Penicillin V Potassium

Drug overview for PENICILLIN V POTASSIUM (penicillin v potassium):

Generic name: PENICILLIN V POTASSIUM (pen-ih-SILL-in VEE poh-TASS-ee-um)
Drug class: Beta-Lactams
Therapeutic class: Anti-Infective Agents

Penicillin V, a natural penicillin, is a beta-lactam antibiotic.

Penicillin V potassium is used for the treatment of mild to moderately severe upper respiratory tract infections caused by susceptible streptococci or mild skin and skin structure infections caused by susceptible streptococci or staphylococci and for prophylaxis of certain streptococcal infections. For some infections, oral penicillin V is used after an initial response is obtained with parenteral penicillin G. Penicillin V should not be used for initial treatment of severe infections, including pneumonia, empyema, bacteremia, pericarditis, meningitis, or arthritis.

In addition, the high incidence of staphylococci resistant to the drug should be considered. For additional information on the uses of penicillin V potassium, see Uses in the Natural Penicillins General Statement 8:12.16.04.

DRUG IMAGES

PENICILLIN VK 500 MG TABLET

The following indications for PENICILLIN V POTASSIUM (penicillin v potassium) have been approved by the FDA:

Indications:
Acute bacterial otitis media
Erysipelas
Fusospirochetal pharyngitis
Gingivostomatitis
Infection prevention from tooth extraction
Pharyngitis due to Streptococcus pyogenes
Pharyngitis
Pneumococcal acute otitis media
Rheumatic fever prevention
Scarlet fever
Skin and skin structure infection
Staphylococcus aureus skin and skin structure infection
Streptococcus acute otitis media
Tonsillitis due to Streptococcus pyogenes
Upper respiratory pneumococcal infection
Upper respiratory streptococcal infection

Professional Synonyms:
Acute otitis media due to Diplococcus pneumoniae
Acute otitis media due to Fraenkel's Pneumococcus
Acute otitis media due to Pneumococcus
Acute otitis media due to Pneumonococcus
Acute otitis media due to Streptococcus pneumoniae
Acute otitis media due to Streptococcus species
Bacterial otitis media
Epidemic sore throat
Fraenkel-Weichselbaum Pneumococcus acute otitis media
Fusospirochetal infection of the oropharynx
Infection of skin and/or subcutaneous tissue
Infection prophylaxis for tooth extraction
Patch of erysipelas
Pharyngitis due to group A beta-hemolytic streptococci
Pharyngitis due to Streptococcus epidemicus
Pneumococcal upper respiratory tract infection
Rheumatic fever prophylaxis
Rose
Scarlatina
Septic sore throat
Skin and skin soft tissue Staphylococcus aureus infection
Skin and soft tissue skin infection
Streptococcal pharyngitis
Streptococcus pyogenes tonsillitis
Throat inflammation
Upper respiratory Diplococcus pneumoniae infection
Upper respiratory infection due to Streptococcus
Upper respiratory infection from Fraenkel's Pneumococcus
Upper respiratory Streptococcus pneumoniae infection
Upper respiratory tract infection due to Pneumococcus
Upper respiratory tract infection due to S. pneumoniae
URI due to Fraenkel-Weichselbaum Pneumococcus
Vincent's angina

The following dosing information is available for PENICILLIN V POTASSIUM (penicillin v potassium):

Dosing
Administration
PENICILLIN V POTASSIUM
PENICILLIN V POTASSIUM

Dosage of penicillin V potassium is expressed in terms of penicillin V. Although dosage of the drug is usually expressed as mg of penicillin V, it may be expressed in terms of penicillin V units.

Potency of penicillin V potassium preparations containing 125, 250, or 500 mg of penicillin V is approximately equivalent to 200,000, 400,000, or 800,000 penicillin V units, respectively.

The American Academy of Pediatrics (AAP) states that the usual dosage of oral penicillin V for the treatment of mild to moderate infections in pediatric patients beyond the neonatal period is 25-75 mg/kg daily given in 3 or 4 divided doses.

Some clinicians recommend that children younger than 5 years of age receive oral penicillin V in a dosage of 125 mg 4 times daily and that those older than 5 years of age receive a dosage of 250-500 mg every 6 hours.

The manufacturers state that pediatric patients 12 years of age or older may receive the usual adult dosage of penicillin V. Some clinicians state that children older than 5 years of age may receive the usual adult dosage of the drug.

Dosage adjustments are not usually necessary in patients with renal impairment. Some clinicians suggest increasing the dosing interval to every 8 hours in patients with creatinine clearance less than 10 mL/minute.

No enhanced Administration information available for this drug.

Dosing information for PENICILLIN V POTASSIUM
DRUG LABEL	DOSING TYPE	DOSING INSTRUCTIONS
PENICILLIN VK 250 MG TABLET	Maintenance	Adults take 1 tablet (250 mg) by oral route every 6 hours
PENICILLIN VK 500 MG TABLET	Maintenance	Adults take 1 tablet (500 mg) by oral route every 8 hours

Generic dosing information for PENICILLIN V POTASSIUM
DRUG LABEL	DOSING TYPE	DOSING INSTRUCTIONS
PENICILLIN VK 250 MG TABLET	Maintenance	Adults take 1 tablet (250 mg) by oral route every 6 hours
PENICILLIN VK 500 MG TABLET	Maintenance	Adults take 1 tablet (500 mg) by oral route every 8 hours

The following drug interaction information is available for PENICILLIN V POTASSIUM (penicillin v potassium):

Contraindicated
Severe
Moderate

There are 1 contraindications. These drug combinations generally should not be dispensed or administered to the same patient. A manufacturer label warning that indicates the contraindication warrants inclusion of a drug combination in this category, regardless of clinical evidence or lack of clinical evidence to support the contraindication.

