)
Other than with probenecid, no specific clinical drug interaction studies have been conducted.
The concomitant use of ertapenem and valproic acid/ divalproex sodium is generally not recommended. Antibacterials other than carbapenems should be considered to treat infections in patients whose seizures are well controlled on valproic acid or divalproex sodium. If administration of Invanz is necessary, supplemental anticonvulsant therapy should be considered.
Case reports in the literature have shown that coadministration of carbapenems, including ertapenem, to patients receiving valproic acid or divalproex sodium results in a reduction of valproic acid concentrations. The valproic acid concentrations may drop below the therapeutic range as a result of this interaction, therefore increasing the risk of breakthrough seizures. Increasing the dose of valproic acid or divalproex sodium may not be sufficient to overcome this interaction. Although the mechanism of this interaction is unknown, data from in vitro and animal studies suggest that carbapenems may inhibit the hydrolysis of valproic acid's glucuronide metabolite (VPA-g) back to valproic acid, thus decreasing the serum concentrations of valproic acid.

Adverse Effects

Adult patients.

The total number of patients treated with ertapenem in clinical studies was over 1900 of which over 1850 received a 1 g dose of Invanz. Most adverse experiences reported in these clinical studies were described as mild to moderate in severity. Drug related adverse experiences were reported in approximately 20% of patients treated with ertapenem. Ertapenem was discontinued due to adverse experiences thought to be drug related in 1.3% of patients.
The most common drug related adverse experiences reported during parenteral therapy in patients treated with ertapenem were diarrhoea (4.3%), infused vein complication (3.9%), nausea (2.9%) and headache (2.1%).
The following drug related adverse experiences shown in Table 10 were reported during parenteral therapy in ≥ 1.0% of patients treated with ertapenem.
Additional drug related adverse experiences that were reported during parenteral therapy with ertapenem with an incidence > 0.1% but < 1.0% within each body system are listed below.

Body as a whole.

Asthenia/ fatigue, candidiasis, oedema/ swelling, fever, pain, abdominal pain, chest pain.

Cardiovascular system.

Extravasation, hypotension, bradycardia.

Digestive system.

Acid regurgitation, anorexia, oral candidiasis, constipation, C. difficile associated diarrhoea, dry mouth, dyspepsia.

Nervous system and psychiatric.

Confusion, dizziness, insomnia, somnolence.

Respiratory system.

Dyspnoea.

Skin and skin appendage.

Erythema, pruritus.

Special senses.

Taste perversion.

Urogenital system.

Vaginal pruritus.
In clinical studies, seizure was reported during parenteral therapy in 0.2% of patients treated with ertapenem, 0.3% of patients treated with piperacillin/ tazobactam and 0% of patients treated with ceftriaxone.
In the majority of clinical studies, parenteral therapy was followed by a switch to an appropriate oral antimicrobial (see Clinical Trials). During the entire treatment period and a 14 day post-treatment follow-up period, drug related adverse experiences in patients treated with ertapenem included those listed above as well as rash and vaginitis at an incidence of ≥ 1.0% (common) and allergic reactions, malaise and fungal infections at an incidence of > 0.1% but < 1.0% (uncommon).
In a clinical study for the treatment of diabetic foot infections in which 289 adult diabetic patients were treated with ertapenem, the drug related adverse experience profile was generally similar to that seen in previous clinical trials.

Paediatric patients.

Clinical studies enrolled 384 paediatric patients treated with ertapenem. The overall adverse experience profile is comparable to that in adult patients. Table 11 shows the incidence of drug related adverse experiences reported during parenteral therapy in ≥ 1.0% of paediatric patients in these studies.
In the paediatric clinical studies, the majority of the patients had parenteral therapy followed by a switch to an appropriate oral antimicrobial (see Clinical Trials). During the entire treatment period and a 14 day post-treatment follow-up period, drug related adverse experiences reported with an incidence of ≥ 1.0% in patients treated with ertapenem were no different than those listed in Table 11.
Additional drug related adverse experiences that were reported during parenteral therapy with ertapenem with an incidence > 0.5% but < 1.0% within each body system are listed below.

General disorders and administration site conditions.

Infusion site induration, infusion site pruritus, infusion site warmth.

Vascular disorders.

Phlebitis.

Postmarketing experience.

The following postmarketing adverse experiences have been reported.

Immune system.

Anaphylaxis including anaphylactoid reactions.

Psychiatric disorders.

Altered mental status (including agitation, aggression, delirium, disorientation, mental status changes).

Nervous system disorders.

Depressed level of consciousness, dyskinesia, gait disturbance, hallucinations, myoclonus, tremor. Seizures (very rare). Seizures occurred most frequently in elderly patients and those with pre-existing CNS disorders (e.g. brain lesions or history of seizures) and/or compromised renal function (see Precautions).

Gastrointestinal disorders.

Teeth staining.

Skin and other subcutaneous tissue disorders.

