Usual Adult Dose for Bacterial Infection

5 to 24 million units/day IV in equally divided doses every 4 to 6 hours

Comments:

• Dose depends on the nature and severity of the infection.

Uses: For the treatment of serious infections (septicemia, empyema, pneumonia, pericarditis, endocarditis, meningitis) due to susceptible strains of Staphylococcus species (non-penicillinase-producing strains)

Usual Adult Dose for Pneumonia

12 to 24 million units/day IV in equally divided doses every 4 to 6 hours

Comments:

• Dose depends on the nature and severity of the infection.

Uses: For the treatment of serious infections (septicemia, empyema, pneumonia, pericarditis, endocarditis, meningitis) due to susceptible strains of Streptococcus pyogenes, other beta-hemolytic streptococci (including groups C, H, G, L, M), S pneumoniae

Usual Adult Dose for Septicemia

12 to 24 million units/day IV in equally divided doses every 4 to 6 hours

Comments:

• Dose depends on the nature and severity of the infection.

Uses: For the treatment of serious infections (septicemia, empyema, pneumonia, pericarditis, endocarditis, meningitis) due to susceptible strains of Streptococcus pyogenes, other beta-hemolytic streptococci (including groups C, H, G, L, M), S pneumoniae

Usual Adult Dose for Streptococcal Infection

12 to 24 million units/day IV in equally divided doses every 4 to 6 hours

Comments:

• Dose depends on the nature and severity of the infection.

Uses: For the treatment of serious infections (septicemia, empyema, pneumonia, pericarditis, endocarditis, meningitis) due to susceptible strains of Streptococcus pyogenes, other beta-hemolytic streptococci (including groups C, H, G, L, M), S pneumoniae

Usual Adult Dose for Endocarditis

Streptococci infection: 12 to 24 million units/day IV in equally divided doses every 4 to 6 hours
Staphylococci infection: 5 to 24 million units/day IV in equally divided doses every 4 to 6 hours
Erysipelothrix infection: 12 to 20 million units/day IV in divided doses every 4 to 6 hours for 4 to 6 weeks
Listeria infection: 15 to 20 million units/day IV in divided doses every 4 to 6 hours for 4 weeks

Comments:

• Dose for streptococcal or staphylococcal infection depends on the nature and severity of the infection.

Use: For the treatment of endocarditis due to susceptible strains of S pyogenes, other beta-hemolytic streptococci (including groups C, H, G, L, M), S pneumoniae, Staphylococcus species (non-penicillinase-producing strains), Erysipelothrix rhusiopathiae, Listeria monocytogenes

Usual Adult Dose for Meningitis

Streptococci infection: 12 to 24 million units/day IV in equally divided doses every 4 to 6 hours
Staphylococci infection: 5 to 24 million units/day IV in equally divided doses every 4 to 6 hours
Listeria infection: 15 to 20 million units/day IV in divided doses every 4 to 6 hours for 2 weeks
Pasteurella infection: 4 to 6 million units/day IV in divided doses every 4 to 6 hours for 2 weeks

Comments:

• Dose for streptococcal or staphylococcal infection depends on the nature and severity of the infection.

Use: For the treatment of meningitis due to S pyogenes, other beta-hemolytic streptococci (including groups C, H, G, L, M), S pneumoniae, Staphylococcus species (non-penicillinase-producing strains), L monocytogenes, Pasteurella multocida

Infectious Diseases Society of America (IDSA) Recommendations: 24 million units/day IV in divided doses every 4 hours

Duration of therapy:

• L monocytogenes: At least 21 days
• S agalactiae: 14 to 21 days
• S pneumoniae: 10 to 14 days

Comments:

• A recommended agent for infection due to L monocytogenes or S agalactiae; use with an aminoglycoside should be considered.
• Considered standard therapy for S pneumoniae infection with penicillin MIC less than 0.1 mcg/mL
• Current guidelines should be consulted for additional information.

Usual Adult Dose for Meningitis - Pneumococcal

Streptococci infection: 12 to 24 million units/day IV in equally divided doses every 4 to 6 hours
Staphylococci infection: 5 to 24 million units/day IV in equally divided doses every 4 to 6 hours
Listeria infection: 15 to 20 million units/day IV in divided doses every 4 to 6 hours for 2 weeks
Pasteurella infection: 4 to 6 million units/day IV in divided doses every 4 to 6 hours for 2 weeks

Comments:

• Dose for streptococcal or staphylococcal infection depends on the nature and severity of the infection.

Use: For the treatment of meningitis due to S pyogenes, other beta-hemolytic streptococci (including groups C, H, G, L, M), S pneumoniae, Staphylococcus species (non-penicillinase-producing strains), L monocytogenes, Pasteurella multocida

Infectious Diseases Society of America (IDSA) Recommendations: 24 million units/day IV in divided doses every 4 hours

Duration of therapy:

• L monocytogenes: At least 21 days
• S agalactiae: 14 to 21 days
• S pneumoniae: 10 to 14 days

Comments:

• A recommended agent for infection due to L monocytogenes or S agalactiae; use with an aminoglycoside should be considered.
• Considered standard therapy for S pneumoniae infection with penicillin MIC less than 0.1 mcg/mL
• Current guidelines should be consulted for additional information.

