1.3.1 Amoxicillin/Clavulanic Acid SPC, Labeling and Package Leaflet Common

Home , Benzylpenicillin, Methicillin, Monobactam

1.3.1 Amoxicillin/Clavulanic acid SPC, Labeling and Package Leaflet Common

SUMMARY OF PRODUCT CHARACTERISTICS, LABELLING AND PACKAGE LEAFLET

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1.3.1 Amoxicillin/Clavulanic acid SPC, Labeling and Package Leaflet Common

SUMMARY OF PRODUCT CHARACTERISTICS

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1.3.1 Amoxicillin/Clavulanic acid SPC, Labeling and Package Leaflet Common

1. NAME OF THE MEDICINAL PRODUCT

500 mg/125 mg film-coated tablets

2. QUALITATIVE AND QUANTITATIVE COMPOSITION

Each film-coated tablet contains 500 mg amoxicillin (as amoxicillin trihydrate) and 125 mg of clavulanic acid (as potassium clavulanate).

For the full list of excipients, see section 6.1.

3. PHARMACEUTICAL FORM

Film-coated tablet (tablet)

White coloured capsule shaped film coated tablet debossed with "I 06" on one side and plain on other side, tablet length: 19.40 ± 0.10 mm.

4. CLINICAL PARTICULARS

4.1 Therapeutic indications

is indicated for the treatment of the following infections in adults and children (see sections 4.2, 4.4 and 5.1):

- Acute bacterial sinusitis (adequately diagnosed) - Acute otitis media - Acute exacerbations of chronic bronchitis (adequately diagnosed) - Community acquired pneumonia - Cystitis - Pyelonephritis - Skin and soft tissue infections in particular cellulitis, animal bites, severe dental abscess with spreading cellulitis. - Bone and joint infections, in particular osteomyelitis.

Consideration should be given to official guidance on the appropriate use of antibacterial agents.

4.2 Posology and method of administration

Posology

Doses are expressed throughout in terms of amoxicillin/clavulanic acid content except when doses are stated in terms of an individual component. The dose of that is selected to treat an individual infection should take into account:

- The expected pathogens and their likely susceptibility to antibacterial agents (see section 4.4) - The severity and the site of the infection - The age, weight and renal function of the patient as shown below.

The use of alternative presentations of (e.g. those that provide higher doses of

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1.3.1 Amoxicillin/Clavulanic acid SPC, Labeling and Package Leaflet Common amoxicillin and/or different ratios of amoxicillin to clavulanic acid) should be considered as necessary (see sections 4.4 and 5.1).

For adults and children ≥ 40 kg, this formulation of provides a total daily dose of 1500 mg amoxicillin/375 mg clavulanic acid, when administered as recommended below. For children < 40 kg, this formulation of provides a maximum daily dose of 2400 mg amoxicillin/600 mg clavulanic acid, when administered as recommended below.

If it is considered that a higher daily dose of amoxicillin is required, it is recommended that another preparation of amoxicillin/clavulanic acid is selected in order to avoid administration of unnecessarily high daily doses of clavulanic acid (see sections 4.4 and 5.1).

The duration of therapy should be determined by the response of the patient. Some infections (e.g. osteomyelitis) require longer periods of treatment. Treatment should not be extended beyond 14 days without review (see section 4.4 regarding prolonged therapy).

Adults and children ≥ 40 kg - one 500 mg/125 mg dose taken three times a day;

Paediatric population Children < 40 kg

Children may be treated with tablets and suspensions. - 20 mg/5 mg/kg/day to 60 mg/15 mg/kg/day given in three divided doses.

As the tablets cannot be divided children weighing less than 25 kg must not be treated with tablets. The table below presents the received dose (mg/kg body weight) in children weighing 25 kg to 40 kg upon administering a single 500/125 mg tablet.

Body weight [kg] 40 35 30 25 Single dose recommended [mg/kg body weight] (see above) Amoxicillin [mg/kg 12.5 14.3 16.7 20.0 6.67 – 20 body weight] per single dose (1 film-coated tablet) Clavulanic acid [mg/kg 3.1 3.6 4.2 5.0 1.67 - 5 body weight] per single dose (1 film-coated tablet)

Children aged 6 years and below or weighing less than 25 kg should preferably be treated with amoxicillin/clavulanic acid suspension.

No clinical data are available on doses of 4:1 formulations higher than 40 mg/10 mg/kg per day in children under 2 years.

Elderly patients No dose adjustment is considered necessary.

Renal impairment

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1.3.1 Amoxicillin/Clavulanic acid SPC, Labeling and Package Leaflet Common

Dose adjustments are based on the maximum recommended level of amoxicillin. No dose adjustment is required in patients with creatinine clearance (CrCl) greater than 30 ml/min.

Adults and children ≥ 40 kg CrCl: 10-30 ml/min 500 mg/125 mg twice daily CrCl < 10 ml /min 500 mg/125 mg once daily Haemodialysis 500 mg/125 mg every 24 hours, plus 500 mg/125 mg during dialysis, to be repeated at the end of dialysis (as serum concentrations of both amoxicillin and clavulanic acid are decreased)

Children < 40 kg CrCl: 10-30 ml/min 15 mg/3.75 mg/kg twice daily (maximum 500 mg/125 mg twice daily). CrCl < 10 ml /min 15 mg/3.75 mg/kg as a single daily dose (maximum 500 mg/125 mg). Haemodialysis 15 mg/3.75 mg/kg per day once daily. Prior to haemodialysis 15 mg/3.75 mg/kg. In order to restore circulating drug levels, 15 mg/3.75 mg per kg should be administered after haemodialysis.

Hepatic impairment Dose with caution and monitor hepatic function at regular intervals (see sections 4.3 and 4.4).

Method of administration is for oral use. Administer at the start of a meal to minimise potential gastrointestinal intolerance.

Treatment may be initiated with parenteral formulation according to it’s corresponding SmPC and then it can be switched to oral form.

4.3 Contraindications

Hypersensitivity to the active substances or to any of the excipients listed in section 6.1.

History of a severe immediate hypersensitivity reaction (e.g. anaphylaxis) to another beta-lactam agent (e.g. a cephalosporin, carbapenem or monobactam).

History of jaundice/hepatic impairment due to amoxicillin/clavulanic acid (see section 4.8).

4.4 Special warnings and precautions for use

Before initiating therapy with amoxicillin/clavulanic acid, careful enquiry should be made concerning previous hypersensitivity reactions to penicillins, cephalosporins or other beta-lactam agents (see sections 4.3 and 4.8).

Serious and occasionally fatal hypersensitivity (including anaphylactoid and severe cutaneous adverse reactions) reactions have been reported in patients on penicillin therapy. These reactions are more likely to occur in individuals with a history of penicillin hypersensitivity and in atopic individuals. If an allergic reaction occurs, amoxicillin/clavulanic acid therapy must be discontinued and appropriate alternative therapy instituted.

In the case that an infection is proven to be due to an amoxicillin-susceptible organisms(s) then consideration should be given to switching from amoxicillin/clavulanic acid to amoxicillin in accordance with official guidance. PI_Text001167_2 - Updated: Page 5 of 41

1.3.1 Amoxicillin/Clavulanic acid SPC, Labeling and Package Leaflet Common

This presentation of is not suitable for use when there is a high risk that the presumptive pathogens have resistance to beta-lactam agents that is not mediated by beta-lactamases susceptible to inhibition by clavulanic acid. This presentation should not be used to treat penicillin- resistant S. pneumoniae.

Convulsions may occur in patients with impaired renal function or in those receiving high doses (see 4.8).

Amoxicillin/clavulanic acid should be avoided if infectious mononucleosis is suspected since the occurrence of a morbilliform rash has been associated with this condition following the use of amoxicillin.

