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BACTROBAN nasal ointment is indicated for the eradication of nasal colonization with methicillin‑resistant Staphylococcus aureus (MRSA) in adult and pediatric patients (aged 12 years and older) and healthcare workers as part of a comprehensive infection control program to reduce the risk of infection among patients at high risk of MRSA infection during institutional outbreaks of infections with this microorganism.
BACTROBAN nasal ointment is a white to off-white ointment that contains 2.15% w/w mupirocin calcium (equivalent to 2% mupirocin free acid) in a soft white ointment base supplied in single-use 1‑gram tubes.
BACTROBAN nasal ointment is contraindicated in patients with known hypersensitivity to mupirocin or any of the excipients of BACTROBAN nasal ointment.
Systemic allergic reactions, including anaphylaxis, urticaria, angioedema, and generalized rash have been reported in patients treated with formulations of BACTROBAN, including BACTROBAN nasal ointment [see Adverse Reactions (6.2)].
Avoid contact with the eyes. In case of accidental contact, rinse well with water. Application of BACTROBAN nasal ointment to the eye under testing conditions has caused severe symptoms such as burning and tearing. These symptoms resolved within days to weeks after discontinuation of the ointment.
In the event of a sensitization or severe local irritation from BACTROBAN nasal ointment, usage should be discontinued.
Clostridium difficile-associated diarrhea (CDAD) has been reported with use of nearly all antibacterial agents, and may range in severity from mild diarrhea to fatal colitis. Treatment with antibacterial agents alters the normal flora of the colon leading to 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 antibacterial drug use. Careful medical history is necessary since CDAD has been reported to occur over 2 months after the administration of antibacterial agents.
If CDAD is suspected or confirmed, ongoing antibacterial drug use not directed against C. difficile may need to be discontinued. Appropriate fluid and electrolyte management, protein supplementation, antibacterial treatment of C. difficile, and surgical evaluation should be instituted as clinically indicated.
As with other antibacterial products, prolonged use of BACTROBAN nasal ointment may result in overgrowth of nonsusceptible microorganisms, including fungi [see Dosage and Administration (2)].
The following adverse reactions are discussed in more detail in other sections of the labeling:
Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared with rates in the clinical trials of another drug and may not reflect the rates observed in practice.
In clinical trials, 210 domestic (US) and 2,130 foreign adult subjects received BACTROBAN nasal ointment. Less than 1% of domestic or foreign subjects in clinical trials were withdrawn due to adverse reactions.
The most frequently reported adverse reactions in foreign clinical trials were rhinitis (1%), taste perversion (0.8%), and pharyngitis (0.5%).
In domestic clinical trials, 17% (36 of 210) of adults treated with BACTROBAN nasal ointment reported adverse reactions. Table 1 shows the incidence of adverse reactions that were reported in at least 1% of adults enrolled in clinical trials conducted in the US.
Table 1. Adverse Reactions (≥1% Incidence) – Adults in US Trials
The following adverse reactions were reported in less than 1% of adults enrolled in domestic clinical trials: blepharitis, diarrhea, dry mouth, ear pain, epistaxis, nausea, and rash.
In addition to adverse reactions reported from clinical trials, the following reactions have been identified during postmarketing use of BACTROBAN nasal ointment. Because they are reported voluntarily from a population of unknown size, estimates of frequency cannot be made. These reactions have been chosen for inclusion due to a combination of their seriousness, frequency of reporting, or potential causal relationship to BACTROBAN nasal ointment.
Immune System Disorders
Systemic allergic reactions, including anaphylaxis, urticaria, angioedema, and generalized rash [see Warnings and Precautions (5.1)].
There are insufficient human data to establish whether there is a drug-associated risk with BACTROBAN nasal ointment in pregnant women. Mupirocin absorption was negligible following repeated intranasal administration of BACTROBAN nasal ointment [see Clinical Pharmacology 12.3)], but the dose regimen used in this study did not mimic recommended clinical use. No developmental toxicity was observed in rats or rabbits treated with mupirocin subcutaneously during organogenesis at doses of 160 or 40 mg per kg per day, respectively (65 and 32 times the human intranasal dose based on calculations of dose divided by the entire body surface area).
The estimated background risk of major birth defects and miscarriages for the indicated population is unknown. The estimated background risk in the U.S. general population of major birth defects is 2% to 4% and of miscarriage is 15% to 20% of clinically recognized pregnancies.