Usual Adult Dose for Meningitis - Meningococcal

24 million units/day, administered as 2 million units IV every 2 hours

Use: For the treatment of meningococcal meningitis and/or septicemia due to Neisseria meningitidis

IDSA Recommendations: 24 million units/day IV in divided doses every 4 hours for 7 days

Comments:

• Recommended as an alternative agent for infection due to N meningitidis
• Considered standard therapy for N meningitidis infection with penicillin MIC less than 0.1 mcg/mL
• Current guidelines should be consulted for additional information.

Usual Adult Dose for Neurosyphilis

12 to 24 million units/day, administered as 2 to 4 million units IV every 4 hours for 10 to 14 days

Comments:

• Many experts recommend additional therapy with penicillin G benzathine after completion of IV therapy.
• Adequate follow-up (including clinical and serological examinations) recommended for all cases of penicillin-treated syphilis; US CDC guidelines should be consulted.

Use: For the treatment of neurosyphilis due to Treponema pallidum

US CDC Recommendations: 18 to 24 million units/day, administered as 3 to 4 million units IV every 4 hours or a continuous IV infusion for 10 to 14 days

Comments:

• Recommended as the preferred regimen for neurosyphilis and ocular syphilis
• US CDC, National Institutes of Health (NIH), and HIV Medicine Association of the IDSA (HIVMA/IDSA) also recommend this as the preferred regimen for neurosyphilis, ocular syphilis, and otic syphilis in HIV-infected adults.
• Duration of neurosyphilis therapy is shorter than the duration for latent syphilis therapy; penicillin G benzathine can be considered after completing this drug to provide comparable total duration of therapy.
• The patient's sexual partner(s) should also be evaluated/treated.
• Current guidelines should be consulted for additional information.

Usual Adult Dose for Actinomycosis

Cervicofacial disease: 1 to 6 million units/day IV in divided doses every 4 to 6 hours
Thoracic and abdominal disease: 10 to 20 million units/day IV in divided doses every 4 to 6 hours

Uses: For the treatment of actinomycosis (cervicofacial disease, thoracic and abdominal disease) due to Actinomyces israelii

Usual Adult Dose for Inhalation Bacillus anthracis

Minimum of 8 million units/day IV in divided doses every 6 hours

Comments:

• Higher doses may be needed depending on susceptibility of organism.

Use: For the treatment of anthrax due to Bacillus anthracis

US CDC Recommendations: 4 million units IV every 4 hours

Duration of Therapy:

• With possible/confirmed meningitis: At least 2 to 3 weeks or until patient is clinically stable (whichever is longer)
• When meningitis has been excluded: At least 2 weeks or until patient is clinically stable (whichever is longer)
• Patients exposed to aerosolized spores will require prophylaxis to complete an antimicrobial regimen of 60 days from onset of illness.

Comments:

• Recommended as an alternative agent for the treatment of systemic anthrax due to penicillin-susceptible strains (MIC less than 0.125 mcg/mL)
• Recommended for use with a protein synthesis inhibitor; the addition of a bactericidal fluoroquinolone is recommended with possible/confirmed meningitis.
• Systemic anthrax includes anthrax meningitis, inhalation anthrax, injection anthrax, gastrointestinal anthrax, and cutaneous anthrax with systemic involvement, extensive edema, or lesions of the head or neck.
• Current guidelines should be consulted for additional information.

Usual Adult Dose for Cutaneous Bacillus anthracis

Minimum of 8 million units/day IV in divided doses every 6 hours

Comments:

• Higher doses may be needed depending on susceptibility of organism.

Use: For the treatment of anthrax due to Bacillus anthracis

US CDC Recommendations: 4 million units IV every 4 hours

Duration of Therapy:

• With possible/confirmed meningitis: At least 2 to 3 weeks or until patient is clinically stable (whichever is longer)
• When meningitis has been excluded: At least 2 weeks or until patient is clinically stable (whichever is longer)
• Patients exposed to aerosolized spores will require prophylaxis to complete an antimicrobial regimen of 60 days from onset of illness.

Comments:

• Recommended as an alternative agent for the treatment of systemic anthrax due to penicillin-susceptible strains (MIC less than 0.125 mcg/mL)
• Recommended for use with a protein synthesis inhibitor; the addition of a bactericidal fluoroquinolone is recommended with possible/confirmed meningitis.
• Systemic anthrax includes anthrax meningitis, inhalation anthrax, injection anthrax, gastrointestinal anthrax, and cutaneous anthrax with systemic involvement, extensive edema, or lesions of the head or neck.
• Current guidelines should be consulted for additional information.

Usual Adult Dose for Clostridial Infection

20 million units/day IV in divided doses every 4 to 6 hours

Comments:

• Debridement and/or surgery as indicated for gas gangrene.

Uses: For botulism (as adjunctive therapy to antitoxin), gas gangrene, tetanus (as adjunctive therapy to human tetanus immune globulin) due to Clostridium species

Usual Adult Dose for Tetanus

20 million units/day IV in divided doses every 4 to 6 hours

Comments:

• Debridement and/or surgery as indicated for gas gangrene.

