This information is intended for use by health professionals

1. Name of the medicinal product

Phenoxymethylpenicillin Sugar Free 125mg / 5ml Powder for Oral Solution.

2. Qualitative and quantitative composition

Each 5ml contains 138.6mg of Phenoxymethylpenicillin potassium equivalent to phenoxymethylpenicillin 125mg.

Also contains 955.5mg/5ml of Sorbitol (E420).

For a full list of excipients see section 6.1.

3. Pharmaceutical form

Powder for oral solution

Phenoxymethylpenicillin 125mg is a white to off-white fine powder, which when reconstituted as directed, yields a colourless to pale yellow solution.

4. Clinical particulars
4.1 Therapeutic indications

Phenoxymethylpenicillin and phenoxymethylpenicillin potassium are indicated in the treatment of mild to moderately severe infections associated with micro-organisms whose susceptibility to penicillin is within the range of serum levels attained with the dosage form.

Phenoxymethylpenicillin is indicated for the treatment of the following infections (see Section 4.4 and 5.1)

Streptococcal infections:

Pharyngitis

Scarlet fever

Skin and soft tissue infections (e.g. erysipelas)

Pneumococcal infections:

Pneumonia

Otitis media

Vincent's gingivitis and pharyngitis

Phenoxymethylpenicillin is also indicated for (see section 5.1):

Prophylaxis of rheumatic fever and/or chorea

Prophylaxis of pneumococcal infection (e.g. in asplenia and in patients with sickle cell disease)

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

4.2 Posology and method of administration

Posology

For oral administration only.

The dosage and frequency of Phenoxymethylpenicillin depends on the severity and localisation of the infection and expected pathogens.

Phenoxymethylpenicillin Solution should be taken at least 30 minutes before or 2 hours after food, as ingestion of phenoxymethylpenicillin with meals slightly reduces the absorption of the drug.

Phenoxymethylpenicillin 250 mg is approximately equivalent to 400,000 units.

The usual dosage recommendations are as follows:

Adults and children over12 years: 250-500 mg every six hours

Children: Infants (up to 1 year): 62.5mg every 6 hours

1-5 years: 125 mg every six hours

6-12 years: 250 mg every six hours

Prophylactic Use

Prophylaxis of rheumatic fever/ chorea: 250 mg twice daily on a continuing basis

Prophylaxis of pneumococcal infection (e.g. in asplenia and in sickle cell disease):

Adults and children over 12 years: 500mg every 12 hours.

Children 6-12 years: 250mg every 12 hours.

Children below 5 years: 125mg every 12 hours.

Elderly

The dosage is as for adults. The dosage should be reduced if renal function is markedly impaired.

Renal impairment

The dosage should be reduced if renal function is markedly impaired.

Hepatic impairment

Dosage adjustment may be necessary in patients with impaired liver function when they also have renal failure. In this situation the liver may be a major excretion route.

Method of Administration

For instructions on dilution of the product before administration, see section 6.6.

4.3 Contraindications

Phenoxymethylpenicillin is contraindicated in patients known to be Hypersensitivity to Penicillin or to any of the ingredients listed in section 6.1 and should be used with caution in patients with known histories of allergy.

4.4 Special warnings and precautions for use

Penicillin should be used with caution in individuals with histories of significant allergies and/or asthma.

All degrees of hypersensitivity, including fatal anaphylaxis, have been observed with oral penicillin. These reactions are more likely to occur in individuals with a history of sensitivity to penicillins, cephalosporins and other allergens. Enquiries should be made for such a history before therapy is begun. If any allergic reaction occurs, the drug should be discontinued and the patient treated with the usual agents (e.g. adrenaline and other pressor amines, antihistamines and corticosteroids).

Oral therapy should not be relied upon for patients with severe illness, or with nausea, vomiting, gastric dilation, achalasia or intestinal hypermotility. Occasionally patients do not absorb therapeutic amounts of orally administered penicillin.

Administer with caution in the presence of markedly impaired renal function, as safe dosage may be lower than the usually recommended doses.

Streptococcal infections should be treated for a minimum of 10 days, and post therapy cultures should be performed to confirm the eradication of the organisms.

Prolonged use of antibiotics may promote the over growth of non-susceptible organisms, including fungi. If super infection occurs, appropriate measures should be taken.

In patients undergoing long-term Phenoxymethylpenicillin treatment the complete and differential blood count, as well as the liver and kidney function, should be monitored.

Sustained severe diarrhoea should prompt suspicion of pseudomembranous colitis. As this condition may be life-threatening phenoxymethylpenicillin should be withdrawn immediately and treatment guided by bacteriologic studies. It should be noted that each 125mg dose contains about 1/3mmol of potassium, which may be harmful to people on low potassium diets and may cause stomach upset, diarrhoea and hyperkalaemia. High doses should be used with caution in patients receiving potassium-containing drugs or potassium sparing-diuretics.

