Label: PENICILLIN G SODIUM- penicillin g sodium injection, powder, for solution

  • NDC Code(s): 0781-6153-95, 0781-6153-97
  • Packager: Sandoz Inc
  • Category: HUMAN PRESCRIPTION DRUG LABEL
  • DEA Schedule: None
  • Marketing Status: Abbreviated New Drug Application

Drug Label Information

Updated May 12, 2014

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  • SPL UNCLASSIFIED SECTION

    To reduce the development of drug-resistant bacteria and maintain the effectiveness of penicillin G sodium and other antibacterial drugs, penicillin G sodium should be used only to treat or prevent infections that are proven or strongly suspected to be caused by bacteria.

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  • DESCRIPTION

    Penicillin G sodium for Injection, USP is sterile penicillin G sodium powder for reconstitution. It is an antibacterial agent intended for intravenous or intramuscularly use.

    Chemically, penicillin G sodium is designated 4-Thia-1-azabicyclo(3.2.0)-heptane-2-carboxylic acid,3,3-dimethyl-7-oxo-6-[(phenylacetyl)amino]-, [2S -(2α, 5α, 6β)]-, monosodium salt and has the following structural formula:

    Penicillin G Sodium Chemical Structure

    Penicillin G sodium, a water soluble benzylpenicillin, is a white to almost white crystalline powder which is almost odorless and/or after reconstitution a colorless solution. The pH of freshly constituted solutions usually ranges from 5.0 to 7.5.

    Penicillin G sodium for Injection, USP is supplied in vials equivalent to 5,000,000 units (5 million units) of penicillin G as the sodium salt, with 1.68 mEq of sodium per million units of penicillin G.

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  • CLINICAL PHARMACOLOGY

    After an intravenous infusion of penicillin G, peak serum concentrations are attained immediately after completion of the infusion. In a study of ten patients administered a single 5 million unit dose of penicillin G intravenously over 3 to 5 minutes, the mean serum concentrations were 400 mcg/mL, 273 mcg/mL and 3 mcg/mL at 5 to 6 minutes, 10 minutes and 4 hours after completion of the injection, respectively. In a separate study, five healthy adults were administered one million units of penicillin G intravenously, either as a bolus over 4 minutes or as an infusion over 60 minutes. The mean serum concentration eight minutes after completion of the bolus was 45 mcg/mL and eight minutes after completion of the infusion was 14.4 mcg/mL.

    The mean β-phase serum half-life of penicillin G administered by the intravenous route in ten patients with normal renal function was 42 minutes, with a range of 31 to 50 minutes.

    The clearance of penicillin G in normal individuals is predominantly via the kidney. The renal clearance, which is extremely rapid, is the result of glomerular filtration and active tubular transport, with the latter route predominating. Urinary recovery is reported to be 58 to 85% of the administered dose. Renal clearance of penicillin is delayed in premature infants, neonates and in the elderly due to decreased renal function. The serum half-life of penicillin G correlates inversely with age and clearance of creatinine and ranges from 3.2 hours in infants 0 to 6 days of age to 1.4 hours in infants 14 days of age or older.

    Nonrenal clearance includes hepatic metabolism and, to a lesser extent, biliary excretion. The latter routes become more important with renal impairment.

    Probenecid blocks the renal tubular secretion of penicillin. Therefore, the concurrent administration of probenecid prolongs the elimination of penicillin G and, consequently, increases the serum concentrations.

    Penicillin G is distributed to more areas of the body including lung, liver, kidney, muscle, bone and placenta. In the presence of inflammation, levels of penicillin in abscesses, middle ear, pleural, peritoneal and synovial fluids are sufficient to inhibit most susceptible bacteria. Penetration into the eye, brain, cerebrospinal fluid (CSF) or prostate is poor in the absence of inflammation. With inflamed meninges, the penetration of penicillin G into the CSF improves, such that the CSF/serum ratio is 2 to 6%. Inflammation also enhances its penetration into the pericardial fluid. Penicillin G is actively secreted into the bile resulting in levels at least 10 times those achieved simultaneously in serum. Penicillin G penetrates poorly into human polymorphonuclear leukocytes.