Concomitant use of allopurinol during treatment with amoxicillin can increase the likelihood of allergic skin reactions.

Prolonged use may occasionally result in overgrowth of non-susceptible organisms.

The occurrence at the treatment initiation of a feverish generalised erythema associated with pustula may be a symptom of acute generalised exanthemous pustulosis (AGEP) (see Section 4.8). This reaction requires discontinuation and contra-indicates any subsequent administration of amoxicillin.

Amoxicillin/clavulanic acid should be used with caution in patients with evidence of hepatic impairment (see sections 4.2, 4.3 and 4.8).

Hepatic events have been reported predominantly in males and elderly patients and may be associated with prolonged treatment. These events have been very rarely reported in children. In all populations, signs and symptoms usually occur during or shortly after treatment but in some cases may not become apparent until several weeks after treatment has ceased. These are usually reversible. Hepatic events may be severe and in extremely rare circumstances, deaths have been reported. These have almost always occurred in patients with serious underlying disease or taking concomitant medications known to have the potential for hepatic effects (see section 4.8).

Antibiotic-associated colitis has been reported with nearly all antibacterial agents including amoxicillin and may range in severity from mild to life threatening (see section 4.8). Therefore, it is important to consider this diagnosis in patients who present with diarrhoea during or subsequent to the administration of any antibiotics. Should antibiotic-associated colitis occur, should immediately be discontinued, a physician be consulted and an appropriate therapy initiated. Anti- peristaltic drugs are contra-indicated in this situation.

Periodic assessment of organ system functions, including renal, hepatic and haematopoietic function is advisable during prolonged therapy.

Prolongation of prothrombin time has been reported rarely in patients receiving amoxicillin/clavulanic acid. Appropriate monitoring should be undertaken when anticoagulants are prescribed concomitantly. Adjustments in the dose of oral anticoagulants may be necessary to maintain the desired level of anticoagulation (see section 4.5 and 4.8).

In patients with renal impairment, the dose should be adjusted according to the degree of impairment (see section 4.2).

In patients with reduced urine output, crystalluria has been observed very rarely, predominantly with

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1.3.1 Amoxicillin/Clavulanic acid SPC, Labeling and Package Leaflet Common parenteral therapy. During the administration of high doses of amoxicillin, it is advisable to maintain adequate fluid intake and urinary output in order to reduce the possibility of amoxicillin crystalluria. In patients with bladder catheters, a regular check of patency should be maintained (see section 4.9).

During treatment with amoxicillin, enzymatic glucose oxidase methods should be used whenever testing for the presence of glucose in urine because false positive results may occur with non- enzymatic methods.

The presence of clavulanic acid in may cause a non-specific binding of IgG and albumin by red cell membranes leading to a false positive Coombs test.

There have been reports of positive test results using the Bio-Rad Laboratories Platelia Aspergillus EIA test in patients receiving amoxicillin/clavulanic acid who were subsequently found to be free of Aspergillus infection. Cross-reactions with non-Aspergillus polysaccharides and polyfuranoses with Bio-Rad Laboratories Platelia Aspergillus EIA test have been reported. Therefore, positive test results in patients receiving amoxicillin/clavulanic acid should be interpreted cautiously and confirmed by other diagnostic methods.

Sodium This medicine contains less than 1 mmol sodium (23 mg) per tablet, that is to say essentially "sodium- free".

4.5 Interaction with other medicinal products and other forms of interaction

Oral anticoagulants Oral anticoagulants and penicillin antibiotics have been widely used in practice without reports of interaction. However, in the literature there are cases of increased international normalised ratio in patients maintained on acenocoumarol or warfarin and prescribed a course of amoxicillin. If co- administration is necessary, the prothrombin time or international normalised ratio should be carefully monitored with the addition or withdrawal of amoxicillin. Moreover, adjustments in the dose of oral anticoagulants may be necessary (see sections 4.4 and 4.8).

Methotrexate Penicillins may reduce the excretion of methotrexate causing a potential increase in toxicity.

Probenecid Concomitant use of probenecid is not recommended. Probenecid decreases the renal tubular secretion of amoxicillin. Concomitant use of probenecid may result in increased and prolonged blood levels of amoxicillin but not of clavulanic acid.

Mycophenolate mofetil In patients receiving mycophenolate mofetil, reduction in pre-dose concentration of the active metabolite mycophenolic acid (MPA) of approximately 50% has been reported following commencement of oral amoxicillin plus clavulanic acid. The change in pre-dose level may not accurately represent changes in overall MPA exposure. Therefore, a change in the dose of mycophenolate mofetil should not normally be necessary in the absence of clinical evidence of graft dysfunction. However, close clinical monitoring should be performed during the combination and shortly after antibiotic treatment.

4.6 Fertility, pregnancy and lactation

Pregnancy Animal studies do not indicate direct or indirect harmful effects with respect to pregnancy,

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1.3.1 Amoxicillin/Clavulanic acid SPC, Labeling and Package Leaflet Common embryonal/foetal development, parturition or postnatal development (see section 5.3). Limited data on the use of amoxicillin/clavulanic acid during pregnancy in humans do not indicate an increased risk of congenital malformations. In a single study in women with preterm, premature rupture of the foetal membrane it was reported that prophylactic treatment with amoxicillin/clavulanic acid may be associated with an increased risk of necrotising enterocolitis in neonates. Use should be avoided during pregnancy, unless considered essential by the physician.

Breast-feeding Both substances are excreted into breast milk (nothing is known of the effects of clavulanic acid on the breast-fed infant). Consequently, diarrhoea and fungus infection of the mucous membranes are possible in the breast-fed infant, so that breast-feeding might have to be discontinued. The possibility of sensitization should be considered. Amoxicillin/clavulanic acid should only be used during breast-feeding after benefit/risk assessment by the physician in charge.

4.7 Effects on ability to drive and use machines

No studies on the effects on the ability to drive and use machines have been performed. However, undesirable effects may occur (e.g. allergic reactions, dizziness, convulsions), which may influence the ability to drive and use machines (see section 4.8).

4.8 Undesirable effects

The most commonly reported adverse drug reactions (ADRs) are diarrhoea, nausea and vomiting. The ADRs derived from clinical studies and post-marketing surveillance with , sorted by MedDRA System Organ Class are listed below.

- Very common ( 1/10) - Common ( 1/100 to < 1/10) - Uncommon ( 1/1,000 to < 1/100) - Rare ( 1/10,000 to < 1/1,000) - Very rare (< 1/10,000) - Not known (cannot be estimated from the available data)

System organ class Adverse reactions Infections and infestations Common Mucocutaneous candidosis

Not known Overgrowth of non-susceptible organisms

Blood and lymphatic system disorders Rare Reversible leucopenia (including neutropenia) Thrombocytopenia Not known Reversible agranulocytosis Haemolytic anaemia Prolongation of bleeding time and prothrombin time1 Immune system disorders10 Not known Angioneurotic oedema Anaphylaxis Serum sickness-like syndrome Hypersensitivity vasculitis Nervous system disorders Uncommon Dizziness PI_Text001167_2 - Updated: Page 8 of 41

1.3.1 Amoxicillin/Clavulanic acid SPC, Labeling and Package Leaflet Common

System organ class Adverse reactions Headache Not known Reversible hyperactivity Convulsions2 Aseptic meningitis Gastrointestinal disorders Very common Diarrhoea Common Nausea3 Vomiting Uncommon Indigestion Not known Antibiotic-associated colitis4 Black hairy tongue Hepatobiliary disorders Uncommon Rises in AST and/or ALT5 Not known Hepatitis6 Cholestatic jaundice6 Skin and subcutaneous tissue disorders7 Uncommon Skin rash Pruritus Urticaria Rare Erythema multiforme Not known Stevens-Johnson syndrome Toxic epidermal necrolysis Bullous exfoliative-dermatitis Acute generalised exanthemous pustulosis (AGEP)9 Drug reaction with eosinophilia and systemic symptoms (DRESS) Renal and urinary disorders Not known Interstitial nephritis Crystalluria8 1 See section 4.4 2 See section 4.4 3 Nausea is more often associated with higher oral doses. If gastrointestinal reactions are evident, they may be reduced by taking at the start of a meal. 4 Including pseudomembranous colitis and haemorrhagic colitis (see section 4.4) 5 A moderate rise in AST and/or ALT has been noted in patients treated with beta-lactam class antibiotics, but the significance of these findings is unknown. 6 These events have been noted with other penicillins and cephalosporins (see section 4.4). 7 If any hypersensitivity dermatitis reaction occurs, treatment should be discontinued (see section 4.4). 8 See section 4.9 9 See section 4.4 10 See section 4.4

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 national reporting system listed in Appendix V.