Drug Interaction	Drug Names
Live Typhoid Vaccine/Antimicrobials SEVERITY LEVEL: 1-Contraindicated Drug Combination: This drug combination is contraindicated and generally should not be dispensed or administered to the same patient. MECHANISM OF ACTION: The antimicrobial may be active against the organism in the live-vaccine. Antimicrobial therapy may prevent the vaccine organism from replicating enough to trigger an immune response.(1) CLINICAL EFFECTS: Vaccination may be ineffective. PREDISPOSING FACTORS: None determined. PATIENT MANAGEMENT: Do not give oral typhoid vaccine until 72 hours after the last dose of antimicrobial. If possible, to optimize vaccine effectiveness, do not start antibacterial drugs for 72 hours after the last dose of oral typhoid vaccine. A longer interval should be considered for long-acting antimicrobials, such as azithromycin.(3) DISCUSSION: Because antimicrobial therapy may prevent sufficient vaccine-organism replication to generate an immune response, the manufacturer of live-attenuated typhoid vaccine and the Centers for Disease Control (CDC) state that the vaccine should not be administered to patients receiving antimicrobial therapy.(1-3)	VIVOTIF

Drug Interaction

Drug Names

Live Typhoid Vaccine/Antimicrobials

SEVERITY LEVEL: 1-Contraindicated Drug Combination: This drug combination is contraindicated and generally should not be dispensed or administered to the same patient.

MECHANISM OF ACTION: The antimicrobial may be active against the organism in the live-vaccine. Antimicrobial therapy may prevent the vaccine organism from replicating enough to trigger an immune response.(1)

CLINICAL EFFECTS: Vaccination may be ineffective.

PREDISPOSING FACTORS: None determined.

PATIENT MANAGEMENT: Do not give oral typhoid vaccine until 72 hours after the last dose of antimicrobial. If possible, to optimize vaccine effectiveness, do not start antibacterial drugs for 72 hours after the last dose of oral typhoid vaccine. A longer interval should be considered for long-acting antimicrobials, such as azithromycin.(3)

DISCUSSION: Because antimicrobial therapy may prevent sufficient vaccine-organism replication to generate an immune response, the manufacturer of live-attenuated typhoid vaccine and the Centers for Disease Control (CDC) state that the vaccine should not be administered to patients receiving antimicrobial therapy.(1-3)

VIVOTIF

There are 2 severe interactions. These drug interactions can produce serious consequences in most patients. Actions required for severe interactions include, but are not limited to, discontinuing one or both agents, adjusting dosage, altering administration scheduling, and providing additional patient monitoring. Review the full interaction monograph for more information.

Drug Interaction	Drug Names
Methotrexate/Penicillins SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction. MECHANISM OF ACTION: Penicillins may compete with the renal tubular secretion of methotrexate. CLINICAL EFFECTS: The concurrent use of methotrexate and penicillins may result in elevated levels of methotrexate and methotrexate toxicity, leading to increased risk of severe neurotoxicity, stomatitis, and myelosuppression. PREDISPOSING FACTORS: Risk factors for methotrexate toxicity include: - High-dose oncology regimens - Impaired renal function, ascites, or pleural effusions PATIENT MANAGEMENT: Patients receiving concurrent therapy with methotrexate and penicillins should be monitored closely for elevated methotrexate levels and methotrexate toxicity. The dose and duration of leucovorin rescue therapy may need to be increased. DISCUSSION: Elevated methotrexate levels, signs of methotrexate toxicity, and death have been reported following the concurrent use of methotrexate (both low dose and high dose) and penicillin derivatives. In a patient being treated with high-dose methotrexate (8 G/m2), the concurrent use of amoxicillin resulted in a 56% decrease in the clearance of methotrexate and signs of methotrexate toxicity.(1) There are two cases of methotrexate toxicity following the addition of amoxicillin to low-dose methotrexate therapy (7.5 mg-10 mg weekly) for psoriasis. In another case, a patient was found to have a toxic methotrexate level 12 days after her last dose of weekly methotrexate (7.5 mg). The patient had been treated with amoxicillin followed by flucloxacillin.(2) In a case report, dicloxacillin decreased methotrexate clearance 93%.(4) Flucloxacillin was shown to increase the area-under-curve (AUC) of methotrexate by 7.3% in a study in 10 subjects.(5) In a case report, a patient on low-dose methotrexate (5 mg) developed methotrexate pneumonia following the addition of flucloxacillin to his regimen.(5) In a patient being treated with high-dose methotrexate (12 G/m2), the concurrent use of mezlocillin increased the half-life of methotrexate from 10.1 to 27.2 hours.(6) In a case report, a patient developed methotrexate toxicity following the addition of penicillin V potassium to his methotrexate (50 mg weekly).(7) In a case report, penicillin decreased methotrexate clearance 36%.(4) In one report, leucovorin rescue therapy had to be continued for 192 hours following the concurrent use of methotrexate (3 G/m2) and piperacillin. During cycles without concurrent piperacillin, leucovorin rescue therapy was only required for 72 hours.(8) There are two reports of neutropenia and death following the concurrent use of piperacillin and low-dose methotrexate (2.5 mg three times weekly in one patient, 5 mg weekly in another) for psoriasis. One of these patients also received flucloxacillin. (3) In another case report, the concurrent use of piperacillin decreased methotrexate clearance by 67%.(4) In a case report, ticarcillin decreased methotrexate clearance by 60%.(4)	JYLAMVO, METHOTREXATE, METHOTREXATE SODIUM, OTREXUP, RASUVO, TREXALL, XATMEP
Fecal Microbiota Spores/Antibiotics SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction. MECHANISM OF ACTION: Fecal microbiota spores is a suspension of live bacterial spores, which may be compromised by concurrent use of antibiotics.(1) CLINICAL EFFECTS: Antibiotics may decrease the effectiveness of fecal microbiota spores.(1) PREDISPOSING FACTORS: None determined. PATIENT MANAGEMENT: Antibiotics should not be used concurrently with fecal microbiota spores. Antibacterial treatment should be completed for 2 to 4 days before initiating treatment with fecal microbiota spores.(1) DISCUSSION: Antibiotics may compromise the effectiveness of fecal microbiota spores.	VOWST

Drug Interaction

Drug Names

Methotrexate/Penicillins

SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction.