    In the presence of impaired renal function, the β-phase serum half-life of penicillin G is prolonged. β-phase serum half-lives of one to two hours were observed in azotemic patients with serum creatinine concentrations <3 mg/100 mL and ranged as high as 20 hours in anuric patients. A linear relationship, including the lowest range of renal function, is found between the serum elimination rate constant and renal function as measured by creatinine clearance.

    In patients with altered renal function, the presence of hepatic insufficiency further alters the elimination of penicillin G. In one study, the serum half-lives in two anuric patients (excreting <400 mL urine/day) were 7.2 and 10.1 hours. A totally anuric patient with terminal hepatic cirrhosis had a penicillin half-life of 30.5 hours, while another patient with anuria and liver disease had a serum half-life of 16.4 hours.The dosage of penicillin G should be reduced in patients with severe renal impairment, with additional modifications when hepatic disease accompanies the renal impairment.

    Hemodialysis has been shown to reduce penicillin G serum levels.

    Microbiology

    Penicillin G is bactericidal against penicillin-susceptible microorganisms during the stage of active multiplication. It acts by inhibiting biosynthesis of cell-wall mucopeptide. It is not active against the penicillinase-producing bacteria, which include many strains of staphylococci. Penicillin G is highly active in vitro against staphylococci (except penicillinase-producing strains), streptococci (groups A, B, C, G, H, L and M), pneumococci and Neisseria meningitidis. Other organisms susceptible in vitro to penicillin G are Neisseria gonorrhoeae, Corynebacteriumdiphtheriae, Bacillus anthracis, clostridia, Actinomyces species, Spirillum minus, Streptobacillusmonillformis, Listeria monocytogenes, and leptospira; Treponemapallidum is extremely susceptible.

    Some species of gram-negative bacilli were previously considered susceptible to very high intravenous doses of penicillin G (up to 80 million units/day) including some strains of Escherichia coli, Proteus mirabilis, salmonella, shigella, Enterobacteraerogenes (formerly Aerobacteraerogenes) and Alcaligenesfaecalis. Penicillin G is no longer considered a drug of choice for infections caused by these organisms.

    Susceptibility Testing

    Diffusion Techniques

    Quantitative methods that require measurement of zone diameters provide reproducible estimates of the susceptibility of bacteria to antimicrobial compounds. One such standardized procedure1,2 which has been recommended for use with disks to test susceptibility of organisms to penicillin G uses the 10 Unit (U) penicillin disk. Interpretation involves the correlation of the diameters obtained in the disk test with the minimum inhibitory concentration (MIC) for penicillin G.

    Reports from the laboratory providing results of the standard single-disk susceptibility test with a 10 U penicillin disk should be interpreted according to the criteria provided in Table 1.

    Dilution Techniques

    Quantitative methods that are used to determine minimum inhibitory concentrations (MICs) provide reproducible estimates of the susceptibility of bacteria to antimicrobial compounds. One such standardized procedure1,3 uses a standardized dilution method (broth or agar) or equivalent with penicillin powder. The MIC values obtained should be interpreted according to the criteria provided in Table 1.

    Table 1: Susceptibility Interpretive Criteria
    Susceptibility Test Result Interpretive Criteria
    Pathogen Disk diffusion
    (Zone diameter in mm)
    Minimal Inhibitory
    Concentration
    (MIC in mcg/mL)

    S

    I

    R

    S

    I

    R

    Staphylococcus spp.

    ≥29

    -

    ≤28

    ≤0.12

    -

    ≥0.25

    Neisseria gonorrhoeae

    ≥47

    27-46

    ≤26

    ≤0.06

    0.12-1

    ≥2

    Streptococcus spp.

    (beta-hemolytic group)

    ≥24

    -

    -

    ≤0.12

    -

    -

    Streptococcus spp.

    (viridans group)

    ≤0.12

    0.25-2

    ≥4

    Streptococcuspneumoniae (meningitis isolates)

    ≤0.06

    -

    ≥0.12

    Streptococcuspneumoniae (non-meningitis isolates)

    ≤2

    4

    ≥8

    Neisseria meningitidis

    ≤ 0.06

    0.12-0.25

    ≥0.5

    Bacillus anthracis

    ≤0.12

    ≥0.25

    A report of “susceptible” indicates that the pathogen is likely to be inhibited by usually achievable concentrations of the antimicrobial compound in the blood. A report of “Intermediate” (I) indicates that the result should be considered equivocal, 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 the drug can be used. This category also provides a buffer zone that 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.

