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  • CLASSES

    Ophthalmological Anti-infectives
    Other Antibiotics
    Topical Polypeptide Anti-infectives, Plain or in Combination

    BOXED WARNING

    Nephrotoxicity, oliguria, renal failure, renal impairment

    Intramuscular bacitracin is associated with a high incidence of bacitracin-induced nephrotoxicity. Renal failure may occur due to glomerular and tubular necrosis. Bacitracin nephrotoxicity is related to the daily dose and duration of therapy. Intramuscular bacitracin should be used with caution, if at all, in patients with preexisting renal impairment or renal failure and systemic bacitracin use should be restricted to severe infections due to susceptible organisms. It should also be used only where adequate laboratory facilities are available and when constant supervision of the patient is possible. Patients receiving IM bacitracin should undergo microscopic urinalysis regularly and renal function determination both before and during therapy. Patients receiving IM bacitracin should have an adequate intake of fluids, and a urinary pH of 6 should be maintained, by giving sodium bicarbonate or other alkali, to decrease irritation. Patients who develop oliguria while maintaining normal fluid intake, or who experience progressive azotemia during IM bacitracin therapy should discontinue treatment. Avoid using other nephrotoxic drugs, particularly kanamycin, neomycin, polymyxin B, polymyxin E (colistin), and streptomycin.

    DEA CLASS

    OTC, Rx

    DESCRIPTION

    Polypeptide antibiotic; used against gram-positive bacteria usually topically with neomycin and polymyxins to prevent superficial skin and eye infections; oral bacitracin is an orphan drug for pseudomembranous colitis; IV administration should be avoided due to serious nephrotoxicity.

    COMMON BRAND NAMES

    AK-Tracin, BaciiM, Ocu-Tracin

    HOW SUPPLIED

    AK-Tracin/Bacitracin/Ocu-Tracin Ophthalmic Ointment: 1g, 500U
    BaciiM/Bacitracin Intramuscular Inj Pwd F/Sol: 50000U
    Bacitracin/Bacitracin Zinc Topical Ointment: 1g, 500U

    DOSAGE & INDICATIONS

    For the prevention of skin and skin structure infections after a minor compromise in skin integrity such as minor burns or skin abrasion.
    Topical dosage
    Adults, Adolescents, and Children

    Apply a thin film 2 to 3 times per day, not to exceed 5 times per day depending upon the severity of the infection. Topical administration should be used for no longer than 7 days unless directed by the patient's prescriber or health care provider.

    For superficial ophthalmic infection of the conjunctiva and/or cornea caused by susceptible organisms, including the following infections - blepharitis, blepharoconjunctivitis, bacterial conjunctivitis, keratitis, and keratoconjunctivitis.
    Ophthalmic dosage (ophthalmic ointment)
    Adults, Adolescents, and Children

    Apply a thin film to the conjunctiva of the affected eye(s) every 3 to 4 hours for 7 to 10 days.

    For the treatment of pneumonia or pleural empyema caused by susceptible Staphylococci.
    Due to the potential for nephrotoxicity, restrict bacitracin intramuscular therapy to infants with susceptible staphylococcal pneumonia infections and pleural empyema. Intramuscular bacitracin should only be used where adequate laboratory facilities are available and when constant supervision of the patient is possible.
    Intramuscular dosage
    Infants weighing more than 2.5 kg

    1,000 units/kg/day IM divided every 8 to 12 hours.[31047]

    Infants weighing 2.5 kg or less

    900 units/kg/day IM divided every 8 to 12 hours.

    For the treatment and eradication of enteric vancomycin-resistant enterococci (VRE)† in the stool.
    Oral dosage
    Adults

    Oral bacitracin has been reported to be effective for the treatment and eradication of vancomycin-resistant Enterococcus (VRE) in the stool. In a prospective observational study of patients on a renal ward, treatment with oral bacitracin 75,000 units/15 mL PO 4 times daily plus doxycycline (100 mg PO once daily) was NOT efficacious in reducing the carriage of VRE beyond the 2-week treatment period. Although, during the treatment period, the combination did reduce the quantitative enterococcal counts in the stool approximately 3 log/kg, but this decrease did not continue.

    †Indicates off-label use

    MAXIMUM DOSAGE

    Adults

    IM not recommended; however, 100,000 units/day IM (not to exceed 25,000 units/dose IM) has been used for the treatment of pneumonia.

    Geriatric

    IM not recommended; however, 100,000 units/day IM (not to exceed 25,000 units/dose IM) has been used for the treatment of pneumonia.

    Adolescents

    IM not recommended; specific dosing for adolescents not available(use Children dosing - 1200 units/kg/day IM has been used for the treatment of pneumonia.)

    Children

    IM not recommended; however, 1200 units/kg/day IM has been used for the treatment of pneumonia.

    Infants

    > 2.5 kg: 1000 units/kg/day IM.
    <= 2.5 kg: 900 units/kg/day IM.

    DOSING CONSIDERATIONS

    Hepatic Impairment

    No dosage adjustment needed; however, if used systemically, be alert for effects on renal function, which may precipitate hepato-renal failure.

    Renal Impairment

    Due to the severe nephrotoxicity of bacitracin, systemic use is not recommended in patients with renal impairment or failure. Should nephrotoxicity occur during bacitracin treatment, therapy should be discontinued.

    ADMINISTRATION

    NOTE: One unit bacitracin is equivalent to 0.026 mg bacitracin.

    Injectable Administration

    Visually inspect parenteral products for particulate matter and discoloration prior to administration whenever solution and container permit.

    Intramuscular Administration

    For intramuscular injection only; do not give intravenously.
    Patients should be well-hydrated during IM bacitracin therapy, and their urine should be kept at a pH >= 6 by administering sodium bicarbonate or other urinary alkalinizer to decrease renal toxicity. Urine output should be maintained.
     
    Reconstitution:
    Do not use diluents containing parabens since precipitation of bacitracin may result.
    Reconstitute 50,000 units with 9.8 mL of 2% procaine HCl to give a concentration of 5000 units/mL.
    Alternatively, reconstitute 50,000 units with 50 mL of 0.9% Sodium Chloride injection to give a solution containing bacitracin 1000 units/mL; further dilute this solution with 50 mL of 2% procaine HCl injection to give a solution containing 500 units/mL.
    The reconstituted solution is stable for 1 week under refrigeration (2 to 15 degrees C).
     
    Intramuscular injection:
    Inject deeply into upper outer quadrant of the gluteus maximus, alternating left and right. Aspirate prior to injection to avoid injection into a blood vessel.
    Avoid multiple injections in the same region because of pain associated with the injections.

    Topical Administration

    Cleanse affected area before topical application.

    Cream/Ointment/Lotion Formulations

    Available as a topical non-prescription ointment.
    Apply topically to affected area. Treated area may be covered with sterile gauze dressing if desired.

    Extemporaneous Compounding-Topical

    A topical irrigation solution may be compounded by dissolving appropriate amount of bacitracin injection or bacitracin compounding powder in 0.9% Sodium Chloride injection or sterile water for injection for a final concentration of 250 to 1000 units/mL. These solutions degrade rapidly if kept at room temperature. Store refrigerated at 2 to 8 degrees C for no longer than 1 week to maintain potency. Do not freeze.

