Clarithromycin is a semi-synthetic macrolide antibiotic. Chemically, it is 6-0-methylerythromycin. The molecular formula is C38H69NO13, and the molecular weight is 747.96. The structural formula is:
Clarithromycin is a white to off-white crystalline powder. It is soluble in acetone, slightly soluble in methanol, ethanol, and acetonitrile, and practically insoluble in water.
Each Clarithromycin tablet intended for oral administration contains 250 mg or 500 mg of Clarithromycin. In addition, each Clarithromycin tablet contains the following inactive ingredients: croscarmellose sodium, hypromellose, magnesium stearate, microcrystalline cellulose, polyethylene glycol, polysorbate 80, povidone, talc, and titanium dioxide.
Clarithromycin - Clinical Pharmacology
Pharmacokinetics
Clarithromycin is rapidly absorbed from the gastrointestinal tract after oral administration. The absolute bioavailability of 250 mg Clarithromycin tablets was approximately 50%. For a single 500 mg dose of Clarithromycin, food slightly delays the onset of Clarithromycin absorption, increasing the peak time from approximately 2 to 2.5 hours. Food also increases the Clarithromycin peak plasma concentration by about 24%, but does not affect the extent of Clarithromycin bioavailability. Food does not affect the onset of formation of the antimicrobially active metabolite, 14-OH Clarithromycin or its peak plasma concentration but does slightly decrease the extent of metabolite formation, indicated by an 11% decrease in area under the plasma concentration-time curve (AUC). Therefore, Clarithromycin tablets may be given without regard to food.
In nonfasting healthy human subjects (males and females), peak plasma concentrations were attained within 2 to 3 hours after oral dosing. Steady-state peak plasma Clarithromycin concentrations were attained within 3 days and were approximately 1 to 2 mcg/mL with a 250 mg dose administered every 12 hours and 3 to 4 mcg/mL with a 500 mg dose administered every 8 to 12 hours. The elimination half-life of Clarithromycin was about 3 to 4 hours with 250 mg administered every 12 hours but increased to 5 to 7 hours with 500 mg administered every 8 to 12 hours. The nonlinearity of Clarithromycin pharmacokinetics is slight at the recommended doses of 250 mg and 500 mg administered every 8 to 12 hours. With a 250 mg every 12 hours dosing, the principal metabolite, 14-OH Clarithromycin, attains a peak steady-state concentration of about 0.6 mcg/mL and has an elimination half-life of 5 to 6 hours. With a 500 mg every 8 to 12 hours dosing, the peak steady-state concentration of 14-OH Clarithromycin is slightly higher (up to 1 mcg/mL), and its elimination half-life is about 7 to 9 hours. With any of these dosing regimens, the steady-state concentration of this metabolite is generally attained within 3 to 4 days.
After a 250 mg tablet every 12 hours, approximately 20% of the dose is excreted in the urine as Clarithromycin, while after a 500 mg tablet every 12 hours, the urinary excretion of Clarithromycin is somewhat greater, approximately 30%. In comparison, after an oral dose of 250 mg (125 mg/5 mL) suspension every 12 hours, approximately 40% is excreted in urine as Clarithromycin. The renal clearance of Clarithromycin is, however, relatively independent of the dose size and approximates the normal glomerular filtration rate. The major metabolite found in urine is 14-OH Clarithromycin, which accounts for an additional 10% to 15% of the dose with either a 250 mg or a 500 mg tablet administered every 12 hours.
Steady-state concentrations of Clarithromycin and 14-OH Clarithromycin observed following administration of 500 mg doses of Clarithromycin every 12 hours to adult patients with HIV infection were similar to those observed in healthy volunteers. In adult HIV-infected patients taking 500 mg or 1000 mg doses of Clarithromycin every 12 hours, steady-state Clarithromycin Cmax values ranged from 2 to 4 mcg/mL and 5 to 10 mcg/mL, respectively.
The steady-state concentrations of Clarithromycin in subjects with impaired hepatic function did not differ from those in normal subjects; however, the 14-OH Clarithromycin concentrations were lower in the hepatically impaired subjects. The decreased formation of 14-OH Clarithromycin was at least partially offset by an increase in renal clearance of Clarithromycin in the subjects with impaired hepatic function when compared to healthy subjects.