    Quality Control

    Standardized susceptibility test procedures require the use of laboratory control microorganisms1,2,3. The 10 U penicillin G disk and the standard penicillin powder should provide respectively the following zone diameters and MIC values in these laboratory test quality control strains:

    Table 2. Acceptable Quality Control Ranges
    Acceptable Quality Control Ranges
    Microorganism Disk diffusion
    (Zone diameter ranges
    in mm)
    Minimal Inhibitory
    Concentration Range
    (MIC in mcg/mL)

    Enterococcus faecalis

    ATCC® 29212

    1-4

    Neisseria gonorrhoeae

    ATCC® 49226

    26-34

    0.25-1

    (agar dilution method)

    Staphylococcus aureus

    ATCC® 25923

    26-37

    Staphylococcus aureus

    ATCC® 29213

    0.25-2

    Streptococcus pneumoniae

    ATCC® 49619

    24-30

    0.25-1

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  • INDICATIONS AND USAGE

    Therapy

    Penicillin G Sodium for Injection, USP is indicated in the treatment of serious infections caused by susceptible strains of the designated microorganisms in the conditions listed below. Appropriate culture and susceptibility tests should be done before treatment in order to isolate and identify organisms causing infection and to determine their susceptibility to penicillin G. Therapy with Penicillin G Sodium for Injection, USP may be initiated before results of such tests are known when there is reason to believe the infection may involve any of the organisms listed below, however, once these results become available, appropriate therapy should be continued.

    Clinical Indication Infecting Organism

    Septicemia, empyema,

    pneumonia, pericarditis,

    endocarditis, meningitis

    Streptococcus pyogenes

    (group A β-hemolytic

    streptococcus), other

    β-hemolytic streptococci

    including groups C, H, G, L

    and M, Streptococcus

    pneumoniae and

    Staphylococcus species (non-

    penicillinase producing strains)

    Anthrax

    Bacillus anthracis

    Actinomycosis (cervico-

    facial disease and

    thoracic and abdominal

    disease)

    ActinomycesIsraelil

    Botulism (adjunctive

    therapy to antitoxin),

    gas gangrene, and

    tetanus (adjunctive

    therapy to human

    tetanus immune globulin)

    Clostridium species

    Diphtheria (adjunctive

    therapy to antitoxin and

    prevention of the carrier

    state)

    Corynebacterium

    diphtheriae

    Erysipelothrix

    endocarditis

    Erysipelothrix

    rhusiopthiae

    Fusospirochetosis

    (severe infections of the

    oropharynx [Vincent’s],

    lower respiratory tract

    and genital area)

    Fusobacterium species

    and spirochetes

    Listeria infections

    including meningitis and

    endocarditis

    Listeria monocytogenes

    Pasteurella infections

    including bacteremia and

    meningitis

    Pasteurellamultocida

    Haverhill fever

    Streptobacillus

    moniliformis

    Rat-bite fever

    Spirillum minus or

    Streptobacillus

    moniliformis

    Disseminated gonococcal

    infections

    Neisseria gonorrhoeae

    (penicillin-susceptible)

    Syphilis (congenital and

    neurosyphilis)

    Treponemapallidum

    Meningococcal

    meningitis and/or

    septicemia

    Neisseria meningitidis

    Gram-negative bacillary

    infections (bacteremias)

    Escherichia coli,

    Enterobacter aerogenes,

    Alcaligenes faecalis,

    salmonella, shigella and

    Proteus mirabilis, Penicillin G

    is not the drug of choice in the

    treatment of gram-negative

    bacillary infections.

    To reduce the development of drug-resistant bacteria and maintain the effectiveness of penicillin G sodium and other antibacterial drugs, penicillin G sodium should be used only to treat or prevent infections that are proven or strongly suspected to be caused by susceptible bacteria. When culture and susceptibility information are available, they should be considered in selecting or modifying antibacterial therapy. In the absence of such data, local epidemiology and susceptibility patterns may contribute to the empiric selection of therapy.

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  • CONTRAINDICATIONS

    A history of hypersensitivity (anaphylactic) reaction to any penicillin is a contraindication.