Uses: For botulism (as adjunctive therapy to antitoxin), gas gangrene, tetanus (as adjunctive therapy to human tetanus immune globulin) due to Clostridium species

Usual Adult Dose for Botulism

20 million units/day IV in divided doses every 4 to 6 hours

Comments:

• Debridement and/or surgery as indicated for gas gangrene.

Uses: For botulism (as adjunctive therapy to antitoxin), gas gangrene, tetanus (as adjunctive therapy to human tetanus immune globulin) due to Clostridium species

Usual Adult Dose for Diphtheria

2 to 3 million units/day IV in divided doses every 4 to 6 hours for 10 to 12 days

Uses: For diphtheria (as adjunctive therapy to antitoxin and prevention of carrier state) due to Corynebacterium diphtheriae

Usual Adult Dose for Fusospirochetosis

5 to 10 million units/day IV in divided doses every 4 to 6 hours

Uses: For the treatment of fusospirochetosis (severe infections of the oropharynx (Vincent's), lower respiratory tract, genital area) due to Fusobacterium species and spirochetes

Usual Adult Dose for Bacteremia

Pasteurella infections: 4 to 6 million units/day IV in divided doses every 4 to 6 hours for 2 weeks
Gram-negative bacillary infections: No specific guidelines have been suggested by the manufacturer.

Comments:

• Penicillin G is not a drug of choice for treating gram-negative bacillary infections; previously, some species of gram-negative bacilli were considered susceptible to very high IV doses (up to 80 million units/day). Other more effective agents are usually used to treat these infections.

Uses: For the treatment of Pasteurella infections (including bacteremia, meningitis) due to P multocida; for the treatment of gram-negative bacillary infections (bacteremias) due to gram-negative bacillary organisms (i.e., Enterobacteriaceae)

Usual Adult Dose for Gram Negative Infection

Pasteurella infections: 4 to 6 million units/day IV in divided doses every 4 to 6 hours for 2 weeks
Gram-negative bacillary infections: No specific guidelines have been suggested by the manufacturer.

Comments:

• Penicillin G is not a drug of choice for treating gram-negative bacillary infections; previously, some species of gram-negative bacilli were considered susceptible to very high IV doses (up to 80 million units/day). Other more effective agents are usually used to treat these infections.

Uses: For the treatment of Pasteurella infections (including bacteremia, meningitis) due to P multocida; for the treatment of gram-negative bacillary infections (bacteremias) due to gram-negative bacillary organisms (i.e., Enterobacteriaceae)

Usual Adult Dose for Rat-bite Fever

12 to 20 million units/day IV in divided doses every 4 to 6 hours for 3 to 4 weeks

Uses: For the treatment of Haverhill fever due to Streptobacillus moniliformis; for the treatment of rat-bite fever due to Spirillum minus or S moniliformis

Usual Adult Dose for Lyme Disease - Arthritis

American Academy of Neurology (AAN) and IDSA Recommendations: 18 to 24 million units/day IV in divided doses every 4 hours
Duration of therapy: 14 days

Comments:

• IDSA recommends this drug as an alternative parenteral regimen for early neurologic disease (meningitis or radiculopathy), cardiac disease, and late disease (recurrent arthritis after oral regimen, central or peripheral nervous system disease).
• Duration of therapy has ranged from 10 to 28 days.
• Current guidelines should be consulted for additional information.

Usual Adult Dose for Lyme Disease - Carditis

American Academy of Neurology (AAN) and IDSA Recommendations: 18 to 24 million units/day IV in divided doses every 4 hours
Duration of therapy: 14 days

Comments:

• IDSA recommends this drug as an alternative parenteral regimen for early neurologic disease (meningitis or radiculopathy), cardiac disease, and late disease (recurrent arthritis after oral regimen, central or peripheral nervous system disease).
• Duration of therapy has ranged from 10 to 28 days.
• Current guidelines should be consulted for additional information.

Usual Adult Dose for Lyme Disease - Neurologic

American Academy of Neurology (AAN) and IDSA Recommendations: 18 to 24 million units/day IV in divided doses every 4 hours
Duration of therapy: 14 days

Comments:

• IDSA recommends this drug as an alternative parenteral regimen for early neurologic disease (meningitis or radiculopathy), cardiac disease, and late disease (recurrent arthritis after oral regimen, central or peripheral nervous system disease).
• Duration of therapy has ranged from 10 to 28 days.
• Current guidelines should be consulted for additional information.

Usual Adult Dose for Prevention of Perinatal Group B Streptococcal Disease

US CDC Recommendations: 5 million units IV initially followed by 2.5 to 3 million units IV every 4 hours until delivery

Comments:

• A recommended regimen for intrapartum antibiotic prophylaxis for prevention of early-onset group B streptococcal disease
• Use of this drug for at least 4 hours before delivery is considered adequate intrapartum antibiotic prophylaxis.
• Current guidelines should be consulted for additional information.

