Ampicillin Trihydrate

Drug overview for AMPICILLIN TRIHYDRATE (ampicillin trihydrate):

Generic name: AMPICILLIN TRIHYDRATE (AM-pi-SIL-in)
Drug class: Beta-Lactams
Therapeutic class: Anti-Infective Agents

Ampicillin is an aminopenicillin antibiotic.

Ampicillin shares the uses of other aminopenicillins and is used principally for the treatment of infections caused by susceptible gram-negative bacteria (e.g., Haemophilus influenzae, Escherichia coli, Proteus mirabilis, Salmonella). Ampicillin also is used for the treatment of infections caused by susceptible gram-positive bacteria (e.g., Streptococcus pneumoniae, enterococci, nonpenicillinase-producing staphylococci, Listeria); however, like other aminopenicillins, ampicillin generally should not be used for the treatment of streptococcal or staphylococcal infections when a natural penicillin would be effective. Orally administered ampicillin should not be used for the initial treatment of severe, life-threatening infections, but may be used as follow-up therapy after parenteral ampicillin therapy.

For specific information on the uses of ampicillin, see Uses in the Aminopenicillins General Statement 8:12.16.08.

DRUG IMAGES

AMPICILLIN 500 MG CAPSULE

The following indications for AMPICILLIN TRIHYDRATE (ampicillin trihydrate) have been approved by the FDA:

Indications:
Acute bacterial sinusitis
Acute Haemophilus influenzae bacterial sinusitis
Bacterial pneumonia
Bacterial urinary tract infection
Chronic bronchitis with bacterial exacerbation
Enterococcus urinary tract infection
Gastroenteritis due to Salmonella
Haemophilus influenzae acute otitis media
Haemophilus influenzae chronic bronchitis
Haemophilus influenzae pharyngitis
Haemophilus influenzae pneumonia
Paratyphoid fever
Pharyngitis
Pneumococcal acute otitis media
Pneumococcal pharyngitis
Pneumococcal pneumonia
Proteus urinary tract infection
Staphylococcus acute otitis media
Staphylococcus aureus skin and skin structure infection
Staphylococcus epidermidis skin and skin structure infection
Streptococcus acute otitis media
Streptococcus pneumoniae chronic bronchitis

Professional Synonyms:
Acute bacterial exacerbation of chronic bronchitis
Acute otitis media due to Diplococcus pneumoniae
Acute otitis media due to Fraenkel's Pneumococcus
Acute otitis media due to H. flu
Acute otitis media due to Haemophilus influenzae
Acute otitis media due to Hemophilus influenzae
Acute otitis media due to influenza Bacillus
Acute otitis media due to Pfeiffer's Bacillus
Acute otitis media due to Pneumococcus
Acute otitis media due to Pneumonococcus
Acute otitis media due to Staphylococcus species
Acute otitis media due to Streptococcus pneumoniae
Acute otitis media due to Streptococcus species
Acute sinusitis due to H. flu
Acute sinusitis due to H. influenzae
Acute sinusitis due to Haemophilus influenzae
Acute sinusitis due to Hemophilus influenzae
Acute sinusitis due to Influenza bacillus
Acute sinusitis due to Pfeiffer's bacillus
Bacterial exacerbation of chronic bronchitis
Brion-Kayser disease
Chronic bronchitis due to Diplococcus pneumoniae
Chronic bronchitis due to Fraenkel's Pneumococcus
Chronic bronchitis due to H. flu
Chronic bronchitis due to H. influenzae
Chronic bronchitis due to Haemophilus influenzae
Chronic bronchitis due to Hemophilus influenzae
Chronic bronchitis due to influenza Bacillus
Chronic bronchitis due to Pfeiffer's Bacillus
Chronic bronchitis due to Pneumococcus
Chronic bronchitis due to Pneumonococcus
Chronic bronchitis due to Streptococcus pneumoniae
Fraenkel-Weichselbaum pneumococcal chronic bronchitis
Fraenkel-Weichselbaum Pneumococcus acute otitis media
Gastroenteritis due to Salmonella spp.
H. flu pneumonia
H. influenzae pneumonia
Hemophilus influenzae pneumonia
Infection caused by Salmonella enterica Paratyphi
Influenza Bacillus pneumonia
Paratyphoid
Pfeiffer's Bacillus pneumonia
Pharyngitis due to Haemophilus influenzae
Pharyngitis due to Streptococcus pneumoniae
Pneumonia due to Haemophilus influenzae
Pneumonia due to Streptococcus pneumoniae
Salmonella food poisoning
Salmonella gastroenteritis
Schottmuller's disease
Skin and skin soft tissue Staphylococcus aureus infection
Skin and skin soft tissue Staphylococcus epidermidis infection
Staphylococcal acute otitis media
Throat inflammation
Urinary tract infection due to Enterococcus species
Urinary tract infection due to Proteus species
UTI due to Enterococcus species
UTI due to Proteus species

The following dosing information is available for AMPICILLIN TRIHYDRATE (ampicillin trihydrate):

Dosing
Administration
AMPICILLIN TRIHYDRATE
AMPICILLIN TRIHYDRATE

Dosage of ampicillin sodium and ampicillin trihydrate is expressed in terms of ampicillin.

The manufacturers' dosage recommendations for adults usually are the same for both parenteral and oral routes; however, higher serum concentrations usually are attained parenterally, and this route is used for severe infections.

The usual adult dosage of ampicillin for the treatment of respiratory tract or skin and skin structure infections is 250-500 mg every 6 hours. For the treatment of GI or urinary tract infections, the usual adult dosage is 500 mg every 6 hours. For severe infections, larger doses may be required.

The usual adult dosage of ampicillin for the treatment of septicemia or bacterial meningitis is 8-14 g or 150-200 mg/kg daily given parenterally in equally divided doses every 3-4 hours. For the initial treatment of septicemia or meningitis, ampicillin should be given IV for at least 3 days but may then be given IM.

For oral therapy, most manufacturers state that children weighing more than 20 kg may receive the usual adult dosage of ampicillin. For parenteral therapy, some manufacturers recommend that the usual adult dosage be used in children weighing more than 20 kg, whereas other manufacturers and many clinicians recommend that the usual adult dosage be used in those weighing more than 40 kg. Pediatric dosage should not exceed dosage recommended for similar infections in adults.

For the treatment of respiratory tract or skin and skin structure infections, the usual dosage of ampicillin for children weighing 40 kg or less is 25-50 mg/kg daily administered in equally divided doses every 6 hours. For the treatment of GI or urinary tract infections, the usual dosage for children weighing 40 kg or less is 50-100 mg/kg daily given in equally divided doses every 6 hours.

For the treatment of septicemia or CNS infections, the usual pediatric dosage recommended by the manufacturers is 100-200 mg/kg daily given in divided doses every 3-4 hours, starting with IV administration for 3 days and continuing with IM administration. For empiric treatment of bacterial meningitis in neonates and children younger than 2 months of age, many clinicians recommend that an IV ampicillin dosage of 100-300 mg/kg daily be given in divided doses in conjunction with IM gentamicin pending results of in vitro susceptibility tests. For the empiric treatment of bacterial meningitis in children 2 months to 12 years of age, many clinicians recommend that an IV ampicillin dosage of 200-400 mg/kg daily be given in divided doses every 4-6 hours in conjunction with IV chloramphenicol.

If bacterial susceptibility data are not available and clinical and bacteriologic response is unsatisfactory after 24-48 hours, other appropriate anti-infective therapy should be substituted.

When IM or IV ampicillin is used in neonates younger than 7 days of age, the American Academy of Pediatrics (AAP) recommends a dosage of 50 mg/kg every 12 hours in those weighing 2 kg or less or 50 mg/kg every 8 hours in those weighing more than 2 kg. For neonates 8-28 days of age, AAP recommends an IM or IV dosage of 50 mg/kg every 8 hours in those weighing 2 kg or less or 50 mg/kg every 6 hours in those weighing more than 2 kg. AAP states that higher ampicillin dosage may be necessary for the treatment of meningitis in neonates.

For the treatment of meningitis caused by Streptococcus agalactiae (group B streptococci; GBS), some experts recommend that neonates 28 days of age or younger receive IV ampicillin in a dosage of 75 mg/kg every 6 hours, regardless of weight; others recommend a dosage of 200-300 mg/kg daily given IV in 3 divided doses in neonates 7 days of age or younger or a dosage of 300 mg/kg daily given IV in 4 divided doses in neonates older than 7 days of age. AAP states that a dosage of 100 mg/kg every 12 hours is acceptable for the treatment of early-onset group B streptococcal septicemia without meningitis in neonates 7 days of age or younger.

When IM or IV ampicillin is used in pediatric patients beyond the neonatal period, AAP recommends a dosage of 100-150 mg/kg daily given in 4 divided doses for the treatment of mild to moderate infections or a dosage of 200-400 mg/kg daily given in 4 divided doses for the treatment of severe infections. The highest dosage should be used for the treatment of CNS infections. When oral ampicillin is used in pediatric patients beyond the neonatal period, AAP recommends a dosage of 50-100 mg/kg daily in 4 divided doses.

