CEFTAROLINE FOSAMIL: 789 Adverse Event Reports & Safety Profile

11. DESCRIPTION TEFLARO (ceftaroline fosamil) for injection, is a sterile, semi-synthetic, prodrug of the cephalosporin antibacterial class of beta-lactams (β-lactams) for intravenous use. Chemically, the prodrug, ceftaroline fosamil monoacetate monohydrate is (6 R ,7 R )-7-{(2 Z )-2-(ethoxyimino)-2-[5-(phosphonoamino)-1,2,4-thiadiazol-3-yl]acetamido}-3-{[4-(1-methylpyridin-1-ium-4-yl)-1,3-thiazol-2-yl]sulfanyl}-8-oxo-5-thia-1-azabicyclo[4.2.0]oct-2-ene-2-carboxylate monoacetate monohydrate. Its molecular weight is 762.75. The empirical formula is C 22 H 21 N 8 O 8 PS 4 .C 2 H 4 O 2 .H 2 O.

Figure

1: Chemical structure of ceftaroline fosamil Teflaro vials contain either 600 mg or 400 mg of anhydrous ceftaroline fosamil (equivalent to 668 mg and 446 mg, respectively, of ceftaroline fosamil monoacetate monohydrate). The powder for injection is formulated from ceftaroline fosamil monoacetate monohydrate, a pale yellowish-white to light yellow sterile powder. Each vial of 400 mg of anhydrous ceftaroline fosamil includes inactive ingredient L-arginine 263.3 mg/vial as the solubilizer and alkalizing agent. Each vial of 600 mg of anhydrous ceftaroline fosamil includes inactive ingredient L-arginine 395.0 mg/vial as the solubilizer and alkalizing agent. All references to ceftaroline activity are expressed in terms of the prodrug, ceftaroline fosamil. The powder is constituted for IV injection [see Dosage and Administration ( 2.3 )] . The pH of the constituted solution is pH 4.8 to 6.5.

Figure

1: Chemical structure of ceftaroline fosamil

1.

Indications And Usage

Ceftaroline fosamil for injection is a cephalosporin antibacterial indicated in adult and pediatric patients for the treatment of the following infection caused by designated susceptible bacteria: Acute bacterial skin and skin structure infections (ABSSSI) in adult and pediatric patients (at least 34 weeks gestational age and 12 days postnatal age) ( 1.1 ) Community-acquired bacterial pneumonia (CABP) in adult and pediatric patients 2 months of age and older ( 1.2 ) To reduce the development of drug-resistant bacteria and maintain the effectiveness of ceftaroline fosamil for injection and other antibacterial drugs, ceftaroline fosamil for injection should be used only to treat or prevent infections that are proven or strongly suspected to be caused by bacteria. ( 1.3 )

1.1 Acute Bacterial Skin and Skin Structure Infections Ceftaroline fosamil for injection is indicated in adult and pediatric patients (at least 34 weeks gestational age and 12 days postnatal age) for the treatment of acute bacterial skin and skin structure infections (ABSSSI) caused by susceptible isolates of the following Gram-positive and Gram-negative microorganisms: Staphylococcus aureus (including methicillin-susceptible and -resistant isolates), Streptococcus pyogenes , Streptococcus agalactiae , Escherichia coli , Klebsiella pneumoniae, and Klebsiella oxytoca <span class="opacity-50 text-xs">[see Dosage and Administration (2.2) and Use in Specific Populations ( 8.4 )]</span>.

1.2 Community-Acquired Bacterial Pneumonia Ceftaroline fosamil for injection is indicated in adult and pediatric patients 2 months of age and older for the treatment of community-acquired bacterial pneumonia (CABP) caused by susceptible isolates of the following Gram-positive and Gram-negative microorganisms: Streptococcus pneumoniae (including cases with concurrent bacteremia), Staphylococcus aureus (methicillin-susceptible isolates only), Haemophilus influenzae, Klebsiella pneumoniae, Klebsiella oxytoca, and Escherichia coli.