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  • WARNINGS

    SERIOUS AND OCCASIONALLY FATAL HYPERSENSITIVITY (anaphylactic) REACTIONS HAVE BEEN REPORTED IN PATIENTS ON PENICILLIN THERAPY. THESE REACTIONS ARE MORE LIKELY TO OCCUR IN INDIVIDUALS WITH A HISTORY OF PENICILLIN HYPERSENSITIVITY AND/OR A HISTORY OF SENSITIVITY TO MULTIPLE ALLERGENS. THERE HAVE BEEN REPORTS OF INDIVIDUALS WITH A HISTORY OF PENICILLIN HYPERSENSITIVITY WHO HAVE EXPERIENCED SEVERE REACTIONS WHEN TREATED WITH CEPHALOSPORINS. BEFORE INITIATING THERAPY WITH PENICILLIN G, CAREFUL INQUIRY SHOULD BE MADE CONCERNING PREVIOUS HYPERSENSITIVITY REACTIONS TO PENICILLINS, CEPHALOSPORINS, OR OTHER ALLERGENS. IF AN ALLERGIC REACTION OCCURS, PENICILLIN G SHOULD BE DISCONTINUED AND APPROPRIATE THERAPY INSTITUTED. SERIOUS ANAPHYLACTIC REACTIONS REQUIRE IMMEDIATE EMERGENCY TREATMENT WITH EPINEPHRINE. OXYGEN, INTRAVENOUS STEROIDS, AND AIRWAY MANAGEMENT, INCLUDING INTUBATION, SHOULD ALSO BE ADMINISTERED AS INDICATED.

    Clostridium difficile associated diarrhea (CDAD) has been reported with use of nearly all antibacterial agents, including penicillin G sodium, and may range in severity from mild diarrhea to fatal colitis. Treatment with antibacterial agents alters the normal flora of the colon leading to overgrowth of C. difficile.

    C. difficile produces toxins A and B which contribute to the development of CDAD. Hypertoxin producing strains of C. difficile cause increased morbidity and mortality, as these infections can be refractory to antimicrobial therapy and may require colectomy. CDAD must be considered in all patients who present with diarrhea following antibiotic use. Careful medical history is necessary since CDAD has been reported to occur over two months after the administration of antibacterial agents.

    If CDAD is suspected or confirmed, ongoing antibiotic use not directed against C. difficile may need to be discontinued. Appropriate fluid and electrolyte management, protein supplementation, antibiotic treatment of C. difficile, and surgical evaluation should be instituted as clinically indicated.

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  • PRECAUTIONS

    General

    Penicillin should be used with caution in individuals with histories of significant allergies and/or asthma (see WARNINGS). Whenever allergic reactions occur, penicillin should be withdrawn unless, in the opinion of the physician, the condition being treated is life-threatening and amenable only to penicillin therapy.

    Penicillin G Sodium for lnjection, USP by the intravenous route in high doses (above 10 million units) should be administered slowly because of the potential adverse effects of electrolyte imbalance from the sodium content of the penicillin. Penicillin G Sodium for lnjection, USP contains 1.68 mEq of sodium per million units of penicillin G.

    The use of antibiotics may promote overgrowth of nonsusceptible organisms, including fungi. Indwelling intravenous catheters encourage superinfections. Should superinfection occur, appropriate measures should be taken.

    When indicated, incision and drainage or other surgical procedures should be performed in conjunction with antibiotic therapy.

    Prescribing penicillin G sodium 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.

    Laboratory Tests

    Periodic assessment of organ system function, including frequent evaluation of electrolyte balance, hepatic, renal and hematopoietic systems, and cardiac and vascular status should be performed during prolonged therapy with high doses of intravenous penicillin G (see ADVERSE REACTIONS). If any impairment of function is suspected or known to exist, a reduction in the total dosage should be considered (see DOSAGE AND ADMINISTRATION).

    In suspected staphylococcal infections, proper laboratory studies, including susceptibility tests should be performed.

    All infections due to Group A beta-hemolytic streptococci should be treated for at least 10 days.