4.9 Overdose

Symptoms Amoxicillin has been reported to precipitate in bladder catheters, predominantly after intravenous PI_Text001167_2 - Updated: Page 9 of 41

1.3.1 Amoxicillin/Clavulanic acid SPC, Labeling and Package Leaflet Common administration of large doses. A regular check of patency should be maintained (see section 4.4). Gastrointestinal symptoms and disturbance of the fluid and electrolyte balances may be evident. Amoxicillin crystalluria, in some cases leading to renal failure, has been observed (see section 4.4). Convulsions may occur in patients with impaired renal function or in those receiving high doses.

Management Gastrointestinal symptoms may be treated symptomatically, with attention to the water/electrolyte balance. Amoxicillin/clavulanic acid can be removed from the circulation by haemodialysis.

5. PHARMACOLOGICAL PROPERTIES

5.1 Pharmacodynamic properties

Pharmacotherapeutic group: Antibacterials for systemic use, Combinations of penicillins, incl. beta-lactamase inhibitors, ATC code: J01CR02.

Mechanism of action Amoxicillin is a semisynthetic penicillin (beta-lactam antibiotic) that inhibits one or more enzymes (often referred to as penicillin-binding proteins, PBPs) in the biosynthetic pathway of bacterial peptidoglycan, which is an integral structural component of the bacterial cell wall. Inhibition of peptidoglycan synthesis leads to weakening of the cell wall, which is usually followed by cell lysis and death. Amoxicillin is susceptible to degradation by beta-lactamases produced by resistant bacteria and therefore the spectrum of activity of amoxicillin alone does not include organisms which produce these enzymes. Clavulanic acid is a beta-lactam structurally related to penicillins. It inactivates some beta-lactamase enzymes thereby preventing inactivation of amoxicillin. Clavulanic acid alone does not exert a clinically useful antibacterial effect.

Pharmacokinetic/pharmacodynamic relationship The time above the minimum inhibitory concentration (T>MIC) is considered to be the major determinant of efficacy for amoxicillin.

Mechanisms of resistance The two main mechanisms of resistance to amoxicillin/clavulanic acid are:

- Inactivation by those bacterial beta-lactamases that are not themselves inhibited by clavulanic acid, including class B, C and D. - Alteration of PBPs, which reduce the affinity of the antibacterial agent for the target.

Impermeability of bacteria or efflux pump mechanisms may cause or contribute to bacterial resistance, particularly in Gram-negative bacteria.

Breakpoints MIC breakpoints for amoxicillin/clavulanic acid are those of the European Committee on Antimicrobial Susceptibility Testing (EUCAST)

Organism Susceptibility Breakpoints (µg/ml) Susceptible Intermediate Resistant

Haemophilus influenzae1 ≤ 1 - > 1

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1.3.1 Amoxicillin/Clavulanic acid SPC, Labeling and Package Leaflet Common

Moraxella catarrhalis1 ≤ 1 - > 1 Staphylococcus aureus 2 ≤ 2 - > 2 Coagulase-negative ≤ 0.25 > 0.25 staphylococci2 Enterococcus1 ≤ 4 8 > 8 Streptococcus A, B, C, G5 ≤ 0.25 - > 0.25 Streptococcus pneumoniae3 ≤ 0.5 1-2 > 2 Enterobacteriaceae1,4 - - > 8 Gram-negative Anaerobes1 ≤ 4 8 > 8 Gram-positive Anaerobes1 ≤ 4 8 > 8 Non-species related breakpoints1 ≤ 2 4-8 > 8 1 The reported values are for Amoxicillin concentrations. For susceptibility testing purposes, the concentration of Clavulanic acid is fixed at 2 mg/l. 2 The reported values are Oxacillin concentrations. 3 Breakpoint values in the table are based on Ampicillin breakpoints. 4 The resistant breakpoint of R>8 mg/l ensures that all isolates with resistance mechanisms are reported resistant. 5 Breakpoint values in the table are based on Benzylpenicillin breakpoints.

The prevalence of resistance may vary geographically and with time for selected species, and local information on resistance is desirable, particularly when treating severe infections. As necessary, expert advice should be sought when the local prevalence of resistance is such that the utility of the agent in at least some types of infections is questionable.

Commonly susceptible species Aerobic Gram-positive micro-organisms Enterococcus faecalis Gardnerella vaginalis Staphylococcus aureus (methicillin-susceptible) £ Coagulase-negative staphylococci (methicillin-susceptible) Streptococcus agalactiae Streptococcus pneumoniae1 Streptococcus pyogenes and other beta-haemolytic streptococci Streptococcus viridans group Aerobic Gram-negative micro-organisms Capnocytophaga spp. Eikenella corrodens Haemophilus influenzae2 Moraxella catarrhalis Pasteurella multocida Anaerobic micro-organisms Bacteroides fragilis Fusobacterium nucleatum Prevotella spp. Species for which acquired resistance may be a problem Aerobic Gram-positive micro-organisms Enterococcus faecium $ Aerobic Gram-negative micro-organisms Escherichia coli Klebsiella oxytoca

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1.3.1 Amoxicillin/Clavulanic acid SPC, Labeling and Package Leaflet Common

Klebsiella pneumoniae Proteus mirabilis Proteus vulgaris Inherently resistant organisms Aerobic Gram-negative micro-organisms Acinetobacter sp. Citrobacter freundii Enterobacter sp. Legionella pneumophila Morganella morganii Providencia spp. Pseudomonas sp. Serratia sp. Stenotrophomonas maltophilia Other micro-organisms Chlamydophila pneumoniae Chlamydophila psittaci Coxiella burnetti Mycoplasma pneumoniae $ Natural intermediate susceptibility in the absence of acquired mechanism of resistance. £ All methicillin-resistant staphylococci are resistant to amoxicillin/clavulanic acid 1 Streptococcus pneumoniae that are resistant to penicillin should not be treated with this presentation of amoxicillin/clavulanic acid (see sections 4.2 and 4.4). 2 Strains with decreased susceptibility have been reported in some countries in the EU with a frequency higher than 10%.

5.2 Pharmacokinetic properties

Absorption Amoxicillin and clavulanic acid, are fully dissociated in aqueous solution at physiological pH. Both components are rapidly and well absorbed by the oral route of administration. Absorption of amoxicillin/clavulanic acid is optimised when taken at the start of a meal. Following oral administration, amoxicillin and clavulanic acid are approximately 70% bioavailable. The plasma profiles of both components are similar and the time to peak plasma concentration (Tmax) in each case is approximately one hour.

The pharmacokinetic results for a study, in which amoxicillin/clavulanic acid (500 mg/125 mg tablets three times daily) was administered in the fasting state to groups of healthy volunteers are presented below.