Severe cutaneous adverse reactions (SCAR), including Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), drug reaction with eosinophilia and systemic symptoms (DRESS), and acute generalised exanthematous pustulosis (AGEP) have been reported with beta-lactam antibiotics; urticaria.

Musculoskeletal and connective tissue disorders.

Muscular weakness.

Laboratory tests.

Adult patients.

Clinically significant laboratory abnormalities that were measured during parenteral therapy in ≥ 1.0% of patients treated with ertapenem in clinical studies are presented in Table 12.
The most frequently observed drug related laboratory abnormalities during parenteral therapy in patients receiving ertapenem were elevations in ALT, AST, alkaline phosphatase and platelet count.
In the majority of clinical studies, parenteral therapy was followed by a switch to an appropriate oral antimicrobial (see Clinical Trials). During the entire treatment period and a 14 day post-treatment follow-up period, drug related laboratory abnormalities in patients treated with ertapenem were no different than those listed in Table 12.
Other drug related laboratory abnormalities included the following: increases in direct serum bilirubin, total serum bilirubin, eosinophils, indirect serum bilirubin, PTT, urine bacteria, BUN, serum creatinine, serum glucose, monocytes, urine epithelial cells, urine red blood cells; decreases in segmented neutrophils, white blood cells, haematocrit, haemoglobin and platelet count.
In a clinical study for the treatment of diabetic foot infections in which 289 adult diabetic patients were treated with ertapenem, the drug related laboratory adverse experience profile was generally similar to that seen with previous clinical trials.

Paediatric patients.

The overall laboratory adverse experience profile is comparable to that in adults. Table 13 shows the incidence of laboratory adverse experiences reported in ≥ 1.0% of paediatric patients in clinical studies.
Additional drug related laboratory adverse experiences that were reported during parenteral therapy in > 0.5% but < 1.0% of paediatric patients treated with ertapenem in clinical studies include increase in eosinophils.
Other drug related laboratory abnormalities during the entire treatment period plus 14 day follow-up included the following: elevations in ALT, elevations in AST, decreases in white blood cells.

Dosage and Administration

The usual dose of Invanz in patients 13 years of age and older is 1 gram (g) given once a day. The usual dose of Invanz in patients 3 months to 12 years of age is 15 mg/kg twice daily (not to exceed 1 g/day).
Invanz may be administered by intravenous (IV) infusion or intramuscular (IM) injection. When administered intravenously, Invanz should be infused over a period of 30 minutes.
Intramuscular administration of Invanz may be used as an alternative to intravenous administration in the treatment of those infections for which intramuscular therapy is appropriate.
The usual duration of therapy with Invanz is 3 to 14 days but varies by the type of infection and causative pathogen(s). (See Indications.) When clinically indicated, a switch to an appropriate oral antimicrobial may be implemented if clinical improvement has been observed.
In controlled clinical studies, patients were treated from 3 to 14 days. Total treatment duration was determined by the treating physician based on site and severity of the infection, and on the patient's clinical response. In some studies, treatment was converted to oral therapy at the discretion of the treating physician after clinical improvement had been demonstrated.

Patients with renal insufficiency.

Invanz may be used for the treatment of infections in adult patients with renal insufficiency. In patients whose creatinine clearance is > 30 mL/min/1.73 m2, no dosage adjustment is necessary. Adult patients with advanced renal insufficiency (creatinine clearance ≤ 30 mL/min/1.73 m2), including those on haemodialysis, should receive 500 mg daily. There are no data in paediatric patients with renal insufficiency.

Patients on haemodialysis.

In a clinical study in adults, following a single 1 g IV dose of ertapenem given immediately prior to a haemodialysis session, approximately 30% of the dose was recovered in the dialysate. When patients on haemodialysis are given the recommended daily dose of 500 mg of Invanz within 6 hours prior to haemodialysis, a supplementary dose of 150 mg is recommended following the haemodialysis session. If Invanz is given at least 6 hours prior to haemodialysis, no supplementary dose is needed. There are no data in paediatric patients undergoing haemodialysis. There are no data in adult and paediatric patients undergoing peritoneal dialysis or haemofiltration.
When only the serum creatinine is available, the following formula** may be used to estimate creatinine clearance. The serum creatinine should represent a steady state of renal function.
** Cockcroft and Gault equation. Cockcroft DW, Gault MH. Prediction of creatinine clearance from serum creatinine. Nephron. 1976.
No dosage adjustment is recommended in patients with impaired hepatic function (Pharmacology, Pharmacokinetics, Hepatic insufficiency).
In patients 13 years of age and older, the recommended dose of Invanz can be administered without regard to age or gender.

Instructions for use.

Patients 13 years of age and older.

Preparation for intravenous administration.