AAP states that oral ampicillin is inappropriate for the treatment of severe infections.

In patients with renal impairment, doses and/or frequency of administration of ampicillin should be modified in response to the degree of renal impairment, severity of the infection, and susceptibility of the causative organism. Some clinicians suggest that adults with glomerular filtration rates of 10-50 mL/minute receive the usual dose of ampicillin every 6-12 hours and that adults with glomerular filtration rates less than 10 mL/minute receive the usual dose every 12-16 hours. Alternatively, some clinicians suggest that modification of usual dosage of ampicillin is unnecessary in adults with creatinine clearances of 30 mL/minute or greater, but adults with creatinine clearances of 10 mL/minute or less should receive the usual dose of the drug every 8 hours.

Patients undergoing hemodialysis should receive a supplemental dose of ampicillin after each dialysis period.

No enhanced Administration information available for this drug.

Dosing information for AMPICILLIN TRIHYDRATE
DRUG LABEL	DOSING TYPE	DOSING INSTRUCTIONS
AMPICILLIN 500 MG CAPSULE	Maintenance	Adults take 1 capsule (500 mg) by oral route every 6 hours 1/2 hour before a meal or 2 hours after a meal

Generic dosing information for AMPICILLIN TRIHYDRATE
DRUG LABEL	DOSING TYPE	DOSING INSTRUCTIONS
AMPICILLIN 500 MG CAPSULE	Maintenance	Adults take 1 capsule (500 mg) by oral route every 6 hours 1/2 hour before ameal or 2 hours after a meal

The following drug interaction information is available for AMPICILLIN TRIHYDRATE (ampicillin trihydrate):

Contraindicated
Severe
Moderate

There are 1 contraindications. These drug combinations generally should not be dispensed or administered to the same patient. A manufacturer label warning that indicates the contraindication warrants inclusion of a drug combination in this category, regardless of clinical evidence or lack of clinical evidence to support the contraindication.

Drug Interaction	Drug Names
Live Typhoid Vaccine/Antimicrobials SEVERITY LEVEL: 1-Contraindicated Drug Combination: This drug combination is contraindicated and generally should not be dispensed or administered to the same patient. MECHANISM OF ACTION: The antimicrobial may be active against the organism in the live-vaccine. Antimicrobial therapy may prevent the vaccine organism from replicating enough to trigger an immune response.(1) CLINICAL EFFECTS: Vaccination may be ineffective. PREDISPOSING FACTORS: None determined. PATIENT MANAGEMENT: Do not give oral typhoid vaccine until 72 hours after the last dose of antimicrobial. If possible, to optimize vaccine effectiveness, do not start antibacterial drugs for 72 hours after the last dose of oral typhoid vaccine. A longer interval should be considered for long-acting antimicrobials, such as azithromycin.(3) DISCUSSION: Because antimicrobial therapy may prevent sufficient vaccine-organism replication to generate an immune response, the manufacturer of live-attenuated typhoid vaccine and the Centers for Disease Control (CDC) state that the vaccine should not be administered to patients receiving antimicrobial therapy.(1-3)	VIVOTIF

Drug Interaction

Drug Names

Live Typhoid Vaccine/Antimicrobials

SEVERITY LEVEL: 1-Contraindicated Drug Combination: This drug combination is contraindicated and generally should not be dispensed or administered to the same patient.

MECHANISM OF ACTION: The antimicrobial may be active against the organism in the live-vaccine. Antimicrobial therapy may prevent the vaccine organism from replicating enough to trigger an immune response.(1)

CLINICAL EFFECTS: Vaccination may be ineffective.

PREDISPOSING FACTORS: None determined.

PATIENT MANAGEMENT: Do not give oral typhoid vaccine until 72 hours after the last dose of antimicrobial. If possible, to optimize vaccine effectiveness, do not start antibacterial drugs for 72 hours after the last dose of oral typhoid vaccine. A longer interval should be considered for long-acting antimicrobials, such as azithromycin.(3)

DISCUSSION: Because antimicrobial therapy may prevent sufficient vaccine-organism replication to generate an immune response, the manufacturer of live-attenuated typhoid vaccine and the Centers for Disease Control (CDC) state that the vaccine should not be administered to patients receiving antimicrobial therapy.(1-3)

VIVOTIF

There are 3 severe interactions. These drug interactions can produce serious consequences in most patients. Actions required for severe interactions include, but are not limited to, discontinuing one or both agents, adjusting dosage, altering administration scheduling, and providing additional patient monitoring. Review the full interaction monograph for more information.

Drug Interaction	Drug Names
Methotrexate/Penicillins SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction. MECHANISM OF ACTION: Penicillins may compete with the renal tubular secretion of methotrexate. CLINICAL EFFECTS: The concurrent use of methotrexate and penicillins may result in elevated levels of methotrexate and methotrexate toxicity, leading to increased risk of severe neurotoxicity, stomatitis, and myelosuppression. PREDISPOSING FACTORS: Risk factors for methotrexate toxicity include: - High-dose oncology regimens - Impaired renal function, ascites, or pleural effusions PATIENT MANAGEMENT: Patients receiving concurrent therapy with methotrexate and penicillins should be monitored closely for elevated methotrexate levels and methotrexate toxicity. The dose and duration of leucovorin rescue therapy may need to be increased. DISCUSSION: Elevated methotrexate levels, signs of methotrexate toxicity, and death have been reported following the concurrent use of methotrexate (both low dose and high dose) and penicillin derivatives. In a patient being treated with high-dose methotrexate (8 G/m2), the concurrent use of amoxicillin resulted in a 56% decrease in the clearance of methotrexate and signs of methotrexate toxicity.(1) There are two cases of methotrexate toxicity following the addition of amoxicillin to low-dose methotrexate therapy (7.5 mg-10 mg weekly) for psoriasis. In another case, a patient was found to have a toxic methotrexate level 12 days after her last dose of weekly methotrexate (7.5 mg). The patient had been treated with amoxicillin followed by flucloxacillin.(2) In a case report, dicloxacillin decreased methotrexate clearance 93%.(4) Flucloxacillin was shown to increase the area-under-curve (AUC) of methotrexate by 7.3% in a study in 10 subjects.(5) In a case report, a patient on low-dose methotrexate (5 mg) developed methotrexate pneumonia following the addition of flucloxacillin to his regimen.(5) In a patient being treated with high-dose methotrexate (12 G/m2), the concurrent use of mezlocillin increased the half-life of methotrexate from 10.1 to 27.2 hours.(6) In a case report, a patient developed methotrexate toxicity following the addition of penicillin V potassium to his methotrexate (50 mg weekly).(7) In a case report, penicillin decreased methotrexate clearance 36%.(4) In one report, leucovorin rescue therapy had to be continued for 192 hours following the concurrent use of methotrexate (3 G/m2) and piperacillin. During cycles without concurrent piperacillin, leucovorin rescue therapy was only required for 72 hours.(8) There are two reports of neutropenia and death following the concurrent use of piperacillin and low-dose methotrexate (2.5 mg three times weekly in one patient, 5 mg weekly in another) for psoriasis. One of these patients also received flucloxacillin. (3) In another case report, the concurrent use of piperacillin decreased methotrexate clearance by 67%.(4) In a case report, ticarcillin decreased methotrexate clearance by 60%.(4)	JYLAMVO, METHOTREXATE, METHOTREXATE SODIUM, OTREXUP, RASUVO, TREXALL, XATMEP
Cholera Vaccine Live/Selected Antibiotics SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction. MECHANISM OF ACTION: Antibiotics with activity against Vibrio cholerae may attenuate the immunization response to the live cholera vaccine.(1) CLINICAL EFFECTS: Concurrent or recent antibiotic use may make the cholera vaccine ineffective.(1) PREDISPOSING FACTORS: None determined. PATIENT MANAGEMENT: The manufacturer of live cholera vaccine states that it should not be administered to patients who have received antibiotics within 14 days prior to vaccination.(1) If antimalarial prophylaxis with chloroquine is required, administer the live cholera vaccine at least 10 days before beginning chloroquine.(1) Antibiotics linked to this monograph are: macrolides, quinolones, tetracyclines, ampicillin, cefprozil, chloramphenicol, furazolidone, sulfamethoxazole-trimethoprim, and sulfametrole-trimethoprim.(2,3) DISCUSSION: Antibiotics with activity against Vibrio cholerae may attenuate the immunization response to the live cholera vaccine, rendering the vaccine ineffective.	VAXCHORA ACTIVE COMPONENT, VAXCHORA VACCINE
Fecal Microbiota Spores/Antibiotics SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction. MECHANISM OF ACTION: Fecal microbiota spores is a suspension of live bacterial spores, which may be compromised by concurrent use of antibiotics.(1) CLINICAL EFFECTS: Antibiotics may decrease the effectiveness of fecal microbiota spores.(1) PREDISPOSING FACTORS: None determined. PATIENT MANAGEMENT: Antibiotics should not be used concurrently with fecal microbiota spores. Antibacterial treatment should be completed for 2 to 4 days before initiating treatment with fecal microbiota spores.(1) DISCUSSION: Antibiotics may compromise the effectiveness of fecal microbiota spores.	VOWST

There are 2 moderate interactions. The clinician should assess the patient’s characteristics and take action as needed. Actions required for moderate interactions include, but are not limited to, discontinuing one or both agents, adjusting dosage, altering administration.