    Ophthalmic Administration

    For topical ophthalmic administration only.
    Instruct patient on proper instillation of eye ointment (see Patient Information).
    Patients should not wear contact lenses if they have an ocular infection.
    Do not to touch the tip of the applicator to the eye, eyelid, fingertips, or other surface.
    Apply directly into the conjunctival sac. In blepharitis all scales and crusts should be carefully removed and the ointment then spread uniformly over the lid margins.
    Keep tightly closed when not in use.
    To avoid risk of infection, use one open tube per individual patient.

    STORAGE

    Generic:
    - Store between 59 to 77 degrees F
    AK-Tracin:
    - Store at controlled room temperature (between 68 and 77 degrees F)
    BaciiM:
    - Discard product if it contains particulate matter, is cloudy, or discolored
    - Discard reconstituted product if not used within 7 days
    - Store reconstituted product in refrigerator (36 to 46 degrees F)
    - Store unreconstituted product in refrigerator (36 to 46 degrees F)
    Baci-Rx:
    - Protect from moisture
    - Store between 68 to 77 degrees F, excursions permitted 59 to 86 degrees F
    Ocu-Tracin :
    - Store at controlled room temperature (between 68 and 77 degrees F)

    CONTRAINDICATIONS / PRECAUTIONS

    General Information

    Prescribing bacitracin 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.
     
    Topical applications of bacitracin should not be used over large areas of the body; nonprescription use is recommended for minor abrasions, burns and wounds only. Topical bacitracin should not be used for serious burns, deep wounds, puncture wounds, or animal bites without consulting a physician.

    Neomycin hypersensitivity

    Bacitracin should not be used in patients who have known hypersensitivity reactions to bacitracin. Patients with neomycin hypersensitivity may also be sensitive to bacitracin.

    Colitis, diarrhea, GI disease, inflammatory bowel disease, pseudomembranous colitis, ulcerative colitis

    Almost all antibacterial agents have been associated with pseudomembranous colitis (antibiotic-associated colitis) which may range in severity from mild to life-threatening. In the colon, overgrowth of Clostridia may exist when normal flora is altered subsequent to antibacterial administration. The toxin produced by Clostridium difficile is a primary cause of pseudomembranous colitis. It is known that systemic use of antibiotics predisposes patients to development of pseudomembranous colitis. Consideration should be given to the diagnosis of pseudomembranous colitis in patients presenting with diarrhea following antibacterial administration. Systemic antibiotics should be prescribed with caution to patients with inflammatory bowel disease such as ulcerative colitis or other GI disease. If diarrhea develops during therapy, the drug should be discontinued. Following diagnosis of pseudomembranous colitis, therapeutic measures should be instituted. In milder cases, the colitis may respond to discontinuation of the offending agent. In moderate to severe cases, fluids and electrolytes, protein supplementation, and treatment with an antibacterial effective against Clostridium difficile may be warranted. Products inhibiting peristalsis are contraindicated in this clinical situation. Practitioners should be aware that antibiotic-associated colitis has been observed to occur over two months or more following discontinuation of systemic antibiotic therapy; a careful medical history should be taken.

    Nephrotoxicity, oliguria, renal failure, renal impairment

    Intramuscular bacitracin is associated with a high incidence of bacitracin-induced nephrotoxicity. Renal failure may occur due to glomerular and tubular necrosis. Bacitracin nephrotoxicity is related to the daily dose and duration of therapy. Intramuscular bacitracin should be used with caution, if at all, in patients with preexisting renal impairment or renal failure and systemic bacitracin use should be restricted to severe infections due to susceptible organisms. It should also be used only where adequate laboratory facilities are available and when constant supervision of the patient is possible. Patients receiving IM bacitracin should undergo microscopic urinalysis regularly and renal function determination both before and during therapy. Patients receiving IM bacitracin should have an adequate intake of fluids, and a urinary pH of 6 should be maintained, by giving sodium bicarbonate or other alkali, to decrease irritation. Patients who develop oliguria while maintaining normal fluid intake, or who experience progressive azotemia during IM bacitracin therapy should discontinue treatment. Avoid using other nephrotoxic drugs, particularly kanamycin, neomycin, polymyxin B, polymyxin E (colistin), and streptomycin.

    Pregnancy

    Bacitracin is classified in FDA pregnancy risk category C. Adequate studies regarding the risks of systemic therapy during pregnancy have not been conducted; the drug has the potential for nephrotoxicity when administered. IM bacitracin should be used during pregnancy only when clearly needed.

    Breast-feeding

    It is unknown whether systemically administered bacitracin is distributed into breast milk. Intramuscular bacitracin  is only approved for use in the infant population; therefore, it is not expected to be used during breast-feeding. Topical and ophthalmic use would result in minimal absorption; to minimize the amount of drug that reaches the systemic circulation and breast milk, apply pressure over the tear duct by the corner of the eye for 1 minute after ophthalmic administration. Oral ingestion by the nursing infant would also result in minimal absorption. Only water-miscible cream or gel products should be applied to the breast because ointments may expose the infant to high levels of mineral paraffins. Consider the benefits of breast-feeding, the risk of potential infant drug exposure, and the risk of an untreated or inadequately treated condition. If a breast-feeding infant experiences an adverse effect related to a maternally administered drug, healthcare providers are encouraged to report the adverse effect to the FDA.
     

    Myasthenia gravis, neuromuscular disease, pulmonary disease, surgery

    Bacitracin treatment can cause respiratory paralysis as a result of neuromuscular blockade, and concurrent administration with neuromuscular blockers during surgery should be avoided. Patients with pulmonary disease, myasthenia gravis, or other neuromuscular disease are at risk for increased side effects during systemic bacitracin therapy. If signs of respiratory insufficiency or nephrotoxicity occur, the drug should be discontinued.

    Ocular exposure

    Bacitracin topical ointment for external use on the skin only and is not for use in eyes or ears; avoid ocular exposure of the topical ointment.

    Fungal infection

    Prescribing bacitracin 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. Secondary infection, especially fungal infection, may occur with prolonged use of bacitracin products. It is recommended that the topical ointment not be used for longer than 7 days and the ophthalmic preparations should not be used for longer than 10 days to avoid development of secondary infections.

    Contact lenses

    Patients who wear contact lenses should avoid wearing them while being treated with bacitracin ophthalmic products for an ocular infection.

    Children, infants

    Due to the risks of nephrotoxicity, use bacitracin IM with caution in infants and children. Per the manufacturer, use of IM bacitracin should be restricted to infants with staphylococcal pneumonia and empyema when due to organisms shown to be susceptible to bacitracin. It should be used only where adequate laboratory facilities are available and when constant supervision of the patient is possible.

