Indications for use
For the treatment of the following infections caused by ß lactamase producing strains of bacteria sensitive to amoxicillin in combination with clavulanic acid and where clinical experience and/or sensitivity testing indicates the product as the drug of choice:
-Skin infections (including superficial and deep pyodermas) associated with Staphylococcus spp.
-Urinary tract infections associated with Staphylococcus spp, Streptococcus spp, Escherichia coli and Proteus mirabilis.
-Respiratory tract infections associated with Staphylococcus spp, Streptococcus spp and Pasteurella spp.
-Digestive tract infections associated with Escherichia coli.
-Infections of the oral cavity (mucous membrane) associated with Pasteurella spp, Streptococcus spp, Escherichia coli.
Do not use in animals with known hypersensitivity to penicillins or other susbstances of the ß-lactam group or to any excipients.
Do not use in animals with serious dysfunction of the kidneys accompanied by anuria and oliguria.
Do not administer to gerbils, guinea pigs, hamsters, rabbits and chinchillas. Do not use in horses and ruminating animals.
Do not use where resistance to this combination is known to occur.
Special warnings for each target species
Special precautions for use
Official, national and regional antimicrobial policies with respect to the use of broad-spectrum antibiotics should be taken into account.
Do not use in case of bacteria sensitive to narrow spectrum penicillins or to amoxicillin as single substance.
It is advised that upon initiating therapy appropriate sensitivity testing is performed and that therapy is continued only after susceptibility to the combination has been established.
Use of the product deviating from the instructions given in the SPC may increase the prevalence of bacteria resistant to the amoxicillin/clavulanate, and may decrease the effectiveness of treatment with beta-lactam antibiotics
In animals with hepatic and renal dysfunction, the dosing regimen should be carefully evaluated and the use of the product based on a risk/benefit evaluation by the veterinary surgeon.
Caution is advised in the use in small herbivores.
The potential for allergic cross-reactions with other penicillin derivates and cephalosporins should be considered
Mild gastrointestinal signs (diarrhoea, and vomiting) may occur after administration of the product. Treatment may be discontinued depending on the severity of the undesirable effects and a benefit/risk evaluation by the veterinary surgeon.
Allergic reactions (skin reactions, anaphylaxis) may occasionally occur. In these cases, administration should be discontinued and a symptomatic treatment given.
Use during pregnancy or lactation
Laboratory studies in rats and mice have not produced any evidence of teratogenic, foetotoxic or maternotoxic effects.
In pregnant and lactating animals, use only according to the benefit/risk assessment by the responsible veterinarian.
Chloramphenicol, macrolides, sulfonamides and tetracyclines may inhibit the antibacterial effect of penicillins because of the rapid onset of bacteriostatic action.
Penicillins may increase the effect of aminoglycosides.
Amounts to be administered and administration route
The recommended dose of the product is 10 mg amoxicillin /2.5 mg clavulanic acid per kg body weight twice a day by the oral route in dogs and cats, i.e. 1 tablet of Kesium 250 mg per 20 kg body weight, or 1 tablet of Kesium 500 mg per 40 kg body weight every 12 h. In refractory cases the dose may be doubled to 20 mg of amoxicillin / 5 mg clavulanic acid/kg bodyweight twice daily, at the clinician's discretion.
The chewable tablets are flavoured and are accepted by a majority of dogs. The chewable tablets can be administered directly into the mouth of the animals or added to a small quantity of food.
Duration of therapy: The majority of routine cases respond to 5 – 7 days of therapy. In chronic cases, a longer case of therapy is recommended. In such circumstances overall treatment length must be at the clinician's discretion, but should be long enough to ensure complete resolution of the bacterial disease.
To ensure the correct dosage, body weight should be determined as accurately as possible to avoid under-dosing.
In case of overdose diarrhoea, allergic reactions or further symptoms like central nervous excitation manifestations or cramps could appear. Symptomatic treatment should be initiated when necessary.
Amoxicillin is a beta-lactam antibiotic and its structure contains the beta-lactam ring and thiazolidine ring common to all penicillins. Amoxicillin shows activity against susceptible Gram-positive bacteria and Gram-negative bacteria.
Beta-lactam antibiotics prevent the bacterial cell wall from forming by interfering with the final stage of peptidoglycan synthesis. They inhibit the activity of transpeptidase enzymes, which catalyse cross-linkage of the glycopeptide polymer units that form the cell wall. They exert a bactericidal action but cause lysis of growing cells only.
Clavulanic acid is one of the naturally occurring metabolites of the streptomycete Streptomyces clavuligerus. It has a structural similarity to the penicillin nucleus, including possession of a beta-lactam ring. Clavulanic acid is a beta-lactamase inhibitor acting initially competitively but ultimately irreversibly. Clavulanic acid will penetrate the bacterial cell wall binding to both extracellular and intracellular beta-lactamases.
Amoxicillin is susceptible to breakdown by *-lactamase and therefore combination with an effective ß-lactamase inhibitor (clavulanic acid) extends the range of bacteria against which it is active to include *-lactamase producing species.
In vitro potentiated amoxicillin is active against a wide range of clinically important aerobic and anaerobic bacteria including:
Staphylococcus spp. (including b-lactamase producing strains)
Escherichia coli (including most b-lactamase producing strains)
Resistance is shown among Enterobacter spp, Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus.
Dogs diagnosed with Pseudomonas infections should not be treated with this antibiotic combination.
A trend in resistance of E. coli is reported.
After oral administration in dogs and cats, amoxicillin and clavulanic acid are rapidly absorbed. Amoxicillin (pKa 2.8) has a relatively small apparent distribution volume, a low plasma protein binding (34% in dogs) and a short terminal half-life due to active tubular excretion via the kidneys. Following absorption the highest concentrations are found in the kidneys (urine) and the bile and then in liver, lungs, heart and spleen. The distribution of amoxicillin to the cerebrospinal fluid is low unless the meninges are inflamed.
Clavulanic acid (pKa 2.7) is also well-absorbed following oral administration. The penetration to the cerebrospinal fluid is poor. The plasma protein binding is approximately 25% and the elimination half-life is short. Clavulanic acid is mainly eliminated by renal excretion (unchanged in urine).
After single oral administration of 13 mg/kg amoxicillin and 3.15 mg/kg clavulanic acid in cats:
-The maximal plasma concentration (Cmax) of amoxicillin (9.3 µg/mL) was observed 2 hours following administration.
-The maximal plasma concentration (Cmax) of clavulanic acid (4.1 µg/mL) was observed 50 minutes following administration
After single oral administration of 17 mg/kg amoxicillin and 4.3 mg/kg clavulanic acid in dogs:
-The maximal plasma concentration (Cmax) of amoxicillin (8.6 µg/mL) was observed 1.5 hour following administration.
-The maximal plasma concentration (Cmax) of clavulanic acid (4.9 µg/mL) was observed 54 minutes following administration.