Drug Interaction	Drug Names
Oral Contraceptives/Penicillins SEVERITY LEVEL: 3-Moderate Interaction: Assess the risk to the patient and take action as needed. MECHANISM OF ACTION: Estrogens and progesterones are extensively excreted in bile, principally as glycuronide conjugates. Subsequently, they undergo enterohepatic circulation where bacterial hydrolysis occurs, allowing for reabsorption of the oral contraceptives through the bowel wall and eventual urinary excretion. Treatment with antibiotics destroys the gut flora and prevents steroid reabsorption, resulting in lower than normal concentrations of the contraceptive and excretion via the feces rather than the urine. CLINICAL EFFECTS: May observe reduced pharmacologic effects of oral contraceptives with resultant breakthrough bleeding and pregnancy. Reduced effects may be seen for several days after discontinuation of antibiotic therapy. PREDISPOSING FACTORS: None determined. PATIENT MANAGEMENT: Current guidelines suggest that additional precautions are not necessary when non-enzyme inducing antibiotics are used concurrently with hormonal contraceptives; however, some patients may still prefer to use an additional method of contraception. DISCUSSION: Evidence for this interaction is limited and conflicting; however, the CDC and the Faculty of Sexual and Reproductive Healthcare Clinical Effectiveness Unit no longer recommend use of a backup contraceptive method during use of a non-enzyme inducing antibiotic. Reports of breakthrough bleeding and loss of contraceptive protection leading to unwanted pregnancies have occurred in women taking oral contraceptive agents who received concurrent ampicillin, amoxicillin, penicillin G, or oxacillin. Several studies have shown that the administration of ampicillin or penicillin to pregnant and nonpregnant women resulted in lowered urinary estrogen excretion, in some women as soon as three days after ampicillin therapy began. However in one small prospective study, plasma ethinyl estradiol concentrations showed a tendency to decrease during ampicillin administration on the third, fourth, and fifth morning of ampicillin administration, but were never lower than pretreatment values. In another small prospective study of women taking low dose combination contraceptives, concurrent ampicillin therapy neither altered the plasma levels nor the AUC of norethisterone and ethinyl estradiol. In addition, progesterone levels were in an anovulatory range. In another prospective study of 13 women taking long term oral contraceptive steroids, concurrent ampicillin was not associated with any significant changes in plasma concentrations of ethinyl estradiol, levonorgestrel, follicle stimulating hormone or progesterone, although lower concentrations of ethinyl estradiol were noted in two women.	2-METHOXYESTRADIOL, AFIRMELLE, ALTAVERA, ALYACEN, AMETHIA, AMETHYST, APRI, ARANELLE, ASHLYNA, AUBRA, AUBRA EQ, AUROVELA, AUROVELA 24 FE, AUROVELA FE, AVIANE, AYUNA, AZURETTE, BALCOLTRA, BALZIVA, BEYAZ, BLISOVI 24 FE, BLISOVI FE, BRIELLYN, CAMILA, CAMRESE, CAMRESE LO, CAZIANT, CHARLOTTE 24 FE, CHATEAL EQ, CRYSELLE, CYRED, CYRED EQ, DASETTA, DAYSEE, DEBLITANE, DESOGESTR-ETH ESTRAD ETH ESTRA, DIETHYLSTILBESTROL, DOLISHALE, DROSPIRENONE-ETH ESTRA-LEVOMEF, DROSPIRENONE-ETHINYL ESTRADIOL, ELINEST, ELLA, EMZAHH, ENPRESSE, ENSKYCE, ERRIN, ESTARYLLA, ESTRADIOL, ESTRADIOL BENZOATE, ESTRADIOL CYPIONATE, ESTRADIOL HEMIHYDRATE, ESTRADIOL HEMIHYDRATE MICRO, ESTRADIOL MICRONIZED, ESTRADIOL VALERATE, ESTRIOL, ESTRIOL MICRONIZED, ESTRONE, ETHINYL ESTRADIOL, ETHYNODIOL-ETHINYL ESTRADIOL, FALMINA, FEIRZA, FEMLYV, FINZALA, GEMMILY, HAILEY, HAILEY 24 FE, HAILEY FE, HEATHER, ICLEVIA, INCASSIA, ISIBLOOM, JAIMIESS, JASMIEL, JENCYCLA, JOLESSA, JOYEAUX, JULEBER, JUNEL, JUNEL FE, JUNEL FE 24, KAITLIB FE, KALLIGA, KARIVA, KELNOR 1-35, KELNOR 1-50, KURVELO, LARIN, LARIN 24 FE, LARIN FE, LAYOLIS FE, LEENA, LESSINA, LEVONEST, LEVONORG-ETH ESTRAD ETH ESTRAD, LEVONORG-ETH ESTRAD-FE BISGLYC, LEVONORGESTREL-ETH ESTRADIOL, LEVORA-28, LO LOESTRIN FE, LO-ZUMANDIMINE, LOESTRIN, LOESTRIN FE, LOJAIMIESS, LORYNA, LOW-OGESTREL, LUTERA, LYLEQ, LYZA, MARLISSA, MERZEE, MIBELAS 24 FE, MICROGESTIN, MICROGESTIN FE, MILI, MINZOYA, MONO-LINYAH, NATAZIA, NECON, NEXTSTELLIS, NIKKI, NORA-BE, NORETHIN-ETH ESTRA-FERROUS FUM, NORETHINDRON-ETHINYL ESTRADIOL, NORETHINDRONE, NORETHINDRONE-E.ESTRADIOL-IRON, NORGESTIMATE-ETHINYL ESTRADIOL, NORTREL, NYLIA, OCELLA, ORTHO TRI-CYCLEN, ORTHO-NOVUM, PHILITH, PIMTREA, PORTIA, RECLIPSEN, RIVELSA, SAFYRAL, SETLAKIN, SHAROBEL, SIMLIYA, SIMPESSE, SLYND, SPRINTEC, SRONYX, SYEDA, TARINA 24 FE, TARINA FE, TARINA FE 1-20 EQ, TAYTULLA, TILIA FE, TRI-ESTARYLLA, TRI-LEGEST FE, TRI-LINYAH, TRI-LO-ESTARYLLA, TRI-LO-MARZIA, TRI-LO-MILI, TRI-LO-SPRINTEC, TRI-MILI, TRI-SPRINTEC, TRI-VYLIBRA, TRI-VYLIBRA LO, TRIVORA-28, TULANA, TURQOZ, TYBLUME, VALTYA, VELIVET, VESTURA, VIENVA, VIORELE, VOLNEA, VYFEMLA, VYLIBRA, WERA, WYMZYA FE, XARAH FE, XELRIA FE, YASMIN 28, YAZ, ZARAH, ZOVIA 1-35, ZUMANDIMINE
Allopurinol/Amoxicillin, Ampicillin, Bendamustine SEVERITY LEVEL: 3-Moderate Interaction: Assess the risk to the patient and take action as needed. MECHANISM OF ACTION: The exact mechanism is unknown. Allopurinol, amoxicillin, ampicillin, and bendamustine have been documented to cause cases of Stevens-Johnson syndrome (SJS), Toxic epidermal necrolysis (TEN), and Drug reaction with eosinophilia and systemic symptoms (DRESS).(1) CLINICAL EFFECTS: Concurrent administration of allopurinol with amoxicillin, ampicillin or bendamustine may result in an increased incidence of rash which may be severe. PREDISPOSING FACTORS: Patients who are HLA-B*58:01 positive may be at increased risk. PATIENT MANAGEMENT: Consider an alternative to amoxicillin, ampicillin, or bendamustine in patients with a history of serious skin rashes, such as SJS, TEN, or DRESS. Discontinue allopurinol at the first appearance of skin rash or other signs which may indicate a hypersensitivity reaction when used with amoxicillin or ampicillin or bendamustine. Instruct patients to seek medical attention for any peeling skin rash or blisters.(1) DISCUSSION: In the Boston Collaborative Drug Surveillance Program, drug rash was seen in 22.4% of 67 hospitalized patients (relative risk 3.0) receiving concurrent allopurinol and ampicillin compared to 7.5% of 1257 patients receiving only ampicillin and 2.1% of 283 patients rceiving only allopurinol.(4) A hospital drug monitoring program found the observed risk of developing an exanthema with concurrent use is as follows: aminopenicillin without allopurinol 10.1%, aminopenicillin combined with allopurinol 7.2%, allopurinol without aminopenicillin 3.0%, or neither of the two drugs 1.5%.(6) A case-control study did not find a statistically significant increased risk of SJS with concurrent use of allopurinol and amoxicillin or ampicillin (allopurinol alone 4.4% vs. with amoxicillin 6.8%; allopurinol alone 0.1% vs. with ampicillin 2.7% at 1 month)(allopurinol alone 4.4% vs. with amoxicillin 5.7% or allopurinol alone 0.2% vs. with ampicillin 2.9% at 3 months).(8) In a retrospective study looking at mortality data, records were screened for administration of high risk drugs associated with SJS. Allopurinol and ampicillin was one of the drug combinations listed as contributing to mortality in patients (p = 0.049).(9)	ALLOPURINOL, ALLOPURINOL SODIUM, ALOPRIM, DUZALLO, ZYLOPRIM

Drug Interaction

Drug Names

Oral Contraceptives/Penicillins

SEVERITY LEVEL: 3-Moderate Interaction: Assess the risk to the patient and take action as needed.