    ADVERSE REACTIONS

    Severe

    renal tubular necrosis / Delayed / Incidence not known
    oliguria / Early / Incidence not known
    renal failure (unspecified) / Delayed / Incidence not known
    proteinuria / Delayed / Incidence not known
    azotemia / Delayed / Incidence not known
    anaphylactoid reactions / Rapid / Incidence not known
    anaphylactic shock / Rapid / Incidence not known
    respiratory arrest / Rapid / Incidence not known

    Moderate

    hematuria / Delayed / Incidence not known
    eosinophilia / Delayed / Incidence not known
    myasthenia / Delayed / Incidence not known
    respiratory depression / Rapid / Incidence not known
    superinfection / Delayed / Incidence not known
    blurred vision / Early / Incidence not known

    Mild

    cylindruria / Delayed / Incidence not known
    fever / Early / Incidence not known
    urticaria / Rapid / Incidence not known
    pruritus / Rapid / Incidence not known
    vomiting / Early / Incidence not known
    rash (unspecified) / Early / Incidence not known
    injection site reaction / Rapid / Incidence not known
    nausea / Early / Incidence not known

    DRUG INTERACTIONS

    Acetaminophen; Aspirin, ASA; Caffeine: (Minor) Additive nephrotoxicity may occur with concurrent use of systemic bacitracin and other nephrotoxic agents, including salicylates. Topical administration of any preparation containing bacitracin, especially when applied to large surface areas, also should not be given with other drugs that have a nephrotoxic potential.
    Acetaminophen; Caffeine; Magnesium Salicylate; Phenyltoloxamine: (Minor) Additive nephrotoxicity may occur with concurrent use of systemic bacitracin and other nephrotoxic agents, including salicylates. Topical administration of any preparation containing bacitracin, especially when applied to large surface areas, also should not be given with other drugs that have a nephrotoxic potential.
    Acetaminophen; Caffeine; Phenyltoloxamine; Salicylamide: (Minor) Additive nephrotoxicity may occur with concurrent use of systemic bacitracin and other nephrotoxic agents, including salicylates. Topical administration of any preparation containing bacitracin, especially when applied to large surface areas, also should not be given with other drugs that have a nephrotoxic potential.
    Amikacin: (Minor) Additive nephrotoxicity may occur with concurrent use of bacitracin and other nephrotoxic agents. When possible, avoid concomitant administration of systemic bacitracin and other nephrotoxic drugs such as aminoglycosides (particularly kanamycin, streptomycin, and neomycin).Use of topically administrated preparations containing bacitracin, especially when applied to large surface areas, with aminoglycosides may have additive nephrotoxic potential.
    Aminosalicylate sodium, Aminosalicylic acid: (Minor) Additive nephrotoxicity may occur with concurrent use of systemic bacitracin and other nephrotoxic agents, including salicylates. Topical administration of any preparation containing bacitracin, especially when applied to large surface areas, also should not be given with other drugs that have a nephrotoxic potential.
    Amphotericin B cholesteryl sulfate complex (ABCD): (Minor) Additive nephrotoxicity may occur with concurrent use of systemic bacitracin and other nephrotoxic agents, such as amphoteracin B; when possible, avoid concomitant administration. Topical administration of any preparation containing bacitracin, especially when applied to large surface areas, should not be given with other drugs that have a nephrotoxic potential.
    Amphotericin B lipid complex (ABLC): (Minor) Additive nephrotoxicity may occur with concurrent use of systemic bacitracin and other nephrotoxic agents, such as amphoteracin B; when possible, avoid concomitant administration. Topical administration of any preparation containing bacitracin, especially when applied to large surface areas, should not be given with other drugs that have a nephrotoxic potential.
    Amphotericin B liposomal (LAmB): (Minor) Additive nephrotoxicity may occur with concurrent use of systemic bacitracin and other nephrotoxic agents, such as amphoteracin B; when possible, avoid concomitant administration. Topical administration of any preparation containing bacitracin, especially when applied to large surface areas, should not be given with other drugs that have a nephrotoxic potential.
    Amphotericin B: (Minor) Additive nephrotoxicity may occur with concurrent use of systemic bacitracin and other nephrotoxic agents, such as amphoteracin B; when possible, avoid concomitant administration. Topical administration of any preparation containing bacitracin, especially when applied to large surface areas, should not be given with other drugs that have a nephrotoxic potential.
    Aspirin, ASA: (Minor) Additive nephrotoxicity may occur with concurrent use of systemic bacitracin and other nephrotoxic agents, including salicylates. Topical administration of any preparation containing bacitracin, especially when applied to large surface areas, also should not be given with other drugs that have a nephrotoxic potential.
    Aspirin, ASA; Butalbital; Caffeine: (Minor) Additive nephrotoxicity may occur with concurrent use of systemic bacitracin and other nephrotoxic agents, including salicylates. Topical administration of any preparation containing bacitracin, especially when applied to large surface areas, also should not be given with other drugs that have a nephrotoxic potential.
    Aspirin, ASA; Butalbital; Caffeine; Codeine: (Minor) Additive nephrotoxicity may occur with concurrent use of systemic bacitracin and other nephrotoxic agents, including salicylates. Topical administration of any preparation containing bacitracin, especially when applied to large surface areas, also should not be given with other drugs that have a nephrotoxic potential.
    Aspirin, ASA; Caffeine; Dihydrocodeine: (Minor) Additive nephrotoxicity may occur with concurrent use of systemic bacitracin and other nephrotoxic agents, including salicylates. Topical administration of any preparation containing bacitracin, especially when applied to large surface areas, also should not be given with other drugs that have a nephrotoxic potential.
    Aspirin, ASA; Carisoprodol: (Minor) Additive nephrotoxicity may occur with concurrent use of systemic bacitracin and other nephrotoxic agents, including salicylates. Topical administration of any preparation containing bacitracin, especially when applied to large surface areas, also should not be given with other drugs that have a nephrotoxic potential. (Minor) Use skeletal muscle relaxants cautiously in patients receiving systemic bacitracin. If bacitracin is administered parenterally during surgery, there may be increased skeletal muscle relaxation, and postoperative use may reinstate neuromuscular blockade.
    Aspirin, ASA; Carisoprodol; Codeine: (Minor) Additive nephrotoxicity may occur with concurrent use of systemic bacitracin and other nephrotoxic agents, including salicylates. Topical administration of any preparation containing bacitracin, especially when applied to large surface areas, also should not be given with other drugs that have a nephrotoxic potential. (Minor) Use skeletal muscle relaxants cautiously in patients receiving systemic bacitracin. If bacitracin is administered parenterally during surgery, there may be increased skeletal muscle relaxation, and postoperative use may reinstate neuromuscular blockade.
    Aspirin, ASA; Dipyridamole: (Minor) Additive nephrotoxicity may occur with concurrent use of systemic bacitracin and other nephrotoxic agents, including salicylates. Topical administration of any preparation containing bacitracin, especially when applied to large surface areas, also should not be given with other drugs that have a nephrotoxic potential.
    Aspirin, ASA; Omeprazole: (Minor) Additive nephrotoxicity may occur with concurrent use of systemic bacitracin and other nephrotoxic agents, including salicylates. Topical administration of any preparation containing bacitracin, especially when applied to large surface areas, also should not be given with other drugs that have a nephrotoxic potential.
    Aspirin, ASA; Oxycodone: (Minor) Additive nephrotoxicity may occur with concurrent use of systemic bacitracin and other nephrotoxic agents, including salicylates. Topical administration of any preparation containing bacitracin, especially when applied to large surface areas, also should not be given with other drugs that have a nephrotoxic potential.