1.3 Usage To reduce the development of drug-resistant bacteria and maintain the effectiveness of ceftaroline fosamil for injection and other antibacterial drugs, ceftaroline fosamil for injection should be used to treat or prevent infections that are proven or strongly suspected to be caused by susceptible bacteria. Appropriate specimens for microbiological examination should be obtained in order to isolate and identify the causative pathogens and to determine their susceptibility to ceftaroline. When culture and susceptibility information are available, they should be considered in selecting or modifying antibacterial therapy. In the absence of such data, local epidemiology and susceptibility patterns may contribute to the empiric selection of therapy.

2.

Dosage And Administration

Dosage of Ceftaroline Fosamil for Injection by Indication in Adult and Pediatric Patients ( 2.1 , 2.2)

Indication Age Range Dosage Infusion

Time Duration Acute Bacterial Skin and Skin Structure Infections (ABSSSI) 18 years and older 600 mg every 12 hours 5 to 60 minutes 5 to 14 days ≥2 years to <18 years (> 33 kg) 400 mg every 8 hours OR 600 mg every 12 hours 5 to 60 minutes 5 to 14 days ≥2 years to <18 years (≤33kg) 12 mg/kg every 8 hours 5 to 60 minutes 5 to 14 days 2 months to <2 years 8 mg/kg every 8 hours 5 to 60 minutes 5 to 14 days 0* to <2 months 6 mg/kg every 8 hours 30 to 60 minutes 5 to 14 days *Gestational age 34 weeks and older and postnatal age 12 days and older Indication Age Range Dosage Infusion Time Duration Community Acquired Bacterial Pneumonia (CABP) 18 years and older 600 mg every12 hours 5 to 60 minutes 5 to 7 days ≥2 years to < 18 years (> 33 kg) 400 mg every 8 hours OR 600 mg every12 hours 5 to 60 minutes 5 to 14 days ≥2 years to < 18 years (≤ 33kg) 12 mg/kg every8 hours 5 to 60 minutes 5 to 14 days 2 months to < 2 years 8 mg/kg every8 hours 5 to 60 minutes 5 to 14 days Dosage adjustment is required in adult patients with creatinine clearance (CrCl) <50 mL/min and in End-stage Renal Disease (ESRD) including hemodialysis ( 2.3 ) There is insufficient information to recommend a dosage regimen for pediatric patients with CrCL <50 mL/min/1.73 m 2 ( 2.3 )

2.1 Recommended Dosage in Adult Patients The recommended dosage of ceftaroline fosamil for injection is 600 mg administered every 12 hours by intravenous (IV) infusion over 5 to 60 minutes in patients ≥18 years of age. The duration of therapy should be guided by the severity and site of infection and the patient’s clinical and bacteriological progress. The recommended dosage and administration by infection is described in Table 1.

Table

1: Dosage of Ceftaroline Fosamil for Injection by Indication in Adults Indication Dosage Frequency Infusion Time Recommended Duration of Treatment Acute Bacterial Skin and Skin Structure Infections (ABSSSI) 600 mg Every 12 hours 5 to 60 minutes 5-14 days Community-Acquired Bacterial Pneumonia (CABP) 600 mg Every 12 hours 5 to 60 minutes 5-7 days

2.2 Recommended Dosage in Pediatric Patients The recommended dosage of ceftaroline fosamil for injection in pediatric patients is based on the age and weight of the child. The duration of therapy should be guided by the severity, site of infection and the patient’s clinical and bacteriological progress.

Pediatric Patients

2 Months of Age and Older For pediatric patients 2 months of age and older, ceftaroline fosamil for injection is administered every 8 hours by intravenous infusion over 5 to 60 minutes. Ceftaroline fosamil for injection dosing regimen is dependent on the type of infection (ABSSSI, CABP). See dosing Table 2 below.