Usual Adult Dose for Skin or Soft Tissue Infection

IDSA Recommendations: 2 to 4 million units IV every 4 to 6 hours

Comments:

• Recommended for the treatment of non-purulent skin and soft tissue infection (cellulitis)/streptococcal skin infection
• In combination with clindamycin, recommended as the preferred regimen for the treatment of necrotizing infections of the skin, fascia, and muscle due to Streptococcus or Clostridium species
• Current guidelines should be consulted for additional information.

Usual Adult Dose for Joint Infection

IDSA Recommendations:

• Enterococcus species (penicillin-susceptible), streptococci (beta-hemolytic): 20 to 24 million units/day IV continuously or in 6 divided doses
• Propionibacterium acnes: 20 million units/day IV continuously or in 6 divided doses

Duration of therapy:

• Native vertebral osteomyelitis: 6 weeks
• Prosthetic joint infection: 4 to 6 weeks

Comments:

• Recommended as a preferred regimen for the treatment of native vertebral osteomyelitis and prosthetic joint infection due to penicillin-susceptible Enterococcus species, beta-hemolytic streptococci, or P acnes
• Penicillin-susceptible Enterococcus species: For patients with native vertebral osteomyelitis, aminoglycoside should be added for those with infective endocarditis and is optional for others; for patients with prosthetic joint infection, aminoglycoside optional
• Current guidelines should be consulted for additional information.

Usual Adult Dose for Osteomyelitis

IDSA Recommendations:

• Enterococcus species (penicillin-susceptible), streptococci (beta-hemolytic): 20 to 24 million units/day IV continuously or in 6 divided doses
• Propionibacterium acnes: 20 million units/day IV continuously or in 6 divided doses

Duration of therapy:

• Native vertebral osteomyelitis: 6 weeks
• Prosthetic joint infection: 4 to 6 weeks

Comments:

• Recommended as a preferred regimen for the treatment of native vertebral osteomyelitis and prosthetic joint infection due to penicillin-susceptible Enterococcus species, beta-hemolytic streptococci, or P acnes
• Penicillin-susceptible Enterococcus species: For patients with native vertebral osteomyelitis, aminoglycoside should be added for those with infective endocarditis and is optional for others; for patients with prosthetic joint infection, aminoglycoside optional
• Current guidelines should be consulted for additional information.

Usual Adult Dose for Leptospirosis

US CDC Recommendations: 1.5 million units IV every 6 hours

Comments:

• Recommended for severe leptospirosis
• Current guidelines should be consulted for additional information.

Usual Adult Dose for Gonococcal Infection - Disseminated

10 million units/day IV in divided doses every 4 to 6 hours
Duration of therapy: Depends on nature and severity of infection

Comments:

• Due to resistance, penicillins are not recommended by the US CDC.
• Current guidelines should be consulted for additional information.

Use: For the treatment of disseminated gonococcal infections (such as meningitis, endocarditis, arthritis, etc.) due to penicillin-susceptible N gonorrhoeae

Usual Pediatric Dose for Bacterial Infection

American Academy of Pediatrics (AAP) Recommendations:
Neonates:

• Up to 7 days: 50,000 units/kg IM or IV every 12 hours
• Older than 7 days: 50,000 units/kg IM or IV every 8 hours

1 month or older: 100,000 to 300,000 units/kg/day IM or IV divided in 4 to 6 doses

• Meningitis: 300,000 to 400,000 units/kg/day IV divided in 6 doses

Maximum dose: 24 million units/day

Usual Pediatric Dose for Pneumonia

150,000 to 300,000 units/kg/day IV in equally divided doses every 4 to 6 hours
Duration of therapy: Depends on nature and severity of infection

Uses: For the treatment of serious infections (such as pneumonia, endocarditis) due to susceptible strains of streptococci (including S pneumoniae) and meningococcus

AAP Recommendations:

• Infants and children (1 month or older): 250,000 to 400,000 units/kg/day IV in divided doses every 4 to 6 hours

Maximum dose: 24 million units/day

Pediatric Infectious Diseases Society (PIDS) and IDSA Recommendations:
Infants and children older than 3 months:

• S pneumoniae with penicillin MIC up to 2 mcg/mL: 200,000 to 250,000 units/kg/day IV in divided doses every 4 to 6 hours
• Group A Streptococcus: 100,000 to 250,000 units/kg/day IV in divided doses every 4 to 6 hours

Comments:

• AAP: Recommended for invasive pneumococcal infections (nonmeningeal)
• PIDS/IDSA: Recommended as preferred parenteral therapy for community-acquired pneumonia due to S pneumoniae with penicillin MIC up to 2 mcg/mL or group A Streptococcus
• Current guidelines should be consulted for additional information.