    Aspirin, ASA; Pravastatin: (Minor) Additive nephrotoxicity may occur with concurrent use of systemic bacitracin and other nephrotoxic agents, including salicylates. Topical administration of any preparation containing bacitracin, especially when applied to large surface areas, also should not be given with other drugs that have a nephrotoxic potential.
    Atropine; Benzoic Acid; Hyoscyamine; Methenamine; Methylene Blue; Phenyl Salicylate: (Minor) Additive nephrotoxicity may occur with concurrent use of systemic bacitracin and other nephrotoxic agents, including salicylates. Topical administration of any preparation containing bacitracin, especially when applied to large surface areas, also should not be given with other drugs that have a nephrotoxic potential.
    Baclofen: (Minor) Use skeletal muscle relaxants cautiously in patients receiving systemic bacitracin. If bacitracin is administered parenterally during surgery, there may be increased skeletal muscle relaxation, and postoperative use may reinstate neuromuscular blockade.
    Benzoic Acid; Hyoscyamine; Methenamine; Methylene Blue; Phenyl Salicylate: (Minor) Additive nephrotoxicity may occur with concurrent use of systemic bacitracin and other nephrotoxic agents, including salicylates. Topical administration of any preparation containing bacitracin, especially when applied to large surface areas, also should not be given with other drugs that have a nephrotoxic potential.
    Bismuth Subsalicylate: (Minor) Additive nephrotoxicity may occur with concurrent use of systemic bacitracin and other nephrotoxic agents, including salicylates. Topical administration of any preparation containing bacitracin, especially when applied to large surface areas, also should not be given with other drugs that have a nephrotoxic potential.
    Bismuth Subsalicylate; Metronidazole; Tetracycline: (Minor) Additive nephrotoxicity may occur with concurrent use of systemic bacitracin and other nephrotoxic agents, including salicylates. Topical administration of any preparation containing bacitracin, especially when applied to large surface areas, also should not be given with other drugs that have a nephrotoxic potential.
    Bumetanide: (Minor) Additive nephrotoxicity may occur with concurrent use of systemic bacitracin and other nephrotoxic agents. When possible, avoid concomitant administration of systemic bacitracin and other nephrotoxic drugs such as loop diuretics. Topical administration of any preparation containing bacitracin, especially when applied to large surface areas, also should not be given with other drugs that have a nephrotoxic potential. (Minor) Additive nephrotoxicity may occur with concurrent use of these medicines. When possible, avoid concomitant administration of systemic bacitracin and loop diuretics. Use of topically administrated preparations containing bacitracin, especially when applied to large surface areas, may have additive nephrotoxic potential with loop diuretics.
    Capreomycin: (Major) Since capreomycin is eliminated by the kidney, coadministration with other potentially nephrotoxic drugs, including bacitracin, may increase serum concentrations of either drug. Theoretically, the chronic coadministration of these drugs may increase the risk of developing nephrotoxicity, even in patients who have normal renal function. Monitor patients for changes in renal function if these drugs are coadministered.
    Capsaicin; Metaxalone: (Minor) Use skeletal muscle relaxants cautiously in patients receiving systemic bacitracin. If bacitracin is administered parenterally during surgery, there may be increased skeletal muscle relaxation, and postoperative use may reinstate neuromuscular blockade.
    Carisoprodol: (Minor) Use skeletal muscle relaxants cautiously in patients receiving systemic bacitracin. If bacitracin is administered parenterally during surgery, there may be increased skeletal muscle relaxation, and postoperative use may reinstate neuromuscular blockade.
    Chlorzoxazone: (Minor) Use skeletal muscle relaxants cautiously in patients receiving systemic bacitracin. If bacitracin is administered parenterally during surgery, there may be increased skeletal muscle relaxation, and postoperative use may reinstate neuromuscular blockade.
    Choline Salicylate; Magnesium Salicylate: (Minor) Additive nephrotoxicity may occur with concurrent use of systemic bacitracin and other nephrotoxic agents, including salicylates. Topical administration of any preparation containing bacitracin, especially when applied to large surface areas, also should not be given with other drugs that have a nephrotoxic potential.
    Cidofovir: (Severe) The administration of cidofovir with another potentially nephrotoxic agent, such as bacitracin, is contraindicated. Bacitracin should be discontinued at least 7 days prior to beginning cidofovir.
    Cisplatin: (Minor) Additive nephrotoxicity may occur with concurrent use of systemic bacitracin and other nephrotoxic agents, such as cisplatin. When possible, avoid concomitant administration of systemic bacitracin and cisplatin. Use of topically administrated preparations containing bacitracin, especially when applied to large surface areas, may have additive nephrotoxic potential with cisplatin.
    Cobicistat; Elvitegravir; Emtricitabine; Tenofovir Disoproxil Fumarate: (Moderate) Tenofovir-containing products should be avoided with concurrent or recent use of a nephrotoxic agent, such as bacitracin. Tenofovir is primarily excreted via the kidneys by a combination of glomerular filtration and active tubular secretion. Coadministration of tenofovir with drugs that are eliminated by active tubular secretion may increase concentrations of tenofovir and/or the co-administered drug. Drugs that decrease renal function may also increase concentrations of tenofovir. Renal impairment, which may include hypophosphatemia, has been reported with the use of tenofovir with a majority of the cases occurring in patients who have underlying systemic or renal disease or who are concurrently taking nephrotoxic agents. Monitor patients receiving concomitant nephrotoxic agents for changes in serum creatinine and phosphorus.
    Colistimethate, Colistin, Polymyxin E: (Major) Coadministration of these drugs may increase the risk of developing nephrotoxicity, even in patients who have normal renal function. Monitor patients for changes in renal function if these drugs are coadministered. Since colistimethate sodium is eliminated by the kidney, coadministration with other potentially nephrotoxic drugs, including bacitracin, may increase serum concentrations of either drug.
    Cyclobenzaprine: (Minor) Use skeletal muscle relaxants cautiously in patients receiving systemic bacitracin. If bacitracin is administered parenterally during surgery, there may be increased skeletal muscle relaxation, and postoperative use may reinstate neuromuscular blockade.
    Cyclosporine: (Minor) Additive nephrotoxicity may occur with concurrent use of bacitracin and other nephrotoxic agents. When possible, avoid concomitant administration of systemic bacitracin and other nephrotoxic drugs such as cyclosporine. Use of topically administrated preparations containing bacitracin, especially when applied to large surface areas, may have additive nephrotoxic potential with cyclosporine.
    Dantrolene: (Minor) Use skeletal muscle relaxants cautiously in patients receiving systemic bacitracin. If bacitracin is administered parenterally during surgery, there may be increased skeletal muscle relaxation, and postoperative use may reinstate neuromuscular blockade.
    Diazepam: (Minor) Diazepam, which has skeletal muscle relaxant properties, should be used cautiously in patients receiving systemic bacitracin. If bacitracin is administered parenterally during surgery, there may be increased skeletal muscle relaxation, and postoperative use may reinstate neuromuscular blockade.
    Diflunisal: (Minor) Due to the inhibition of renal prostaglandins by diflunisal, concurrent use of diflunisal and other nephrotoxic agents, such as bacitracin, may lead to additive nephrotoxicity. Monitor renal function carefully during concurrent therapy.
    Diphenhydramine; Ibuprofen: (Minor) Due to the inhibition of renal prostaglandins by NSAIDs, concurrent use with other nephrotoxic agents like systemic bacitracin may lead to additive nephrotoxicity.
    Diphenhydramine; Naproxen: (Minor) Due to the inhibition of renal prostaglandins by NSAIDs, concurrent use with other nephrotoxic agents like systemic bacitracin may lead to additive nephrotoxicity.