Table

2: Dosage of Ceftaroline Fosamil for Injection by Indication in Pediatric Patients 2 Months of Age and Older Indication Age Range Dosage and Frequency Infusion time Recommended Duration of Treatment Acute Bacterial Skin and Skin Structure Infections (ABSSSI) OR Community-Acquired Bacterial Pneumonia (CABP) 2 months to < 2 years 8 mg/kg every 8 hours 5 to 60 minutes 5-14 days ≥ 2 years to < 18 years (≤ 33 kg) 12 mg/kg every 8 hours ≥ 2 years to < 18 years (> 33 kg) 400 mg every 8 hours OR 600 mg every 12 hours Pediatric Patients Less Than 2 Months of Age Ceftaroline fosamil for injection are administered every 8 hours by intravenous infusion over 30 to 60 minutes for patients less than 2 months of age. Ceftaroline fosamil for injection dosing regimen is only recommended for patients with ABSSSI. See dosing Table 3 below. Concentrations of ceftaroline fosamil in the cerebrospinal fluid have not been evaluated [see Use in Specific Populations ( 8.4 )]. There is no information for dosing ceftaroline fosamil for injection in infants less than 34 weeks gestational age and less than 12 days postnatal age.

Table

3: Dosage of Ceftaroline Fosamil for Injection in Pediatric Patients less Than 2 Months of Age Indication Age Range Dosage and Frequency Infusion time Recommended Duration of Treatment Acute Bacterial Skin and Skin Structure Infections (ABSSSI) 0* to < 2 months 6 mg/kg every 8 hours 30 to 60 minutes 5-14 days *Gestational age 34 weeks and older and postnatal age 12 days and older.

2.3 Dosage Adjustments in Patients with Renal Impairment Adults : No dosage adjustment is required in adult patients with CrCL &gt; 50 mL/min. The dose in adult patients should be adjusted when creatinine clearance (CrCL) is &lt; 50 mL/min as shown below (see Table 4).

Table

4: Dosage of Ceftaroline Fosamil for Injection in Adult Patients with Renal Impairment Estimated CrCl a (mL/min)

Recommended Dosage

Regimen for Ceftaroline Fosamil for Injection > 50 No dosage adjustment necessary > 30 to ≤ 50 400 mg IV (over 5 to 60 minutes) every 12 hours ≥ 15 to ≤ 30 300 mg IV (over 5 to 60 minutes) every 12 hours End-stage renal disease, including hemodialysis b 200 mg IV (over 5 to 60 minutes) every 12 hours c a Creatinine clearance (CrCl) estimated using the Cockcroft-Gault formula. b End-stage renal disease is defined as CrCl < 15 mL/min. c Ceftaroline fosamil for injection is hemodialyzable; thus, ceftaroline fosamil for injection should be administered after hemodialysis on hemodialysis days. Pediatrics : No dosage adjustment is required in pediatric patients with CrCL > 50 mL/min/1.73 m 2 , estimated using the Schwartz equation. There is insufficient information to recommend a dosage regimen for pediatric patients with CrCL < 50 mL/min/1.73 m 2 .

2.4 Preparation of Ceftaroline Fosamil for Injection for Administration Constitution of Ceftaroline Fosamil for Injection Powder for Injection Aseptic technique must be followed in preparing the infusion solution. The contents of ceftaroline fosamil for injection vial should be constituted with 20 mL Sterile Water for Injection, USP; or 0.9% of sodium chloride injection; or 5% of dextrose injection; or lactated ringer’s injection. Constitution time is less than 2 minutes. Mix gently to constitute and check to see that the contents have dissolved completely. The preparation of ceftaroline fosamil for injection solutions is summarized in Table 5.

Table

5: Preparation of Ceftaroline Fosamil for Injection for Intravenous Use Dosage Strength (mg) Volume of Diluent To Be Added (mL)

Approximate

Ceftaroline fosamil Concentration (mg/mL) Amount to Be Withdrawn 400 20 20 Adults: Total Volume Pediatric*: Volume based on age and weight 600 20 30 Adults: Total Volume Pediatric*: Volume based on age and weight * The recommended dosage of ceftaroline fosamil for injection is based on the age and weight of the child.

