Version May 2024
Not for IV use. Do not inject IV or admix with other IV solutions. There have been reports of inadvertent IV administration of penicillin G benzathine, which has been associated with cardiorespiratory arrest and death. Prior to administration of this drug, carefully read the Warnings, Adverse Reactions, and Administration and Dosage sections of the labeling.
Note: Doses are expressed in units of total penicillin. Penicillin G benzathine and penicillin G procaine is available as 2 separate products: Bicillin C-R 900/300 (benzathine and procaine components in a 3:1 ratio and only approved in infants and children) and Bicillin C-R (benzathine and procaine components in a 1:1 ratio); use caution to ensure appropriate product selection as they are not interchangeable. Bicillin C-R 600,000 unit and 2.4 million unit syringes have been discontinued in the United States for >1 year. Bicillin C-R 1.2 million unit syringes are still available.
Pneumococcal infections:
Note: Not to be used for treatment of pneumococcal meningitis. For meningitis and other severe pneumococcal infections, use other formulations of penicillin.
IM: 1.2 million units on day 1; may be repeated every 2 or 3 days until afebrile for 48 hours.
Streptococcus, group A:
Note: For treatment of group A streptococcal pharyngitis in adults, penicillin G benzathine (Bicillin L-A) is preferred (Ref).
IM: 2.4 million units as a single dose. Alternative dosing: 1.2 million units on day 1 and 1.2 million units on day 3.
Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
There are no dosage adjustments provided in manufacturer's labeling.
There are no dosage adjustments provided in manufacturer's labeling.
Refer to adult dosing.
(For additional information see "Penicillin G benzathine and penicillin G procaine (mixture of long and intermediate-acting intramuscular): Pediatric drug information")
Note: Doses are expressed in units of total penicillin. Penicillin G benzathine and penicillin G procaine is available as 2 separate products: Bicillin C-R 900/300 (benzathine and procaine components in a 3:1 ratio and only approved in infants and children) and Bicillin C-R (benzathine and procaine components in a 1:1 ratio); use caution to ensure appropriate product selection; they are not interchangeable. Bicillin C-R 600,000 unit and 2.4 million unit syringes have been discontinued in the United States for more than 1 year; Bicillin C-R 1.2 million unit syringes are still available, but syringes do not contain graduation marks.
Otitis media or pneumonia caused by Streptococcus pneumoniae: Note: Current guidelines do not include penicillin G benzathine and penicillin G procaine as a therapeutic option (Ref). For severe cases, use other forms of penicillin (Ref).
Infants and Children:
Bicillin C-R: IM: 600,000 units every 2 to 3 days until afebrile for 48 hours.
Bicillin C-R 900/300: IM: 1.2 million units every 2 or 3 days until afebrile for 48 hours.
Streptococcus, group A; pharyngitis/tonsillitis or skin and soft tissue infection (SSTI): Note: Although FDA approved, the combination product with penicillin G benzathine and penicillin G procaine is not included in current SSTI guidelines (Ref).
Bicillin C-R: Infants, Children, and Adolescents:
<14 kg: IM: 600,000 units in a single dose (Ref).
14 to <27 kg: IM: 900,000 units to 1.2 million units in a single dose (Ref).
≥27 kg: IM: 2.4 million units in a single dose (Ref).
Note: Alternatively, 50% of the total dose can be administered on day 1 and 50% on day 3.
Bicillin C-R 900/300: Infants and Children: IM: 1.2 million units in a single dose (Ref). Note: Efficacy in heavier pediatric patients (eg, weight >27 kg) is unknown (Ref).
Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
There are no dosage adjustments provided in manufacturer's labeling.
There are no dosage adjustments provided in manufacturer's labeling.
The following adverse drug reactions are derived from product labeling unless otherwise specified. Also see individual agents.
Postmarketing:
Dermatologic: Stevens-Johnson syndrome
Gastrointestinal: Clostridioides-difficile associated diarrhea
Hypersensitivity: Drug reaction with eosinophilia and systemic symptoms
Hypersensitivity to penicillin(s), procaine, or any component of the formulation.
Concerns related to adverse effects:
• Anaphylactic/hypersensitivity reactions: Serious and occasionally severe or fatal hypersensitivity (anaphylactic) reactions have been reported in patients on penicillin therapy, especially with a history of beta-lactam hypersensitivity (including cephalosporins) and/or a history of sensitivity to multiple allergens. Serious anaphylactic reactions require immediate treatment with supportive care measures and airway protection.
• Fibrosis and atrophy: Quadriceps femoris fibrosis and atrophy have been reported following repeated IM injections of penicillins into the anterolateral thigh.
• Methemoglobinemia: Has been reported with local anesthetics, including procaine; clinically significant methemoglobinemia requires immediate treatment along with discontinuation of the anesthetic and other oxidizing agents. Onset may be immediate or delayed (hours) after anesthetic exposure. Patients with glucose-6-phosphate dehydrogenase deficiency, congenital or idiopathic methemoglobinemia, cardiac or pulmonary compromise, exposure to oxidizing agents or their metabolites, or infants <6 months of age are more susceptible and should be closely monitored for signs and symptoms of methemoglobinemia (eg, cyanosis, headache, rapid pulse, shortness of breath, lightheadedness, fatigue).