    Efavirenz; Emtricitabine; Tenofovir: (Moderate) Tenofovir-containing products should be avoided with concurrent or recent use of a nephrotoxic agent, such as bacitracin. Tenofovir is primarily excreted via the kidneys by a combination of glomerular filtration and active tubular secretion. Coadministration of tenofovir with drugs that are eliminated by active tubular secretion may increase concentrations of tenofovir and/or the co-administered drug. Drugs that decrease renal function may also increase concentrations of tenofovir. Renal impairment, which may include hypophosphatemia, has been reported with the use of tenofovir with a majority of the cases occurring in patients who have underlying systemic or renal disease or who are concurrently taking nephrotoxic agents. Monitor patients receiving concomitant nephrotoxic agents for changes in serum creatinine and phosphorus.
    Emtricitabine; Rilpivirine; Tenofovir disoproxil fumarate: (Moderate) Tenofovir-containing products should be avoided with concurrent or recent use of a nephrotoxic agent, such as bacitracin. Tenofovir is primarily excreted via the kidneys by a combination of glomerular filtration and active tubular secretion. Coadministration of tenofovir with drugs that are eliminated by active tubular secretion may increase concentrations of tenofovir and/or the co-administered drug. Drugs that decrease renal function may also increase concentrations of tenofovir. Renal impairment, which may include hypophosphatemia, has been reported with the use of tenofovir with a majority of the cases occurring in patients who have underlying systemic or renal disease or who are concurrently taking nephrotoxic agents. Monitor patients receiving concomitant nephrotoxic agents for changes in serum creatinine and phosphorus.
    Emtricitabine; Tenofovir disoproxil fumarate: (Moderate) Tenofovir-containing products should be avoided with concurrent or recent use of a nephrotoxic agent, such as bacitracin. Tenofovir is primarily excreted via the kidneys by a combination of glomerular filtration and active tubular secretion. Coadministration of tenofovir with drugs that are eliminated by active tubular secretion may increase concentrations of tenofovir and/or the co-administered drug. Drugs that decrease renal function may also increase concentrations of tenofovir. Renal impairment, which may include hypophosphatemia, has been reported with the use of tenofovir with a majority of the cases occurring in patients who have underlying systemic or renal disease or who are concurrently taking nephrotoxic agents. Monitor patients receiving concomitant nephrotoxic agents for changes in serum creatinine and phosphorus.
    Esomeprazole; Naproxen: (Minor) Due to the inhibition of renal prostaglandins by NSAIDs, concurrent use with other nephrotoxic agents like systemic bacitracin may lead to additive nephrotoxicity.
    Ethacrynic Acid: (Minor) Additive nephrotoxicity may occur with concurrent use of systemic bacitracin and other nephrotoxic agents. When possible, avoid concomitant administration of systemic bacitracin and other nephrotoxic drugs such as loop diuretics. Topical administration of any preparation containing bacitracin, especially when applied to large surface areas, also should not be given with other drugs that have a nephrotoxic potential. (Minor) Additive nephrotoxicity may occur with concurrent use of these medicines. When possible, avoid concomitant administration of systemic bacitracin and loop diuretics. Use of topically administrated preparations containing bacitracin, especially when applied to large surface areas, may have additive nephrotoxic potential with loop diuretics.
    Etodolac: (Minor) Due to the inhibition of renal prostaglandins by NSAIDs, concurrent use with other nephrotoxic agents may lead to additive nephrotoxicity. Monitor renal function carefully during concurrent therapy.
    Famotidine; Ibuprofen: (Minor) Due to the inhibition of renal prostaglandins by NSAIDs, concurrent use with other nephrotoxic agents like systemic bacitracin may lead to additive nephrotoxicity.
    Fenoprofen: (Minor) Due to the inhibition of renal prostaglandins by NSAIDs, concurrent use with other nephrotoxic agents like systemic bacitracin may lead to additive nephrotoxicity.
    Foscarnet: (Minor) Additive nephrotoxicity may occur with concurrent use of systemic bacitracin and other nephrotoxic agents. When possible, avoid concomitant administration of systemic bacitracin and other nephrotoxic drugs such as foscarnet. Use of topically administrated preparations containing bacitracin, especially when applied to large surface areas, may have additive nephrotoxic potential with foscarnet.
    Furosemide: (Minor) Additive nephrotoxicity may occur with concurrent use of systemic bacitracin and other nephrotoxic agents. When possible, avoid concomitant administration of systemic bacitracin and other nephrotoxic drugs such as loop diuretics. Topical administration of any preparation containing bacitracin, especially when applied to large surface areas, also should not be given with other drugs that have a nephrotoxic potential. (Minor) Additive nephrotoxicity may occur with concurrent use of these medicines. When possible, avoid concomitant administration of systemic bacitracin and loop diuretics. Use of topically administrated preparations containing bacitracin, especially when applied to large surface areas, may have additive nephrotoxic potential with loop diuretics.
    Ganciclovir: (Minor) Concurrent use of nephrotoxic agents, including systemic bacitracin, with ganciclovir should be done cautiously to avoid additive nephrotoxicity.
    General anesthetics: (Moderate) General anesthetics should be used cautiously in patients receiving systemic bacitracin. Systemic bacitracin may act synergistcally to increase or prolong skeletal muscle relaxation produced by neuromuscular blocking agents and/or general anesthetics. If bacitracin is administered parenterally during surgery, there may be increased skeletal muscle relaxation, and postoperative use may reinstate neuromuscular blockade.
    Gentamicin: (Minor) Additive nephrotoxicity may occur with concurrent use of bacitracin and other nephrotoxic agents. When possible, avoid concomitant administration of systemic bacitracin and other nephrotoxic drugs such as aminoglycosides (particularly kanamycin, streptomycin, and neomycin).Use of topically administrated preparations containing bacitracin, especially when applied to large surface areas, with aminoglycosides may have additive nephrotoxic potential.
    Hyaluronidase, Recombinant; Immune Globulin: (Moderate) Immune Globulin (IG) products have been reported to be associated with renal dysfunction, acute renal failure, osmotic nephrosis, and death. Patients predisposed to acute renal failure include patients receiving known nephrotoxic drugs like bacitracin. Coadminister IG products at the minimum concentration available and the minimum rate of infusion practicable. Also, closely monitor renal function.
    Hydrocodone; Ibuprofen: (Minor) Due to the inhibition of renal prostaglandins by NSAIDs, concurrent use with other nephrotoxic agents like systemic bacitracin may lead to additive nephrotoxicity.
    Hyoscyamine; Methenamine; Methylene Blue; Phenyl Salicylate; Sodium Biphosphate: (Minor) Additive nephrotoxicity may occur with concurrent use of systemic bacitracin and other nephrotoxic agents, including salicylates. Topical administration of any preparation containing bacitracin, especially when applied to large surface areas, also should not be given with other drugs that have a nephrotoxic potential.
    Ibuprofen: (Minor) Due to the inhibition of renal prostaglandins by NSAIDs, concurrent use with other nephrotoxic agents like systemic bacitracin may lead to additive nephrotoxicity.
    Ibuprofen; Oxycodone: (Minor) Due to the inhibition of renal prostaglandins by NSAIDs, concurrent use with other nephrotoxic agents like systemic bacitracin may lead to additive nephrotoxicity.
    Ibuprofen; Pseudoephedrine: (Minor) Due to the inhibition of renal prostaglandins by NSAIDs, concurrent use with other nephrotoxic agents like systemic bacitracin may lead to additive nephrotoxicity.
    Ifosfamide: (Moderate) Nephrotoxic agents, such as systemic bacitracin, can increase the nephrotoxicity of ifosfamide. Damaged kidney tubules may be less likely to convert mesna to its active kidney protecting form, which may contribute to the potential for increased ifosfamide toxicity. Clinicians should be alert for an increased risk of ifosfamide toxicity, including neurotoxicity, renal toxicity, and bone marrow suppression.