Usual Pediatric Dose for Streptococcal Infection

150,000 to 300,000 units/kg/day IV in equally divided doses every 4 to 6 hours
Duration of therapy: Depends on nature and severity of infection

Uses: For the treatment of serious infections (such as pneumonia, endocarditis) due to susceptible strains of streptococci (including S pneumoniae) and meningococcus

AAP Recommendations:

• Infants and children (1 month or older): 250,000 to 400,000 units/kg/day IV in divided doses every 4 to 6 hours

Maximum dose: 24 million units/day

Pediatric Infectious Diseases Society (PIDS) and IDSA Recommendations:
Infants and children older than 3 months:

• S pneumoniae with penicillin MIC up to 2 mcg/mL: 200,000 to 250,000 units/kg/day IV in divided doses every 4 to 6 hours
• Group A Streptococcus: 100,000 to 250,000 units/kg/day IV in divided doses every 4 to 6 hours

Comments:

• AAP: Recommended for invasive pneumococcal infections (nonmeningeal)
• PIDS/IDSA: Recommended as preferred parenteral therapy for community-acquired pneumonia due to S pneumoniae with penicillin MIC up to 2 mcg/mL or group A Streptococcus
• Current guidelines should be consulted for additional information.

Usual Pediatric Dose for Endocarditis

150,000 to 300,000 units/kg/day IV in divided doses every 4 to 6 hours
Duration of therapy: Depends on the nature and severity of infection

Uses: For the treatment of endocarditis due to susceptible strains of streptococci (including S pneumoniae) and meningococcus

Usual Pediatric Dose for Meningitis - Meningococcal

250,000 units/kg/day IV in equally divided doses every 4 hours
Duration of therapy: 7 to 14 days, depending on nature and severity of infection
Maximum dose: 12 to 20 million units/day

AAP Recommendations: 300,000 units/kg/day IV in divided doses every 4 to 6 hours
Maximum dose: 12 million units/day

IDSA Recommendations:

• Neonates, age 0 to 7 days: 150,000 units/kg/day IV in divided doses every 8 to 12 hours
• Neonates, age 8 to 28 days: 200,000 units/kg/day IV in divided doses every 6 to 8 hours
• Infants and children: 300,000 units/kg/day IV in divided doses every 4 to 6 hours

Maximum dose: 24 million units/day

Comments:

• IDSA: Recommended as an alternative agent for infection due to N meningitidis; considered standard therapy for N meningitidis infection with penicillin MIC less than 0.1 mcg/mL; smaller doses and longer intervals may be appropriate for very low birthweight neonates (less than 2 kg).
• Current guidelines should be consulted for additional information.

Usual Pediatric Dose for Meningitis

250,000 units/kg/day IV in divided doses every 4 hours
Duration of therapy: 7 to 14 days, depending on nature and severity of infection
Maximum dose: 12 to 20 million units/day

Use: For the treatment of meningitis due to susceptible strains of pneumococcus

AAP Recommendations:

• Infants and children (1 month or older): 250,000 to 400,000 units/kg/day IV in divided doses every 4 to 6 hours

Maximum dose: 24 million units/day

IDSA Recommendations:

• Neonates, age 0 to 7 days: 150,000 units/kg/day IV in divided doses every 8 to 12 hours
• Neonates, age 8 to 28 days: 200,000 units/kg/day IV in divided doses every 6 to 8 hours
• Infants and children: 300,000 units/kg/day IV in divided doses every 4 to 6 hours

Maximum dose: 24 million units/day

Duration of therapy:

• L monocytogenes: At least 21 days
• S agalactiae: 14 to 21 days
• S pneumoniae: 10 to 14 days

Comments:

• AAP: Recommended for invasive pneumococcal infections (meningitis)
• IDSA: A recommended agent for infection due to L monocytogenes or S agalactiae; considered standard therapy for S pneumoniae infection with penicillin MIC less than 0.1 mcg/mL; smaller doses and longer intervals may be appropriate for very low birthweight neonates (less than 2 kg).
• Current guidelines should be consulted for additional information.

Usual Pediatric Dose for Meningitis - Pneumococcal

250,000 units/kg/day IV in divided doses every 4 hours
Duration of therapy: 7 to 14 days, depending on nature and severity of infection
Maximum dose: 12 to 20 million units/day

Use: For the treatment of meningitis due to susceptible strains of pneumococcus

AAP Recommendations:

• Infants and children (1 month or older): 250,000 to 400,000 units/kg/day IV in divided doses every 4 to 6 hours

Maximum dose: 24 million units/day

IDSA Recommendations:

• Neonates, age 0 to 7 days: 150,000 units/kg/day IV in divided doses every 8 to 12 hours
• Neonates, age 8 to 28 days: 200,000 units/kg/day IV in divided doses every 6 to 8 hours
• Infants and children: 300,000 units/kg/day IV in divided doses every 4 to 6 hours

Maximum dose: 24 million units/day

Duration of therapy:

• L monocytogenes: At least 21 days
• S agalactiae: 14 to 21 days
• S pneumoniae: 10 to 14 days

Comments:

• AAP: Recommended for invasive pneumococcal infections (meningitis)
• IDSA: A recommended agent for infection due to L monocytogenes or S agalactiae; considered standard therapy for S pneumoniae infection with penicillin MIC less than 0.1 mcg/mL; smaller doses and longer intervals may be appropriate for very low birthweight neonates (less than 2 kg).
• Current guidelines should be consulted for additional information.