The pharmacokinetics of Clarithromycin was also altered in subjects with impaired renal function. (See PRECAUTIONS and DOSAGE AND ADMINISTRATION.)
Clarithromycin and the 14-OH Clarithromycin metabolite distribute readily into body tissues and fluids. There are no data available on cerebrospinal fluid penetration. Because of high intracellular concentrations, tissue concentrations are higher than serum concentrations. Examples of tissue and serum concentrations are presented below.
Concentration (after 250 mg q12h)
| Tissue Type |
Tissue (mcg/g) |
Serum (mcg/mL) |
| Tonsil |
1.6 |
0.8 |
| Lung |
8.8 |
1.7 |
Clarithromycin 500 mg every 8 hours was given in combination with omeprazole 40 mg daily to healthy adult males. The plasma levels of Clarithromycin and 14-hydroxy-Clarithromycin were increased by the concomitant administration of omeprazole. For Clarithromycin, the mean Cmax was 10% greater, the mean Cmin was 27% greater, and the mean AUC0-8 was 15% greater when Clarithromycin was administered with omeprazole than when Clarithromycin was administered alone. Similar results were seen for 14-hydroxy-Clarithromycin, the mean Cmax was 45% greater, the mean Cmin was 57% greater, and the mean AUC0-8 was 45% greater. Clarithromycin concentrations in the gastric tissue and mucus were also increased by concomitant administration of omeprazole.
Clarithromycin Tissue Concentrations 2 hours after Dose (mcg/mL)/(mcg/g)
| Treatment |
N |
antrum |
fundus |
N |
mucus |
| Clarithromycin |
5 |
10.48 ± 2.01 |
20.81 ± 7.64 |
4 |
4.15 ± 7.74 |
Clarithromycin +
Omeprazole |
5 |
19.96 ± 4.71 |
24.25 ± 6.37 |
4 |
39.29 ± 32.79 |
For information about other drugs indicated in combination with Clarithromycin, refer to the CLINICAL PHARMACOLOGY section of their package inserts.
Microbiology
Clarithromycin exerts its antibacterial action by binding to the 50S ribosomal subunit of susceptible microorganisms resulting in inhibition of protein synthesis.
Clarithromycin is active in vitro against a variety of aerobic and anaerobic gram-positive and gram-negative microorganisms as well as most Mycobacterium avium complex (MAC) microorganisms.
Additionally, the 14-OH Clarithromycin metabolite also has clinically significant antimicrobial activity. The 14-OH Clarithromycin is twice as active against Haemophilus influenzae microorganisms as the parent compound. However, for Mycobacterium avium complex (MAC) isolates the 14-OH metabolite is 4 to 7 times less active than Clarithromycin. The clinical significance of this activity against Mycobacterium avium complex is unknown.
Clarithromycin has been shown to be active against most strains of the following microorganisms both in vitro and in clinical infections as described in the INDICATIONS AND USAGE section:
Aerobic Gram-positive MicroorganismsStaphylococcus aureus
Streptococcus pneumoniae
Streptococcus pyogenes
Aerobic Gram-negative MicroorganismsHaemophilus influenzae
Haemophilus parainfluenzae
Moraxella catarrhalis
Other MicroorganismsMycoplasma pneumoniae
Chlamydia pneumoniae (TWAR)
MycobacteriaMycobacterium avium complex (MAC) consisting of:
Mycobacterium avium
Mycobacterium intracellulare
Beta-lactamase production should have no effect on Clarithromycin activity.
NOTE: Most strains of methicillin-resistant and oxacillin-resistant staphylococci are resistant to Clarithromycin.
Omeprazole/Clarithromycin dual therapy; ranitidine bismuth citrate/Clarithromycin dual therapy; omeprazole/Clarithromycin/amoxicillin triple therapy; and lansoprazole/Clarithromycin/amoxicillin triple therapy have been shown to be active against most strains of Helicobacter pylori in vitro and in clinical infections as described in the INDICATIONS AND USAGEsection.