MECHANISM OF ACTION: Estrogens and progesterones are extensively excreted in bile, principally as glycuronide conjugates. Subsequently, they undergo enterohepatic circulation where bacterial hydrolysis occurs, allowing for reabsorption of the oral contraceptives through the bowel wall and eventual urinary excretion. Treatment with antibiotics destroys the gut flora and prevents steroid reabsorption, resulting in lower than normal concentrations of the contraceptive and excretion via the feces rather than the urine.

CLINICAL EFFECTS: May observe reduced pharmacologic effects of oral contraceptives with resultant breakthrough bleeding and pregnancy. Reduced effects may be seen for several days after discontinuation of antibiotic therapy.

PREDISPOSING FACTORS: None determined.

PATIENT MANAGEMENT: Current guidelines suggest that additional precautions are not necessary when non-enzyme inducing antibiotics are used concurrently with hormonal contraceptives; however, some patients may still prefer to use an additional method of contraception.

DISCUSSION: Evidence for this interaction is limited and conflicting; however, the CDC and the Faculty of Sexual and Reproductive Healthcare Clinical Effectiveness Unit no longer recommend use of a backup contraceptive method during use of a non-enzyme inducing antibiotic. Reports of breakthrough bleeding and loss of contraceptive protection leading to unwanted pregnancies have occurred in women taking oral contraceptive agents who received concurrent ampicillin, amoxicillin, penicillin G, or oxacillin. Several studies have shown that the administration of ampicillin or penicillin to pregnant and nonpregnant women resulted in lowered urinary estrogen excretion, in some women as soon as three days after ampicillin therapy began.

However in one small prospective study, plasma ethinyl estradiol concentrations showed a tendency to decrease during ampicillin administration on the third, fourth, and fifth morning of ampicillin administration, but were never lower than pretreatment values. In another small prospective study of women taking low dose combination contraceptives, concurrent ampicillin therapy neither altered the plasma levels nor the AUC of norethisterone and ethinyl estradiol. In addition, progesterone levels were in an anovulatory range. In another prospective study of 13 women taking long term oral contraceptive steroids, concurrent ampicillin was not associated with any significant changes in plasma concentrations of ethinyl estradiol, levonorgestrel, follicle stimulating hormone or progesterone, although lower concentrations of ethinyl estradiol were noted in two women.

2-METHOXYESTRADIOL, AFIRMELLE, ALTAVERA, ALYACEN, AMETHIA, AMETHYST, APRI, ARANELLE, ASHLYNA, AUBRA, AUBRA EQ, AUROVELA, AUROVELA 24 FE, AUROVELA FE, AVIANE, AYUNA, AZURETTE, BALCOLTRA, BALZIVA, BEYAZ, BLISOVI 24 FE, BLISOVI FE, BRIELLYN, CAMILA, CAMRESE, CAMRESE LO, CAZIANT, CHARLOTTE 24 FE, CHATEAL EQ, CRYSELLE, CYRED, CYRED EQ, DASETTA, DAYSEE, DEBLITANE, DESOGESTR-ETH ESTRAD ETH ESTRA, DIETHYLSTILBESTROL, DOLISHALE, DROSPIRENONE-ETH ESTRA-LEVOMEF, DROSPIRENONE-ETHINYL ESTRADIOL, ELINEST, ELLA, EMZAHH, ENPRESSE, ENSKYCE, ERRIN, ESTARYLLA, ESTRADIOL, ESTRADIOL BENZOATE, ESTRADIOL CYPIONATE, ESTRADIOL HEMIHYDRATE, ESTRADIOL HEMIHYDRATE MICRO, ESTRADIOL MICRONIZED, ESTRADIOL VALERATE, ESTRIOL, ESTRIOL MICRONIZED, ESTRONE, ETHINYL ESTRADIOL, ETHYNODIOL-ETHINYL ESTRADIOL, FALMINA, FEIRZA, FEMLYV, FINZALA, GEMMILY, HAILEY, HAILEY 24 FE, HAILEY FE, HEATHER, ICLEVIA, INCASSIA, ISIBLOOM, JAIMIESS, JASMIEL, JENCYCLA, JOLESSA, JOYEAUX, JULEBER, JUNEL, JUNEL FE, JUNEL FE 24, KAITLIB FE, KALLIGA, KARIVA, KELNOR 1-35, KELNOR 1-50, KURVELO, LARIN, LARIN 24 FE, LARIN FE, LAYOLIS FE, LEENA, LESSINA, LEVONEST, LEVONORG-ETH ESTRAD ETH ESTRAD, LEVONORG-ETH ESTRAD-FE BISGLYC, LEVONORGESTREL-ETH ESTRADIOL, LEVORA-28, LO LOESTRIN FE, LO-ZUMANDIMINE, LOESTRIN, LOESTRIN FE, LOJAIMIESS, LORYNA, LOW-OGESTREL, LUTERA, LYLEQ, LYZA, MARLISSA, MERZEE, MIBELAS 24 FE, MICROGESTIN, MICROGESTIN FE, MILI, MINZOYA, MONO-LINYAH, NATAZIA, NECON, NEXTSTELLIS, NIKKI, NORA-BE, NORETHIN-ETH ESTRA-FERROUS FUM, NORETHINDRON-ETHINYL ESTRADIOL, NORETHINDRONE, NORETHINDRONE-E.ESTRADIOL-IRON, NORGESTIMATE-ETHINYL ESTRADIOL, NORTREL, NYLIA, OCELLA, ORTHO TRI-CYCLEN, ORTHO-NOVUM, PHILITH, PIMTREA, PORTIA, RECLIPSEN, RIVELSA, SAFYRAL, SETLAKIN, SHAROBEL, SIMLIYA, SIMPESSE, SLYND, SPRINTEC, SRONYX, SYEDA, TARINA 24 FE, TARINA FE, TARINA FE 1-20 EQ, TAYTULLA, TILIA FE, TRI-ESTARYLLA, TRI-LEGEST FE, TRI-LINYAH, TRI-LO-ESTARYLLA, TRI-LO-MARZIA, TRI-LO-MILI, TRI-LO-SPRINTEC, TRI-MILI, TRI-SPRINTEC, TRI-VYLIBRA, TRI-VYLIBRA LO, TRIVORA-28, TULANA, TURQOZ, TYBLUME, VALTYA, VELIVET, VESTURA, VIENVA, VIORELE, VOLNEA, VYFEMLA, VYLIBRA, WERA, WYMZYA FE, XARAH FE, XELRIA FE, YASMIN 28, YAZ, ZARAH, ZOVIA 1-35, ZUMANDIMINE

Allopurinol/Amoxicillin, Ampicillin, Bendamustine

SEVERITY LEVEL: 3-Moderate Interaction: Assess the risk to the patient and take action as needed.

MECHANISM OF ACTION: The exact mechanism is unknown. Allopurinol, amoxicillin, ampicillin, and bendamustine have been documented to cause cases of Stevens-Johnson syndrome (SJS), Toxic epidermal necrolysis (TEN), and Drug reaction with eosinophilia and systemic symptoms (DRESS).(1)

CLINICAL EFFECTS: Concurrent administration of allopurinol with amoxicillin, ampicillin or bendamustine may result in an increased incidence of rash which may be severe.

PREDISPOSING FACTORS: Patients who are HLA-B*58:01 positive may be at increased risk.