Usual Pediatric Dose for Meningitis - Streptococcus Group B

AAP Recommendations:

• Infants 7 days or younger: 250,000 to 450,000 units/kg/day IV in 3 divided doses
• Infants older than 7 days: 450,000 to 500,000 units/kg/day IV in 4 divided doses

Duration of therapy (uncomplicated meningitis): 14 days

Comments:

• Longer duration of therapy may be needed for patients with prolonged or complicated infections.
• Current guidelines should be consulted for additional information.

Usual Pediatric Dose for Congenital Syphilis

1 month or older: 200,000 to 300,000 units/kg/day, administered as 50,000 units/kg IV every 4 to 6 hours for 10 to 14 days

Use: For the treatment of congenital syphilis due to T pallidum

US CDC and AAP Recommendations:
Neonates: 50,000 units/kg IV every 12 hours during the first 7 days of life, then 50,000 units/kg IV every 8 hours
Total duration of therapy: 10 days

1 month or older: 200,000 to 300,000 units/kg/day, administered as 50,000 units/kg IV every 4 to 6 hours for 10 days

Comments:

• Recommended as a preferred regimen for neonates with proven, highly probable, or possible congenital syphilis, for infants and children (1 month or older) who possibly have congenital syphilis or who have neurologic involvement, for children older than 2 years with late and previously untreated congenital syphilis
• US CDC, NIH, HIVMA/IDSA, PIDS, and AAP also recommend this regimen for HIV-exposed and HIV-infected children.
• In neonates, dose should be based on chronological age.
• If more than 1 day of therapy is missed in neonates with proven or highly probable disease, the entire course should be repeated.
• Some experts recommend following this regimen with penicillin G benzathine.
• Current guidelines should be consulted for additional information.

Usual Pediatric Dose for Neurosyphilis

1 month or older: 200,000 to 300,000 units/kg/day, administered as 50,000 units/kg IV every 4 to 6 hours for 10 to 14 days

Use: For the treatment of neurosyphilis due to T pallidum

AAP Recommendations for Patients Older than 1 Month and US CDC, NIH, HIVMA/IDSA, PIDS, and AAP Recommendations for HIV-Exposed and HIV-Infected Children: 200,000 to 300,000 units/kg/day, administered as 50,000 units/kg IV every 4 to 6 hours for 10 to 14 days
Maximum dose: 18 to 24 million units/day

US CDC, NIH, and HIVMA/IDSA Recommendations for HIV-Infected Adolescents: 18 to 24 million units/day, administered as 3 to 4 million units IV every 4 hours or a continuous infusion for 10 to 14 days

Comments:

• Recommended as the preferred regimen for neurosyphilis in patients older than 1 month, for neurosyphilis (including ocular) in HIV-exposed and HIV-infected children, and for neurosyphilis, ocular syphilis, and otic syphilis in HIV-infected adolescents
• Duration of neurosyphilis therapy is shorter than the duration for latent syphilis therapy; penicillin G benzathine can be considered after completing this drug to provide comparable total duration of therapy.
• The patient's sexual partner(s) should also be evaluated/treated.
• Current guidelines should be consulted for additional information.

Usual Pediatric Dose for Inhalation Bacillus anthracis

AAP Recommendations:
Up to 4 weeks of age:

• Gestational age 32 to 34 weeks, up to 1 week of age: 200,000 units/kg/day IV in divided doses every 12 hours
• Gestational age 32 to 34 weeks, 1 to 4 weeks of age: 300,000 units/kg/day IV in divided doses every 8 hours
• Gestational age 34 to 37 weeks and term neonate, up to 1 week of age: 300,000 units/kg/day IV in divided doses every 8 hours
• Gestational age 34 to 37 weeks and term neonate, 1 to 4 weeks of age: 400,000 units/kg/day IV in divided doses every 6 hours

1 month or older: 400,000 units/kg/day IV in divided doses every 4 hours
Maximum dose: 4 million units/dose

Duration of therapy:

• Severe anthrax (up to 4 weeks of age): At least 2 to 3 weeks or until patient is clinically stable (whichever is longer)
• Systemic anthrax with possible/confirmed meningitis (1 month or older): At least 2 to 3 weeks or until patient is clinically stable (whichever is longer)
• Systemic anthrax when meningitis has been excluded (1 month or older): At least 14 days or until patient is clinically stable (whichever is longer)
• Patients will require prophylaxis to complete an antimicrobial regimen of up to 60 days from onset of illness.

Comments:

• Recommended as an alternative agent for the treatment of systemic/severe anthrax due to penicillin-susceptible strains
• Recommended for use with a protein synthesis inhibitor when used for systemic anthrax; the addition of a bactericidal fluoroquinolone is recommended with possible/confirmed meningitis.
• Systemic/severe anthrax includes anthrax meningitis, inhalation anthrax, injection anthrax, gastrointestinal anthrax, and cutaneous anthrax with systemic involvement, extensive edema, or lesions of the head or neck.
• Current guidelines should be consulted for additional information.