Mean ( SD) pharmacokinetic parameters

Active substance(s) Dose Cmax Tmax * AUC (0-24h) T 1/2 administered (mg) (g/ml) (h) ((g.h/ml) (h) Amoxicillin AMX/CA 500 7.19 1.5 53.5 1.15 500/125 mg  2.26 (1.0-2.5)  8.87  0.20 Clavulanic acid AMX/CA 125 2.40 1.5 15.72 0.98 500 mg/125 mg  0.83 (1.0-2.0)  3.86  0.12

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1.3.1 Amoxicillin/Clavulanic acid SPC, Labeling and Package Leaflet Common

AMX – amoxicillin, CA – clavulanic acid * Median (range)

Amoxicillin and clavulanic acid serum concentrations achieved with amoxicillin/clavulanic acid are similar to those produced by the oral administration of equivalent doses of amoxicillin or clavulanic acid alone.

Distribution About 25% of total plasma clavulanic acid and 18% of total plasma amoxicillin is bound to protein. The apparent volume of distribution is around 0.3-0.4 l/kg for amoxicillin and around 0.2 l/kg for clavulanic acid.

Following intravenous administration, both amoxicillin and clavulanic acid have been found in gall bladder, abdominal tissue, skin, fat, muscle tissues, synovial and peritoneal fluids, bile and pus. Amoxicillin does not adequately distribute into the cerebrospinal fluid.

From animal studies there is no evidence for significant tissue retention of drug-derived material for either component. Amoxicillin, like most penicillins, can be detected in breast milk. Trace quantities of clavulanic acid can also be detected in breast milk (see section 4.6).

Both amoxicillin and clavulanic acid have been shown to cross the placental barrier (see section 4.6).

Biotransformation Amoxicillin is partly excreted in the urine as the inactive penicilloic acid in quantities equivalent to up to 10 to 25% of the initial dose. Clavulanic acid is extensively metabolized in man and eliminated in urine and faeces and as carbon dioxide in expired air.

Elimination The major route of elimination for amoxicillin is via the kidney, whereas for clavulanic acid it is by both renal and non-renal mechanisms.

Amoxicillin/clavulanic acid has a mean elimination half-life of approximately one hour and a mean total clearance of approximately 25 l/h in healthy subjects. Approximately 60 to 70% of the amoxicillin and approximately 40 to 65% of the clavulanic acid are excreted unchanged in urine during the first 6 h after administration of single Amoxicillin/clavulanic acid 250 mg/125 mg or 500 mg/125 mg tablets. Various studies have found the urinary excretion to be 50-85% for amoxicillin and between 27-60% for clavulanic acid over a 24 hour period. In the case of clavulanic acid, the largest amount of drug is excreted during the first 2 hours after administration.

Concomitant use of probenecid delays amoxicillin excretion but does not delay renal excretion of clavulanic acid (see section 4.5).

Age The elimination half-life of amoxicillin is similar for children aged around 3 months to 2 years and older children and adults. For very young children (including preterm newborns) in the first week of life the interval of administration should not exceed twice daily administration due to immaturity of the renal pathway of elimination. Because elderly patients are more likely to have decreased renal function, care should be taken in dose selection, and it may be useful to monitor renal function.

Gender Following oral administration of amoxicillin/clavulanic acid to healthy males and female subjects, gender has no significant impact on the pharmacokinetics of either amoxicillin or clavulanic acid.

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1.3.1 Amoxicillin/Clavulanic acid SPC, Labeling and Package Leaflet Common

Renal impairment The total serum clearance of amoxicillin/clavulanic acid decreases proportionately with decreasing renal function. The reduction in drug clearance is more pronounced for amoxicillin than for clavulanic acid, as a higher proportion of amoxicillin is excreted via the renal route. Doses in renal impairment must therefore prevent undue accumulation of amoxicillin while maintaining adequate levels of clavulanic acid (see section 4.2).

Hepatic impairment Hepatically impaired patients should be dosed with caution and hepatic function monitored at regular intervals.

5.3 Preclinical safety data

Non-clinical data reveal no special hazard for humans based on studies of safety pharmacology, genotoxicity and toxicity to reproduction. Repeat dose toxicity studies performed in dogs with amoxicillin/clavulanic acid demonstrate gastric irritancy and vomiting, and discoloured tongue. Carcinogenicity studies have not been conducted with or its components.

6. PHARMACEUTICAL PARTICULARS

6.1 List of excipients

- Tablet core Microcrystalline cellulose, (E460) Sodium starch glycolate (type A) Colloidal anhydrous silica (E551) Magnesium stearate (E470b) - Film coating Titanium dioxide (E171) Hypromellose (E464) Macrogol 400

6.2 Incompatibilities

Not applicable.

6.3 Shelf life

2 years

6.4 Special precautions for storage

Strip and blister Do not store above 25°C. Store in the original package in order to protect from moisture.

6.5 Nature and contents of container

Strip (Alu/Alu): 10, 12, 14, 16, 20, 21, 24, 30, 100 or 500 film-coated tablets, in a box. Blister (OPA/Alu/PVC-Alu): 10, 12, 14, 16, 20, 21, 24, 30, 100 or 500 film-coated tablets, in a box.

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1.3.1 Amoxicillin/Clavulanic acid SPC, Labeling and Package Leaflet Common

Not all pack sizes may be marketed.

6.6 Special precautions for disposal and other handling

No special requirements for disposal. Any unused medicinal product or waste material should be disposed of in accordance with local requirements.

7. MARKETING AUTHORISATION HOLDER

KRKA, d.d., Novo mesto, Šmarješka cesta 6, 8501 Novo mesto, Slovenia

8. MARKETING AUTHORISATION NUMBER(S)

[To be completed nationally]

9. DATE OF FIRST AUTHORISATION/RENEWAL OF THE AUTHORISATION

Date of first authorisation: [To be completed nationally] Date of latest renewal: [To be completed nationally]

10. DATE OF REVISION OF THE TEXT

[To be completed nationally]

Detailed information on this medicinal product is available on the website of: {name of Member State Agency (link)}

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1.3.1 Amoxicillin/Clavulanic acid SPC, Labeling and Package Leaflet Common

1. NAME OF THE MEDICINAL PRODUCT

875 mg/125 mg film-coated tablets

2. QUALITATIVE AND QUANTITATIVE COMPOSITION

Each film-coated tablet contains 875 mg amoxicillin as (amoxicillin trihydrate) and 125 mg of clavulanic acid (as potassium clavulanate).

For the full list of excipients, see section 6.1.

3. PHARMACEUTICAL FORM

Film-coated tablet (tablet)

White coloured capsule shaped film coated tablet debossed with "I 07" on one side and plain on other side, tablet length: 21.70 ± 0.10mm.

4. CLINICAL PARTICULARS

4.1 Therapeutic indications

is indicated for the treatment of the following infections in adults and children (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

Posology

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1.3.1 Amoxicillin/Clavulanic acid SPC, Labeling and Package Leaflet Common

The use of alternative presentations of (e.g. those that provide higher doses of amoxicillin and/or different ratios of amoxicillin to clavulanic acid) should be considered as necessary (see sections 4.4 and 5.1).

For adults and children ≥ 40 kg, this formulation of provides a total daily dose of 1750 mg amoxicillin/ 250 mg clavulanic acid with twice daily dosing and 2625 mg amoxicillin/375 mg clavulanic acid with three times daily dosing, when administered as recommended below. For children < 40 kg, this formulation of provides a maximum daily dose of 1000-2800 mg amoxicillin/143-400 mg clavulanic acid, when administered as recommended below.

Adults and children ≥ 40 kg

- standard dose: (for all indications) 875 mg/125 mg two times a day; - higher dose - (particularly for infections such as otitis media, sinusitis, lower respiratory tract infections and urinary tract infections): 875 mg/125 mg three times a day.