PATIENT MANAGEMENT: Consider an alternative to amoxicillin, ampicillin, or bendamustine in patients with a history of serious skin rashes, such as SJS, TEN, or DRESS. Discontinue allopurinol at the first appearance of skin rash or other signs which may indicate a hypersensitivity reaction when used with amoxicillin or ampicillin or bendamustine. Instruct patients to seek medical attention for any peeling skin rash or blisters.(1)

DISCUSSION: In the Boston Collaborative Drug Surveillance Program, drug rash was seen in 22.4% of 67 hospitalized patients (relative risk 3.0) receiving concurrent allopurinol and ampicillin compared to 7.5% of 1257 patients receiving only ampicillin and 2.1%

of 283 patients rceiving only allopurinol.(4) A hospital drug monitoring program found the observed risk of developing an exanthema with concurrent use is as follows: aminopenicillin without allopurinol 10.1%, aminopenicillin combined with allopurinol 7.2%,

allopurinol without aminopenicillin 3.0%, or neither of the two drugs 1.5%.(6)

A case-control study did not find a statistically significant increased risk of SJS with concurrent use of allopurinol and amoxicillin or ampicillin (allopurinol alone 4.4% vs. with amoxicillin 6.8%; allopurinol alone 0.1% vs. with ampicillin 2.7% at 1 month)(allopurinol alone 4.4% vs. with amoxicillin 5.7% or allopurinol alone 0.2% vs. with ampicillin 2.9% at 3 months).(8) In a retrospective study looking at mortality data, records were screened for administration of high risk drugs associated with SJS. Allopurinol and ampicillin was one of the drug combinations listed as contributing to mortality in patients (p = 0.049).(9)

ALLOPURINOL, ALLOPURINOL SODIUM, ALOPRIM, DUZALLO, ZYLOPRIM

Severe List
Clostridioides difficile infection

The following adverse reaction information is available for AMPICILLIN TRIHYDRATE (ampicillin trihydrate):

Overview
Severe
Less Severe

Adverse reaction overview.

No enhanced Common Adverse Effects information available for this drug.

There are 27 severe adverse reactions.

More Frequent	Less Frequent
None.	Anaphylaxis Exfoliative dermatitis Urticaria

Rare/Very Rare
Abnormal hepatic function tests Acute generalized exanthematous pustulosis Agranulocytosis Autoimmune hemolytic anemia Clostridioides difficile infection Crystalluria DRESS syndrome Drug-induced hepatitis Enterocolitis Eosinophilia Erythema multiforme Furred tongue Hypersensitivity angiitis Idiopathic thrombocytopenic purpura Interstitial nephritis Laryngeal edema Leukopenia Maculopapular rash Obstructive hyperbilirubinemia Seizure disorder Serum sickness Stevens-johnson syndrome Thrombocytopenic disorder Toxic epidermal necrolysis

Rare/Very Rare

Abnormal hepatic function tests
Acute generalized exanthematous pustulosis
Agranulocytosis
Autoimmune hemolytic anemia
Clostridioides difficile infection
Crystalluria
DRESS syndrome
Drug-induced hepatitis
Enterocolitis
Eosinophilia
Erythema multiforme
Furred tongue
Hypersensitivity angiitis
Idiopathic thrombocytopenic purpura
Interstitial nephritis
Laryngeal edema
Leukopenia
Maculopapular rash
Obstructive hyperbilirubinemia
Seizure disorder
Serum sickness
Stevens-johnson syndrome
Thrombocytopenic disorder
Toxic epidermal necrolysis

There are 16 less severe adverse reactions.

More Frequent	Less Frequent
Diarrhea Nausea Skin rash Vomiting Vulvovaginal candidiasis	Abdominal pain with cramps Pruritus of skin

Rare/Very Rare
Acute cognitive impairment Agitation Anemia Behavioral disorders Dental discoloration Dizziness Insomnia Mucocutaneous candidiasis Symptoms of anxiety

The following precautions are available for AMPICILLIN TRIHYDRATE (ampicillin trihydrate):

Pediatric
Pregnant
Lactation
Geriatric

No enhanced Pediatric Use information available for this drug.

Contraindicated

None

Severe Precaution

None

Management or Monitoring Precaution

None

Safe use of ampicillin during pregnancy has not been established. There are no adequate or controlled studies using ampicillin in pregnant women, and the drug should be used during pregnancy only when clearly needed. However, ampicillin has been administered to pregnant women, especially in the treatment of urinary tract infections, without evidence of adverse effects to the fetus.

Because ampicillin is distributed into milk, the drug should be used with caution in nursing women.

No enhanced Geriatric Use information available for this drug.

The following icd codes are available for AMPICILLIN TRIHYDRATE (ampicillin trihydrate)'s list of indications:

Acute bacterial sinusitis
J01	Acute sinusitis
J01.0	Acute maxillary sinusitis
J01.00	Acute maxillary sinusitis, unspecified
J01.01	Acute recurrent maxillary sinusitis
J01.1	Acute frontal sinusitis
J01.10	Acute frontal sinusitis, unspecified
J01.11	Acute recurrent frontal sinusitis
J01.2	Acute ethmoidal sinusitis
J01.20	Acute ethmoidal sinusitis, unspecified
J01.21	Acute recurrent ethmoidal sinusitis
J01.3	Acute sphenoidal sinusitis
J01.30	Acute sphenoidal sinusitis, unspecified
J01.31	Acute recurrent sphenoidal sinusitis
J01.4	Acute pansinusitis
J01.40	Acute pansinusitis, unspecified
J01.41	Acute recurrent pansinusitis
J01.8	Other acute sinusitis
J01.80	Other acute sinusitis
J01.81	Other acute recurrent sinusitis
J01.9	Acute sinusitis, unspecified
J01.90	Acute sinusitis, unspecified
J01.91	Acute recurrent sinusitis, unspecified
Acute haemophilus influenzae bacterial sinusitis
B96.3	Hemophilus influenzae [h. influenzae] as the cause of diseases classified elsewhere
J01	Acute sinusitis
J01.0	Acute maxillary sinusitis
J01.00	Acute maxillary sinusitis, unspecified
J01.01	Acute recurrent maxillary sinusitis
J01.1	Acute frontal sinusitis
J01.10	Acute frontal sinusitis, unspecified
J01.11	Acute recurrent frontal sinusitis
J01.2	Acute ethmoidal sinusitis
J01.20	Acute ethmoidal sinusitis, unspecified
J01.21	Acute recurrent ethmoidal sinusitis
J01.3	Acute sphenoidal sinusitis
J01.30	Acute sphenoidal sinusitis, unspecified
J01.31	Acute recurrent sphenoidal sinusitis
J01.4	Acute pansinusitis
J01.40	Acute pansinusitis, unspecified
J01.41	Acute recurrent pansinusitis
J01.8	Other acute sinusitis
J01.80	Other acute sinusitis
J01.81	Other acute recurrent sinusitis
J01.9	Acute sinusitis, unspecified
J01.90	Acute sinusitis, unspecified
J01.91	Acute recurrent sinusitis, unspecified
Bacterial pneumonia
J15.9	Unspecified bacterial pneumonia
Bacterial urinary tract infection
N30.0	Acute cystitis
N30.00	Acute cystitis without hematuria
N30.01	Acute cystitis with hematuria
N30.9	Cystitis, unspecified
N30.90	Cystitis, unspecified without hematuria
N30.91	Cystitis, unspecified with hematuria
N39.0	Urinary tract infection, site not specified
O23.0	Infections of kidney in pregnancy
O23.00	Infections of kidney in pregnancy, unspecified trimester
O23.01	Infections of kidney in pregnancy, first trimester
O23.02	Infections of kidney in pregnancy, second trimester
O23.03	Infections of kidney in pregnancy, third trimester
O23.1	Infections of bladder in pregnancy
O23.10	Infections of bladder in pregnancy, unspecified trimester
O23.11	Infections of bladder in pregnancy, first trimester
O23.12	Infections of bladder in pregnancy, second trimester
O23.13	Infections of bladder in pregnancy, third trimester
O23.2	Infections of urethra in pregnancy
O23.20	Infections of urethra in pregnancy, unspecified trimester
O23.21	Infections of urethra in pregnancy, first trimester
O23.22	Infections of urethra in pregnancy, second trimester
O23.23	Infections of urethra in pregnancy, third trimester
O23.3	Infections of other parts of urinary tract in pregnancy
O23.30	Infections of other parts of urinary tract in pregnancy, unspecified trimester
O23.31	Infections of other parts of urinary tract in pregnancy, first trimester
O23.32	Infections of other parts of urinary tract in pregnancy, second trimester
O23.33	Infections of other parts of urinary tract in pregnancy, third trimester
O23.4	Unspecified infection of urinary tract in pregnancy
O23.40	Unspecified infection of urinary tract in pregnancy, unspecified trimester
O23.41	Unspecified infection of urinary tract in pregnancy, first trimester
O23.42	Unspecified infection of urinary tract in pregnancy, second trimester
O23.43	Unspecified infection of urinary tract in pregnancy, third trimester
O23.90	Unspecified genitourinary tract infection in pregnancy, unspecified trimester
O23.91	Unspecified genitourinary tract infection in pregnancy, first trimester
O23.92	Unspecified genitourinary tract infection in pregnancy, second trimester
O23.93	Unspecified genitourinary tract infection in pregnancy, third trimester
P39.3	Neonatal urinary tract infection
T83	Complications of genitourinary prosthetic devices, implants and grafts
T83.5	Infection and inflammatory reaction due to prosthetic device, implant and graft in urinary system
T83.51	Infection and inflammatory reaction due to urinary catheter
T83.59	Infection and inflammatory reaction due to prosthetic device, implant and graft in urinary system
T83.6	Infection and inflammatory reaction due to prosthetic device, implant and graft in genital tract
Chronic bronchitis with bacterial exacerbation
J44.0	Chronic obstructive pulmonary disease with (acute) lower respiratory infection
Enterococcus urinary tract infection
B95.2	Enterococcus as the cause of diseases classified elsewhere
N30.0	Acute cystitis
N30.00	Acute cystitis without hematuria
N30.01	Acute cystitis with hematuria
N30.9	Cystitis, unspecified
N30.90	Cystitis, unspecified without hematuria
N30.91	Cystitis, unspecified with hematuria
N39.0	Urinary tract infection, site not specified
O23.0	Infections of kidney in pregnancy
O23.00	Infections of kidney in pregnancy, unspecified trimester
O23.01	Infections of kidney in pregnancy, first trimester
O23.02	Infections of kidney in pregnancy, second trimester
O23.03	Infections of kidney in pregnancy, third trimester
O23.1	Infections of bladder in pregnancy
O23.10	Infections of bladder in pregnancy, unspecified trimester
O23.11	Infections of bladder in pregnancy, first trimester
O23.12	Infections of bladder in pregnancy, second trimester
O23.13	Infections of bladder in pregnancy, third trimester
O23.2	Infections of urethra in pregnancy
O23.20	Infections of urethra in pregnancy, unspecified trimester
O23.21	Infections of urethra in pregnancy, first trimester
O23.22	Infections of urethra in pregnancy, second trimester
O23.23	Infections of urethra in pregnancy, third trimester
O23.3	Infections of other parts of urinary tract in pregnancy
O23.30	Infections of other parts of urinary tract in pregnancy, unspecified trimester
O23.31	Infections of other parts of urinary tract in pregnancy, first trimester
O23.32	Infections of other parts of urinary tract in pregnancy, second trimester
O23.33	Infections of other parts of urinary tract in pregnancy, third trimester
O23.4	Unspecified infection of urinary tract in pregnancy
O23.40	Unspecified infection of urinary tract in pregnancy, unspecified trimester
O23.41	Unspecified infection of urinary tract in pregnancy, first trimester
O23.42	Unspecified infection of urinary tract in pregnancy, second trimester
O23.43	Unspecified infection of urinary tract in pregnancy, third trimester
O23.9	Unspecified genitourinary tract infection in pregnancy
O23.90	Unspecified genitourinary tract infection in pregnancy, unspecified trimester
O23.91	Unspecified genitourinary tract infection in pregnancy, first trimester
O23.92	Unspecified genitourinary tract infection in pregnancy, second trimester
O23.93	Unspecified genitourinary tract infection in pregnancy, third trimester
Gastroenteritis due to salmonella
A02.0	Salmonella enteritis
Haemophilus influenzae acute otitis media
B96.3	Hemophilus influenzae [h. influenzae] as the cause of diseases classified elsewhere
H66.0	Acute suppurative otitis media
H66.00	Acute suppurative otitis media without spontaneous rupture of ear drum
H66.001	Acute suppurative otitis media without spontaneous rupture of ear drum, right ear
H66.002	Acute suppurative otitis media without spontaneous rupture of ear drum, left ear
H66.003	Acute suppurative otitis media without spontaneous rupture of ear drum, bilateral
H66.004	Acute suppurative otitis media without spontaneous rupture of ear drum, recurrent, right ear
H66.005	Acute suppurative otitis media without spontaneous rupture of ear drum, recurrent, left ear
H66.006	Acute suppurative otitis media without spontaneous rupture of ear drum, recurrent, bilateral
H66.007	Acute suppurative otitis media without spontaneous rupture of ear drum, recurrent, unspecified ear
H66.009	Acute suppurative otitis media without spontaneous rupture of ear drum, unspecified ear
H66.01	Acute suppurative otitis media with spontaneous rupture of ear drum
H66.011	Acute suppurative otitis media with spontaneous rupture of ear drum, right ear
H66.012	Acute suppurative otitis media with spontaneous rupture of ear drum, left ear
H66.013	Acute suppurative otitis media with spontaneous rupture of ear drum, bilateral
H66.014	Acute suppurative otitis media with spontaneous rupture of ear drum, recurrent, right ear
H66.015	Acute suppurative otitis media with spontaneous rupture of ear drum, recurrent, left ear
H66.016	Acute suppurative otitis media with spontaneous rupture of ear drum, recurrent, bilateral
H66.017	Acute suppurative otitis media with spontaneous rupture of ear drum, recurrent, unspecified ear
H66.019	Acute suppurative otitis media with spontaneous rupture of ear drum, unspecified ear
H66.9	Otitis media, unspecified
H66.90	Otitis media, unspecified, unspecified ear
H66.91	Otitis media, unspecified, right ear
H66.92	Otitis media, unspecified, left ear
H66.93	Otitis media, unspecified, bilateral
Haemophilus influenzae chronic bronchitis
J44.0	Chronic obstructive pulmonary disease with (acute) lower respiratory infection
Haemophilus influenzae pharyngitis
B96.3	Hemophilus influenzae [h. influenzae] as the cause of diseases classified elsewhere
J02.8	Acute pharyngitis due to other specified organisms
Haemophilus influenzae pneumonia
J14	Pneumonia due to hemophilus influenzae
Paratyphoid fever
A01.1	Paratyphoid fever A
A01.2	Paratyphoid fever B
A01.3	Paratyphoid fever C