    Patients being treated for gonococcal infection should have a serologic test for syphilis before receiving penicillin. All cases of penicillin treated syphilis should receive adequate follow-up including clinical and serological examinations. The recommended follow-up varies with the stage of syphilis being treated. See CDC recommendations.

    Drug Interactions

    Bacteriostatic antibacterials (i.e., chloramphenicol, erythromycins, sulfonamides or tetracyclines) may antagonize the bactericidal effect of penicillin, and concurrent use of these drugs should be avoided. This has been documented in vitro, however, the clinical significance of this interaction is not well-documented.

    Penicillin blood levels may be prolonged by concurrent administration of probenecid which blocks the renal tubular secretion of penicillins.

    Other drugs may compete with Penicillin G for renal tubular secretion and thus prolong the serum half-life of penicillin. These drugs include: aspirin, phenylbutazone, sulfonamides, indomethacin, thiazide diuretics, furosemide and ethacrynic acid.

    Drug/Laboratory Test Interactions

    After treatment with penicillin G, a false-positive reaction for glucose in the urine may occur with Benedict’s solution, Fehling’s solution or Clinitest® tablet, but not with the enzyme-based tests, such as Clinistix® and Tes-Tape®.

    Penicillin G has been associated with pseudoproteinuria by certain test methods.

    Carcinogenesis, Mutagenesis, Impairment of Fertility

    No long-term animal studies have been conducted with this drug.

    Pregnancy

    Teratogenic Effects

    Pregnancy Category B

    Reproduction studies performed in the mouse, rat, and rabbit have revealed no evidence of impaired fertility or harm to the fetus due to penicillin G. Human experience with the penicillins during pregnancy has not shown any positive evidence of adverse effects on the fetus. There are, however, no adequate and well controlled studies in pregnant women showing conclusively that harmful effects of these drugs on the fetus can be excluded. Because animal reproduction studies are not always predictive of human response, this drug should be used during pregnancy only if clearly needed.

    Nursing Mothers

    Penicillins are excreted in human milk. Caution should be exercised when penicillins are administered to a nursing woman.

    Pediatric Use

    lncompletely developed renal function in newborns may delay elimination of penicillin; therefore, appropriate reductions in the dosage and frequency of administration should be made in these patients. All newborns treated with penicillins should be monitored closely for clinical and laboratory evidence of toxic or adverse effects (see PRECAUTIONS).

    Pediatric doses are generally determined on a weight basis and should be calculated for each patient individually. Recommended guidelines for pediatric dosages are presented in DOSAGE AND ADMINISTRATION.

    The potential for toxic effects in children from chemicals that may leach from the single dose premixed intravenous preparation in plastic containers has not been evaluated.

    Information for Patients

    Patients should be counseled that antibacterial drugs including penicillin G sodium should only be used to treat bacterial infections. They do not treat viral infections (e.g., the common cold). When penicillin G sodium is prescribed to treat a bacterial infection, patients should be told that although it is common to feel better early in the course of therapy, the medication should be taken exactly as directed. Skipping doses or not completing the full course of therapy may: (1) decrease the effectiveness of the immediate treatment, and (2) increase the likelihood that bacteria will develop resistance and will not be treatable by penicillin G sodium or other antibacterial drugs in the future.

    Diarrhea is a common problem caused by antibiotics which usually ends when the antibiotic is discontinued. Sometimes after starting treatment with antibiotics, patients can develop watery and bloody stools (with or without stomach cramps and fever) even as late as two or more months after having taken the last dose of the antibiotic. If this occurs, patients should contact their physician as soon as possible.

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  • ADVERSE REACTIONS

    Body as a Whole

    The Jarisch-Herxheimer reaction is a systemic reaction, that may occur after the initiation of penicillin therapy in patients with syphilis or other spirochetal infections (i.e., Lyme disease and Relapsing fever). The reaction begins one to two hours after initiation of therapy and disappears within 12 to 24 hours. It is characterized by fever, chills, myalgias, headache, exacerbation of cutaneous lesions, tachycardia, hyperventiliation, vasodilation with flushing and mild hypotension. The pathogenesis of the Herxheimer reaction may be due to the release from the spirochaete of host stable pyrogen.