Paediatric population Children < 40 kg

Children may be treated with tablets and suspensions.

As the tablets cannot be divided children weighing less than 25 kg must not be treated with tablets. Children aged 6 years and below or weighing less than 25 kg should preferably be treated with amoxicillin/clavulanic acid suspension.

Recommended doses for 875 mg/125 mg amoxicillin/clavulanic acid - 25 mg/3.6 mg/kg/day to 45 mg/6.4 mg/kg/day given as two divided doses; - up to 70 mg/10 mg/kg/day given as two divided doses may be considered for some infections (such as otitis media, sinusitis and lower respiratory tract infections).

The table below presents the received dose (mg/kg body weight) in children weighing 25 kg to 40 kg upon administering a single 875/125 mg tablet.

Single dose recommended Body weight [kg] 40 35 30 25 [mg/kg body weight] (see above) Amoxicillin [mg/kg body weight] 12,5 – 22,5 per single dose (1 film-coated 21,9 25,0 29,2 35,0 tablet) (up to 35) Clavulanic acid [mg/kg body 1,8 – 3,2 weight] per single dose (1 film- 3,1 3,6 4,2 5,0 coated tablet) (up to 5)

No clinical data are available for 7:1 formulations regarding doses higher than 45 mg/6.4 mg per kg per day in children under 2 years

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1.3.1 Amoxicillin/Clavulanic acid SPC, Labeling and Package Leaflet Common

There are no clinical data for 7:1 formulations for patients under 2 months of age. Dosing recommendations in this population therefore cannot be made.

Elderly patients No dose adjustment is considered necessary.

Renal impairment

No dose adjustment is required in patients with creatinine clearance (CrCl) greater than 30 ml/min. In patients with creatinine clearance less than 30 ml/min, the use of presentations with an amoxicillin to clavulanic acid ratio of 7:1 is not recommended, as no recommendations for dose adjustments are available.

Hepatic impairment Dose with caution and monitor hepatic function at regular intervals (see sections 4.3 and 4.4).

Method of administration is for oral use. Administer at the start of a meal to minimise potential gastrointestinal intolerance.

Treatment may be initiated with parenteral formulation according to it’s corresponding SmPC and then it can be switched to oral form.

4.3 Contraindications

Hypersensitivity to the active substances or to any of the excipients listed in section 6.1.

History of a severe immediate hypersensitivity reaction (e.g. anaphylaxis) to another beta-lactam agent (e.g. a cephalosporin, carbapenem or monobactam).

History of jaundice/hepatic impairment due to amoxicillin/clavulanic acid (see section 4.8).

4.4 Special warnings and precautions for use

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Convulsions may occur in patients with impaired renal function or in those receiving high doses (see 4.8).

Concomitant use of allopurinol during treatment with amoxicillin can increase the likelihood of allergic skin reactions.

Prolonged use may occasionally result in overgrowth of non-susceptible organisms.

Amoxicillin/clavulanic acid should be used with caution in patients with evidence of hepatic impairment (see sections 4.2, 4.3 and 4.8).

Periodic assessment of organ system functions, including renal, hepatic and haematopoietic function is advisable during prolonged therapy.

In patients with renal impairment, the dose should be adjusted according to the degree of impairment (see section 4.2).

In patients with reduced urine output, crystalluria has been observed very rarely, predominantly with parenteral therapy. During the administration of high doses of amoxicillin, it is advisable to maintain adequate fluid intake and urinary output in order to reduce the possibility of amoxicillin crystalluria. In patients with bladder catheters, a regular check of patency should be maintained (see section 4.9).

During treatment with amoxicillin, enzymatic glucose oxidase methods should be used whenever

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1.3.1 Amoxicillin/Clavulanic acid SPC, Labeling and Package Leaflet Common testing for the presence of glucose in urine because false positive results may occur with non- enzymatic methods.

The presence of clavulanic acid in may cause a non-specific binding of IgG and albumin by red cell membranes leading to a false positive Coombs test.

Sodium This medicine contains less than 1 mmol sodium (23 mg) per tablet, that is to say essentially "sodium- free".

4.5 Interaction with other medicinal products and other forms of interaction

Methotrexate Penicillins may reduce the excretion of methotrexate causing a potential increase in toxicity.

4.6 Fertility, pregnancy and lactation

Pregnancy Animal studies do not indicate direct or indirect harmful effects with respect to pregnancy, embryonal/foetal development, parturition or postnatal development (see section 5.3). Limited data on the use of amoxicillin/clavulanic acid during pregnancy in humans do not indicate an increased risk of congenital malformations. In a single study in women with preterm, premature rupture of the foetal membrane it was reported that prophylactic treatment with amoxicillin/clavulanic acid may be associated with an increased risk of necrotising enterocolitis in neonates. Use should be avoided

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1.3.1 Amoxicillin/Clavulanic acid SPC, Labeling and Package Leaflet Common during pregnancy, unless considered essential by the physician.

4.7 Effects on ability to drive and use machines

4.8 Undesirable effects

System organ class Adverse reactions Infections and infestations Common Mucocutaneous candidosis

Not known Overgrowth of non-susceptible organisms

1.3.1 Amoxicillin/Clavulanic acid SPC, Labeling and Package Leaflet Common

System organ class Adverse reactions Very common Diarrhoea Common Nausea3 Vomiting Uncommon Indigestion Not known Antibiotic-associated colitis4 Black hairy tongue Hepatobiliary disorders Uncommon Rises in AST and/or ALT5 Not known Hepatitis6 Cholestatic jaundice6 Skin and subcutaneous tissue disorders7 Uncommon Skin rash Pruritus Urticaria Rare Erythema multiforme Not known Stevens-Johnson syndrome Toxic epidermal necrolysis Bullous exfoliative-dermatitis Acute generalised exanthemous pustulosis (AGEP)9 Drug reaction with eosinophilia and systemic symptoms (DRESS) Renal and urinary disorders Not known Interstitial nephritis Crystalluria8 1 See section 4.4 2 See section 4.4 3 Nausea is more often associated with higher oral doses. If gastrointestinal reactions are evident, they may be reduced by taking at the start of a meal. 4 Including pseudomembranous colitis and haemorrhagic colitis (see section 4.4) 5 A moderate rise in AST and/or ALT has been noted in patients treated with beta-lactam class antibiotics, but the significance of these findings is unknown. 6 These events have been noted with other penicillins and cephalosporins (see section 4.4). 7 If any hypersensitivity dermatitis reaction occurs, treatment should be discontinued (see section 4.4). 8 See section 4.9 9 See section 4.4 10 See section 4.4

4.9 Overdose

Symptoms Amoxicillin has been reported to precipitate in bladder catheters, predominantly after intravenous administration of large doses. A regular check of patency should be maintained (see section 4.4). Gastrointestinal symptoms and disturbance of the fluid and electrolyte balances may be evident. Amoxicillin crystalluria, in some cases leading to renal failure, has been observed (see section 4.4). Convulsions may occur in patients with impaired renal function or in those receiving high doses.

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1.3.1 Amoxicillin/Clavulanic acid SPC, Labeling and Package Leaflet Common

Management Gastrointestinal symptoms may be treated symptomatically, with attention to the water/electrolyte balance. Amoxicillin/clavulanic acid can be removed from the circulation by haemodialysis.

5. PHARMACOLOGICAL PROPERTIES

5.1 Pharmacodynamic properties

Pharmacotherapeutic group: Antibacterials for systemic use, Combinations of penicillins, incl. beta-lactamase inhibitors, ATC code: J01CR02.

Pharmacokinetic/pharmacodynamic relationship The time above the minimum inhibitory concentration (T>MIC) is considered to be the major determinant of efficacy for amoxicillin.