See Table

2 Dilution of the Constituted Solution of Ceftaroline Fosamil for Injection The constituted solution must be further diluted in a range between 50 mL to 250 mL before intravenous infusion into patients. Use the same diluent used for constitution of the powder for this further dilution, unless sterile water for injection was used earlier. If sterile water for injection was used earlier, then appropriate infusion solutions include: 0.9% Sodium Chloride Injection, USP; 5% Dextrose Injection, USP; 2.5% Dextrose Injection, USP, and 0.45% Sodium Chloride Injection, USP; or Lactated Ringer's Injection, USP. Dilution of the Constituted Solution of Ceftaroline Fosamil for Injection in the 50 mL Infusion Bags Only Preparation of 600 mg of ceftaroline fosamil for injection dose in 50 mL infusion bag (for adult patients): Withdraw 20 mL of diluent from the infusion bag. Proceed to inject entire content of the ceftaroline fosamil for injection vial into the bag to provide a total volume of 50 mL. The resultant concentration is approximately 12 mg/mL. Preparation of 400 mg of ceftaroline fosamil for injection dose in 50 mL infusion bag (for adult patients or pediatric patients weighing > 33 kg): Withdraw 20 mL of diluent from the infusion bag. Proceed to inject entire content of the ceftaroline fosamil for injection vial into the bag to provide a total volume of 50 mL. The resultant concentration is approximately 8 mg/mL. Preparation of ceftaroline fosamil for injection dose in the infusion bag (for pediatric patients weighing ≤ 33 kg): The amount of solution withdrawn from the constituted ceftaroline fosamil for injection vial for pediatric patients weighing ≤ 33 kg for dilution in the infusion bag will vary according to the weight and age of the child. The infusion solution concentration for administration should not exceed 12 mg/ml ceftaroline fosamil. Discard unused portion. The color of ceftaroline fosamil for injection infusion solutions ranges from clear, light to dark yellow depending on the concentration and storage conditions. When stored as recommended, the product potency is not affected. Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration, whenever solution and container permit.

2.5 Storage of Constituted Solutions Stability in Baxter ® Mini-Bag Plus ™ : Solutions of ceftaroline fosamil for injection in concentrations ranging from 4 to 12 mg/mL in Baxter Mini-Bag Plus containers with 0.9% Sodium Chloride Injection may be stored for up to 6 hours at room temperature or for up to 24 hours at 2ºC to 8ºC (36ºF to 46ºF). Stability testing in the Baxter Mini-Bag Plus has solely been conducted on 50 mL and 100 mL containers (0.9% Sodium Chloride Injection). Stability in Infusion Bag : Studies have shown that the constituted solution in the infusion bag should be used within 6 hours when stored at room temperature or within 24 hours when stored under refrigeration at 2ºC to 8ºC (36ºF to 46ºF).

2.6 Drug Compatibilities The compatibility of ceftaroline fosamil for injection with other drugs has not been established. Ceftaroline fosamil for injection should not be mixed with or physically added to solutions containing other drugs.

4.

Contraindications

Ceftaroline fosamil for injection is contraindicated in patients with known serious hypersensitivity to ceftaroline or other members of the cephalosporin class. Anaphylaxis has been reported with ceftaroline. Known serious hypersensitivity to ceftaroline or other members of the cephalosporin class. ( 4 )

6.

Adverse Reactions

The following serious adverse reactions are described in greater detail in the Warnings and Precautions section Hypersensitivity Reactions [see Warnings and Precautions ( 5.1 )] Clostridioides difficile -Associated diarrhea [see Warnings and Precautions ( 5.2 )]

Neurological Adverse

Reactions [see Warnings and Precautions ( 5.3 )]

Direct

Coombs’ Test Seroconversion [see Warnings and Precautions ( 5.4 )] The most common adverse reactions occurring in >2 % of adult patients and ≥3% of pediatric patients are diarrhea, nausea, and rash. Additional adverse reactions that occurred in ≥3% of pediatric patients include vomiting and pyrexia. ( 6.1 ) To report SUSPECTED ADVERSE REACTIONS, contact Apotex Corp. at 1-800-706-5575 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.

6.1 Clinical Trials Experience Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in clinical trials of a drug cannot be compared directly to rates from clinical trials of another drug and may not reflect rates observed in practice.