MECHANISM OF ACTION: Penicillins may compete with the renal tubular secretion of methotrexate.

CLINICAL EFFECTS: The concurrent use of methotrexate and penicillins may result in elevated levels of methotrexate and methotrexate toxicity, leading to increased risk of severe neurotoxicity, stomatitis, and myelosuppression.

PREDISPOSING FACTORS: Risk factors for methotrexate toxicity include: - High-dose oncology regimens - Impaired renal function, ascites, or pleural effusions

PATIENT MANAGEMENT: Patients receiving concurrent therapy with methotrexate and penicillins should be monitored closely for elevated methotrexate levels and methotrexate toxicity. The dose and duration of leucovorin rescue therapy may need to be increased.

DISCUSSION: Elevated methotrexate levels, signs of methotrexate toxicity, and death have been reported following the concurrent use of methotrexate (both low dose and high dose) and penicillin derivatives. In a patient being treated with high-dose methotrexate (8 G/m2), the concurrent use of amoxicillin resulted in a 56% decrease in the clearance of methotrexate and signs of methotrexate toxicity.(1) There are two cases of methotrexate toxicity following the addition of amoxicillin to low-dose methotrexate therapy (7.5 mg-10 mg weekly) for psoriasis.

In another case, a patient was found to have a toxic methotrexate level 12 days after her last dose of weekly methotrexate (7.5 mg). The patient had been treated with amoxicillin followed by flucloxacillin.(2) In a case report, dicloxacillin decreased methotrexate clearance 93%.(4)

Flucloxacillin was shown to increase the area-under-curve (AUC) of methotrexate by 7.3% in a study in 10 subjects.(5) In a case report, a patient on low-dose methotrexate (5 mg) developed methotrexate pneumonia following the addition of flucloxacillin to his regimen.(5)

In a patient being treated with high-dose methotrexate (12 G/m2), the concurrent use of mezlocillin increased the half-life of methotrexate from 10.1 to 27.2 hours.(6)

In a case report, a patient developed methotrexate toxicity following the addition of penicillin V potassium to his methotrexate (50 mg weekly).(7) In a case report, penicillin decreased methotrexate clearance 36%.(4) In one report, leucovorin rescue therapy had to be continued for 192 hours following the concurrent use of methotrexate (3 G/m2) and piperacillin.

During cycles without concurrent piperacillin, leucovorin rescue therapy was only required for 72 hours.(8) There are two reports of neutropenia and death following the concurrent use of piperacillin and low-dose methotrexate (2.5 mg three times weekly in one patient, 5 mg weekly in another) for psoriasis. One of these patients also received flucloxacillin.

(3) In another case report, the concurrent use of piperacillin decreased methotrexate clearance by 67%.(4) In a case report, ticarcillin decreased methotrexate clearance by 60%.(4)

JYLAMVO, METHOTREXATE, METHOTREXATE SODIUM, OTREXUP, RASUVO, TREXALL, XATMEP

Fecal Microbiota Spores/Antibiotics

SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction.

MECHANISM OF ACTION: Fecal microbiota spores is a suspension of live bacterial spores, which may be compromised by concurrent use of antibiotics.(1)

CLINICAL EFFECTS: Antibiotics may decrease the effectiveness of fecal microbiota spores.(1)

PREDISPOSING FACTORS: None determined.

PATIENT MANAGEMENT: Antibiotics should not be used concurrently with fecal microbiota spores. Antibacterial treatment should be completed for 2 to 4 days before initiating treatment with fecal microbiota spores.(1)

DISCUSSION: Antibiotics may compromise the effectiveness of fecal microbiota spores.

VOWST

There are 2 moderate interactions. The clinician should assess the patient’s characteristics and take action as needed. Actions required for moderate interactions include, but are not limited to, discontinuing one or both agents, adjusting dosage, altering administration.