    Immune Globulin IV, IVIG, IGIV: (Moderate) Immune Globulin (IG) products have been reported to be associated with renal dysfunction, acute renal failure, osmotic nephrosis, and death. Patients predisposed to acute renal failure include patients receiving known nephrotoxic drugs like bacitracin. Coadminister IG products at the minimum concentration available and the minimum rate of infusion practicable. Also, closely monitor renal function.
    Indomethacin: (Minor) Due to the inhibition of renal prostaglandins by indomethacin, concurrent use with other nephrotoxic agents like systemic bacitracin may lead to additive nephrotoxicity.
    Kanamycin: (Major) Kanamycin is a nephrotoxic drug. Additive nephrotoxicity is possible if kanamycin is administered with other nephrotoxic medications such as bacitracin. The manufacturer of kanamycin indicates that these combinations should be avoided. Use of topically administrated preparations containing bacitracin, especially when applied to large surface areas, with aminoglycosides may have additive nephrotoxic potential.
    Ketoprofen: (Minor) Due to the inhibition of renal prostaglandins by ketoprofen, concurrent use with other nephrotoxic agents like systemic bacitracin may lead to additive nephrotoxicity.
    Ketorolac: (Minor) Due to the inhibition of renal prostaglandins by ketorolac, concurrent use with other nephrotoxic agents like systemic bacitracin may lead to additive nephrotoxicity.
    Lansoprazole; Naproxen: (Minor) Due to the inhibition of renal prostaglandins by NSAIDs, concurrent use with other nephrotoxic agents like systemic bacitracin may lead to additive nephrotoxicity.
    Loop diuretics: (Minor) Additive nephrotoxicity may occur with concurrent use of systemic bacitracin and other nephrotoxic agents. When possible, avoid concomitant administration of systemic bacitracin and other nephrotoxic drugs such as loop diuretics. Topical administration of any preparation containing bacitracin, especially when applied to large surface areas, also should not be given with other drugs that have a nephrotoxic potential. (Minor) Additive nephrotoxicity may occur with concurrent use of these medicines. When possible, avoid concomitant administration of systemic bacitracin and loop diuretics. Use of topically administrated preparations containing bacitracin, especially when applied to large surface areas, may have additive nephrotoxic potential with loop diuretics.
    Magnesium Salicylate: (Minor) Additive nephrotoxicity may occur with concurrent use of systemic bacitracin and other nephrotoxic agents, including salicylates. Topical administration of any preparation containing bacitracin, especially when applied to large surface areas, also should not be given with other drugs that have a nephrotoxic potential.
    Meclofenamate Sodium: (Minor) Due to the inhibition of renal prostaglandins by NSAIDs, concurrent use with other nephrotoxic agents like systemic bacitracin may lead to additive nephrotoxicity.
    Mefenamic Acid: (Minor) Due to the inhibition of renal prostaglandins by NSAIDs, concurrent use with other nephrotoxic agents like systemic bacitracin may lead to additive nephrotoxicity.
    Meloxicam: (Minor) Due to the inhibition of renal prostaglandins by meloxicam, concurrent use with other nephrotoxic agents like systemic bacitracin may lead to additive nephrotoxicity.
    Metaxalone: (Minor) Use skeletal muscle relaxants cautiously in patients receiving systemic bacitracin. If bacitracin is administered parenterally during surgery, there may be increased skeletal muscle relaxation, and postoperative use may reinstate neuromuscular blockade.
    Methohexital: (Moderate) Systemic bacitracin may act synergistcally to increase or prolong skeletal muscle relaxation produced by neuromuscular blocking agents and/or general anesthetics.
    Nabumetone: (Minor) Due to the inhibition of renal prostaglandins by nabumetone, concurrent use with other nephrotoxic agents, like systemic bacitracin, may lead to additive nephrotoxicity.
    Naproxen: (Minor) Due to the inhibition of renal prostaglandins by NSAIDs, concurrent use with other nephrotoxic agents like systemic bacitracin may lead to additive nephrotoxicity.
    Naproxen; Pseudoephedrine: (Minor) Due to the inhibition of renal prostaglandins by NSAIDs, concurrent use with other nephrotoxic agents like systemic bacitracin may lead to additive nephrotoxicity.
    Naproxen; Sumatriptan: (Minor) Due to the inhibition of renal prostaglandins by NSAIDs, concurrent use with other nephrotoxic agents like systemic bacitracin may lead to additive nephrotoxicity.
    Neomycin: (Minor) Additive nephrotoxicity may occur with concurrent use of bacitracin and other nephrotoxic agents. When possible, avoid concomitant administration of systemic bacitracin and other nephrotoxic drugs such as aminoglycosides (particularly kanamycin, streptomycin, and neomycin).Use of topically administrated preparations containing bacitracin, especially when applied to large surface areas, with aminoglycosides may have additive nephrotoxic potential.
    Neuromuscular blockers: (Moderate) Systemic bacitracin may act synergistcally to increase or prolong skeletal muscle relaxation produced by neuromuscular blocking agents and/or general anesthetics. Use of topically administrated preparations containing bacitracin, especially when applied to large surface areas, may have additive nephrotoxic potential.
    OnabotulinumtoxinA: (Minor) Use botulinum Toxin Type A , which has skeletal muscle relaxant properties, cautiously in patients receiving systemic bacitracin. If bacitracin is administered parenterally during surgery, there may be increased skeletal muscle relaxation, and postoperative use may reinstate neuromuscular blockade.
    Oral Contraceptives: (Moderate) It would be prudent to recommend alternative or additional contraception when oral contraceptives (OCs) are used in conjunction with antibiotics. It was previously thought that antibiotics may decrease the effectiveness of OCs containing estrogens due to stimulation of metabolism or a reduction in enterohepatic circulation via changes in GI flora. One retrospective study reviewed the literature to determine the effects of oral antibiotics on the pharmacokinetics of contraceptive estrogens and progestins, and also examined clinical studies in which the incidence of pregnancy with OCs and antibiotics was reported. It was concluded that the antibiotics ampicillin, ciprofloxacin, clarithromycin, doxycycline, metronidazole, ofloxacin, roxithromycin, temafloxacin, and tetracycline did not alter plasma concentrations of OCs. Antituberculous drugs (e.g., rifampin) were the only agents associated with OC failure and pregnancy. Based on the study results, these authors recommended that back-up contraception may not be necessary if OCs are used reliably during oral antibiotic use. Another review concurred with these data, but noted that individual patients have been identified who experienced significant decreases in plasma concentrations of combined OC components and who appeared to ovulate; the agents most often associated with these changes were rifampin, tetracyclines, and penicillin derivatives. These authors concluded that because females most at risk for OC failure or noncompliance may not be easily identified and the true incidence of such events may be under-reported, and given the serious consequence of unwanted pregnancy, that recommending an additional method of contraception during short-term antibiotic use may be justified. During long-term antibiotic administration, the risk for drug interaction with OCs is less clear, but alternative or additional contraception may be advisable in selected circumstances. Data regarding progestin-only contraceptives or for newer combined contraceptive deliveries (e.g., patches, rings) are not available.
    Orphenadrine: (Minor) Use skeletal muscle relaxants cautiously in patients receiving systemic bacitracin. If bacitracin is administered parenterally during surgery, there may be increased skeletal muscle relaxation, and postoperative use may reinstate neuromuscular blockade.
    Oxaprozin: (Minor) Due to the inhibition of renal prostaglandins by NSAIDs, concurrent use with other nephrotoxic agents like systemic bacitracin may lead to additive nephrotoxicity.
    Paromomycin: (Minor) Additive nephrotoxicity may occur with concurrent use of bacitracin and other nephrotoxic agents. When possible, avoid concomitant administration of systemic bacitracin and other nephrotoxic drugs such as aminoglycosides (particularly kanamycin, streptomycin, and neomycin).Use of topically administrated preparations containing bacitracin, especially when applied to large surface areas, with aminoglycosides may have additive nephrotoxic potential.