    Hypersensitivity Reactions

    The reported incidence of allergic reactions to all penicillins ranges from 0.7 to 10 percent in different studies (see WARNINGS). Sensitization is usually the result of previous treatment with a penicillin, but some individuals have had immediate reactions when first treated. In such cases, it is postulated that prior exposure to penicillin may have occurred via trace amounts present in milk or vaccines.

    Two types of allergic reactions to penicillin are noted clinically – Immediate and delayed.

    Immediate reactions usually occur within 20 minutes of administration and range in severity from urticaria and pruritus to angloneurotic edema, laryngospasm, bronchospasm, hypotension, vascular collapse and death (see WARNINGS). Such immediate anaphylactic reactions are very rare and usually occur after parenteral therapy, but a few cases of anaphylaxis have been reported following oral therapy. Another type of immediate reaction, an accelerated reaction, may occur between 20 minutes and 45 hours after administration and may include urticaria, pruritus, fever and, occasionally, laryngeal edema.

    Delayed reactions to penicillin therapy usually occur within 1 to 2 weeks after initiation of therapy. Manifestations include serum sickness-like symptoms, i.e., fever, malaise, urticaria, myalgia, arthralgia, abdominal pain and various skin rashes, ranging from maculopapular eruptions to exfoliative dermatitis.

    Contact dermatitis has been observed in individuals who prepare penicillin solutions.

    Gastrointestinal System

    Pseudomembranous colitis has been reported with the onset occurring during or after penicillin G treatment. Nausea, vomiting, stomatitis, black or hairy tongue, and other symptoms of gastrointestinal irritation may occur, especially during oral therapy.

    Hematologic System

    Reactions include neutropenia, which resolves after penicillin therapy is discontinued; Coombs-positive hemolytic anemia, an uncommon reaction, occurs in patients treated with intravenous penicillin G in doses greater than 10 million units/day and who have previously received large doses of the drug; and with large doses of penicillin, a bleeding diathesis, can occur secondary to platelet dysfunction.

    Metabolic

    Penicillin G Sodium for lnjection, USP (1 million units contains 1.68 mEq of sodium ion) may cause serious and even fatal electrolyte disturbances when given intravenously in large doses.

    Cardiovascular System

    High dosage of penicillin G sodium may result in congestive heart failure due to high sodium intake.

    Nervous System

    Neurotoxic reactions including hyperreflexia, myoclonic twitches, seizures and coma have been reported following the administration of massive intravenous doses, and are more likely in patients with impaired renal function.

    Urogenital System

    Renal tubular damage and interstitial nephritis have been associated with large intravenous doses of penicillin G. Manifestations of this reaction may include fever, rash, eosinophilia, proteinuria, eosinophiluria, hematuria and a rise in serum urea nitrogen. Discontinuation of penicillin G results in resolution in the majority of patients.

    Local Reactions

    Phlebitis and thrombophlebitis may occur with intravenous administration.

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  • OVERDOSAGE

    Dose related toxicity may arise with the use of massive doses of intravenous penicillins (40 to 100 million units per day), particularly in patients with severe renal impairment (see PRECAUTIONS). The manifestations may include agitation, confusion, asterixis, hallucinations, stupor, coma, multifocal myocionus, seizures and encephalopathy. Hyperkalemia is also possible (see ADVERSE REACTIONS: Metabolic).

    In case of overdosage, discontinue penicillin, treat symptomatically and institute supportive measures as required. If necessary, hemodialysis may be used to reduce blood levels of penicillin G, although the degree of effectiveness of this procedure is questionable.

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  • DOSAGE AND ADMINISTRATION

    Penicillin G Sodium for lnjection, USP may be given intravenously or intramuscularly. The usual dose recommendations are as follows:

    Adult Patients

    Clinical Indication Dosage

    Serious infections due to

    susceptible strains of

    streptococci (including

    S. pneumoniae) and

    staphylococci-septicemia,

    empyema, pneumonia,

    pericarditis, endocarditis and

    meningitis

    5 to 24 million units/day

    depending on the infection

    and its severity administered

    in equally divided doses

    every 4 to 6 hours

    Anthrax

    Minimum of 8 million

    units/day in divided doses

    every 6 hours. Higher doses

    may be required depending

    on susceptibility of organism.