Drug Interaction	Drug Names
Oral Contraceptives/Penicillins SEVERITY LEVEL: 3-Moderate Interaction: Assess the risk to the patient and take action as needed. MECHANISM OF ACTION: Estrogens and progesterones are extensively excreted in bile, principally as glycuronide conjugates. Subsequently, they undergo enterohepatic circulation where bacterial hydrolysis occurs, allowing for reabsorption of the oral contraceptives through the bowel wall and eventual urinary excretion. Treatment with antibiotics destroys the gut flora and prevents steroid reabsorption, resulting in lower than normal concentrations of the contraceptive and excretion via the feces rather than the urine. CLINICAL EFFECTS: May observe reduced pharmacologic effects of oral contraceptives with resultant breakthrough bleeding and pregnancy. Reduced effects may be seen for several days after discontinuation of antibiotic therapy. PREDISPOSING FACTORS: None determined. PATIENT MANAGEMENT: Current guidelines suggest that additional precautions are not necessary when non-enzyme inducing antibiotics are used concurrently with hormonal contraceptives; however, some patients may still prefer to use an additional method of contraception. DISCUSSION: Evidence for this interaction is limited and conflicting; however, the CDC and the Faculty of Sexual and Reproductive Healthcare Clinical Effectiveness Unit no longer recommend use of a backup contraceptive method during use of a non-enzyme inducing antibiotic. Reports of breakthrough bleeding and loss of contraceptive protection leading to unwanted pregnancies have occurred in women taking oral contraceptive agents who received concurrent ampicillin, amoxicillin, penicillin G, or oxacillin. Several studies have shown that the administration of ampicillin or penicillin to pregnant and nonpregnant women resulted in lowered urinary estrogen excretion, in some women as soon as three days after ampicillin therapy began. However in one small prospective study, plasma ethinyl estradiol concentrations showed a tendency to decrease during ampicillin administration on the third, fourth, and fifth morning of ampicillin administration, but were never lower than pretreatment values. In another small prospective study of women taking low dose combination contraceptives, concurrent ampicillin therapy neither altered the plasma levels nor the AUC of norethisterone and ethinyl estradiol. In addition, progesterone levels were in an anovulatory range. In another prospective study of 13 women taking long term oral contraceptive steroids, concurrent ampicillin was not associated with any significant changes in plasma concentrations of ethinyl estradiol, levonorgestrel, follicle stimulating hormone or progesterone, although lower concentrations of ethinyl estradiol were noted in two women.	2-METHOXYESTRADIOL, AFIRMELLE, ALTAVERA, ALYACEN, AMETHIA, AMETHYST, APRI, ARANELLE, ASHLYNA, AUBRA, AUBRA EQ, AUROVELA, AUROVELA 24 FE, AUROVELA FE, AVIANE, AYUNA, AZURETTE, BALCOLTRA, BALZIVA, BEYAZ, BLISOVI 24 FE, BLISOVI FE, BRIELLYN, CAMILA, CAMRESE, CAMRESE LO, CAZIANT, CHARLOTTE 24 FE, CHATEAL EQ, CRYSELLE, CYRED, CYRED EQ, DASETTA, DAYSEE, DEBLITANE, DESOGESTR-ETH ESTRAD ETH ESTRA, DIETHYLSTILBESTROL, DOLISHALE, DROSPIRENONE-ETH ESTRA-LEVOMEF, DROSPIRENONE-ETHINYL ESTRADIOL, ELINEST, ELLA, EMZAHH, ENPRESSE, ENSKYCE, ERRIN, ESTARYLLA, ESTRADIOL, ESTRADIOL BENZOATE, ESTRADIOL CYPIONATE, ESTRADIOL HEMIHYDRATE, ESTRADIOL HEMIHYDRATE MICRO, ESTRADIOL MICRONIZED, ESTRADIOL VALERATE, ESTRIOL, ESTRIOL MICRONIZED, ESTRONE, ETHINYL ESTRADIOL, ETHYNODIOL-ETHINYL ESTRADIOL, FALMINA, FEIRZA, FEMLYV, FINZALA, GEMMILY, HAILEY, HAILEY 24 FE, HAILEY FE, HEATHER, ICLEVIA, INCASSIA, ISIBLOOM, JAIMIESS, JASMIEL, JENCYCLA, JOLESSA, JOYEAUX, JULEBER, JUNEL, JUNEL FE, JUNEL FE 24, KAITLIB FE, KALLIGA, KARIVA, KELNOR 1-35, KELNOR 1-50, KURVELO, LARIN, LARIN 24 FE, LARIN FE, LAYOLIS FE, LEENA, LESSINA, LEVONEST, LEVONORG-ETH ESTRAD ETH ESTRAD, LEVONORG-ETH ESTRAD-FE BISGLYC, LEVONORGESTREL-ETH ESTRADIOL, LEVORA-28, LO LOESTRIN FE, LO-ZUMANDIMINE, LOESTRIN, LOESTRIN FE, LOJAIMIESS, LORYNA, LOW-OGESTREL, LUTERA, LYLEQ, LYZA, MARLISSA, MERZEE, MIBELAS 24 FE, MICROGESTIN, MICROGESTIN FE, MILI, MINZOYA, MONO-LINYAH, NATAZIA, NECON, NEXTSTELLIS, NIKKI, NORA-BE, NORETHIN-ETH ESTRA-FERROUS FUM, NORETHINDRON-ETHINYL ESTRADIOL, NORETHINDRONE, NORETHINDRONE-E.ESTRADIOL-IRON, NORGESTIMATE-ETHINYL ESTRADIOL, NORTREL, NYLIA, OCELLA, ORTHO TRI-CYCLEN, ORTHO-NOVUM, PHILITH, PIMTREA, PORTIA, RECLIPSEN, RIVELSA, SAFYRAL, SETLAKIN, SHAROBEL, SIMLIYA, SIMPESSE, SLYND, SPRINTEC, SRONYX, SYEDA, TARINA 24 FE, TARINA FE, TARINA FE 1-20 EQ, TAYTULLA, TILIA FE, TRI-ESTARYLLA, TRI-LEGEST FE, TRI-LINYAH, TRI-LO-ESTARYLLA, TRI-LO-MARZIA, TRI-LO-MILI, TRI-LO-SPRINTEC, TRI-MILI, TRI-SPRINTEC, TRI-VYLIBRA, TRI-VYLIBRA LO, TRIVORA-28, TULANA, TURQOZ, TYBLUME, VALTYA, VELIVET, VESTURA, VIENVA, VIORELE, VOLNEA, VYFEMLA, VYLIBRA, WERA, WYMZYA FE, XARAH FE, XELRIA FE, YASMIN 28, YAZ, ZARAH, ZOVIA 1-35, ZUMANDIMINE
Selected Anticoagulants (Vit K antag)/Selected Penicillins SEVERITY LEVEL: 3-Moderate Interaction: Assess the risk to the patient and take action as needed. MECHANISM OF ACTION: Unknown. CLINICAL EFFECTS: Large doses of parenterally administered penicillins and oral amoxicillin appear to increase the risk of bleeding during concurrent administration of anticoagulants. PREDISPOSING FACTORS: Renal failure may predispose patients to penicillin-induced coagulation abnormalities. A study suggests that various inflammatory syndromes or the nature of the infection can affect INR levels. The risk for bleeding episodes may be greater in patients with additional disease-associated factors (e.g. thrombocytopenia). Drug associated risk factors include concurrent use of multiple drugs which inhibit anticoagulant/antiplatelet metabolism and/or have an inherent risk for bleeding (e.g. NSAIDs). PATIENT MANAGEMENT: Monitor patient INR for an increase in the hypoprothrombinemic response to anticoagulants during concomitant administration of penicillins. Adjust the dose of warfarin accordingly. When concurrent therapy is warranted, monitor patients receiving concurrent therapy for signs of blood loss, including decreased hemoglobin and/or hematocrit, fecal occult blood, and/or decreased blood pressure and promptly evaluate patients with any symptoms. Discontinue anticoagulation in patients with active pathologic bleeding. Instruct patients to report any signs and symptoms of bleeding, such as unusual bleeding from the gums or nose; unusual bruising; red or black, tarry stools; red, pink or dark brown urine; acute abdominal or joint pain and/or swelling. The time of highest risk for a coumarin-type drug interaction is when the precipitant drug is initiated or discontinued. Contact the prescriber before initiating, altering the dose or discontinuing either drug. DISCUSSION: High dose parenteral administration of penicillins and oral amoxicillin have been reported to cause an increase in the hypoprothrombinemic effects of warfarin producing bleeding. Significant clinical effects have been reported with combined administration of warfarin and either carbenicillin or penicillin G. There have been several case reports and retrospective reviews documenting increased acenocoumarol and warfarin effects, including bleeding, following the addition of amoxicillin, with and without clavulanic acid, to therapy. In a randomized controlled trial, adult ambulatory patients that had no recent and ongoing infectious or inflammatory conditions received warfarin to a target INR between 2 and 3 with amoxicillin-clavulanic acid (1 gram twice daily for seven days) or placebo. The results showed the mean maximum INR increase from baseline to day 10 did not differ between amoxicillin/clavulanic acid (0.22 +/- 0.3) and the placebo period (0.24 +/- 0.6, p = 0.94). No patient experienced an INR of greater than 3.5. No bleeding events were reported during the entire study. A prospective cross-sectional observational study in 120 patients evaluated warfarin drug interactions, particularly with high-dose amoxicillin/clavulanate. The study found that patients on amoxicillin/clavulanate had a relative risk of having an INR >=4 of 4.8 compared to patients not on amoxicillin/clavulanate (95% CI 2.1-11.3, p < 0.001). This risk was primarily driven by patients on high-dose amoxicillin/clavulanate, who were 5.8 times more likely to have INR >=4 (95% CI 3.5-9.6, p<0.001). Significantly more patients on high-dose than normal dose amoxicillin/clavulanate had an INR value >= 4 (87.5% v. 28.9%, respectively). Nine out of ten patients who experienced bleeding during hospitalization were prescribed amoxicillin/clavulanate. A large systematic review was performed on 72 warfarin drug-drug interactions studies that reported on bleeding, thromboembolic events, or death. Most studies were retrospective cohorts. A meta-analysis of 11 of those studies found a higher rate of clinically significant bleeding in patients on warfarin and antimicrobials (OR=1.63; 95% CI 1.45-1.83). Increased bleeding risk was also seen in subgroup analyses with penicillins (OR=1.59; 95% CI 1.14-2.20) and amoxicillin (OR=1.78; 95% CI 1.14-2.79). A case-control nested cohort study of Medicare beneficiaries with warfarin prescriptions was evaluated for antibiotic use and warfarin toxicity in older adults. An increased risk of bleeding was associated with penicillins with an adjusted odds ratio of 1.92. Parenteral penicillins linked to this monograph include: almecillin, amdinocillin, amoxicillin, ampicillin, azlocillin, bacampicillin, carbenicillin, cyclacillin, hetacillin, mezlocillin, penicillin, penicillin G, penicillin V, phenethicillin, piperacillin, and ticarcillin. Oral penicillins linked to this monograph include: amoxicillin and penicillin.	ANISINDIONE, DICUMAROL, JANTOVEN, WARFARIN SODIUM