Mechanisms of resistance The two main mechanisms of resistance to amoxicillin/clavulanic acid are:

Impermeability of bacteria or efflux pump mechanisms may cause or contribute to bacterial resistance, particularly in Gram-negative bacteria.

Breakpoints MIC breakpoints for amoxicillin/clavulanic acid are those of the European Committee on Antimicrobial Susceptibility Testing (EUCAST)

Organism Susceptibility Breakpoints (µg/ml) Susceptible Intermediate Resistant

Haemophilus influenzae1 ≤ 1 - > 1 Moraxella catarrhalis1 ≤ 1 - > 1 Staphylococcus aureus 2 ≤ 2 - > 2 Coagulase-negative ≤ 0.25 > 0.25 staphylococci2 Enterococcus1 ≤ 4 8 > 8 PI_Text001167_2 - Updated: Page 23 of 41

1.3.1 Amoxicillin/Clavulanic acid SPC, Labeling and Package Leaflet Common

Streptococcus A, B, C, G5 ≤ 0.25 - > 0.25 Streptococcus pneumoniae3 ≤ 0.5 1-2 > 2 Enterobacteriaceae1,4 - - > 8 Gram-negative Anaerobes1 ≤ 4 8 > 8 Gram-positive Anaerobes1 ≤ 4 8 > 8 Non-species related breakpoints1 ≤ 2 4-8 > 8 1 The reported values are for Amoxicillin concentrations. For susceptibility testing purposes, the concentration of Clavulanic acid is fixed at 2 mg/l. 2 The reported values are Oxacillin concentrations. 3 Breakpoint values in the table are based on Ampicillin breakpoints. 4 The resistant breakpoint of R>8 mg/l ensures that all isolates with resistance mechanisms are reported resistant. 5 Breakpoint values in the table are based on Benzylpenicillin breakpoints.

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1.3.1 Amoxicillin/Clavulanic acid SPC, Labeling and Package Leaflet Common

Aerobic Gram-negative micro-organisms Acinetobacter sp. Citrobacter freundii Enterobacter sp. Legionella pneumophila Morganella morganii Providencia spp. Pseudomonas sp. Serratia sp. Stenotrophomonas maltophilia Other micro-organisms Chlamydophila pneumoniae Chlamydophila psittaci Coxiella burnetti Mycoplasma pneumoniae $ Natural intermediate susceptibility in the absence of acquired mechanism of resistance. £ All methicillin-resistant staphylococci are resistant to amoxicillin/clavulanic acid 1 Streptococcus pneumoniae that are resistant to penicillin should not be treated with this presentation of amoxicillin/clavulanic acid (see sections 4.2 and 4.4). 2 Strains with decreased susceptibility have been reported in some countries in the EU with a frequency higher than 10%.

5.2 Pharmacokinetic properties

The pharmacokinetic results for a study, in which amoxicillin/clavulanic acid (875 mg/125 mg tablets given twice daily) was administered in the fasting state to groups of healthy volunteers are presented below.

Mean (± SD) pharmacokinetic parameters

Active substance(s) Dose Cmax Tmax * AUC (0- T 1/2 administered 24h) (mg) (µg/ml) (h) ((µg.h/ml) (h) Amoxicillin AMX/CA 875 11.64 1.50 (1.0- 53.52 1.19 875 mg/125 mg ± 2.78 2.5) ± 12.31 ± 0.21 Clavulanic acid AMX/CA 125 2.18 1.25 (1.0- 10.16 0.96 875 mg/125 mg ± 0.99 2.0) ± 3.04 ± 0.12 AMX – amoxicillin, CA – clavulanic acid * Median (range)

Amoxicillin and clavulanic acid serum concentrations achieved with amoxicillin/clavulanic acid are

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1.3.1 Amoxicillin/Clavulanic acid SPC, Labeling and Package Leaflet Common similar to those produced by the oral administration of equivalent doses of amoxicillin or clavulanic acid alone.

Both amoxicillin and clavulanic acid have been shown to cross the placental barrier (see section 4.6).

Elimination The major route of elimination for amoxicillin is via the kidney, whereas for clavulanic acid it is by both renal and non-renal mechanisms.

Concomitant use of probenecid delays amoxicillin excretion but does not delay renal excretion of clavulanic acid (see section 4.5).

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1.3.1 Amoxicillin/Clavulanic acid SPC, Labeling and Package Leaflet Common must therefore prevent undue accumulation of amoxicillin while maintaining adequate levels of clavulanic acid (see section 4.2).

Hepatic impairment Hepatically impaired patients should be dosed with caution and hepatic function monitored at regular intervals.

5.3 Preclinical safety data

6. PHARMACEUTICAL PARTICULARS

6.1 List of excipients

6.2 Incompatibilities

Not applicable.

6.3 Shelf life

2 years

6.4 Special precautions for storage

Strip and blister Do not store above 25°C. Store in the original package in order to protect from moisture.

6.5 Nature and contents of container

Strip (Alu/Alu): 10, 12, 14, 16, 20, 21, 24, 30, 100 or 500 film-coated tablets, in a box. Blister (OPA/Alu/PVC-Alu): 10, 12, 14, 16, 20, 21, 24, 30, 100 or 500 film-coated tablets, in a box.

Not all pack sizes may be marketed.

6.6 Special precautions for disposal and other handling

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1.3.1 Amoxicillin/Clavulanic acid SPC, Labeling and Package Leaflet Common

No special requirements for disposal. Any unused medicinal product or waste material should be disposed of in accordance with local requirements.

7. MARKETING AUTHORISATION HOLDER

KRKA, d.d., Novo mesto, Šmarješka cesta 6, 8501 Novo mesto, Slovenia

8. MARKETING AUTHORISATION NUMBER(S)

[To be completed nationally]

9. DATE OF FIRST AUTHORISATION/RENEWAL OF THE AUTHORISATION

Date of first authorisation: [To be completed nationally] Date of latest renewal: [To be completed nationally]

10. DATE OF REVISION OF THE TEXT

[To be completed nationally]

Detailed information on this medicinal product is available on the website of: {name of Member State Agency (link)}

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1.3.1 Amoxicillin/Clavulanic acid SPC, Labeling and Package Leaflet Common

LABELLING

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1.3.1 Amoxicillin/Clavulanic acid SPC, Labeling and Package Leaflet Common

PARTICULARS TO APPEAR ON THE OUTER PACKAGING

BOX/for strips and blisters

1. NAME OF THE MEDICINAL PRODUCT

500 mg/125 mg film-coated tablets 875 mg/125 mg film-coated tablets amoxicillin/clavulanic acid

2. STATEMENT OF ACTIVE SUBSTANCE(S)

500 mg/125 mg film-coated tablets Each film-coated tablet contains 500 mg amoxicillin (as amoxicillin trihydrate) and 125 mg clavulanic acid (as potassium clavulanate).

875 mg/125 mg film-coated tablets Each film-coated tablet contains 875 mg amoxicillin as (amoxicillin trihydrate) and 125 mg clavulanic acid (as potassium clavulanate).

3. LIST OF EXCIPIENTS

4. PHARMACEUTICAL FORM AND CONTENTS

Film-coated tablet (tablet)

10 film-coated tablets 12 film-coated tablets 14 film-coated tablets 16 film-coated tablets 20 film-coated tablets 21 film-coated tablets 24 film-coated tablets 30 film-coated tablets 100 film-coated tablets 500 film-coated tablets

5. METHOD AND ROUTE(S) OF ADMINISTRATION

Read the package leaflet before use. Oral use

6. SPECIAL WARNING THAT THE MEDICINAL PRODUCT MUST BE STORED OUT OF THE SIGHT AND REACH OF CHILDREN

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1.3.1 Amoxicillin/Clavulanic acid SPC, Labeling and Package Leaflet Common

Keep out of the sight and reach of children.