Adult Patients

Ceftaroline fosamil for injection was evaluated in four controlled comparative Phase 3 clinical trials (two in ABSSSI and two in CABP) which included 1,300 adult patients treated with ceftaroline fosamil for injection (600 mg administered by IV over 1 hour every 12h) and 1,297 patients treated with comparator (vancomycin plus aztreonam or ceftriaxone) for a treatment period up to 21 days. The median age of patients treated with ceftaroline fosamil for injection was 54 years, ranging between 18 and 99 years old. Patients treated with ceftaroline fosamil for injection were predominantly male (63%) and Caucasian (82%).

Serious Adverse

Reactions and Adverse Reactions Leading to Discontinuation In the four pooled adult Phase 3 clinical trials, serious adverse reactions (SARs) occurred in 98/1,300 (7.5%) of patients receiving ceftaroline fosamil for injection and 100/1,297 (7.7%) of patients receiving comparator drugs. Treatment discontinuation due to adverse reactions occurred in 35/1,300 (2.7%) of patients receiving ceftaroline fosamil for injection and 48/1,297 (3.7%) of patients receiving comparator drugs with the most common adverse reactions leading to discontinuation being hypersensitivity for both treatment groups at a rate of 0.3% in the ceftaroline fosamil for injection group and 0.5% in comparator group.

Most Common Adverse

Reactions No adverse reactions occurred in greater than 5% of adult patients receiving ceftaroline fosamil for injection. The most common adverse reactions occurring in > 2% of patients receiving ceftaroline fosamil for injection in the pooled adult phase 3 clinical trials were diarrhea, nausea, and rash.

Table

6 lists adverse reactions occurring in ≥ 2% of patients receiving ceftaroline fosamil for injection in the pooled adult Phase 3 clinical trials.

Table

6: Adverse Reactions Occurring in ≥ 2% of Patients Receiving Ceftaroline Fosamil for Injection in the Pooled Adult Phase 3 Clinical Trials Adverse Reactions Pooled Phase 3 Clinical Trials (four trials, two in ABSSSI and two in CABP)

Ceftaroline

Fosamil for Injection (N=1,300)

Pooled

Comparators a (N=1,297)

Gastrointestinal Disorders Diarrhea

5 % 3 % Nausea 4 % 4 % Constipation 2 % 2 % Vomiting 2 % 2 % Laboratory Investigations Increased transaminases 2% 3 % Metabolism and Nutrition disorders Hypokalemia 2 % 3 % Skin and Subcutaneous Tissue Disorders Rash 3% 2% Vascular Disorders Phlebitis 2% 1% a Comparators included vancomycin 1 gram IV every 12h plus aztreonam 1 gram IV every 12h in the Phase 3 ABSSSI trials, and ceftriaxone 1 gram IV every 24h in the Phase 3 CABP trials.

Other Adverse Reactions Observed During

Clinical Trials of Ceftaroline Fosamil for Injection Following is a list of additional adverse reactions reported by the 1,740 adult patients who received ceftaroline fosamil for injection in any clinical trial with incidences less than 2%. Blood and lymphatic system disorders - Anemia, Eosinophilia, Neutropenia, Thrombocytopenia Cardiac disorders - Bradycardia, Palpitations Gastrointestinal disorders - Abdominal pain General disorders and administration site conditions - Pyrexia Hepatobiliary disorders - Hepatitis Immune system disorders - Hypersensitivity, Anaphylaxis Infections and infestations - Clostridioides difficile colitis Metabolism and nutrition disorders - Hyperglycemia, Hyperkalemia Nervous system disorders - Dizziness, Convulsion Renal and urinary disorders - Renal failure Skin and subcutaneous tissue disorders - Urticaria Pediatric Patients Ceftaroline fosamil for injection was evaluated in three clinical trials (one in ABSSSI and two in CABP) which included 257 pediatric patients 2 months to < 18 years of age treated with ceftaroline fosamil for injection, and 102 patients treated with comparator agents for a treatment period up to 21 days. In two trials, one in ABSSSI and one in CABP, the dose was selected to result in exposures comparable to adult exposure with 600 mg administered by IV infusion every 12h. In an additional pediatric trial in complicated CABP the dose was higher. The median age of pediatric patients treated with ceftaroline fosamil for injection was 5 years, ranging from 2 months to < 18 years of age. Patients treated with ceftaroline fosamil for injection were predominantly male (55%) and Caucasian (92%). A single study enrolled 11 pediatric patients with a gestational age of ≥34 weeks and a postnatal age of 12 days to less than 2 months of age. The safety findings were similar to those observed in adult and pediatric patients 2 months of age and older.