HelicobacterHelicobacter pylori
Pretreatment Resistance
Clarithromycin pretreatment resistance rates were 3.5% (4/113) in the omeprazole/Clarithromycin dual-therapy studies (M93-067, M93-100) and 9.3% (41/439) in the omeprazole/Clarithromycin/amoxicillin triple-therapy studies (126, 127, M96-446). Clarithromycin pretreatment resistance was 12.6% (44/348) in the ranitidine bismuth citrate/Clarithromycin b.i.d. versus t.i.d. clinical study (H2BA3001). Clarithromycin pretreatment resistance rates were 9.5% (91/960) by E-test and 11.3% (12/106) by agar dilution in the lansoprazole/Clarithromycin/amoxicillin triple-therapy clinical trials (M93-125, M93-130, M93-131, M95-392, and M95-399).
Amoxicillin pretreatment susceptible isolates (<0.25 mcg/mL) were found in 99.3% (436/439) of the patients in the omeprazole/Clarithromycin/amoxicillin clinical studies (126, 127, M96-446). Amoxicillin pretreatment minimum inhibitory concentrations (MICs) >0.25 mcg/mL occurred in 0.7% (3/439) of the patients, all of whom were in the Clarithromycin/amoxicillin study arm. Amoxicillin pretreatment susceptible isolates (<0.25 mcg/mL) occurred in 97.8% (936/957) and 98.0% (98/100) of the patients in the lansoprazole/Clarithromycin/amoxicillin triple-therapy clinical trials by E-test and agar dilution, respectively. Twenty-one of the 957 patients (2.2%) by E-test and 2 of 100 patients (2.0%) by agar dilution had amoxicillin pretreatment MICs of >0.25 mcg/mL. Two patients had an unconfirmed pretreatment amoxicillin minimum inhibitory concentration (MIC) of >256 mcg/mL by E-test.
Clarithromycin Susceptibility Test Results and Clinical/Bacteriological Outcomes
Clarithromycin
Pretreatment Results |
Clarithromycin
Post-treatment Results |
H. pylori
negative –
eradicated |
H. pylori positive –
not eradicated
Post-treatment
susceptibility results |
| S |
I† |
R† |
No MIC |
|
| Omeprazole 40 mg q.d./Clarithromycin 500 mg t.i.d. for 14 days followed by omeprazole 20 mg q.d. for another 14 days (M93-067, M93-100) |
| Susceptible† |
108 |
72 |
1 |
|
26 |
9 |
| Intermediate† |
1 |
|
|
|
1 |
|
| Resistant† |
4 |
|
|
|
4 |
|
| Ranitidine bismuth citrate 400 mg b.i.d./Clarithromycin 500 mg t.i.d. for 14 days followed by ranitidine bismuth citrate 400 mg b.i.d. for another 14 days (H2BA3001) |
| Susceptible† |
124 |
98 |
4 |
|
14 |
8 |
| Intermediate† |
3 |
2 |
|
|
|
1 |
| Resistant† |
17 |
1 |
|
|
15 |
1 |
| Ranitidine bismuth citrate 400 mg b.i.d./Clarithromycin 500 mg b.i.d. for 14 days followed by ranitidine bismuth citrate 400 mg b.i.d. for another 14 days (H2BA3001) |
| Susceptible† |
125 |
106 |
1 |
1 |
12 |
5 |
| Intermediate† |
2 |
2 |
|
|
|
|
| Resistant† |
20 |
1 |
|
|
19 |
|
Omeprazole 20 mg b.i.d./Clarithromycin 500 mg b.i.d./amoxicillin 1 g
b.i.d. for 10 days (126, 127, M96-446) |
| Susceptible† |
171 |
153 |
7 |
|
3 |
8 |
| Intermediate† |
|
|
|
|
|
|
| Resistant† |
14 |
4 |
1 |
|
6 |
3 |
| Lansoprazole 30 mg b.i.d./Clarithromycin 500 mg b.i.d./amoxicillin 1 g b.i.d. for 14 days (M95-399, M93-131, M95-392) |
| Susceptible† |
112 |
105 |
|
|
|
7 |
| Intermediate† |
3 |
3 |
|
|
|
|
| Resistant† |
17 |
6 |
|
|
7 |
4 |
| Lansoprazole 30 mg b.i.d./Clarithromycin 500 mg b.i.d./amoxicillin 1 g b.i.d. for 10 days (M95-399) |
| Susceptible† |
42 |
40 |
1 |
|
1 |
|
| Intermediate† |
|
|
|
|
|
|
| Resistant† |
4 |
1 |
|
|
3 |
|