    Pentamidine: (Moderate) Additive nephrotoxicity may occur. Both bacitracin and pentamidine may cause a decline in renal function. Bacitracin renal toxicity may occur when the drug is systemically administered or given via topical administration over large surface areas or in prolonged topical use (e.g., severe burns). When possible, avoid concomitant administration of systemic bacitracin and other nephrotoxic drugs such as intravenous pentamidine. Monitor renal function closely.
    Piroxicam: (Minor) Due to the inhibition of renal prostaglandins by piroxicam, concurrent use with other nephrotoxic agents, like systemic bacitracin, may lead to additive nephrotoxicity.
    Polymyxin B: (Major) Additive nephrotoxicity may occur with concurrent use of systemic bacitracin and other nephrotoxic agents, such as polymyxin B; when possible, avoid concomitant administration. Topical administration of any preparation containing bacitracin, especially when applied to large surface areas, should also not be given with other drugs that have a nephrotoxic potential.
    Polymyxins: (Major) Coadministration of these drugs may increase the risk of developing nephrotoxicity, even in patients who have normal renal function. Monitor patients for changes in renal function if these drugs are coadministered. Since colistimethate sodium is eliminated by the kidney, coadministration with other potentially nephrotoxic drugs, including bacitracin, may increase serum concentrations of either drug.
    Pyridostigmine: (Moderate) Parenteral administration of high doses of certain antibiotics such as bacitracin may intensify or produce neuromuscular block through their own pharmacologic actions. If unexpected prolongation of neuromuscular block or resistance to its reversal with pyridostigmine occurs, consider the possibility of an antibiotic effect.
    RimabotulinumtoxinB: (Minor) Botulinum Toxin Type B, which has skeletal muscle relaxant properties, should be used cautiously in patients receiving systemic bacitracin. If bacitracin is administered parenterally during surgery, there may be increased skeletal muscle relaxation, and postoperative use may reinstate neuromuscular blockade.
    Salicylates: (Minor) Additive nephrotoxicity may occur with concurrent use of systemic bacitracin and other nephrotoxic agents, including salicylates. Topical administration of any preparation containing bacitracin, especially when applied to large surface areas, also should not be given with other drugs that have a nephrotoxic potential.
    Salsalate: (Minor) Additive nephrotoxicity may occur with concurrent use of systemic bacitracin and other nephrotoxic agents, including salicylates. Topical administration of any preparation containing bacitracin, especially when applied to large surface areas, also should not be given with other drugs that have a nephrotoxic potential.
    Skeletal Muscle Relaxants: (Minor) Use skeletal muscle relaxants cautiously in patients receiving systemic bacitracin. If bacitracin is administered parenterally during surgery, there may be increased skeletal muscle relaxation, and postoperative use may reinstate neuromuscular blockade.
    Streptomycin: (Minor) Additive nephrotoxicity may occur with concurrent use of bacitracin and other nephrotoxic agents. When possible, avoid concomitant administration of systemic bacitracin and other nephrotoxic drugs such as aminoglycosides (particularly kanamycin, streptomycin, and neomycin).Use of topically administrated preparations containing bacitracin, especially when applied to large surface areas, with aminoglycosides may have additive nephrotoxic potential.
    Sulindac: (Minor) Due to the inhibition of renal prostaglandins by sulindac, concurrent use with other nephrotoxic agents, like systemic bacitracin, may lead to additive nephrotoxicity.
    Tacrolimus: (Minor) Additive nephrotoxicity may occur with concurrent use of these medicines. When possible, avoid concomitant administration of systemic bacitracin and other nephrotoxic drugs such as tacrolimus. Use of topically administrated preparations containing bacitracin, especially when applied to large surface areas, may have additive nephrotoxic potential.
    Telavancin: (Minor) Concurrent or sequential use of telavancin with other potentially nephrotoxic drugs such as systemic bacitracin may lead to additive nephrotoxicity. Closely monitor renal function and adjust telavancin doses based on calculated creatinine clearance.
    Tenofovir Alafenamide: (Moderate) Tenofovir-containing products should be avoided with concurrent or recent use of a nephrotoxic agent, such as bacitracin. Tenofovir is primarily excreted via the kidneys by a combination of glomerular filtration and active tubular secretion. Coadministration of tenofovir alafenamide with drugs that are eliminated by active tubular secretion may increase concentrations of tenofovir and/or the co-administered drug. Drugs that decrease renal function may also increase concentrations of tenofovir. Renal impairment, which may include hypophosphatemia, has been reported with the use of tenofovir with a majority of the cases occurring in patients who have underlying systemic or renal disease or who are concurrently taking nephrotoxic agents. Monitor patients receiving concomitant nephrotoxic agents for changes in serum creatinine and phosphorus, and urine glucose and protein.
    Tenofovir, PMPA: (Moderate) Tenofovir-containing products should be avoided with concurrent or recent use of a nephrotoxic agent, such as bacitracin. Tenofovir is primarily excreted via the kidneys by a combination of glomerular filtration and active tubular secretion. Coadministration of tenofovir with drugs that are eliminated by active tubular secretion may increase concentrations of tenofovir and/or the co-administered drug. Drugs that decrease renal function may also increase concentrations of tenofovir. Renal impairment, which may include hypophosphatemia, has been reported with the use of tenofovir with a majority of the cases occurring in patients who have underlying systemic or renal disease or who are concurrently taking nephrotoxic agents. Monitor patients receiving concomitant nephrotoxic agents for changes in serum creatinine and phosphorus.
    Thiopental: (Moderate) Systemic bacitracin may act synergistcally to increase or prolong skeletal muscle relaxation produced by neuromuscular blocking agents and/or general anesthetics.
    Tizanidine: (Minor) Tizanidine, which has skeletal muscle relaxant properties, should be used cautiously in patients receiving systemic bacitracin. If bacitracin is administered parenterally during surgery, there may be increased skeletal muscle relaxation, and postoperative use may reinstate neuromuscular blockade.
    Tobramycin: (Minor) Additive nephrotoxicity may occur with concurrent use of bacitracin and other nephrotoxic agents. When possible, avoid concomitant administration of systemic bacitracin and other nephrotoxic drugs such as aminoglycosides (particularly kanamycin, streptomycin, and neomycin).Use of topically administrated preparations containing bacitracin, especially when applied to large surface areas, with aminoglycosides may have additive nephrotoxic potential.
    Torsemide: (Minor) Additive nephrotoxicity may occur with concurrent use of systemic bacitracin and other nephrotoxic agents. When possible, avoid concomitant administration of systemic bacitracin and other nephrotoxic drugs such as loop diuretics. Topical administration of any preparation containing bacitracin, especially when applied to large surface areas, also should not be given with other drugs that have a nephrotoxic potential. (Minor) Additive nephrotoxicity may occur with concurrent use of these medicines. When possible, avoid concomitant administration of systemic bacitracin and loop diuretics. Use of topically administrated preparations containing bacitracin, especially when applied to large surface areas, may have additive nephrotoxic potential with loop diuretics.
    Valganciclovir: (Minor) Concurrent use of nephrotoxic agents, such as systemic bacitracin, with valganciclovir should be done cautiously to avoid additive nephrotoxicity.
    Vancomycin: (Moderate) Additive nephrotoxicity may occur with concurrent use of systemic bacitracin and other nephrotoxic agents. When possible, avoid concomitant administration of systemic bacitracin and other nephrotoxic drugs such as vancomycin. Renal function should be monitored closely and vancomycin doses should be adjusted according to vancomycin serum concentrations if these drugs must be used together.