Sorbitol:

Patients with rare hereditary problems of fructose intolerance should not take this medicine.

Severe empyema, bacteraemia, pericarditis, meningitis and arthritis should not be treated with Penicillin V during the acute phase.

Patients with a past history of rheumatic fever receiving continuous prophylaxis may harbour penicillin-resistant organisms. In these patients, the use of another prophylactic agent should be considered.

Oral penicillin should not be used as adjunctive prophylaxis for genito - urinary instrumentation or surgery, lower intestinal tract surgery, sigmoidoscopy and child birth.

4.5 Interaction with other medicinal products and other forms of interaction

Aminoglycosides: Neomycin is reported to reduce the absorption of phenoxymethylpenicillin.

Anticoagulants: Penicillins may interfere with anticoagulant control.

Bacteriostatic antibiotics: Certain bacteriostatic antibiotics such as Chloramphenicol, Erythromycin and Tetracyclines have been reported to antagonise the bactericidal activity of penicillins and concomitant use is not recommended.

Guar gum: Reduced absorption of Phenoxymethylpenicillin.

Methotrexate: Use of Phenoxymethylpenicillin while taking methotrexate can cause reduced excretion of methotrexate thereby increasing the risk of toxicity.

Probenecid: Reduced excretion of phenoxymethylpenicillin by competing with it for renal tubular secretion.

Sulfinpyrazone: Excretion of penicillins reduced by sulfinpyrazone.

Typhoid vaccine (oral): Penicillins may inactivate oral typhoid vaccine if ingested concomitantly.

During treatment with phenoxymethylpenicillin non-enzymatic urinary glucose tests may be false-positive.

4.6 Fertility, pregnancy and lactation

Fertility

Fertility data for phenoxymethylpenicillin are not available.

Pregnancy:

There are no or a limited amount of data from the use of Phenoxymethylpenicillin in pregnant women. As a precautionary measure, it is preferable to avoid the use of Phenoxymethylpenicillin during pregnancy.

Lactation:

Phenoxymethylpenicillin metabolites are excreted in human milk to such an extent that effects on breastfed newborns are likely.

4.7 Effects on ability to drive and use machines

None known

4.8 Undesirable effects

The most common reactions to oral penicillin are gastrointestinal effects and hypersensitivity reactions. Although hypersensitivity reactions have been reported much less frequently after oral than after parenteral therapy, it should be remembered that all forms of hypersensitivity, including fatal anaphylaxis have been observed with oral penicillin.

The following convention has been utilised for the classification of undesirable effects:-

Very common (≥1/10)

Common (≥1/100, <1/10)

Uncommon (≥1/1000, <1/100)

Rare (≥1/10,000, <1/1000)

Very rare (<1/10,000)

Not known (cannot be estimated from the available data).

Infections and infestations

Not known

Pseudomembranous colitis

Blood and lymphatic disorders

Very rare

Changes in blood counts, including, thrombocytopenia, neutropenia, leucopenia, eosinophilia and haemolytic anaemia.

Not known

Coagulation disorders (including prolongation of bleeding time and defective platelet function)

Gastrointestinal disorders

Common

Nausea, vomiting, abdominal pain, diarrhoea

Not known

Sore mouth and black hairy tongue (discolouration of tongue)

Hepatobiliary disorders

Very rare

Hepatitis and cholestatic jaundice

Immune disorders

Common

Allergic reactions (typically manifest as skin reactions (See Skin and subcutaneous disorders))

Rare

Severe allergic reactions causing angioedema, laryngeal oedema and anaphylaxis

Unknown

Serum sickness-like reactions characterised by fever, chills, arthralgia and oedema

Nervous system disorders

Unknown

Central nervous system toxicity including convulsions (especially with high doses or in severe renal impairment); paraesthesia may occur with prolonged use, Neuropathy (usually associated with high doses of parenteral penicillin)

Renal and urinary disorders

Very rare

Interstitial nephritis

Uncommon

Nephropathy (usually associated with high doses of parenteral penicillin)

Skin and subcutaneous disorders

Common

Urticarial, erythematous or mobilliform rash and pruritus

Rare

Exfoliative dermatitis

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 Yellow Card Scheme at Website: www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store.

4.9 Overdose

Symptoms: A large oral overdose of penicillin may cause nausea, vomiting, stomach pain, diarrhoea, and rarely, major motor seizures. If other symptoms are present, consider the possibility of an allergic reaction. Hyperkalaemia may result from overdosage, particularly for patients with renal insufficiency.

Management: No specific antidote is known. Symptomatic and supportive therapy is recommended. Activated charcoal with a cathartic, such as sorbitol may hasten drug elimination. Penicillin may be removed by haemodialysis.

5. Pharmacological properties
5.1 Pharmacodynamic properties

General properties

Pharmacotherapeutic group: Antibacterials for systemic use, beta-lactamase sensitive penicillins, ATC Code: J01C E02.