A01.4	Paratyphoid fever, unspecified
Pharyngitis
J02	Acute pharyngitis
J02.0	Streptococcal pharyngitis
J02.8	Acute pharyngitis due to other specified organisms
J02.9	Acute pharyngitis, unspecified
Pneumococcal acute otitis media
B95.3	Streptococcus pneumoniae as the cause of diseases classified elsewhere
H66.0	Acute suppurative otitis media
H66.00	Acute suppurative otitis media without spontaneous rupture of ear drum
H66.001	Acute suppurative otitis media without spontaneous rupture of ear drum, right ear
H66.002	Acute suppurative otitis media without spontaneous rupture of ear drum, left ear
H66.003	Acute suppurative otitis media without spontaneous rupture of ear drum, bilateral
H66.004	Acute suppurative otitis media without spontaneous rupture of ear drum, recurrent, right ear
H66.005	Acute suppurative otitis media without spontaneous rupture of ear drum, recurrent, left ear
H66.006	Acute suppurative otitis media without spontaneous rupture of ear drum, recurrent, bilateral
H66.007	Acute suppurative otitis media without spontaneous rupture of ear drum, recurrent, unspecified ear
H66.009	Acute suppurative otitis media without spontaneous rupture of ear drum, unspecified ear
H66.01	Acute suppurative otitis media with spontaneous rupture of ear drum
H66.011	Acute suppurative otitis media with spontaneous rupture of ear drum, right ear
H66.012	Acute suppurative otitis media with spontaneous rupture of ear drum, left ear
H66.013	Acute suppurative otitis media with spontaneous rupture of ear drum, bilateral
H66.014	Acute suppurative otitis media with spontaneous rupture of ear drum, recurrent, right ear
H66.015	Acute suppurative otitis media with spontaneous rupture of ear drum, recurrent, left ear
H66.016	Acute suppurative otitis media with spontaneous rupture of ear drum, recurrent, bilateral
H66.017	Acute suppurative otitis media with spontaneous rupture of ear drum, recurrent, unspecified ear
H66.019	Acute suppurative otitis media with spontaneous rupture of ear drum, unspecified ear
H66.4	Suppurative otitis media, unspecified
H66.40	Suppurative otitis media, unspecified, unspecified ear
H66.41	Suppurative otitis media, unspecified, right ear
H66.42	Suppurative otitis media, unspecified, left ear
H66.43	Suppurative otitis media, unspecified, bilateral
H66.9	Otitis media, unspecified
H66.91	Otitis media, unspecified, right ear
H66.92	Otitis media, unspecified, left ear
H66.93	Otitis media, unspecified, bilateral
Pneumococcal pharyngitis
J02.0	Streptococcal pharyngitis
Pneumococcal pneumonia
J13	Pneumonia due to streptococcus pneumoniae
Proteus urinary tract infection
B96.4	Proteus (mirabilis) (morganii) as the cause of diseases classified elsewhere
N30.0	Acute cystitis
N30.00	Acute cystitis without hematuria
N30.01	Acute cystitis with hematuria
N30.9	Cystitis, unspecified
N30.90	Cystitis, unspecified without hematuria
N30.91	Cystitis, unspecified with hematuria
N39.0	Urinary tract infection, site not specified
O23.0	Infections of kidney in pregnancy
O23.00	Infections of kidney in pregnancy, unspecified trimester
O23.01	Infections of kidney in pregnancy, first trimester
O23.02	Infections of kidney in pregnancy, second trimester
O23.03	Infections of kidney in pregnancy, third trimester
O23.1	Infections of bladder in pregnancy
O23.10	Infections of bladder in pregnancy, unspecified trimester
O23.11	Infections of bladder in pregnancy, first trimester
O23.12	Infections of bladder in pregnancy, second trimester
O23.13	Infections of bladder in pregnancy, third trimester
O23.2	Infections of urethra in pregnancy
O23.20	Infections of urethra in pregnancy, unspecified trimester
O23.21	Infections of urethra in pregnancy, first trimester
O23.22	Infections of urethra in pregnancy, second trimester
O23.23	Infections of urethra in pregnancy, third trimester
O23.3	Infections of other parts of urinary tract in pregnancy
O23.30	Infections of other parts of urinary tract in pregnancy, unspecified trimester
O23.31	Infections of other parts of urinary tract in pregnancy, first trimester
O23.32	Infections of other parts of urinary tract in pregnancy, second trimester
O23.33	Infections of other parts of urinary tract in pregnancy, third trimester
O23.4	Unspecified infection of urinary tract in pregnancy
O23.40	Unspecified infection of urinary tract in pregnancy, unspecified trimester
O23.41	Unspecified infection of urinary tract in pregnancy, first trimester
O23.42	Unspecified infection of urinary tract in pregnancy, second trimester
O23.43	Unspecified infection of urinary tract in pregnancy, third trimester
O23.9	Unspecified genitourinary tract infection in pregnancy
O23.90	Unspecified genitourinary tract infection in pregnancy, unspecified trimester
O23.91	Unspecified genitourinary tract infection in pregnancy, first trimester
O23.92	Unspecified genitourinary tract infection in pregnancy, second trimester
O23.93	Unspecified genitourinary tract infection in pregnancy, third trimester
Staph epidermidis skin and skin structure infection
B95.7	Other staphylococcus as the cause of diseases classified elsewhere
H60.1	Cellulitis of external ear
H60.10	Cellulitis of external ear, unspecified ear
H60.11	Cellulitis of right external ear
H60.12	Cellulitis of left external ear
H60.13	Cellulitis of external ear, bilateral
J34.0	Abscess, furuncle and carbuncle of nose
L02	Cutaneous abscess, furuncle and carbuncle
L02.0	Cutaneous abscess, furuncle and carbuncle of face
L02.02	Furuncle of face
L02.03	Carbuncle of face
L02.1	Cutaneous abscess, furuncle and carbuncle of neck
L02.12	Furuncle of neck
L02.13	Carbuncle of neck
L02.2	Cutaneous abscess, furuncle and carbuncle of trunk
L02.22	Furuncle of trunk
L02.221	Furuncle of abdominal wall
L02.222	Furuncle of back [any part, except buttock]
L02.223	Furuncle of chest wall
L02.224	Furuncle of groin
L02.225	Furuncle of perineum
L02.226	Furuncle of umbilicus
L02.229	Furuncle of trunk, unspecified
L02.23	Carbuncle of trunk
L02.231	Carbuncle of abdominal wall
L02.232	Carbuncle of back [any part, except buttock]
L02.233	Carbuncle of chest wall
L02.234	Carbuncle of groin
L02.235	Carbuncle of perineum
L02.236	Carbuncle of umbilicus
L02.239	Carbuncle of trunk, unspecified
L02.3	Cutaneous abscess, furuncle and carbuncle of buttock
L02.32	Furuncle of buttock
L02.33	Carbuncle of buttock
L02.4	Cutaneous abscess, furuncle and carbuncle of limb
L02.42	Furuncle of limb
L02.421	Furuncle of right axilla
L02.422	Furuncle of left axilla
L02.423	Furuncle of right upper limb
L02.424	Furuncle of left upper limb
L02.425	Furuncle of right lower limb
L02.426	Furuncle of left lower limb
L02.429	Furuncle of limb, unspecified
L02.43	Carbuncle of limb
L02.431	Carbuncle of right axilla
L02.432	Carbuncle of left axilla
L02.433	Carbuncle of right upper limb
L02.434	Carbuncle of left upper limb
L02.435	Carbuncle of right lower limb
L02.436	Carbuncle of left lower limb
L02.439	Carbuncle of limb, unspecified
L02.5	Cutaneous abscess, furuncle and carbuncle of hand
L02.52	Furuncle hand
L02.521	Furuncle right hand
L02.522	Furuncle left hand
L02.529	Furuncle unspecified hand
L02.53	Carbuncle of hand
L02.531	Carbuncle of right hand
L02.532	Carbuncle of left hand
L02.539	Carbuncle of unspecified hand
L02.6	Cutaneous abscess, furuncle and carbuncle of foot
L02.62	Furuncle of foot
L02.621	Furuncle of right foot
L02.622	Furuncle of left foot
L02.629	Furuncle of unspecified foot
L02.63	Carbuncle of foot
L02.631	Carbuncle of right foot
L02.632	Carbuncle of left foot
L02.639	Carbuncle of unspecified foot
L02.8	Cutaneous abscess, furuncle and carbuncle of other sites
L02.82	Furuncle of other sites
L02.821	Furuncle of head [any part, except face]
L02.828	Furuncle of other sites
L02.83	Carbuncle of other sites
L02.831	Carbuncle of head [any part, except face]
L02.838	Carbuncle of other sites
L02.9	Cutaneous abscess, furuncle and carbuncle, unspecified
L02.92	Furuncle, unspecified
L02.93	Carbuncle, unspecified
L03	Cellulitis and acute lymphangitis
L03.0	Cellulitis and acute lymphangitis of finger and toe
L03.01	Cellulitis of finger
L03.011	Cellulitis of right finger
L03.012	Cellulitis of left finger
L03.019	Cellulitis of unspecified finger
L03.03	Cellulitis of toe
L03.031	Cellulitis of right toe
L03.032	Cellulitis of left toe
L03.039	Cellulitis of unspecified toe
L03.1	Cellulitis and acute lymphangitis of other parts of limb
L03.11	Cellulitis of other parts of limb
L03.111	Cellulitis of right axilla
L03.112	Cellulitis of left axilla
L03.113	Cellulitis of right upper limb
L03.114	Cellulitis of left upper limb
L03.115	Cellulitis of right lower limb
L03.116	Cellulitis of left lower limb
L03.119	Cellulitis of unspecified part of limb
L03.2	Cellulitis and acute lymphangitis of face and neck
L03.21	Cellulitis and acute lymphangitis of face
L03.211	Cellulitis of face
L03.22	Cellulitis and acute lymphangitis of neck
L03.221	Cellulitis of neck
L03.3	Cellulitis and acute lymphangitis of trunk
L03.31	Cellulitis of trunk
L03.311	Cellulitis of abdominal wall
L03.312	Cellulitis of back [any part except buttock]
L03.313	Cellulitis of chest wall
L03.314	Cellulitis of groin
L03.315	Cellulitis of perineum
L03.316	Cellulitis of umbilicus
L03.317	Cellulitis of buttock
L03.319	Cellulitis of trunk, unspecified
L03.8	Cellulitis and acute lymphangitis of other sites
L03.81	Cellulitis of other sites
L03.811	Cellulitis of head [any part, except face]
L03.818	Cellulitis of other sites
L03.9	Cellulitis and acute lymphangitis, unspecified
L03.90	Cellulitis, unspecified
L08.9	Local infection of the skin and subcutaneous tissue, unspecified
N48.22	Cellulitis of corpus cavernosum and penis
Staphylococcus acute otitis media