Animal Data: Developmental toxicity studies have been performed with mupirocin administered subcutaneously to rats and rabbits at doses up to 160 mg per kg per day during organogenesis. This dose is 65 and 130 times, respectively, the human intranasal dose (approximately 20 mg mupirocin per day) based on calculations of dose divided by the entire body surface area. Maternal toxicity was observed (body weight loss/decreased body weight gain and reduced feeding) in both species with no evidence of developmental toxicity in rats. In rabbits, excessive maternal toxicity at the high dose precluded the evaluation of fetal outcomes. There was no developmental toxicity in rabbits at 40 mg per kg per day, 32 times the human intranasal dose based on calculations of dose divided by the entire body surface area.
Mupirocin administered subcutaneously to rats in a pre- and postnatal development study (dosed during late gestation through lactation) was associated with reduced offspring viability in the early postnatal period at a dose of 106.7 mg per kg, in the presence of injection site irritation and/or subcutaneous hemorrhaging. This dose is 37 times the human intranasal dose based on calculations of dose divided by the entire body surface area. The no-observed adverse effect level in this study was 44.2 mg per kg per day, which is 18 times the human intranasal dose.
It is not known whether mupirocin is present in human milk, has effects on the breastfed child, or has effects on milk production. However, breastfeeding is not expected to result in exposure of the child to the drug due to the negligible systemic absorption of mupirocin in humans following intranasal administration of BACTROBAN nasal ointment [see Clinical Pharmacology (12.3)].The developmental and health benefits of breastfeeding should be considered along with the mother’s clinical need for BACTROBAN nasal ointment and any potential adverse effects on the breastfed child from BACTROBAN nasal ointment or from the underlying maternal condition.
The safety and effectiveness of BACTROBAN nasal ointment in children younger than 12 years have not been established [see Clinical Pharmacology (12.3)].
Pharmacokinetic data in neonates and premature infants indicate that, unlike in adults, significant systemic absorption occurred following intranasal administration of BACTROBAN nasal ointment in this population.
BACTROBAN (mupirocin calcium) nasal ointment, 2% contains the dihydrate crystalline calcium hemi‑salt of the RNA synthetase inhibitor antibacterial, mupirocin. Chemically, it is (αE,2S,3R,4R,5S)-5-[(2S,3S,4S,5S)-2,3-epoxy-5-hydroxy-4-methylhexyl]tetrahydro-3,4-dihydroxy-β-methyl-2H-pyran-2-crotonic acid, ester with 9-hydroxynonanoic acid, calcium salt (2:1), dihydrate.
The molecular formula of mupirocin calcium is (CHO)Ca•2HO, and the molecular weight is 1075.3. The molecular weight of mupirocin free acid is 500.6. The structural formula of mupirocin calcium is:
Figure 1. Structure of Mupirocin Calcium
BACTROBAN nasal ointment is a white to off‑white ointment that contains 2.15% w/w mupirocin calcium (equivalent to 2% mupirocin free acid) in a soft white ointment base. The inactive ingredients are paraffin and a mixture of glycerin esters (SOFTISAN 649).
Mupirocin is an RNA synthetase inhibitor antibacterial [see Microbiology (12.4)].
Following single or repeated intranasal applications of 0.2 grams of BACTROBAN nasal ointment 3 times daily for 3 days to 5 healthy adult male subjects, no evidence of systemic absorption of mupirocin was demonstrated. The dosage regimen used in this trial was for pharmacokinetic characterization only; see Dosage and Administration (2) for proper clinical dosing information.
In this trial, the concentrations of mupirocin in urine and of monic acid in urine and serum were below the limit of determination of the assay for up to 72 hours after the applications. The lowest levels of determination of the assay used were 50 ng per mL of mupirocin in urine, 75 ng per mL of monic acid in urine, and 10 ng per mL of monic acid in serum. Based on the detectable limit of the urine assay for monic acid, one can extrapolate that a mean of 3.3% (range: 1.2% to 5.1%) of the applied dose could be systemically absorbed from the nasal mucosa of adults.
The effect of concurrent application of BACTROBAN nasal ointment with other intranasal products has not been studied [see Dosage and Administration (2)].
In a trial conducted in 7 healthy adult male subjects, the elimination half‑life after intravenous administration of mupirocin was 20 to 40 minutes for mupirocin and 30 to 80 minutes for monic acid.
Metabolism: Following intravenous or oral administration, mupirocin is rapidly metabolized. The principal metabolite, monic acid, demonstrates no antibacterial activity.
Excretion: Monic acid is predominantly eliminated by renal excretion.
Pediatric Patients: The pharmacokinetic properties of mupirocin following intranasal application of BACTROBAN nasal ointment have not been adequately characterized in neonates or other children younger than 12 years, and in addition, the safety and efficacy of the product in children younger than 12 years have not been established.
Mupirocin is an RNA synthetase inhibitor antibacterial produced by fermentation using the organism Pseudomonas fluorescens.
Mechanism of Action
Mupirocin inhibits bacterial protein synthesis by reversibly and specifically binding to bacterial isoleucyl‑transfer RNA (tRNA) synthetase.