Do not mix or co-infuse Invanz with other medications.
Do not use diluents containing dextrose (α-d-glucose).
Invanz must be reconstituted and then diluted prior to administration.
1. Reconstitute the contents of a 1 g vial of Invanz with 10 mL of one of the following: water for injections, 0.9% sodium chloride injection or bacteriostatic water for injections.
2. Shake well to dissolve and immediately transfer the contents of the reconstituted vial to 50 mL of 0.9% sodium chloride injection. The resulting solution is chemically and physically stable only if used within 6 hours at room temperature, or stored for 24 hours at 2 to 8°C and used within 4 hours after removal from refrigeration.
3. To ensure adequate potency and to avoid microbiological hazard, the Invanz solution should be used as soon as practicable after reconstitution and further dilution. If storage is unavoidable, the solution should be held at 2 to 8°C for not more than 24 hours, and used as soon as practicable within 4 hours after removal from refrigeration. The Invanz solution should not be frozen.
4. Invanz should be infused over a period of 30 minutes.

Preparation for intramuscular administration.

Invanz must be reconstituted prior to administration.
1. Reconstitute the contents of a 1 g vial of Invanz with 3.2 mL of 1.0% lignocaine HCl injection*** (without adrenaline). Shake vial thoroughly to form solution. This solution is chemically and physically stable for only 1 hour at 2 to 8°C.
2. Immediately withdraw the contents of the vial and administer by deep intramuscular injection into a large muscle mass (such as the gluteal muscles or lateral part of the thigh).
3. To ensure adequate potency and to avoid microbiological hazard, the reconstituted solution should be used immediately or stored at 2 to 8°C for not more than 1 hour.

Note.

This reconstituted solution is for intramuscular administration only. It must not be administered intravenously.
*** See the prescribing information for lignocaine HCl.

Paediatric patients 3 months to 12 years of age.

Preparation for intravenous administration.

Do not mix or co-infuse Invanz with other medications.
Do not use diluents containing dextrose (α-d-glucose).
Invanz must be reconstituted and then diluted prior to administration.
1. Reconstitute the contents of a 1 g vial of Invanz with 10 mL of one of the following: water for injections, 0.9% sodium chloride injection or bacteriostatic water for injections.
2. Shake well to dissolve and immediately withdraw a volume equal to 15 mg/kg of bodyweight and dilute in 0.9% sodium chloride injection to a final concentration of 20 mg/mL or less. The resulting solution is chemically and physically stable only if used within 6 hours at room temperature, or stored for 24 hours at 2 to 8°C and used within 4 hours after removal from refrigeration.
3. To ensure adequate potency and to avoid microbiological hazard, the Invanz solution should be used as soon as practicable after reconstitution and further dilution. If storage is unavoidable, the solution should be held at 2 to 8°C for not more than 24 hours and used as soon as practicable within 4 hours after removal from refrigeration. The Invanz solution should not be frozen.
4. Invanz should be infused over a period of 30 minutes.

Preparation for intramuscular administration.

Invanz must be reconstituted prior to administration.
1. Reconstitute the contents of a 1 g vial of Invanz with 3.2 mL of 1.0% lignocaine HCl injection*** (without adrenaline). Shake vial thoroughly to form solution. This solution is chemically and physically stable for only 1 hour at 2 to 8°C.
2. Immediately withdraw a volume equal to 15 mg/kg of bodyweight (not to exceed 1 g/day) and administer by deep intramuscular injection into a large muscle mass (such as the gluteal muscles or lateral part of the thigh).
***See the prescribing information for lignocaine HCl.
To ensure adequate potency and to avoid microbiological hazard, the reconstituted solution should be used immediately or stored at 2 to 8°C for not more than 1 hour.

Note.

This reconstituted solution is for intramuscular administration only. It must not be administered intravenously.
Parenteral drug products should be inspected visually for particulate matter and discolouration prior to use, whenever solution and container permit. Solutions of Invanz range from colourless to pale yellow. Variations of colour within this range do not affect the potency of the product.
Product is for single use in one patient only. Discard any residue.

Overdosage

No specific information is available on the treatment of overdosage with Invanz. Intentional overdosing of Invanz is unlikely. Intravenous administration of Invanz at a 3 g daily dose for 8 days to healthy adult volunteers did not result in significant toxicity. In clinical studies in adults, inadvertent administration of up to 3 g in a day did not result in clinically important adverse experiences. In paediatric clinical studies, a single IV dose of 40 mg/kg up to a maximum of 2 g did not result in toxicity.
In the event of an overdose, Invanz should be discontinued and general supportive treatment given until renal elimination takes place.
Invanz can be removed by haemodialysis; however, no information is available on the use of haemodialysis to treat overdosage.
Contact Poisons Information Centre on 131 126 for advice on management of overdosage.

Presentation

Invanz is supplied as a sterile lyophilised powder for intravenous infusion or intramuscular injection containing 1 gram ertapenem as free acid.

Storage

Before reconstitution.

Store lyophilised powder below 25°C.
Before reconstitution, Invanz has a shelf-life of 24 months when stored below 25°C.

Reconstituted and infusion solutions.

For storage instructions for the reconstituted injection, see Dosage and Administration, Instructions for use, above.

Poison Schedule

S4.