B95.6	Staphylococcus aureus as the cause of diseases classified elsewhere
B95.7	Other staphylococcus as the cause of diseases classified elsewhere
B95.8	Unspecified staphylococcus as the cause of diseases classified elsewhere
H66.00	Acute suppurative otitis media without spontaneous rupture of ear drum
H66.001	Acute suppurative otitis media without spontaneous rupture of ear drum, right ear
H66.002	Acute suppurative otitis media without spontaneous rupture of ear drum, left ear
H66.003	Acute suppurative otitis media without spontaneous rupture of ear drum, bilateral
H66.004	Acute suppurative otitis media without spontaneous rupture of ear drum, recurrent, right ear
H66.005	Acute suppurative otitis media without spontaneous rupture of ear drum, recurrent, left ear
H66.006	Acute suppurative otitis media without spontaneous rupture of ear drum, recurrent, bilateral
H66.007	Acute suppurative otitis media without spontaneous rupture of ear drum, recurrent, unspecified ear
H66.009	Acute suppurative otitis media without spontaneous rupture of ear drum, unspecified ear
H66.01	Acute suppurative otitis media with spontaneous rupture of ear drum
H66.011	Acute suppurative otitis media with spontaneous rupture of ear drum, right ear
H66.012	Acute suppurative otitis media with spontaneous rupture of ear drum, left ear
H66.013	Acute suppurative otitis media with spontaneous rupture of ear drum, bilateral
H66.014	Acute suppurative otitis media with spontaneous rupture of ear drum, recurrent, right ear
H66.015	Acute suppurative otitis media with spontaneous rupture of ear drum, recurrent, left ear
H66.016	Acute suppurative otitis media with spontaneous rupture of ear drum, recurrent, bilateral
H66.017	Acute suppurative otitis media with spontaneous rupture of ear drum, recurrent, unspecified ear
H66.019	Acute suppurative otitis media with spontaneous rupture of ear drum, unspecified ear
H66.4	Suppurative otitis media, unspecified
H66.40	Suppurative otitis media, unspecified, unspecified ear
H66.41	Suppurative otitis media, unspecified, right ear
H66.42	Suppurative otitis media, unspecified, left ear
H66.43	Suppurative otitis media, unspecified, bilateral
H66.9	Otitis media, unspecified
H66.91	Otitis media, unspecified, right ear
H66.92	Otitis media, unspecified, left ear
H66.93	Otitis media, unspecified, bilateral
Staphylococcus aureus skin and skin structure infection
B95.6	Staphylococcus aureus as the cause of diseases classified elsewhere
H60.1	Cellulitis of external ear
H60.10	Cellulitis of external ear, unspecified ear
H60.11	Cellulitis of right external ear
H60.12	Cellulitis of left external ear
H60.13	Cellulitis of external ear, bilateral
J34.0	Abscess, furuncle and carbuncle of nose
L02	Cutaneous abscess, furuncle and carbuncle
L02.0	Cutaneous abscess, furuncle and carbuncle of face
L02.02	Furuncle of face
L02.03	Carbuncle of face
L02.1	Cutaneous abscess, furuncle and carbuncle of neck
L02.12	Furuncle of neck
L02.13	Carbuncle of neck
L02.2	Cutaneous abscess, furuncle and carbuncle of trunk
L02.22	Furuncle of trunk
L02.221	Furuncle of abdominal wall
L02.222	Furuncle of back [any part, except buttock]
L02.223	Furuncle of chest wall
L02.224	Furuncle of groin
L02.225	Furuncle of perineum
L02.226	Furuncle of umbilicus
L02.229	Furuncle of trunk, unspecified
L02.23	Carbuncle of trunk
L02.231	Carbuncle of abdominal wall
L02.232	Carbuncle of back [any part, except buttock]
L02.233	Carbuncle of chest wall
L02.234	Carbuncle of groin
L02.235	Carbuncle of perineum
L02.236	Carbuncle of umbilicus
L02.239	Carbuncle of trunk, unspecified
L02.3	Cutaneous abscess, furuncle and carbuncle of buttock
L02.32	Furuncle of buttock
L02.33	Carbuncle of buttock
L02.4	Cutaneous abscess, furuncle and carbuncle of limb
L02.42	Furuncle of limb
L02.421	Furuncle of right axilla
L02.422	Furuncle of left axilla
L02.423	Furuncle of right upper limb
L02.424	Furuncle of left upper limb
L02.425	Furuncle of right lower limb
L02.426	Furuncle of left lower limb
L02.429	Furuncle of limb, unspecified
L02.43	Carbuncle of limb
L02.431	Carbuncle of right axilla
L02.432	Carbuncle of left axilla
L02.433	Carbuncle of right upper limb
L02.434	Carbuncle of left upper limb
L02.435	Carbuncle of right lower limb
L02.436	Carbuncle of left lower limb
L02.439	Carbuncle of limb, unspecified
L02.5	Cutaneous abscess, furuncle and carbuncle of hand
L02.52	Furuncle hand
L02.521	Furuncle right hand
L02.522	Furuncle left hand
L02.529	Furuncle unspecified hand
L02.53	Carbuncle of hand
L02.531	Carbuncle of right hand
L02.532	Carbuncle of left hand
L02.539	Carbuncle of unspecified hand
L02.6	Cutaneous abscess, furuncle and carbuncle of foot
L02.62	Furuncle of foot
L02.621	Furuncle of right foot
L02.622	Furuncle of left foot
L02.629	Furuncle of unspecified foot
L02.63	Carbuncle of foot
L02.631	Carbuncle of right foot
L02.632	Carbuncle of left foot
L02.639	Carbuncle of unspecified foot
L02.8	Cutaneous abscess, furuncle and carbuncle of other sites
L02.82	Furuncle of other sites
L02.821	Furuncle of head [any part, except face]
L02.828	Furuncle of other sites
L02.83	Carbuncle of other sites
L02.831	Carbuncle of head [any part, except face]
L02.838	Carbuncle of other sites
L02.9	Cutaneous abscess, furuncle and carbuncle, unspecified
L02.92	Furuncle, unspecified
L02.93	Carbuncle, unspecified
L03.01	Cellulitis of finger
L03.011	Cellulitis of right finger
L03.012	Cellulitis of left finger
L03.019	Cellulitis of unspecified finger
L03.03	Cellulitis of toe
L03.031	Cellulitis of right toe
L03.032	Cellulitis of left toe
L03.039	Cellulitis of unspecified toe
L03.1	Cellulitis and acute lymphangitis of other parts of limb
L03.11	Cellulitis of other parts of limb
L03.111	Cellulitis of right axilla
L03.112	Cellulitis of left axilla
L03.113	Cellulitis of right upper limb
L03.114	Cellulitis of left upper limb
L03.115	Cellulitis of right lower limb
L03.116	Cellulitis of left lower limb
L03.119	Cellulitis of unspecified part of limb
L03.2	Cellulitis and acute lymphangitis of face and neck
L03.21	Cellulitis and acute lymphangitis of face
L03.211	Cellulitis of face
L03.22	Cellulitis and acute lymphangitis of neck
L03.221	Cellulitis of neck
L03.3	Cellulitis and acute lymphangitis of trunk
L03.31	Cellulitis of trunk
L03.311	Cellulitis of abdominal wall
L03.312	Cellulitis of back [any part except buttock]
L03.313	Cellulitis of chest wall
L03.314	Cellulitis of groin
L03.315	Cellulitis of perineum
L03.316	Cellulitis of umbilicus
L03.317	Cellulitis of buttock
L03.319	Cellulitis of trunk, unspecified
L03.8	Cellulitis and acute lymphangitis of other sites
L03.81	Cellulitis of other sites
L03.811	Cellulitis of head [any part, except face]
L03.818	Cellulitis of other sites
L03.9	Cellulitis and acute lymphangitis, unspecified
L03.90	Cellulitis, unspecified
L08.89	Other specified local infections of the skin and subcutaneous tissue
L08.9	Local infection of the skin and subcutaneous tissue, unspecified
N48.22	Cellulitis of corpus cavernosum and penis
Streptococcus acute otitis media
B95.0	Streptococcus, group a, as the cause of diseases classified elsewhere
B95.4	Other streptococcus as the cause of diseases classified elsewhere
B95.5	Unspecified streptococcus as the cause of diseases classified elsewhere
H66.0	Acute suppurative otitis media
H66.00	Acute suppurative otitis media without spontaneous rupture of ear drum
H66.001	Acute suppurative otitis media without spontaneous rupture of ear drum, right ear
H66.002	Acute suppurative otitis media without spontaneous rupture of ear drum, left ear
H66.003	Acute suppurative otitis media without spontaneous rupture of ear drum, bilateral
H66.004	Acute suppurative otitis media without spontaneous rupture of ear drum, recurrent, right ear
H66.005	Acute suppurative otitis media without spontaneous rupture of ear drum, recurrent, left ear
H66.006	Acute suppurative otitis media without spontaneous rupture of ear drum, recurrent, bilateral
H66.007	Acute suppurative otitis media without spontaneous rupture of ear drum, recurrent, unspecified ear
H66.009	Acute suppurative otitis media without spontaneous rupture of ear drum, unspecified ear
H66.01	Acute suppurative otitis media with spontaneous rupture of ear drum
H66.011	Acute suppurative otitis media with spontaneous rupture of ear drum, right ear
H66.012	Acute suppurative otitis media with spontaneous rupture of ear drum, left ear
H66.013	Acute suppurative otitis media with spontaneous rupture of ear drum, bilateral
H66.014	Acute suppurative otitis media with spontaneous rupture of ear drum, recurrent, right ear
H66.015	Acute suppurative otitis media with spontaneous rupture of ear drum, recurrent, left ear
H66.016	Acute suppurative otitis media with spontaneous rupture of ear drum, recurrent, bilateral
H66.017	Acute suppurative otitis media with spontaneous rupture of ear drum, recurrent, unspecified ear
H66.019	Acute suppurative otitis media with spontaneous rupture of ear drum, unspecified ear
H66.4	Suppurative otitis media, unspecified
H66.40	Suppurative otitis media, unspecified, unspecified ear
H66.41	Suppurative otitis media, unspecified, right ear
H66.42	Suppurative otitis media, unspecified, left ear
H66.43	Suppurative otitis media, unspecified, bilateral
H66.9	Otitis media, unspecified
H66.90	Otitis media, unspecified, unspecified ear
H66.91	Otitis media, unspecified, right ear
H66.92	Otitis media, unspecified, left ear
H66.93	Otitis media, unspecified, bilateral
Streptococcus pneumoniae chronic bronchitis
B95.3	Streptococcus pneumoniae as the cause of diseases classified elsewhere
J41	Simple and mucopurulent chronic bronchitis
J41.0	Simple chronic bronchitis
J41.1	Mucopurulent chronic bronchitis
J42	Unspecified chronic bronchitis