Mupirocin is bactericidal at concentrations achieved topically by intranasal administration. Mupirocin is highly protein bound (greater than 97%) and the effect of nasal secretions on the minimum inhibitory concentrations (MICs) of intranasally applied mupirocin has not been determined.
When mupirocin resistance occurs, it results from the production of a modified isoleucyl‑tRNA synthetase, or the acquisition of, by genetic transfer, a plasmid mediating a new isoleucyl-tRNA synthetase. High‑level plasmid‑mediated resistance (MIC ≥512 mcg/mL) has been reported in increasing numbers of isolates of S. aureus and with higher frequency in coagulase‑negative staphylococci. Mupirocin resistance occurs with greater frequency in methicillin‑resistant than methicillin‑susceptible staphylococci.
Due to its mode of action, mupirocin does not demonstrate cross resistance with other classes of antimicrobial agents.
BACTROBAN nasal ointment has been shown to be active against most isolates of MRSA, both in vitro and in clinical trials [see Indications and Usage (1)].
Susceptibility Test Methods
High-level mupirocin resistance (≥512 mcg/mL) may be determined using standard disk diffusion or broth microdilution tests. The significance of these results, with regard to decolonization regimens, should be evaluated at each medical facility, in conjunction with laboratory, medical, and infection control staff.
Long‑term studies in animals to evaluate carcinogenic potential of mupirocin have not been conducted.
Results of the following studies performed with mupirocin calcium or mupirocin sodium in vitro and in vivo did not indicate a potential for genotoxicity: rat primary hepatocyte unscheduled DNA synthesis, sediment analysis for DNA strand breaks, Salmonella reversion test (Ames), Escherichia coli mutation assay, metaphase analysis of human lymphocytes, mouse lymphoma assay, and bone marrow micronuclei assay in mice.
In a fertility/reproductive performance study (with dosing through lactation), mupirocin administered subcutaneously to male and female rats at doses up to 100 mg per kg per day, which is 41 times the human intranasal dose (approximately 20 mg mupirocin per day) based on calculations of dose divided by the entire body surface area, did not result in impaired fertility or impaired reproductive performance attributable to mupirocin.
All adequate and well-controlled trials of this product were vehicle-controlled; therefore, no data from direct, head-to-head comparisons with other products are available. The safety and effectiveness of applications of this medication for greater than 5 days have not been established. There are no human clinical or pre-clinical animal data to support the use of this product in a chronic manner or in manners other than those described in this prescribing information.
In clinical trials, 210 domestic (US) and 2,130 foreign adult subjects received BACTROBAN nasal ointment. Greater than 90% of subjects in clinical trials had eradication of nasal colonization 2 to 4 days after therapy was completed. Approximately 30% recolonization was reported in 1 domestic trial within 4 weeks after completion of therapy. These eradication rates were clinically and statistically superior to those reported in subjects in the vehicle-treated arms of the adequate and well-controlled trials. Those treated with vehicle had eradication rates of 5% to 30% at 2 to 4 days post-therapy with 85% to 100% recolonization within 4 weeks.
BACTROBAN nasal ointment is a white to off-white ointment that contains mupirocin calcium (equivalent to 2% mupirocin free acid).
BACTROBAN nasal ointment, 2% is supplied in single-use 1‑gram tubes.
NDC 0029-1526-03 Single-use 1‑gram tube in Package of 10: NDC 0029-1526-11.
Store between 20°C and 25°C (68°F and 77°F); excursions permitted to 15°C to 30°C (59°F to 86°F). Do not refrigerate.
Advise the patient to read the FDA-approved patient labeling (Patient Information).
Advise the patient to administer BACTROBAN nasal ointment as follows:
BACTROBAN is a registered trademark of the GSK group of companies.
SOFTISAN is a trademark of its respective owner and is not a trademark of the GSK group of companies. The maker of this brand is not affiliated with and does not endorse the GSK group of companies or its products.
Research Triangle Park, NC 27709
©2017 the GSK group of companies. All rights reserved.
PHARMACIST‑DETACH HERE AND GIVE INSTRUCTIONS TO PATIENT
PRINCIPAL DISPLAY PANEL
BACTROBAN (mupirocin calcium)
Nasal Ointment, 2%
10 x 1.0 gram Single-Use Tubes
This shrink-wrapped unit represents one 5-day course of therapy.
Store at 20- 25C (68 – 77F); excursions permitted 15 - 30C (59 – 86F).. Do not refrigerate.
Do not use if seal on tube nozzle is broken.
Usual Dosage: For intranasal use only. Apply one-half the contents of a tube in one nostril. Apply other half of tube contents in other nostril. See accompanying prescribing information.
Research Triangle Park, NC 27709
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