    Actinomycosis

      Cervicofacial disease

    1 to 6 million units/day(*)

      Thoracic and abdominal

        disease

    10 to 20 million units/day(*)

    Clostridial infections

      Botulism (adjunctive

        therapy to antitoxin)

      Gas gangrene

        (debridement and/or

        surgery as indicated)

      Tetanus (adjunctive

        therapy to human tetanus

        immune globulin)

    20 million units/day(*)

    Diphtheria (adjunctive therapy

    to antitoxin and for the

    prevention of the carrier state)

    2 to 3 million units/day in

    divided doses for 10 to

    12 days(*)

    Erysipelothrix

    endocarditis

    12 to 20 million units/day for

    4 to 6 weeks(*)

    Fusospirochetosis

    (severe infections of the

    oropharnyx [Vincent’s], lower

    respiratory tract

    and genital area)

    5 to 10 million

    units/day(*)

    Listeria infections

      Meningitis

    15 to 20 million units/day for

    2 weeks(*)

      Endocarditis

    15 to 20 million units/day for

    4 weeks(*)

    Pasteurella infections including

    bacteremia and meningitis

    4 to 6 million units/day for

    2 weeks(*)

    Haverhill fever, Rat-bite fever

    12 to 20 million units/day for

    3 to 4 weeks(*)

    Disseminated gonococcal

    infections, such as meningitis

    endocarditis, arthritis, etc.,

    caused by penicillin-

    susceptible organisms

    10 million units/day(*);

    duration depends on the type

    of infection

    Syphilis (neurosyphilis)

    12 to 24 million units/day, as

    2 to 4 MU every 4 hours for

    10 to 14 days; many experts

    recommend additional

    therapy with Benzathine PCN

    G 2.4 MU IM weekly for

    3 doses after completion of

    IV therapy

    Meningococcal meningitis

    and/or septicemia

    24 million units/day as

    2 million units every 2 hours

    Serious infections, such as

    pneumonia and endocarditis,

    due to susceptible strains of

    streptococci (including S.

    pneumoniae) and

    meningococcus

    150,000 units/kg/day

    divided in equal doses every

    4 to 6 hours; duration

    depends on infecting

    organism and type of

    infection

    Meningitis caused by

    susceptible strains of

    pneumococcus and

    meningococcus

    250,000 units/kg/day

    divided in equal doses every

    4 hours for 7 to 14 days

    depending on the infecting

    organism (maximum dose of

    12 to 20 million units/day)

    Disseminated

    Gonococcal infections

    (penicillin-susceptible

    strains)

    weight 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

    equal doses every

    4 hours for 10 to 14 days

      Endocarditis

    250,000 units/kg/day in

    equal doses every 4 hours

    for 4 weeks

    Arthritis, meningitis,

    endocarditis

    weight 45 kg or greater:

    10 million units/day in

    4 equally divided doses with

    the duration of therapy

    depending on the type of

    infection

    Syphilis (congenital and

    neurosyphilis) after the

    newborn period

    200,000 to 300,000

    units/kg/day (administered as

    50,000 units/kg every 4 to 6

    hours) for 10 to 14 days

    Diphtheria (adjunctive therapy

    to antitoxin and for prevention

    of the carrier state)

    150,000 to 250,000

    units/kg/day in equal doses

    every 6 hours for 7 to 10

    days

    Rat-bite fever; Haverhill fever

    (with endocarditis caused by

    S. moniliformis)

    150,000 to 250,000

    units/kg/day in equal doses

    every 4 hours for 4 weeks

    *Because of its short half-life, Penicillin G is administered in divided doses, usually every 4 to 6 hours with the exception of meningococcal meningitis/septicemia, i.e., every 2 hours.

    Pediatric Patients

    This product should not be administered to patients requiring less than one million units per dose. (see PRECAUTIONS: Pediatric Use).

    Renal Impairment

    Penicillin G is relatively nontoxic, and dosage adjustments are generally required only in cases of severe renal impairment.

    The recommended dosage regimens are as follows:

    Creatinine clearance less than 10 mL/min/1.73 m2; administer a full loading dose (see recommended dosages in the tables above) followed by one-half of the loading dose every 8 to 10 hours.

    Uremic patients with a creatinine clearance greater than 10 mL/min/1.73m2; administer a full loading dose (see recommended dosages in the tables above) followed by one-half of the loading dose every 4 to 5 hours.