Usual Pediatric Dose for Cutaneous Bacillus anthracis

AAP Recommendations:
Up to 4 weeks of age:

• Gestational age 32 to 34 weeks, up to 1 week of age: 200,000 units/kg/day IV in divided doses every 12 hours
• Gestational age 32 to 34 weeks, 1 to 4 weeks of age: 300,000 units/kg/day IV in divided doses every 8 hours
• Gestational age 34 to 37 weeks and term neonate, up to 1 week of age: 300,000 units/kg/day IV in divided doses every 8 hours
• Gestational age 34 to 37 weeks and term neonate, 1 to 4 weeks of age: 400,000 units/kg/day IV in divided doses every 6 hours

1 month or older: 400,000 units/kg/day IV in divided doses every 4 hours
Maximum dose: 4 million units/dose

Duration of therapy:

• Severe anthrax (up to 4 weeks of age): At least 2 to 3 weeks or until patient is clinically stable (whichever is longer)
• Systemic anthrax with possible/confirmed meningitis (1 month or older): At least 2 to 3 weeks or until patient is clinically stable (whichever is longer)
• Systemic anthrax when meningitis has been excluded (1 month or older): At least 14 days or until patient is clinically stable (whichever is longer)
• Patients will require prophylaxis to complete an antimicrobial regimen of up to 60 days from onset of illness.

Comments:

• Recommended as an alternative agent for the treatment of systemic/severe anthrax due to penicillin-susceptible strains
• Recommended for use with a protein synthesis inhibitor when used for systemic anthrax; the addition of a bactericidal fluoroquinolone is recommended with possible/confirmed meningitis.
• Systemic/severe anthrax includes anthrax meningitis, inhalation anthrax, injection anthrax, gastrointestinal anthrax, and cutaneous anthrax with systemic involvement, extensive edema, or lesions of the head or neck.
• Current guidelines should be consulted for additional information.

Usual Pediatric Dose for Diphtheria

150,000 to 250,000 units/kg/day IV in equally divided doses every 6 hours for 7 to 10 days

Uses: For diphtheria (as adjunctive therapy to antitoxin and prevention of carrier state) due to C diphtheriae

AAP Recommendations:
1 month or older: 100,000 to 300,000 units/kg/day IV divided in 4 to 6 doses for 14 days

Comments:

• Antimicrobial therapy is not a substitute for primary therapy (antitoxin).
• Current guidelines should be consulted for additional information.

Usual Pediatric Dose for Rat-bite Fever

150,000 to 250,000 units/kg/day in equally divided doses every 4 hours for 4 weeks

Comments:

• AAP Recommendations: As IV therapy for 5 days to at least 4 weeks; current guidelines should be consulted for additional information.

Uses: For the treatment of Haverhill fever with endocarditis due to S moniliformis; for the treatment of rat-bite fever due to S minus or S moniliformis

Usual Pediatric Dose for Lyme Disease - Arthritis

AAN and IDSA Recommendations:
Children: 200,000 to 400,000 units/kg/day IV in divided doses every 4 hours
Maximum dose: 18 to 24 million units/day
Duration of therapy: 14 days

Comments:

• IDSA recommends this drug as an alternative parenteral regimen for early neurologic disease (meningitis or radiculopathy), cardiac disease, and late disease (recurrent arthritis after oral regimen, central or peripheral nervous system disease).
• Duration of therapy has ranged from 10 to 28 days.
• Current guidelines should be consulted for additional information.

Usual Pediatric Dose for Lyme Disease - Carditis

AAN and IDSA Recommendations:
Children: 200,000 to 400,000 units/kg/day IV in divided doses every 4 hours
Maximum dose: 18 to 24 million units/day
Duration of therapy: 14 days

Comments:

• IDSA recommends this drug as an alternative parenteral regimen for early neurologic disease (meningitis or radiculopathy), cardiac disease, and late disease (recurrent arthritis after oral regimen, central or peripheral nervous system disease).
• Duration of therapy has ranged from 10 to 28 days.
• Current guidelines should be consulted for additional information.

Usual Pediatric Dose for Lyme Disease - Neurologic

AAN and IDSA Recommendations:
Children: 200,000 to 400,000 units/kg/day IV in divided doses every 4 hours
Maximum dose: 18 to 24 million units/day
Duration of therapy: 14 days

Comments:

• IDSA recommends this drug as an alternative parenteral regimen for early neurologic disease (meningitis or radiculopathy), cardiac disease, and late disease (recurrent arthritis after oral regimen, central or peripheral nervous system disease).
• Duration of therapy has ranged from 10 to 28 days.
• Current guidelines should be consulted for additional information.

Usual Pediatric Dose for Skin or Soft Tissue Infection

IDSA Recommendations:
1 month or older: 60,000 to 100,000 units/kg IV every 6 hours
Maximum dose: 2 to 4 million units/dose

Comments:

• Recommended for the treatment of non-purulent skin and soft tissue infection (cellulitis)/streptococcal skin infection
• In combination with clindamycin, recommended as the preferred regimen for the treatment of necrotizing infections of the skin, fascia, and muscle due to Streptococcus or Clostridium species
• Current guidelines should be consulted for additional information.