7. OTHER SPECIAL WARNING(S), IF NECESSARY

Contains a penicillin.

8. EXPIRY DATE

EXP

9. SPECIAL STORAGE CONDITIONS

Strip and blister Do not store above 25°C. Store in the original package in order to protect from moisture.

10. SPECIAL PRECAUTIONS FOR DISPOSAL OF UNUSED MEDICINAL PRODUCTS OR WASTE MATERIALS DERIVED FROM SUCH MEDICINAL PRODUCTS, IF APPROPRIATE

11. NAME AND ADDRESS OF THE MARKETING AUTHORISATION HOLDER

KRKA, d.d., Novo mesto, Šmarješka cesta 6, 8501 Novo mesto, Slovenia

12. MARKETING AUTHORISATION NUMBER(S)

[To be completed nationally]

13. BATCH NUMBER

Lot

14. GENERAL CLASSIFICATION FOR SUPPLY

[To be completed nationally]

15. INSTRUCTIONS ON USE

16. INFORMATION IN BRAILLE

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1.3.1 Amoxicillin/Clavulanic acid SPC, Labeling and Package Leaflet Common

875 mg/125 mg

17. UNIQUE IDENTIFIER – 2D BARCODE

2D barcode carrying the unique identifier included.

18. UNIQUE IDENTIFIER - HUMAN READABLE DATA

PC SN NN

In case secondary packaging will be performed in India, additional data will be added on the boxes due to national requirements in India (e.g. Artwork code, License code, etc.).

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1.3.1 Amoxicillin/Clavulanic acid SPC, Labeling and Package Leaflet Common

MINIMUM PARTICULARS TO APPEAR ON BLISTERS OR STRIPS

STRIP [Alu/Alu] and BLISTER [OPA/Alu/PVC-Alu]

1. NAME OF THE MEDICINAL PRODUCT

500 mg/125 mg film-coated tablets 875 mg/125 mg film-coated tablets

Multilingual strip and blister: 500 mg/125 mg tablets 875 mg/125 mg tablets amoxicillin/clavulanic acid

2. NAME OF THE MARKETING AUTHORISATION HOLDER

KRKA

3. EXPIRY DATE

EXP

4. BATCH NUMBER

Lot

5. OTHER

In case primary packaging will be performed in India, additional data will be added on the strips and blisters due to national requirements in India (e.g. Artwork code, License code etc.).

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1.3.1 Amoxicillin/Clavulanic acid SPC, Labeling and Package Leaflet Common

PACKAGE LEAFLET

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1.3.1 Amoxicillin/Clavulanic acid SPC, Labeling and Package Leaflet Common

Package leaflet: Information for the patient

500 mg/125 mg film-coated tablets 875 mg/125 mg film-coated tablets amoxicillin/clavulanic acid

Read all of this leaflet carefully before you start taking this medicine because it contains important information for you. - Keep this leaflet. You may need to read it again. - If you have any further questions, ask your doctor or pharmacist. - This medicine has been prescribed for you only. Do not pass it on to others. It may harm them, even if their signs of illness are the same as yours. - If you get any side effects, talk to your doctor or pharmacist. This includes any possible side effects not listed in this leaflet. See section 4.

What is in this leaflet 1. What is and what it is used for 2. What you need to know before you take 3. How to take 4. Possible side effects 5. How to store 6. Contents of the pack and other information

1. What is and what it is used for

is an antibiotic and works by killing bacteria that cause infections. It contains two different active ingredients called amoxicillin and clavulanic acid. Amoxicillin belongs to a group of medicines called “penicillins” that can sometimes be stopped from working (made inactive). The other active component (clavulanic acid) stops this from happening.

is used in adults and children to treat the following infections: - middle ear and sinus infections - respiratory tract infections - urinary tract infections - skin and soft tissue infections including dental infections - bone and joint infections.

2. What you need to know before you take

Do not take - if you are allergic to amoxicillin, clavulanic acid or any of the other ingredients of this medicine (listed in section 6), - if you have ever had a severe allergic (hypersensitive) reaction to any other antibiotic. This can include a skin rash or swelling of the face or neck, - if you have ever had liver problems or jaundice (yellowing of the skin) when taking an antibiotic.

Do not take if any of the above apply to you or your child. If you are not sure, talk to your doctor or pharmacist before taking .

Warnings and precautions

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1.3.1 Amoxicillin/Clavulanic acid SPC, Labeling and Package Leaflet Common

Talk to your doctor or pharmacist before taking if you: - have glandular fever - are being treated for liver or kidney problems - are not passing water regularly.

If you are not sure if any of the above apply to you, talk to your doctor or pharmacist before taking .

In some cases, your doctor may investigate the type of bacteria that is causing your or your child's infection. Depending on the results, you or your child may be given a different strength of or a different medicine.

Conditions you need to look out for can make some existing conditions worse, or cause serious side effects. These include allergic reactions, convulsions (fits) and inflammation of the large intestine. You must look out for certain symptoms while you or your child is taking , to reduce the risk of any problems. See "Conditions you need to look out for" in Section 4.

Blood and urine tests If you or your child is having blood tests (such as red blood cell status tests or liver function tests) or urine tests (for glucose), let the doctor or nurse know that you or your child is taking . This is because can affect the results of these types of tests.

Other medicines and Tell your doctor or pharmacist if you or your child is taking, have recently taken or might take any other medicines. If you are taking allopurinol (used for gout) with , it may be more likely that you’ll have an allergic skin reaction. If you are taking probenecid (used for gout), your doctor may decide to adjust your dose of . If medicines to help stop blood clots (such as warfarin) are taken with then extra blood tests may be needed. can affect how methotrexate (a medicine used to treat cancer or rheumatic diseases) works. may affect how mycophenolate mofetil (a medicine used to prevent the rejection of transplanted organs) works.

with food, drink Take at the start of a meal or slightly before and swallow the tablets whole with a glass of water.

Pregnancy, breast-feeding and fertility If you are pregnant or breast-feeding, think you may be pregnant or are planning to have a baby, ask your doctor or pharmacist for advice before taking this medicine.

Driving and using machines can have side effects and the symptoms may make you unfit to drive. Don’t drive or operate machinery unless you are feeling well.

contains sodium This medicine contains less than 1 mmol sodium (23 mg) per tablet, that is to say essentially "sodium- free".

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1.3.1 Amoxicillin/Clavulanic acid SPC, Labeling and Package Leaflet Common

3. How to take

Always take this medicine exactly as your doctor or pharmacist has told you. Check with your doctor or pharmacist if you are not sure.

Adults and children weighing 40 kg and over 500 mg/125 mg film-coated tablets The usual dose is: - 1 tablet three times a day

875 mg/125 mg film-coated tablets - Usual dose – 1 tablet two times a day - Higher dose – 1 tablet three times a day

Use in children Children weighing less than 40 kg Children aged 6 years or less should preferably be treated with amoxicillin/clavulanic acid oral suspension.

500 mg/125 mg film-coated tablets Ask your doctor or pharmacist for advice when giving tablets to children weighing less than 40 kg. The tablets are not suitable for children weighing less than 25 kg.

875 mg/125 mg film-coated tablets Ask your doctor or pharmacist for advice when giving tablets to children weighing less than 40 kg. The tablets are not suitable for children weighing less than 25 kg.

Patients with kidney and liver problems - If you or your chlid has kidney problems the dose might be changed. A different strength or a different medicine may be chosen by your doctor. - If you or your child has liver problems you may have more frequent blood tests to check how your liver is working.