Drug Interaction

Drug Names

Oral Contraceptives/Penicillins

SEVERITY LEVEL: 3-Moderate Interaction: Assess the risk to the patient and take action as needed.

MECHANISM OF ACTION: Estrogens and progesterones are extensively excreted in bile, principally as glycuronide conjugates. Subsequently, they undergo enterohepatic circulation where bacterial hydrolysis occurs, allowing for reabsorption of the oral contraceptives through the bowel wall and eventual urinary excretion. Treatment with antibiotics destroys the gut flora and prevents steroid reabsorption, resulting in lower than normal concentrations of the contraceptive and excretion via the feces rather than the urine.

CLINICAL EFFECTS: May observe reduced pharmacologic effects of oral contraceptives with resultant breakthrough bleeding and pregnancy. Reduced effects may be seen for several days after discontinuation of antibiotic therapy.

PREDISPOSING FACTORS: None determined.

PATIENT MANAGEMENT: Current guidelines suggest that additional precautions are not necessary when non-enzyme inducing antibiotics are used concurrently with hormonal contraceptives; however, some patients may still prefer to use an additional method of contraception.

DISCUSSION: Evidence for this interaction is limited and conflicting; however, the CDC and the Faculty of Sexual and Reproductive Healthcare Clinical Effectiveness Unit no longer recommend use of a backup contraceptive method during use of a non-enzyme inducing antibiotic. Reports of breakthrough bleeding and loss of contraceptive protection leading to unwanted pregnancies have occurred in women taking oral contraceptive agents who received concurrent ampicillin, amoxicillin, penicillin G, or oxacillin. Several studies have shown that the administration of ampicillin or penicillin to pregnant and nonpregnant women resulted in lowered urinary estrogen excretion, in some women as soon as three days after ampicillin therapy began.

However in one small prospective study, plasma ethinyl estradiol concentrations showed a tendency to decrease during ampicillin administration on the third, fourth, and fifth morning of ampicillin administration, but were never lower than pretreatment values. In another small prospective study of women taking low dose combination contraceptives, concurrent ampicillin therapy neither altered the plasma levels nor the AUC of norethisterone and ethinyl estradiol. In addition, progesterone levels were in an anovulatory range. In another prospective study of 13 women taking long term oral contraceptive steroids, concurrent ampicillin was not associated with any significant changes in plasma concentrations of ethinyl estradiol, levonorgestrel, follicle stimulating hormone or progesterone, although lower concentrations of ethinyl estradiol were noted in two women.