• Procaine sensitivity: If there is a history of hypersensitivity to procaine, test with 0.1 mL of procaine 1% or 2% solution. If erythema, wheal, flare, or eruption occurs, patient may be sensitive to procaine; do not use penicillin G procaine in these patients. Treat sensitivity with supportive measures, including antihistamines.
• Severe cutaneous adverse reactions: Severe cutaneous adverse reactions (SCAR) (eg, Stevens-Johnson syndrome, toxic epidermal necrolysis, drug reaction with eosinophilia and systemic symptoms, acute generalized exanthematous pustulosis) have been reported; discontinue immediately if SCAR is suspected.
• Superinfection: Prolonged use may result in fungal or bacterial superinfection, including Clostridioides difficile-associated diarrhea (CDAD) and pseudomembranous colitis; CDAD has been observed >2 months postantibiotic treatment.
Disease-related concerns:
• Renal impairment: Use with caution in patients with renal impairment.
Other warnings/precautions:
• Appropriate administration: Not for IV use; reports of inadvertent IV administration have been associated with cardiopulmonary arrest and death. Administer by deep IM injection only. Injection into or near an artery or nerve could result in severe neurovascular damage or permanent neurological damage or gangrene possibly requiring amputation, necrosis/sloughing at or surrounding the injection site, or other serious complications.
• Choice of preparation: Penicillin G benzathine-penicillin G procaine (eg, Bicillin C-R) is not the same preparation as penicillin G procaine. Dispensing errors have occurred (CDC 2005).
• Prolonged use: Extended duration of therapy or use associated with high serum concentrations (eg, in renal insufficiency) may be associated with an increased risk for some adverse reactions (neutropenia, hemolytic anemia, serum sickness).
Bicillin C-R 600,000 unit and 2.4 million unit syringes have been discontinued in the United States for >1 year. Bicillin C-R 1.2 million unit syringes are still available.
Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product
Injection, suspension [prefilled syringe]:
Bicillin C-R:
600,000 units: Penicillin G benzathine 300,000 units and penicillin G procaine 300,000 units per 1 mL (1 mL) [DSC]
1,200,000 units: Penicillin G benzathine 600,000 units and penicillin G procaine 600,000 units per 2 mL (2 mL)
2,400,000 units: Penicillin G benzathine 1,200,000 units and penicillin G procaine 1,200,000 units per 4 mL (4 mL) [DSC]
Bicillin C-R 900/300: 1,200,000 units: Penicillin G benzathine 900,000 units and penicillin G procaine 300,000 units per 2 mL (2 mL)
No
Suspension (Bicillin C-R 900/300 Intramuscular)
900000-300000 units/2 mL (per mL): $132.61
Suspension (Bicillin C-R Intramuscular)
1200000 units/2 mL (per mL): $132.61
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IM: Administer by deep IM injection at a slow, steady rate in the dorsogluteal region (upper outer quadrant of the buttock) or ventrogluteal region (anterolateral thigh). When repeated doses are indicated, vary the injection site. Do not inject near an artery or a nerve; permanent neurological damage or gangrene may result. Do not mix with other IV solutions. Do not administer IV, intravascularly, or intra-arterially.
Parenteral: IM: For IM administration only. Do not administer IV, intravascularly, or intra-arterially. Avoid injection near an artery or a nerve; permanent neurological damage or gangrene may result.
Administer by deep IM injection at a slow, steady rate in the upper outer quadrant of the buttock or anterolateral thigh; in infants and small children, injections in the midlateral aspect of the thigh are preferred. Needle may become blocked if injection is not at a slow, steady rate due to high concentration of suspended material. Dose is usually administered in a single treatment session; multiple IM sites may be required to administer full dose. When repeated doses are indicated, vary the injection site.
Pneumococcal infections: Treatment of moderately severe pneumonia and otitis media due to susceptible Pneumococcus spp. (eg, Streptococcus pneumoniae).
Streptococcal infections, group A: Treatment of moderately severe to severe infections, without associated bacteremia, of the upper respiratory tract, scarlet fever, erysipelas, and skin and soft tissue infections due to group A streptococci.
Note: Bicillin C-R 900/300 is only indicated in pediatric patients.
Limitations of use: Not considered appropriate for the treatment of sexually transmitted diseases, including syphilis, gonorrhea, yaws, bejel, and pinta. When high, sustained serum levels are required, use alternative penicillin preparations.
Penicillin may be confused with penicillAMINE
Bicillin may be confused with Wycillin
Penicillin G benzathine should only be administered by deep intramuscular (IM) injection; IV administration of penicillin G benzathine has been associated with cardiopulmonary arrest and death.