Phenoxymethylpenicillin is a beta-lactamase sensitive natural penicillin.

Mechanism of Action:

Phenoxymethylpenicillin acts through interference with the final stage of synthesis of the bacterial cell wall. The action depends on its ability to bind certain membrane-bound proteins, (penicillin-binding proteins or PBPs) that are located beneath the cell wall. These proteins are involved in maintaining cell wall structure, in cell wall synthesis and in cell division, and appear to possess transpeptidase and carboxypeptidase activity.

PK/PD relationship

The time above the minimum inhibitory concentration (T>MIC) is considered to be the major determinant of efficacy for phenoxymethylpenicillin.

Mechanism(s) of Resistance:

Phenoxymethylpenicillin is inhibited by penicillinase and other beta-lactamases that are produced by certain microorganisms. The incidence of beta-lactamase producing organisms is increasing.

Mechanisms of resistance

The two main mechanisms of resistance to phenoxymethylpenicillin are:

• Inactivation by bacterial penicillinases and other beta-lactamases

• 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.

EUCAST clinical MIC breakpoints to separate susceptible (S) pathogens from resistant (R) pathogens (version 1.0 22.11.210) are:

The susceptibility of streptococci Groups A, C and G and S. pneumoniae to phenoxymethylpenicillin is inferred from the susceptibility to benzylpenicillin.

EUCAST Species-related breakpoints (Susceptible≦/Resistant>) Units: mg/L

Staphylococcus

≤0.12/>0.12

Streptococcus A, C, G

≤0.25/>0.25

S. pneumoniae

≤ 0.06/>2

Staphylococci: Most staphylococci are penicillinase-producers. Penicillinase-producing strains are resistant. The benzylpenicillin breakpoint (shown) will mostly, but not unequivocally, separate beta-lactamase producers from non-producers.

Streptococcus pneumoniae: For phenoxymethylpenicillin, report S. pneumoniae with benzylpenicillin MICs above 0.06 mg/L resistant.

The prevalence of acquired resistance may vary geographically and with time for selected species and local information on resistance is desirable, particularly when treating severe infections. Expert advice should be sought as necessary 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

Streptococcus A,C,G

Species for which acquired resistance may be a problem

Staphylococcus aureus

Streptococcus pneumoniae

Staphylococcus epidermidis

5.2 Pharmacokinetic properties

Absorption: Rapidly but incompletely absorbed after oral administration (about 60% of an oral dose is absorbed). Calcium and potassium salts are better absorbed than the free acid. Absorption appears to be reduced in patients with coeliac disease. Absorption appears to be more rapid in fasting than non-fasting subjects.

Blood concentration: after an oral dose of 125mg, peak serum concentrations of 200 to 700ng/ml are attained in 2 hours. After an oral dose of 500mg, peak serum concentrations reach 3 to 5micrograms/ml in 30 to 60 minutes.

Half-life: Biological half-life is about 30 minutes, increased to about 4 hours in severe renal impairment.

Distribution: Widely distributed throughout the body and enters pleural and ascitic fluids and also in cerebrospinal fluid when the meninges are inflamed; Phenoxymethylpenicillin crosses the placenta and is secreted in trace amounts in breast milk; (protein binding 50% to 80% bound plasma proteins).

Biotransformation: It is metabolised in the liver; several metabolites have been identified, including penicilloic acid.

Elimination: Unchanged drug and metabolites are excreted rapidly in the urine. (20% to 35% of an oral dose is excreted in the urine in 24 hours).

5.3 Preclinical safety data

There are no pre-clinical data of relevance to the prescriber which are additional to that already included in other sections of this SPC.

6. Pharmaceutical particulars
6.1 List of excipients

Sorbitol (E420)

Powdarome Strawberry Premium (Nature identical flavouring and natural flavouring, maize maltodextrin, INS1520 propylene glycol)

Sodium Saccharin

6.2 Incompatibilities

Not applicable.

6.3 Shelf life

24 months.

The shelf life after reconstitution is 7 days.

6.4 Special precautions for storage

Store powder in a dry place below 25°C

After reconstitution, phenoxymethylpenicillin oral solution must be stored between 2°C to 8°C and used within 7 days.

6.5 Nature and contents of container

150ml HDPE bottle with a 28mm child resistant cap. Each bottle contains 100 ml of reconstituted solution with a dosing syringe of 5ml.

6.6 Special precautions for disposal and other handling

No special requirements.

Add 86.0ml of water to the powder and shake vigorously. This will make 100ml of solution.

The solution should be used within 7 days of reconstitution.

Shake well before use.

7. Marketing authorisation holder

Brown & Burk UK Ltd

5, Marryat Close

Hounslow West

Middlesex

TW4 5DQ

UK

8. Marketing authorisation number(s)

PL 25298/0042

9. Date of first authorisation/renewal of the authorisation

13-Jan-2012/29-Jun-2016

10. Date of revision of the text

24-09-2019