DOSAGE AND ADMINISTRATION The pharmacy bulk package is for preparation of solutions for IV infusion only. Ampicillin and sulbactam for injection should be administered by slow intravenous injection over at least 10 to 15 minutes or can also be delivered in greater dilutions with 50 to 100 mL of a compatible diluent as an intravenous infusion over 15 to 30 minutes. The recommended adult dosage of ampicillin and sulbactam for injection is 1.5 g (1 g ampicillin as the sodium salt plus 0.5 g sulbactam as the sodium salt) to 3 g (2 g ampicillin as the sodium salt plus 1 g sulbactam as the sodium salt) every six hours. This 1.5 to 3 g range represents the total of ampicillin content plus the sulbactam content of ampicillin and sulbactam for injection, and corresponds to a range of 1 g ampicillin/0.5 g sulbactam to 2 g ampicillin/1 g sulbactam. The total dose of sulbactam should not exceed 4 grams per day. Pediatric Patients 1 Year of Age or Older The recommended daily dose of ampicillin and sulbactam for injection in pediatric patients is 300 mg per kg of body weight administered via intravenous infusion in equally divided doses every 6 hours. This 300 mg/kg/day dosage represents the total ampicillin content plus the sulbactam content of ampicillin and sulbactam for injection, and corresponds to 200 mg ampicillin/100 mg sulbactam per kg per day. The safety and efficacy of ampicillin and sulbactam for injection administered via intramuscular injection in pediatric patients have not been established. Pediatric patients weighing 40 kg or more should be dosed according to adult recommendations, and the total dose of sulbactam should not exceed 4 grams per day. The course of intravenous therapy should not routinely exceed 14 days. In clinical trials, most children received a course of oral antimicrobials following initial treatment with intravenous ampicillin and sulbactam for injection. (see CLINICAL STUDIES section). Impaired Renal Function In patients with impairment of renal function the elimination kinetics of ampicillin and sulbactam are similarly affected, hence the ratio of one to the other will remain constant whatever the renal function. The dose of ampicillin and sulbactam in such patients should be administered less frequently in accordance with the usual practice for ampicillin and according to the following recommendations: TABLE 3 Ampicillin and Sulbactam for Injection Dosage Guide for Patients with Renal Impairment Creatinine Clearance (mL/min/1.73 m 2 ) Ampicillin/Sulbactam Half-Life (Hours) Recommended Ampicillin and Sulbactam for Injection Dosage ≥30 1 1.5 to 3 g q 6h to q 8h 15 to 29 5 1.5 to 3 g q 12h 5 to 14 9 1.5 to 3 g q 24h When only serum creatinine is available, the following formula (based on sex, weight, and age of the patient) may be used to convert this value into creatinine clearance. The serum creatinine should represent a steady state of renal function. Males weight (kg) × (140 – age) 72 × serum creatinine Females 0.85 × above value COMPATIBILITY, RECONSTITUTION AND STABILITY When concomitant therapy with aminoglycosides is indicated, ampicillin and sulbactam and aminoglycosides should be reconstituted and administered separately, due to the in vitro inactivation of aminoglycosides by any of the aminopenicillins. DIRECTIONS FOR USE Intravenous Administration Directions for Proper Use of Pharmacy Bulk Package Ampicillin and sulbactam for injection sterile powder for intravenous use may be reconstituted with any of the compatible diluents described in this insert. Solutions should be allowed to stand after dissolution to allow any foaming to dissipate in order to permit visual inspection for complete solubilization. Ampicillin and sulbactam for injection concentrations between 3 and 45 mg (2 to 30 mg ampicillin/1 to 15 mg sulbactam/mL) are recommended for intravenous use. The 15 gram bottle may be reconstituted with either 92 mL Sterile Water for Injection or 0.9% Sodium Chloride Injection. The diluent should be added in two separate aliquots in a suitable work area, such as a laminar flow hood. Add 50 mL of solution, shake to dissolve. Then add an additional 42 mL and shake. The solution should be allowed to stand after dissolution to allow any foaming to dissipate in order to permit visual inspection for complete solubilization. The resultant solution will have a final concentration of approximately 100 mg/mL ampicillin and 50 mg/mL sulbactam. The closure may be penetrated only one time after reconstitution, if needed, using a suitable sterile transfer device or dispensing set that allows for measured dispensing of the contents. After reconstitution, use within two hours if stored at room temperature, or within four hours if stored under refrigeration. Reconstituted Bulk Solution Should Not be Used For Direct Infusion If the reconstituted bulk solution is stored for less than one hour at room temperature (20°C/68°F) prior to further dilution, the use periods indicated in Table 4 apply for the diluted solutions. If the bulk solution is stored for one to two hours at room temperature (20°C/68°F) and then diluted with Sterile Water for Injection or 0.9% Sodium Chloride Injection to the following concentrations, the use periods indicated in Table 5 apply. Any unused portions of solution that remain after the indicated time periods should be discarded. TABLE 4 Maximum Concentration (mg/mL) Diluent Ampicillin/Sulbactam Use Periods Sterile Water for Injection 45 (30/15) 8 hrs at 21°C 45 (30/15) 48 hrs at 4°C 30 (20/10) 72 hrs at 4°C 0.9% Sodium Chloride Injection 45 (30/15) 8 hrs at 21°C 45 (30/15) 48 hrs at 4°C 30 (20/10) 72 hrs at 4°C 5% Dextrose Injection 30 (20/10) 2 hrs at 21°C 30 (20/10) 4 hrs at 4°C 3 (2/1) 2 hrs at 21°C Lactated Ringer's Injection 45 (30/15) 8 hrs at 21°C 45 (30/15) 24 hrs at 4°C M/6 Sodium Lactate Injection 45 (30/15) 8 hrs at 21°C 45 (30/15) 12 hrs at 4°C 5% Dextrose in 0.45% Saline 3 (2/1) 4 hrs at 21°C 15 (10/5) 4 hrs at 4°C 10% Invert Sugar 3 (2/1) 4 hrs at 21°C 30 (20/10) 3 hrs at 4°C TABLE 5 Maximum Concentration (mg/mL) IV Solution Ampicillin/Sulbactam Use Period Sterile Water for Injection, USP 45 (30/15) 4 hrs at 21°C 45 (30/15) 24 hrs at 4°C 0.9% Sodium Chloride Injection, USP 45 (30/15) 4 hrs at 21°C 45 (30/15) 24 hrs at 4°C