Serious Adverse

Reactions and Adverse Reactions Leading to Discontinuation In the three pooled pediatric clinical trials, SARs occurred in 10/257 (4%) of patients receiving ceftaroline fosamil for injection and 3/102 (3%) of patients receiving comparator drugs. Treatment discontinuation due to adverse reactions occurred in 10/257 (3.9%) of patients receiving ceftaroline fosamil for injection and 2/102 (2%) of patients receiving comparator drugs with the most common adverse reaction leading to discontinuation being rash in 2/257 (0.8%) of patients treated with ceftaroline fosamil for injection.

Most Common Adverse

Reactions No adverse reactions occurred in greater than 8% of pediatric patients receiving ceftaroline fosamil for injection. The most common adverse reactions occurring in ≥ 3% of patients receiving ceftaroline fosamil for injection in the pooled pediatric clinical trials were diarrhea, nausea, vomiting, pyrexia and rash.

Table

7 lists adverse reactions occurring in ≥ 3% of patients receiving ceftaroline fosamil for injection in the pooled pediatric clinical trials.

Table

7: Adverse Reactions Occurring in ≥ 3% of Patients Receiving Ceftaroline Fosamil for Injection in the Pooled Pediatric Clinical Trials Adverse Reactions Pooled Pediatric Clinical Trials (three trials, one in ABSSSI and two in CABP)

Ceftaroline

Fosamil for Injection (N=257)

Pooled

Comparators a (N=102)

Gastrointestinal Disorders Diarrhea

8 % 10 % Nausea 3 % 1 % Vomiting 5 % 12 % General and Administrative Site disorders Pyrexia 3% 2 % Skin and Subcutaneous Tissue Disorders Rash 7% 4% a Comparators included vancomycin or cefazolin with or without aztreonam in the ABSSSI trial and ceftriaxone alone or ceftriaxone plus vancomycin in the CABP trials Following is a list of additional adverse reactions reported by the 257 patients who received ceftaroline fosamil for injection in the pediatric clinical trials with incidences less than 3%. Investigations – Alanine aminotransferase increased, Aspartate aminotransferase increased Nervous system disorders – Headache Skin and subcutaneous tissue disorders - Pruritus

6.2 Postmarketing Experience The following adverse reactions have been identified during post approval use of ceftaroline fosamil for injection in adult patients. Because these adverse reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure. Blood and lymphatic system disorders : Agranulocytosis, leukopenia, eosinophilic pneumonia. Nervous system disorders: Encephalopathy, seizures <span class="opacity-50 text-xs">[see Warnings and Precautions (5.3)]</span>

5.

Warnings And Precautions

Serious hypersensitivity (anaphylactic) reactions have been reported with beta-lactam antibacterial drugs, including ceftaroline. If a hypersensitivity reaction occurs, discontinue ceftaroline fosamil for injection. ( 5.1 ) Clostridiodes difficile -associated diarrhea (CDAD) has been reported with nearly all systemic antibacterial agents, including ceftaroline fosamil for injection. Evaluate if diarrhea occurs. ( 5.2 ) Neurological adverse reactions have been reported in patients treated with cephalosporins, including ceftaroline. If neurological adverse reactions occur, consider discontinuing ceftaroline fosamil for injection or making appropriate dosage adjustments in patients with renal impairment. ( 2.3 , 5.3 )

Direct

Coombs’ test seroconversion has been reported with ceftaroline. If anemia develops during or after therapy, a diagnostic workup for drug- induced hemolytic anemia should be performed and consideration given to discontinuation of ceftaroline fosamil for injection. ( 5.4 )