    PREGNANCY AND LACTATION

    Pregnancy

    Bacitracin is classified in FDA pregnancy risk category C. Adequate studies regarding the risks of systemic therapy during pregnancy have not been conducted; the drug has the potential for nephrotoxicity when administered. IM bacitracin should be used during pregnancy only when clearly needed.

    It is unknown whether systemically administered bacitracin is distributed into breast milk. Intramuscular bacitracin  is only approved for use in the infant population; therefore, it is not expected to be used during breast-feeding. Topical and ophthalmic use would result in minimal absorption; to minimize the amount of drug that reaches the systemic circulation and breast milk, apply pressure over the tear duct by the corner of the eye for 1 minute after ophthalmic administration. Oral ingestion by the nursing infant would also result in minimal absorption. Only water-miscible cream or gel products should be applied to the breast because ointments may expose the infant to high levels of mineral paraffins. Consider the benefits of breast-feeding, the risk of potential infant drug exposure, and the risk of an untreated or inadequately treated condition. If a breast-feeding infant experiences an adverse effect related to a maternally administered drug, healthcare providers are encouraged to report the adverse effect to the FDA.
     

    MECHANISM OF ACTION

    Bacitracin is bacteriostatic in action but may be bactericidal, depending on the antibiotic concentration and the susceptibility of the specific organism. Bacitracin inhibits the incorporation of amino acids and nucleotides into the cell wall. Bacitracin interferes with the final dephosphorylation step in the phospholipid carrier cycle, which causes impedance of mucopeptide transfer to the growing cell wall. Bacterial plasma membranes are also damaged by bacitracin. If bacteria are susceptible to bacitracin, resistance usually develops slowly.
     
    Bacitracin is active against many gram-positive organisms and some gram-negative organisms. Unlike penicillins, bacitracin is active against protoplasts. The gram-positive spectrum includes staphylococci (including some penicillin G-resistant strains), streptococci, anaerobic cocci, clostridia, and corynebacteria. Gonococci, meningococci, and fusobacteria are gram-negative organisms susceptible to bacitracin. Other susceptible organisms include Treponema pallidum, T. vincenti, and Actinomyces israelii. However, among systemic diseases, only staphlycoccal infections qualify for consideration for bacitracin therapy. Bacitracin is assayed against a standard and its activity is expressed in units with bacitacin 1 mg having a potency of not less than 50 units.

    PHARMACOKINETICS

    Bacitracin is most commonly administered topically or via ophthalmic administration, but it may also be given intramuscularly. There is no absorption of bacitracin from the normal GI tract, pleura, or synovia. There is minimal binding to plasma protein. Bacitracin distributes widely following IM administration, appearing in all body organs including ascitic and pleural fluids, but not in the CSF unless the meninges are inflamed. Bacitracin is excreted slowly by glomerular filtration following IM administration and, if given orally, is excreted in the feces. After IM doses, 10—40% appears in the urine within 24 hours. Some bacitracin remains unaccounted for and is believed to be either retained by the body or destroyed. It is not known if any metabolism takes place.

    Oral Route

    Oral bioavailability of bacitracin is poor; when given orally, the drug is primarily used for local action within the intestines. There is no absorption of bacitracin from the normal GI tract. Bacitracin is excreted in the feces following oral administration.

    Intramuscular Route

    Absorption of bacitracin following IM administration is rapid, with maximum serum concentrations achieved in about 1—2 hours, ranging from 0.2—2 mcg/mL. Bacitracin distributes widely following IM administration, appearing in all body organs including ascitic and pleural fluids, but not in the CSF unless the meninges are inflamed. Bacitracin is excreted slowly by glomerular filtration following IM administration. After IM doses, 10—40% appears in the urine within 24 hours.

    Topical Route

    There is minimal absorption of bacitracin through normal skin. Bacitracin, however, is readily absorbed topically through large areas of denuded or burned skin or granulating areas.