2-METHOXYESTRADIOL, AFIRMELLE, ALTAVERA, ALYACEN, AMETHIA, AMETHYST, APRI, ARANELLE, ASHLYNA, AUBRA, AUBRA EQ, AUROVELA, AUROVELA 24 FE, AUROVELA FE, AVIANE, AYUNA, AZURETTE, BALCOLTRA, BALZIVA, BEYAZ, BLISOVI 24 FE, BLISOVI FE, BRIELLYN, CAMILA, CAMRESE, CAMRESE LO, CAZIANT, CHARLOTTE 24 FE, CHATEAL EQ, CRYSELLE, CYRED, CYRED EQ, DASETTA, DAYSEE, DEBLITANE, DESOGESTR-ETH ESTRAD ETH ESTRA, DIETHYLSTILBESTROL, DOLISHALE, DROSPIRENONE-ETH ESTRA-LEVOMEF, DROSPIRENONE-ETHINYL ESTRADIOL, ELINEST, ELLA, EMZAHH, ENPRESSE, ENSKYCE, ERRIN, ESTARYLLA, ESTRADIOL, ESTRADIOL BENZOATE, ESTRADIOL CYPIONATE, ESTRADIOL HEMIHYDRATE, ESTRADIOL HEMIHYDRATE MICRO, ESTRADIOL MICRONIZED, ESTRADIOL VALERATE, ESTRIOL, ESTRIOL MICRONIZED, ESTRONE, ETHINYL ESTRADIOL, ETHYNODIOL-ETHINYL ESTRADIOL, FALMINA, FEIRZA, FEMLYV, FINZALA, GEMMILY, HAILEY, HAILEY 24 FE, HAILEY FE, HEATHER, ICLEVIA, INCASSIA, ISIBLOOM, JAIMIESS, JASMIEL, JENCYCLA, JOLESSA, JOYEAUX, JULEBER, JUNEL, JUNEL FE, JUNEL FE 24, KAITLIB FE, KALLIGA, KARIVA, KELNOR 1-35, KELNOR 1-50, KURVELO, LARIN, LARIN 24 FE, LARIN FE, LAYOLIS FE, LEENA, LESSINA, LEVONEST, LEVONORG-ETH ESTRAD ETH ESTRAD, LEVONORG-ETH ESTRAD-FE BISGLYC, LEVONORGESTREL-ETH ESTRADIOL, LEVORA-28, LO LOESTRIN FE, LO-ZUMANDIMINE, LOESTRIN, LOESTRIN FE, LOJAIMIESS, LORYNA, LOW-OGESTREL, LUTERA, LYLEQ, LYZA, MARLISSA, MERZEE, MIBELAS 24 FE, MICROGESTIN, MICROGESTIN FE, MILI, MINZOYA, MONO-LINYAH, NATAZIA, NECON, NEXTSTELLIS, NIKKI, NORA-BE, NORETHIN-ETH ESTRA-FERROUS FUM, NORETHINDRON-ETHINYL ESTRADIOL, NORETHINDRONE, NORETHINDRONE-E.ESTRADIOL-IRON, NORGESTIMATE-ETHINYL ESTRADIOL, NORTREL, NYLIA, OCELLA, ORTHO TRI-CYCLEN, ORTHO-NOVUM, PHILITH, PIMTREA, PORTIA, RECLIPSEN, RIVELSA, SAFYRAL, SETLAKIN, SHAROBEL, SIMLIYA, SIMPESSE, SLYND, SPRINTEC, SRONYX, SYEDA, TARINA 24 FE, TARINA FE, TARINA FE 1-20 EQ, TAYTULLA, TILIA FE, TRI-ESTARYLLA, TRI-LEGEST FE, TRI-LINYAH, TRI-LO-ESTARYLLA, TRI-LO-MARZIA, TRI-LO-MILI, TRI-LO-SPRINTEC, TRI-MILI, TRI-SPRINTEC, TRI-VYLIBRA, TRI-VYLIBRA LO, TRIVORA-28, TULANA, TURQOZ, TYBLUME, VALTYA, VELIVET, VESTURA, VIENVA, VIORELE, VOLNEA, VYFEMLA, VYLIBRA, WERA, WYMZYA FE, XARAH FE, XELRIA FE, YASMIN 28, YAZ, ZARAH, ZOVIA 1-35, ZUMANDIMINE

Selected Anticoagulants (Vit K antag)/Selected Penicillins

SEVERITY LEVEL: 3-Moderate Interaction: Assess the risk to the patient and take action as needed.

MECHANISM OF ACTION: Unknown.

CLINICAL EFFECTS: Large doses of parenterally administered penicillins and oral amoxicillin appear to increase the risk of bleeding during concurrent administration of anticoagulants.

PREDISPOSING FACTORS: Renal failure may predispose patients to penicillin-induced coagulation abnormalities. A study suggests that various inflammatory syndromes or the nature of the infection can affect INR levels. The risk for bleeding episodes may be greater in patients with additional disease-associated factors (e.g. thrombocytopenia).

Drug associated risk factors include concurrent use of multiple drugs which inhibit anticoagulant/antiplatelet metabolism and/or have an inherent risk for bleeding (e.g. NSAIDs).

PATIENT MANAGEMENT: Monitor patient INR for an increase in the hypoprothrombinemic response to anticoagulants during concomitant administration of penicillins. Adjust the dose of warfarin accordingly. When concurrent therapy is warranted, monitor patients receiving concurrent therapy for signs of blood loss, including decreased hemoglobin and/or hematocrit, fecal occult blood, and/or decreased blood pressure and promptly evaluate patients with any symptoms.

Discontinue anticoagulation in patients with active pathologic bleeding. Instruct patients to report any signs and symptoms of bleeding, such as unusual bleeding from the gums or nose; unusual bruising; red or black, tarry stools; red, pink or dark brown urine; acute abdominal or joint pain and/or swelling. The time of highest risk for a coumarin-type drug interaction is when the precipitant drug is initiated or discontinued. Contact the prescriber before initiating, altering the dose or discontinuing either drug.