Patients not eradicated of H. pylori following omeprazole/Clarithromycin, ranitidine bismuth citrate/Clarithromycin, omeprazole/Clarithromycin/amoxicillin, or lansoprazole/Clarithromycin/amoxicillin therapy would likely have Clarithromycin resistant H. pylori isolates. Therefore, for patients who fail therapy, Clarithromycin susceptibility testing should be done, if possible. Patients with Clarithromycin resistant H. pylori should not be treated with any of the following: omeprazole/Clarithromycin dual therapy; ranitidine bismuth citrate/Clarithromycin dual therapy; omeprazole/Clarithromycin/amoxicillin triple therapy; lansoprazole/Clarithromycin/amoxicillin triple therapy; or other regimens which include Clarithromycin as the sole antimicrobial agent.
Amoxicillin Susceptibility Test Results and Clinical/Bacteriological Outcomes
In the omeprazole/Clarithromycin/amoxicillin triple-therapy clinical trials, 84.9% (157/185) of the patients who had pretreatment amoxicillin susceptible MICs (<0.25 mcg/mL) were eradicated of H. pylori and 15.1% (28/185) failed therapy. Of the 28 patients who failed triple therapy, 11 had no post-treatment susceptibility test results, and 17 had post-treatment H. pylori isolates with amoxicillin susceptible MICs. Eleven of the patients who failed triple therapy also had post-treatment H. pylori isolates with Clarithromycin resistant MICs.
In the lansoprazole/Clarithromycin/amoxicillin triple-therapy clinical trials, 82.6% (195/236) of the patients that had pretreatment amoxicillin susceptible MICs (<0.25 mcg/mL) were eradicated of H. pylori. Of those with pretreatment amoxicillin MICs of >0.25 mcg/mL, three of six had the H. pylori eradicated. A total of 12.8% (22/172) of the patients failed the 10-and 14-day triple-therapy regimens. Post-treatment susceptibility results were not obtained on 11 of the patients who failed therapy. Nine of the 11 patients with amoxicillin post-treatment MICs that failed the triple-therapy regimen also had Clarithromycin resistant H. pylori isolates.
The following in vitro data are available, but their clinical significance is unknown. Clarithromycin exhibits in vitro activity against most strains of the following microorganisms; however, the safety and effectiveness of Clarithromycin in treating clinical infections due to these microorganisms have not been established in adequate and well-controlled clinical trials.
Aerobic Gram-positive MicroorganismsStreptococcus agalactiae
Streptococci (Groups C, F, G)
Viridans group streptococci
Aerobic Gram-negative MicroorganismsBordetella pertussis
Legionella pneumophila
Pasteurella multocida
Anaerobic Gram-positive MicroorganismsClostridium perfringens
Peptococcus niger
Propionibacterium acnes
Anaerobic Gram-negative MicroorganismsPrevotella melaninogenica (formerly Bacteriodes melaninogenicus)
Susceptibility Testing Excluding Mycobacteria and Helicobacter
Dilution TechniquesQuantitative methods are used to determine antimicrobial minimum inhibitory concentrations (MICs). These MICs provide estimates of the susceptibility of bacteria to antimicrobial compounds. The MICs should be determined using a standardized procedure. Standardized procedures are based on a dilution method1 (broth or agar) or equivalent with standardized inoculum concentrations and standardized concentrations of Clarithromycin powder. The MIC values should be interpreted according to the following criteria:
For testing Staphylococcus spp.