Bicillin C-R (penicillin G benzathine and penicillin G procaine) may be confused with Bicillin L-A (penicillin G benzathine). Penicillin G benzathine is the only product currently approved for the treatment of syphilis. Administration of penicillin G benzathine and penicillin G procaine combination instead of Bicillin L-A may result in inadequate treatment response.
Refer to individual components.
Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the Lexicomp drug interactions program by clicking on the “Launch drug interactions program” link above.
Acemetacin: May increase the serum concentration of Penicillins. Risk C: Monitor therapy
Aminoglycosides: Penicillins may decrease the serum concentration of Aminoglycosides. Primarily associated with extended spectrum penicillins, and patients with renal dysfunction. Risk C: Monitor therapy
Bacillus clausii: Antibiotics may diminish the therapeutic effect of Bacillus clausii. Management: Bacillus clausii should be taken in between antibiotic doses during concomitant therapy. Risk D: Consider therapy modification
BCG (Intravesical): Antibiotics may diminish the therapeutic effect of BCG (Intravesical). Risk X: Avoid combination
BCG Vaccine (Immunization): Antibiotics may diminish the therapeutic effect of BCG Vaccine (Immunization). Risk C: Monitor therapy
Cholera Vaccine: Antibiotics may diminish the therapeutic effect of Cholera Vaccine. Management: Avoid cholera vaccine in patients receiving systemic antibiotics, and within 14 days following the use of oral or parenteral antibiotics. Risk X: Avoid combination
Dichlorphenamide: Penicillins may enhance the hypokalemic effect of Dichlorphenamide. Risk C: Monitor therapy
Fecal Microbiota (Live) (Oral): May diminish the therapeutic effect of Antibiotics. Risk X: Avoid combination
Fecal Microbiota (Live) (Rectal): Antibiotics may diminish the therapeutic effect of Fecal Microbiota (Live) (Rectal). Risk X: Avoid combination
Immune Checkpoint Inhibitors (Anti-PD-1, -PD-L1, and -CTLA4 Therapies): Antibiotics may diminish the therapeutic effect of Immune Checkpoint Inhibitors (Anti-PD-1, -PD-L1, and -CTLA4 Therapies). Risk C: Monitor therapy
Lactobacillus and Estriol: Antibiotics may diminish the therapeutic effect of Lactobacillus and Estriol. Risk C: Monitor therapy
Methotrexate: Penicillins may increase the serum concentration of Methotrexate. Risk C: Monitor therapy
Mycophenolate: Penicillins may decrease serum concentrations of the active metabolite(s) of Mycophenolate. This effect appears to be the result of impaired enterohepatic recirculation. Risk C: Monitor therapy
Probenecid: May increase the serum concentration of Penicillins. Risk C: Monitor therapy
Sodium Benzoate: Penicillins may diminish the therapeutic effect of Sodium Benzoate. Risk C: Monitor therapy
Sodium Picosulfate: Antibiotics may diminish the therapeutic effect of Sodium Picosulfate. Management: Consider using an alternative product for bowel cleansing prior to a colonoscopy in patients who have recently used or are concurrently using an antibiotic. Risk D: Consider therapy modification
Tetracyclines: May diminish the therapeutic effect of Penicillins. Risk C: Monitor therapy
Typhoid Vaccine: Antibiotics may diminish the therapeutic effect of Typhoid Vaccine. Only the live attenuated Ty21a strain is affected. Management: Avoid use of live attenuated typhoid vaccine (Ty21a) in patients being treated with systemic antibacterial agents. Postpone vaccination until 3 days after cessation of antibiotics and avoid starting antibiotics within 3 days of last vaccine dose. Risk D: Consider therapy modification
Vitamin K Antagonists (eg, warfarin): Penicillins may enhance the anticoagulant effect of Vitamin K Antagonists. Risk C: Monitor therapy
As a class, penicillin antibiotics are widely used in pregnant women. Based on available data, penicillin antibiotics are generally considered compatible for use during pregnancy (Ailes 2016; Bookstaver 2015; Crider 2009; Damkier 2019; Erić 2012; Heinonen 1977; Lamont 2014; Muanda 2017a; Muanda 2017b).
See individual monographs for additional information.
Soluble penicillin G is present in breast milk.
The manufacturer recommends that caution be exercised when administering this combination to breastfeeding women. See individual monographs for additional information.
Hypersensitivity reactions with first dose, injection-site reactions, periodic renal and hematologic function tests with prolonged therapy
Inhibits bacterial cell wall synthesis by binding to one or more of the penicillin-binding proteins (PBPs); which in turn inhibits the final transpeptidation step of peptidoglycan synthesis in bacterial cell walls, thus inhibiting cell wall biosynthesis. Bacteria eventually lyse due to ongoing activity of cell wall autolytic enzymes (autolysins and murein hydrolases) while cell wall assembly is arrested.
Absorption: IM: Released slowly
Distribution: Highest levels in the kidney; lesser amounts in liver, skin, intestines
Protein binding: ~60%
Time to peak, serum: IM: Within 3 hours
Altered kidney function: Excretion of the drug is considerably delayed in neonates, children, and individuals with renal function impairment.
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