5.1 Hypersensitivity Reactions Serious and occasionally fatal hypersensitivity (anaphylactic) reactions and serious skin reactions have been reported in patients receiving beta-lactam antibacterial drugs. Before therapy with ceftaroline fosamil for injection is instituted, careful inquiry about previous hypersensitivity reactions to other cephalosporins, penicillins, or carbapenems should be made. Maintain clinical supervision if this product is to be given to a penicillin- or other beta-lactam-allergic patient, because cross sensitivity among beta-lactam antibacterial agents has been clearly established. If an allergic reaction to ceftaroline fosamil for injection occurs, discontinue ceftaroline fosamil for injection and institute appropriate treatment and supportive measures.

5.2 Clostridioides difficile - Associated Diarrhea Clostridioides difficile -associated diarrhea (CDAD) has been reported for nearly all systemic antibacterial agents, including ceftaroline fosamil for injection, and may range in severity from mild diarrhea to fatal colitis. Treatment with antibacterial agents alters the normal flora of the colon and may permit overgrowth of C. difficile . C. difficile produces toxins A and B which contribute to the development of CDAD. Hypertoxin-producing strains of C. difficile cause increased morbidity and mortality, as these infections can be refractory to antimicrobial therapy and may require colectomy. CDAD must be considered in all patients who present with diarrhea following antibiotic use. Careful medical history is necessary because CDAD has been reported to occur more than 2 months after the administration of antibacterial agents. If CDAD is suspected or confirmed, antibacterials not directed against C. difficile should be discontinued, if possible. Appropriate fluid and electrolyte management, protein supplementation, antibiotic treatment of C. difficile , and surgical evaluation should be instituted as clinically indicated <span class="opacity-50 text-xs">[see Adverse Reactions ( 6.1 )]</span>.

5.3 Neurological Adverse Reactions Neurological adverse reactions have been reported during postmarketing surveillance in patients treated with cephalosporins, including ceftaroline fosamil for injection. These reactions include encephalopathy and seizures <span class="opacity-50 text-xs">[see Adverse Reactions ( 6.2 )]</span> . Most cases occurred in patients with renal impairment who did not receive appropriate dosage adjustment. The neurological adverse reactions were reversible and resolved after discontinuation of ceftaroline fosamil for injection or after hemodialysis. If neurological adverse reactions associated with ceftaroline fosamil for injection therapy occur, consider discontinuing ceftaroline fosamil for injection or making appropriate dosage adjustments in patients with renal impairment <span class="opacity-50 text-xs">[see Dosage and Administration ( 2.3 )]</span> .

5.4 Direct Coombs&apos; Test Seroconversion Seroconversion from a negative to a positive direct Coombs’ test result occurred in 120/1,114 (10.8%) of adult patients receiving ceftaroline fosamil for injection and 49/1,116 (4.4%) of patients receiving comparator drugs in the four pooled adult Phase 3 trials. In the pooled adult Phase 3 CABP trials, 51/520 (9.8%) of ceftaroline fosamil for injection-treated patients compared to 24/534 (4.5%) of ceftriaxone-treated patients seroconverted from a negative to a positive direct Coombs’ test result. No adverse reactions representing hemolytic anemia were reported in any treatment group. Seroconversion from a negative to a positive direct Coombs’ test result occurred in 42/234 (17.9%) of children receiving ceftaroline fosamil for injection and 3/93 (3.2%) of patients receiving comparator drugs in the three pooled pediatric trials. No adverse reactions representing hemolytic anemia were reported in any treatment group. If anemia develops during or after treatment with ceftaroline fosamil for injection, drug-induced hemolytic anemia should be considered. Diagnostic studies including a direct Coombs’ test, should be performed. If drug-induced hemolytic anemia is suspected, discontinuation of ceftaroline fosamil for injection should be considered and supportive care should be administered to the patient (i.e. transfusion) if clinically indicated.

5.5 Development of Drug-Resistant Bacteria Prescribing ceftaroline fosamil for injection in the absence of a proven or strongly suspected bacterial infection or a prophylactic indication is unlikely to provide benefit to the patient and increases the risk of the development of drug-resistant bacteria.