    Additional dosage modifications should be made in patients with hepatic disease and renal impairment.

    For most acute infections, treatment should be continued for at least 48 to 72 hours after the patient becomes asymptomatic. Antibiotic therapy for Group A β-hemolytic streptococcal infections should be maintained for at least 10 days to reduce the risk of rheumatic fever.

    Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration whenever solution and container permit.

    Preparation of Solution

    Solutions of penicillin should be prepared as follows: Loosen powder. Hold vial horizontally and rotate it while slowly directing the stream of diluent against the wall of the vial. Shake vial vigorously after all the diluent has been added. Depending on the route of administration, use Sterile Water for Injection, USP, 0.9% Sodium Chloride Injection, USP, or Dextrose Injections, USP.

    Note: Penicillins are rapidly inactivated in the presence of carbohydrate solutions at alkaline pH.

    PREPARATION OF SOLUTION – 5 million units
    Diluent Added Final Concentration

    8 mL

    500,000 units/mL

    3 mL

    1,000,000 units/mL

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  • HOW SUPPLIED

    Penicillin G Sodium for lnjection, USP, for IM or IV use, is supplied in dry powder form in vials containing 5,000,000 units (5 million units) of crystalline penicillin G as the sodium salt, with 1.68 mEq of sodium per million units of penicillin G, in tray packs of 10 (NDC 0781-6153-95) and in tray packs of 50 (NDC 0781-6153-97).

    STORAGE

    Store dry powder at 20°-25°C (68°-77°F) (see USP Controlled Room Temperature).

    Sterile constituted solution may be kept in refrigerator (2° to 8°C) for 3 days without significant loss of potency.

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  • REFERENCES

    1.
    Clinical and Laboratory Standards Institute. Performance Standards for Antimicrobial Susceptibility Testing; Twenty-Second Informational Supplement. CLSI document M100-S22. Clinical and Laboratory Standards Institute, 950 West Valley Road, Suite 2500, Wayne, Pennsylvania 19087, USA, 2012.
    2.
    Clinical and Laboratory Standards Institute. Performance Standards for Antimicrobial Disk Susceptibility Test; Approved Standard-Eleventh Edition. CLSI document M02-A11. Clinical and Laboratory Standards Institute, 950 West Valley Road, Suite 2500, Wayne, Pennsylvania 19087, USA, 2012.
    3.
    Clinical and Laboratory Standards Institute. Methods for Dilution Antimicrobial Susceptibility Test for Bacteria That Grow Aerobically; Approved Standard-Ninth Edition. CLSI document M07-A9. Clinical and Laboratory Standards Institute, 950 West Valley Road, Suite 2500, Wayne, Pennsylvania 19087, USA, 2012.

    46079166

    05-2014M

    Manufactured in Austria by Sandoz GmbH

    for Sandoz Inc., Princeton, NJ 08540

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  • 5,000,000 Unit Vial Label

    NDC 0781-6153-94

    Penicillin G Sodium

    for Injection, USP

    5,000,000 Units*

    (5 million units)

    For IM or IV use

    Rx only

    SANDOZ

    5,000,000 Unit Vial Label
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  • INGREDIENTS AND APPEARANCE
    PENICILLIN G SODIUM 
    penicillin g sodium injection, powder, for solution
    Product Information
    Product Type HUMAN PRESCRIPTION DRUG Item Code (Source) NDC:0781-6153
    Route of Administration INTRAMUSCULAR, INTRAVENOUS
    Active Ingredient/Active Moiety
    Ingredient Name Basis of Strength Strength
    PENICILLIN G SODIUM (UNII: YS5LY7JF4N) (PENICILLIN G - UNII:Q42T66VG0C) PENICILLIN G 5000000 [USP'U]
    Packaging
    # Item Code Package Description Marketing Start Date Marketing End Date
    1 NDC:0781-6153-95 10 in 1 CARTON
    1 1 in 1 VIAL
    2 NDC:0781-6153-97 50 in 1 CARTON
    2 1 in 1 VIAL
    Marketing Information
    Marketing Category Application Number or Monograph Citation Marketing Start Date Marketing End Date
    ANDA ANDA065068 02/26/2001
    Labeler - Sandoz Inc (110342024)
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