DISCUSSION: High dose parenteral administration of penicillins and oral amoxicillin have been reported to cause an increase in the hypoprothrombinemic effects of warfarin producing bleeding. Significant clinical effects have been reported with combined administration of warfarin and either carbenicillin or penicillin G. There have been several case reports and retrospective reviews documenting increased acenocoumarol and warfarin effects, including bleeding, following the addition of amoxicillin, with and without clavulanic acid, to therapy.

In a randomized controlled trial, adult ambulatory patients that had no recent and ongoing infectious or inflammatory conditions received warfarin to a target INR between 2 and 3 with amoxicillin-clavulanic acid (1 gram twice daily for seven days) or placebo. The results showed the mean maximum INR increase from baseline to day 10 did not differ between amoxicillin/clavulanic acid (0.22 +/- 0.3) and the placebo period (0.24 +/- 0.6, p = 0.94). No patient experienced an INR of greater than 3.5.

No bleeding events were reported during the entire study. A prospective cross-sectional observational study in 120 patients evaluated warfarin drug interactions, particularly with high-dose amoxicillin/clavulanate. The study found that patients on amoxicillin/clavulanate had a relative risk of having an INR >=4 of 4.8

compared to patients not on amoxicillin/clavulanate (95% CI 2.1-11.3, p < 0.001). This risk was primarily driven by patients on high-dose amoxicillin/clavulanate, who were 5.8 times more likely to have INR >=4 (95% CI 3.5-9.6, p<0.001).

Significantly more patients on high-dose than normal dose amoxicillin/clavulanate had an INR value >= 4 (87.5% v. 28.9%, respectively). Nine out of ten patients who experienced bleeding during hospitalization were prescribed amoxicillin/clavulanate. A large systematic review was performed on 72 warfarin drug-drug interactions studies that reported on bleeding, thromboembolic events, or death.

Most studies were retrospective cohorts. A meta-analysis of 11 of those studies found a higher rate of clinically significant bleeding in patients on warfarin and antimicrobials (OR=1.63; 95% CI 1.45-1.83). Increased bleeding risk was also seen in subgroup analyses with penicillins (OR=1.59; 95% CI 1.14-2.20) and amoxicillin (OR=1.78; 95% CI 1.14-2.79).

A case-control nested cohort study of Medicare beneficiaries with warfarin prescriptions was evaluated for antibiotic use and warfarin toxicity in older adults. An increased risk of bleeding was associated with penicillins with an adjusted odds ratio of 1.92.

Parenteral penicillins linked to this monograph include: almecillin, amdinocillin, amoxicillin, ampicillin, azlocillin, bacampicillin, carbenicillin, cyclacillin, hetacillin, mezlocillin, penicillin, penicillin G, penicillin V, phenethicillin, piperacillin, and ticarcillin. Oral penicillins linked to this monograph include: amoxicillin and penicillin.

ANISINDIONE, DICUMAROL, JANTOVEN, WARFARIN SODIUM

Severe List
Clostridioides difficile infection

The following adverse reaction information is available for PENICILLIN V POTASSIUM (penicillin v potassium):

Overview
Severe
Less Severe

Adverse reaction overview.

No enhanced Common Adverse Effects information available for this drug.

There are 27 severe adverse reactions.

More Frequent	Less Frequent
None.	Anaphylaxis Exfoliative dermatitis Urticaria

Rare/Very Rare
Abnormal hepatic function tests Acute generalized exanthematous pustulosis Agranulocytosis Autoimmune hemolytic anemia Clostridioides difficile infection Crystalluria DRESS syndrome Drug-induced hepatitis Enterocolitis Eosinophilia Erythema multiforme Furred tongue Hypersensitivity angiitis Idiopathic thrombocytopenic purpura Interstitial nephritis Laryngeal edema Leukopenia Maculopapular rash Obstructive hyperbilirubinemia Seizure disorder Serum sickness Stevens-johnson syndrome Thrombocytopenic disorder Toxic epidermal necrolysis

Rare/Very Rare

Abnormal hepatic function tests
Acute generalized exanthematous pustulosis
Agranulocytosis
Autoimmune hemolytic anemia
Clostridioides difficile infection
Crystalluria
DRESS syndrome
Drug-induced hepatitis
Enterocolitis
Eosinophilia
Erythema multiforme
Furred tongue
Hypersensitivity angiitis
Idiopathic thrombocytopenic purpura
Interstitial nephritis
Laryngeal edema
Leukopenia
Maculopapular rash
Obstructive hyperbilirubinemia
Seizure disorder
Serum sickness
Stevens-johnson syndrome
Thrombocytopenic disorder
Toxic epidermal necrolysis

There are 16 less severe adverse reactions.

More Frequent	Less Frequent
Diarrhea Nausea Skin rash Vomiting Vulvovaginal candidiasis	Abdominal pain with cramps Pruritus of skin

Rare/Very Rare
Acute cognitive impairment Agitation Anemia Behavioral disorders Dental discoloration Dizziness Insomnia Mucocutaneous candidiasis Symptoms of anxiety

The following precautions are available for PENICILLIN V POTASSIUM (penicillin v potassium):

Pediatric
Pregnant
Lactation
Geriatric

No enhanced Pediatric Use information available for this drug.

Contraindicated

None

Severe Precaution

None

Management or Monitoring Precaution

None

Available data regarding use of penicillin V in pregnant women, including first-trimester exposures, have not revealed evidence of an association between the drug and congenital defects. Some clinicians state that penicillin V is considered low risk and safe for use during pregnancy.

Penicillin V is distributed into milk. Some clinicians state that oral penicillin V usually is considered compatible with breast-feeding; others state that the drug should be used with caution in nursing women.

No enhanced Geriatric Use information available for this drug.