| MIC (mcg/mL) |
Interpretation |
| ≤2.0 |
Susceptible (S) |
| 4.0 |
Intermediate (I) |
| ≥8.0 |
Resistant (R) |
For testing Streptococcus spp. including Streptococcus pneumoniae
|
| MIC (mcg/mL) |
Interpretation |
| ≤0.25 |
Susceptible (S) |
| 0.5 |
Intermediate (I) |
| ≥1.0 |
Resistant (R) |
For testing Haemophilus spp.
|
| MIC (mcg/mL) |
Interpretation |
| ≤8.0 |
Susceptible (S) |
| 16.0 |
Intermediate (I) |
| ≥32.0 |
Resistant (R) |
Note: When testing Streptococcus spp., including Streptococcus pneumoniae, susceptibility and resistance to Clarithromycin can be predicted using erythromycin.
A report of “Susceptible” indicates that the pathogen is likely to be inhibited if the antimicrobial compound in the blood reaches the concentrations usually achievable. A report of “Intermediate” indicates that the result should be considered equivocal, and, if the microorganism is not fully susceptible to alternative, clinically feasible drugs, the test should be repeated. This category implies possible clinical applicability in body sites where the drug is physiologically concentrated or in situations where high dosage of drug can be used. This category also provides a buffer zone which prevents small uncontrolled technical factors from causing major discrepancies in interpretation. A report of “Resistant” indicates that the pathogen is not likely to be inhibited if the antimicrobial compound in the blood reaches the concentrations usually achievable; other therapy should be selected.
Standardized susceptibility test procedures require the use of laboratory control microorganisms to control the technical aspects of the laboratory procedures. Standard Clarithromycin powder should provide the following MIC values:
|
| Microorganism |
|
MIC (mcg/mL) |
| S. aureus |
ATCC 29213 |
0.12 to 0.5 |
| S. pneumoniae |
ATCC 49619 |
0.03 to 0.12 |
| 4Haemophilus influenzae |
ATCC 49247 |
4 to 16 |
Diffusion TechniquesQuantitative methods that require measurement of zone diameters also provide reproducible estimates of the susceptibility of bacteria to antimicrobial compounds. One such standardized procedure2 requires the use of standardized inoculum concentrations. This procedure uses paper disks impregnated with 15 mcg Clarithromycin to test the susceptibility of microorganisms to Clarithromycin.
Reports from the laboratory providing results of the standard single-disk susceptibility test with a 15 mcg Clarithromycin disk should be interpreted according to the following criteria:
For testing Staphylococcus spp.
| Zone diameter (mm) |
Interpretation |
| ≥18 |
Susceptible (S) |
| 14 to 17 |
Intermediate (I) |
| ≤13 |
Resistant (R) |
For testing Streptococcus spp. including Streptococcus pneumoniae
|
| Zone diameter (mm) |
Interpretation |
| ≥21 |
Susceptible (S) |
| 17 to 20 |
Intermediate (I) |
| ≤16 |
Resistant (R) |
For testing Haemophilus spp.
|
| Zone diameter (mm) |
Interpretation |
| ≥13 |
Susceptible (S) |
| 11 to 12 |
Intermediate (I) |
| ≤10 |
Resistant (R) |
Note: When testing Streptococcus spp., including Streptococcus pneumoniae, susceptibility and resistance to Clarithromycin can be predicted using erythromycin.
Interpretation should be as stated above for results using dilution techniques. Interpretation involves correlation of the diameter obtained in the disk test with the MIC for Clarithromycin. As with standardized dilution techniques, diffusion methods require the use of laboratory control microorganisms that are used to control the technical aspects of the laboratory procedures. For the diffusion technique, the 15 mcg Clarithromycin disk should provide the following zone diameters in this laboratory test quality control strain:
|
| Microorganism |
|
Zone diameter (mm) |
| S. aureus |
ATCC 25923 |
26 to 32 |
| S. pneumoniae |
ATCC 49619 |
25 to 31 |
| Haemophilus influenzae |
ATCC 49247 |
11 to 17 |
In vitro Activity of Clarithromycin against Mycobacteria
Clarithromycin has demonstrated in vitro activity against Mycobacterium avium complex (MAC) microorganisms isolated from both AIDS and non-AIDS patients. While gene probe techniques may be used to distinguish M. avium species from M. intracellulare, many studies only reported results on M. avium complex (MAC) isolates.