How to take - Swallow the tablets whole with a glass of water at the start of a meal or slightly before - Space the doses evenly during the day, at least 4 hours apart. Do not take 2 doses in 1 hour. - Do not take for more than 2 weeks. If you or your child still feels unwell you should go back to see the doctor.

If you take more than you should If you take too much , signs might include an upset stomach (feeling sick, being sick or diarrhoea) or convulsions. Talk to your doctor as soon as possible. Take the medicine carton or bottle to show the doctor.

If you forget to Do not take a double dose to make up for a forgotten dose. If you forget to take a dose, take it as soon as you remember. You should not take the next dose too soon, but wait about 4 hours before taking the next dose.

If you stop taking Keep taking until the treatment is finished, even if you feel better. You need every dose to help fight the infection. If some bacteria survive they can cause the infection to come back.

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1.3.1 Amoxicillin/Clavulanic acid SPC, Labeling and Package Leaflet Common

If you have any further questions on the use of this medicine, ask your doctor or pharmacist.

4. Possible side effects

Like all medicines, this medicine can cause side effects, although not everybody gets them.

Conditions you need to look out for Allergic reactions: - skin rash - inflammation of blood vessels (vasculitis) which may be visible as red or purple raised spots on the skin, but can affect other parts of the body - fever, joint pain, swollen glands in the neck, armpit or groin - swelling, sometimes of the face or mouth (angioedema), causing difficulty in breathing - collapse.

Contact a doctor immediately if you get any of these symptoms. Stop taking .

Inflammation of large intestine Inflammation of the large intestine, causing watery diarrhoea usually with blood and mucus, stomach pain and/or fever.

Contact your doctor as soon as possible for advice if you get these symptoms.

Very common: may affect more than 1 in 10 people - diarrhoea (in adults)

Common: may affect up to 1 in 10 people - thrush (candida – a yeast infection of the vagina, mouth or skin folds) feeling sick (nausea), especially when taking high doses if affected take before food - vomiting - diarrhoea (in children)

Uncommon: may affect up to 1 in 100 people - skin rash, itching - raised itchy rash (hives) - indigestion - dizziness - headache. Uncommon side effects that may show up in your blood tests: - increase in some substances (enzymes) produced by the liver.

Rare: may affect up to 1 in 1,000 people - skin rash, which may blister, and looks like small targets (central dark spots surrounded by a paler area, with a dark ring around the edge – erythema multiforme) If you notice any of these symptoms contact a doctor urgently.

Rare side effects that may show up in your blood tests: - low number of cells involved in blood clotting. - low number of white blood cells.

Frequency not known: frequency cannot be estimated from the available data

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1.3.1 Amoxicillin/Clavulanic acid SPC, Labeling and Package Leaflet Common

- Allergic reactions (see above) - Inflammation of the large intestine (see above) - Inflammation of the protective membrane surrounding the brain (aseptic meningitis) - Serious skin reactions: - a widespread rash with blisters and peeling skin, particularly around the mouth, nose, eyes and genitals (Stevens-Johnson syndrome), and a more severe form, causing extensive peeling of the skin (more than 30% of the body surface – toxic epidermal necrolysis) - widespread red skin rash with small pus-containing blisters (bullous exfoliative dermatitis) - a red, scaly rash with bumps under the skin and blisters (exanthemous pustulosis) - flu-like symptoms with a rash, fever, swollen glands, and abnormal blood test results (including increased white blood cells (eosinophilia) and liver enzymes) (Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS)). Contact a doctor immediately if you get any of these symptoms. - inflammation of the liver (hepatitis) - jaundice, caused by increases in the blood of bilirubin (a substance produced in the liver) which may make your skin and whites of the eyes appear yellow - inflammation of tubes in the kidney - blood takes longer to clot - hyperactivity - convulsions (in people taking high doses of or who have kidney problems) - black tongue which looks hairy Side effects that may show up in your blood or urine tests: - severe reduction in the number of white blood cells - low number of red blood cells (haemolytic anaemia) - crystals in urine.

Reporting of side effects If you get any side effects, talk to your doctor or pharmacist. This includes any possible side effects not listed in this leaflet. You can also report side effects directly via the national reporting system listed in Appendix V. By reporting side effects you can help provide more information on the safety of this medicine.

5. How to store

Keep this medicine out of the sight and reach of children.

Do not use this medicine after the expiry date which is stated on the packaging after EXP. The expiry date refers to the last day of that month.

Strip and blister Do not store above 25°C. Store in the original package in order to protect from moisture.

Do not throw away any medicines via wastewater or household waste. Ask your pharmacist how to throw away medicines you no longer use. These measures will help protect the environment.

6. Contents of the pack and other information

What contains - The active substances are amoxicillin and clavulanic acid. 500 mg/125 mg film-coated tablets

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1.3.1 Amoxicillin/Clavulanic acid SPC, Labeling and Package Leaflet Common

Each film-coated tablet contains 500 mg amoxicillin (as amoxicillin trihydrate) and 125 mg of clavulanic acid (as potassium clavulanate). 875 mg/125 mg film-coated tablets Each film-coated tablet contains 875 mg amoxicillin as (amoxicillin trihydrate) and 125 mg of clavulanic acid (as potassium clavulanate). - The other ingredients (excipients) are microcrystalline cellulose (E460), sodium starch glycolate (type A), colloidal anhydrous silica (E551) and magnesium stearate (E470b) in the tablet core and titanium dioxide (E171), hypromellose (E464) and macrogol in the film coating. See section 2 " contains sodium".

What looks like and contents of the pack 500 mg/125 mg film-coated tablets White coloured capsule shaped film coated tablet (tablet) debossed with "I 06" on one side and plain on other side, tablet length: 19.40 ± 0.10 mm. 875 mg/125 mg film-coated tablets White coloured capsule shaped film coated tablet (tablet) debossed with "I 07" on one side and plain on other side, tablet length: 21.70 ± 0.10mm.

is available in boxes of: - 10, 12, 14, 16, 20, 21, 24, 30, 100 or 500 film-coated tablets in strips, - 10, 12, 14, 16, 20, 21, 24, 30, 100 or 500 film-coated tablets in blisters.

Not all pack sizes may be marketed.

Marketing Authorisation Holder KRKA, d.d., Novo mesto, Šmarješka cesta 6, 8501 Novo mesto, Slovenia

Manufacturer [To be completed nationally]

This medicinal product is authorised in the Member States of the EEA under the following names:

[To be completed nationally]

This leaflet was last revised in [To be completed nationally]

Detailed information on this medicine is available on the website of {name of Member State Agency (link)}

Advice/medical education Antibiotics are used to treat infections caused by bacteria. They have no effect against infections caused by viruses.

Sometimes an infection caused by bacteria does not respond to a course of an antibiotic. One of the commonest reasons for this to occur is because the bacteria causing the infection are resistant to the antibiotic that is being taken. This means that they can survive and even multiply despite the

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1.3.1 Amoxicillin/Clavulanic acid SPC, Labeling and Package Leaflet Common antibiotic.

Bacteria can become resistant to antibiotics for many reasons. Using antibiotics carefully can help to reduce the chance of bacteria becoming resistant to them.

When your doctor prescribes a course of an antibiotic it is intended to treat only your current illness. Paying attention to the following advice will help prevent the emergence of resistant bacteria that could stop the antibiotic working.

1. It is very important that you take the antibiotic at the right dose, at the right times and for the right number of days. Check with your doctor or pharmacist if you are not sure. 2. Do not take an antibiotic unless it has been prescribed specifically for you and only for the infection it was prescribed. 3. Do not take antibiotics that have been prescribed for other people even if they had an infection that was similar to yours. 4. Do not give antibiotics prescribed for you to other people. 5. If you have any antibiotic left over when you have taken the course as prescribed you should take the remainder to a pharmacy for appropriate disposal.

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