Usual Pediatric Dose for Tetanus

AAP Recommendations: 100,000 units/kg/day IV in divided doses every 4 to 6 hours
Maximum dose: 12 million units/day
Duration of therapy: 7 to 10 days

Comments:

• Recommended as alternative therapy
• Current guidelines should be consulted for additional information.

Usual Pediatric Dose for Gonococcal Infection - Disseminated

Less than 45 kg:

• Arthritis: 100,000 units/kg/day in 4 equally divided doses for 7 to 10 days
• Meningitis: 250,000 units/kg/day in equally divided doses every 4 hours for 10 to 14 days
• Endocarditis: 250,000 units/kg/day in equally divided doses every 4 hours for 4 weeks

At least 45 kg:

• Arthritis, meningitis, endocarditis: 10 million units/day in equally divided doses
• Duration of therapy: Depends on the type of infection

Comments:

• Due to resistance, penicillins are not recommended by the US CDC.
• Current guidelines should be consulted for additional information.

Use: For the treatment of disseminated gonococcal infections (arthritis, meningitis, endocarditis) due to penicillin-susceptible N gonorrhoeae

Renal Dose Adjustments

Uremic patients with CrCl greater than 10 mL/min/1.73 m2: Administer a full loading dose followed by one-half of the loading dose every 4 to 5 hours.
CrCl less than 10 mL/min/1.73 M2: Administer a full loading dose followed by one-half of the loading dose every 8 to 10 hours.

Comments:

• Additional dose reductions are recommended in patients with liver disease and renal dysfunction.
• Because incompletely developed renal function in neonates may delay elimination of penicillin, appropriate reduction in dose and frequency of administration are recommended.
• Some clinicians recommend a maximum dose of 4 to 10 million units/day in patients with severe renal failure.

Liver Dose Adjustments

Liver dysfunction: No adjustment recommended.

Comments:

• Dose reductions are recommended in patients with liver disease and renal dysfunction.

Dose Adjustments

A reduction in total dose should be considered if any impairment of organ system function (including electrolyte balance, hepatic, renal, and hematopoietic systems, and cardiac and vascular status) occurs or is suspected.

Precautions

CONTRAINDICATIONS:

• History of hypersensitivity (anaphylactic) reaction to any penicillin
• Solutions containing dextrose: Known allergy to corn or corn products

Consult WARNINGS section for additional precautions.

Dialysis

Data not available

Comments:

• Hemodialysis has been shown to reduce penicillin G serum levels.
• Some clinicians recommend a maximum dose of 4 to 10 million units/day in patients with severe renal failure.

Other Comments

Administration advice:

• May administer IM or by continuous IV drip for doses of 5 million units or less; administer the 20 million-unit dose via IV infusion only.
• In general, administer IV when large doses are needed.
• Administer large IV doses (more than 10 million units) slowly as electrolyte imbalances may occur due to the potassium content of this drug.
• Due to its short half-life, administer penicillin G in divided doses, usually every 4 to 6 hours; however, administer every 2 hours when used for meningococcal meningitis/septicemia.
• For most acute infections, continue treatment for at least 48 to 72 hours after patient becomes asymptomatic; for group A beta-hemolytic streptococcal infections, continue treatment for at least 10 days to reduce the risk of rheumatic fever.

Storage requirements:

• Dry powder: Store at below 30C (86F).
• Sterile solution: May store in refrigerator for 7 days without significant loss of potency

Reconstitution/preparation techniques:

• The manufacturer product information should be consulted.

IV compatibility:

• Compatible: Water for Injection, Sterile Isotonic Sodium Chloride Solution for Parenteral Use

General:

• This drug is for the treatment of serious infections due to susceptible strains of the designated bacteria.
• In suspected staphylococcal infections, proper laboratory studies (including susceptibility tests) are recommended.
• To reduce the development of drug-resistant organisms and maintain effective therapy, this drug should be used only to treat or prevent infections proven or strongly suspected to be caused by susceptible bacteria.
• Culture and susceptibility information should be considered when selecting/modifying antibacterial therapy or, if no data are available, local epidemiology and susceptibility patterns may be considered when selecting empiric therapy.
• Appropriate culture and susceptibility testing recommended before therapy to isolate and identify infecting organisms and to establish susceptibility to this drug. Therapy may be started before test results are known; appropriate therapy should be continued when results are available.

Monitoring:

• Cardiovascular: Cardiac and vascular status (periodically during prolonged therapy with high doses of IV penicillin G)
• General: For clinical and laboratory signs of toxicity in all neonates; organ system function (periodically during prolonged therapy with high doses of IV penicillin G)
• Hematologic: Hematopoietic system function (periodically during prolonged therapy with high doses of IV penicillin G)
• Hepatic: Hepatic system function (periodically during prolonged therapy with high doses of IV penicillin G)
• Metabolic: Electrolyte balance (frequently during prolonged therapy with high doses of IV penicillin G)
• Renal: Renal system function (periodically during prolonged therapy with high doses of IV penicillin G)

Patient advice:

• Avoid missing doses and complete the entire course of therapy.
• Contact physician as soon as possible if watery and bloody stools (with or without stomach cramps and fever) develop.