Various in vitro methodologies employing broth or solid media at different pH’s, with and without oleic acid-albumin-dextrose-catalase (OADC), have been used to determine Clarithromycin MIC values for mycobacterial species. In general, MIC values decrease more than 16-fold as the pH of Middlebrook 7H12 broth media increases from 5.0 to 7.4. At pH 7.4, MIC values determined with Mueller-Hinton agar were 4- to 8-fold higher than those observed with Middlebrook 7H12 media. Utilization of oleic acid-albumin-dextrose-catalase (OADC) in these assays has been shown to further alter MIC values.
Clarithromycin activity against 80 MAC isolates from AIDS patients and 211 MAC isolates from non-AIDS patients was evaluated using a micro-dilution method with Middlebrook 7H9 broth. Results showed an MIC value of ≤4.0 mcg/mL in 81% and 89% of the AIDS and non-AIDS MAC isolates, respectively. Twelve percent of the non-AIDS isolates had an MIC value ≤0.5 mcg/mL. Clarithromycin was also shown to be active against phagocytized M. avium complex (MAC) in mouse and human macrophage cell cultures as well as in the beige mouse infection model.
Clarithromycin activity was evaluated against Mycobacterium tuberculosis microorganisms. In one study utilizing the agar dilution method with Middlebrook 7H10 media, 3 of 30 clinical isolates had an MIC of 2.5 mcg/mL. Clarithromycin inhibited all isolates at >10.0 mcg/mL.
Susceptibility Testing for Mycobacterium avium Complex (MAC)
The disk diffusion and dilution techniques for susceptibility testing against gram-positive and gram-negative bacteria should not be used for determining Clarithromycin MIC values against mycobacteria. In vitro susceptibility testing methods and diagnostic products currently available for determining minimum inhibitory concentration (MIC) values against Mycobacterium avium complex (MAC) organisms have not been standardized or validated. Clarithromycin MIC values will vary depending on the susceptibility testing method employed, composition and pH of the media, and the utilization of nutritional supplements. Breakpoints to determine whether clinical isolates of M. avium or M. intracellulare are susceptible or resistant to Clarithromycin have not been established.
Susceptibility Test for Helicobacter pylori
The reference methodology for susceptibility testing of H. pylori is agar dilution MICs3 One to three micro-liters of an inoculum equivalent to a No. 2 McFarland standard (1 x 107-1 x 108 CFU/mL for H. pylori) are inoculated directly onto freshly prepared antimicrobial containing Mueller-Hinton agar plates with 5% aged defibrinated sheep blood (>2-weeks old). The agar dilution plates are incubated at 35°C in a microaerobic environment produced by a gas generating system suitable for Campylobacter species. After 3 days of incubation, the MICs are recorded as the lowest concentration of antimicrobial agent required to inhibit growth of the organism. The Clarithromycin and amoxicillin MIC values should be interpreted according to the following criteria:
|
| Clarithromycin MIC (mcg/mL) |
Interpretation |
| <0.25 |
Susceptible (S) |
| 0.5 – 1.0 |
Intermediate (I) |
| >2.0 |
Resistant (R) |
| Amoxicillin MIC (mcg/mL)* |
Interpretation |
| <0.25 |
Susceptible (S) |
Standardized susceptibility test procedures require the use of laboratory control microorganisms to control the technical aspects of the laboratory procedures. Standard Clarithromycin and amoxicillin powders should provide the following MIC values:
|
| Microorganisms |
Antimicrobial Agent |
MIC (mcg/mL) |
| H. pylori ATCC 43504 |
Clarithromycin |
0.015 - 0.12 mcg/mL |
| H. pylori ATCC 43504 |
Amoxicillin |
0.015 - 0.12 mcg/mL |
Indications and Usage for ClarithromycinClarithromycin tablets are indicated for the treatment of mild to moderate infections caused by susceptible strains of the designated microorganisms in the conditions as listed below:
Adults
Pharyngitis/Tonsillitis due to Streptococcus pyogenes (The usual drug of choi