The following icd codes are available for PENICILLIN V POTASSIUM (penicillin v potassium)'s list of indications:

Acute bacterial otitis media
H66	Suppurative and unspecified otitis media
H66.0	Acute suppurative otitis media
H66.00	Acute suppurative otitis media without spontaneous rupture of ear drum
H66.001	Acute suppurative otitis media without spontaneous rupture of ear drum, right ear
H66.002	Acute suppurative otitis media without spontaneous rupture of ear drum, left ear
H66.003	Acute suppurative otitis media without spontaneous rupture of ear drum, bilateral
H66.004	Acute suppurative otitis media without spontaneous rupture of ear drum, recurrent, right ear
H66.005	Acute suppurative otitis media without spontaneous rupture of ear drum, recurrent, left ear
H66.006	Acute suppurative otitis media without spontaneous rupture of ear drum, recurrent, bilateral
H66.007	Acute suppurative otitis media without spontaneous rupture of ear drum, recurrent, unspecified ear
H66.009	Acute suppurative otitis media without spontaneous rupture of ear drum, unspecified ear
H66.01	Acute suppurative otitis media with spontaneous rupture of ear drum
H66.011	Acute suppurative otitis media with spontaneous rupture of ear drum, right ear
H66.012	Acute suppurative otitis media with spontaneous rupture of ear drum, left ear
H66.013	Acute suppurative otitis media with spontaneous rupture of ear drum, bilateral
H66.014	Acute suppurative otitis media with spontaneous rupture of ear drum, recurrent, right ear
H66.015	Acute suppurative otitis media with spontaneous rupture of ear drum, recurrent, left ear
H66.016	Acute suppurative otitis media with spontaneous rupture of ear drum, recurrent, bilateral
H66.017	Acute suppurative otitis media with spontaneous rupture of ear drum, recurrent, unspecified ear
H66.019	Acute suppurative otitis media with spontaneous rupture of ear drum, unspecified ear
H66.4	Suppurative otitis media, unspecified
H66.40	Suppurative otitis media, unspecified, unspecified ear
H66.41	Suppurative otitis media, unspecified, right ear
H66.42	Suppurative otitis media, unspecified, left ear
H66.43	Suppurative otitis media, unspecified, bilateral
H66.9	Otitis media, unspecified
H66.90	Otitis media, unspecified, unspecified ear
H66.91	Otitis media, unspecified, right ear
H66.92	Otitis media, unspecified, left ear
H66.93	Otitis media, unspecified, bilateral
Erysipelas
A46	Erysipelas
Fusospirochetal pharyngitis
A69.1	Other vincent's infections
Gingivostomatitis
K05.10	Chronic gingivitis, plaque induced
Pharyngitis
J02	Acute pharyngitis
J02.0	Streptococcal pharyngitis
J02.8	Acute pharyngitis due to other specified organisms
J02.9	Acute pharyngitis, unspecified
Pharyngitis due to streptococcus pyogenes
J02.0	Streptococcal pharyngitis
Pneumococcal acute otitis media
B95.3	Streptococcus pneumoniae as the cause of diseases classified elsewhere
H66.0	Acute suppurative otitis media
H66.00	Acute suppurative otitis media without spontaneous rupture of ear drum
H66.001	Acute suppurative otitis media without spontaneous rupture of ear drum, right ear
H66.002	Acute suppurative otitis media without spontaneous rupture of ear drum, left ear
H66.003	Acute suppurative otitis media without spontaneous rupture of ear drum, bilateral
H66.004	Acute suppurative otitis media without spontaneous rupture of ear drum, recurrent, right ear
H66.005	Acute suppurative otitis media without spontaneous rupture of ear drum, recurrent, left ear
H66.006	Acute suppurative otitis media without spontaneous rupture of ear drum, recurrent, bilateral
H66.007	Acute suppurative otitis media without spontaneous rupture of ear drum, recurrent, unspecified ear
H66.009	Acute suppurative otitis media without spontaneous rupture of ear drum, unspecified ear
H66.01	Acute suppurative otitis media with spontaneous rupture of ear drum
H66.011	Acute suppurative otitis media with spontaneous rupture of ear drum, right ear
H66.012	Acute suppurative otitis media with spontaneous rupture of ear drum, left ear
H66.013	Acute suppurative otitis media with spontaneous rupture of ear drum, bilateral
H66.014	Acute suppurative otitis media with spontaneous rupture of ear drum, recurrent, right ear
H66.015	Acute suppurative otitis media with spontaneous rupture of ear drum, recurrent, left ear
H66.016	Acute suppurative otitis media with spontaneous rupture of ear drum, recurrent, bilateral
H66.017	Acute suppurative otitis media with spontaneous rupture of ear drum, recurrent, unspecified ear
H66.019	Acute suppurative otitis media with spontaneous rupture of ear drum, unspecified ear
H66.4	Suppurative otitis media, unspecified
H66.40	Suppurative otitis media, unspecified, unspecified ear
H66.41	Suppurative otitis media, unspecified, right ear
H66.42	Suppurative otitis media, unspecified, left ear
H66.43	Suppurative otitis media, unspecified, bilateral
H66.9	Otitis media, unspecified
H66.91	Otitis media, unspecified, right ear
H66.92	Otitis media, unspecified, left ear
H66.93	Otitis media, unspecified, bilateral
Rheumatic fever prevention
B95.0	Streptococcus, group a, as the cause of diseases classified elsewhere
J02.0	Streptococcal pharyngitis
J03.00	Acute streptococcal tonsillitis, unspecified
Scarlet fever
A38	Scarlet fever
A38.0	Scarlet fever with otitis media
A38.1	Scarlet fever with myocarditis
A38.8	Scarlet fever with other complications
A38.9	Scarlet fever, uncomplicated
Skin and skin structure infection
H05.01	Cellulitis of orbit
H05.011	Cellulitis of right orbit
H05.012	Cellulitis of left orbit
H05.013	Cellulitis of bilateral orbits
H05.019	Cellulitis of unspecified orbit
H60.1	Cellulitis of external ear
H60.10	Cellulitis of external ear, unspecified ear
H60.11	Cellulitis of right external ear
H60.12	Cellulitis of left external ear
H60.13	Cellulitis of external ear, bilateral
K12.2	Cellulitis and abscess of mouth
L03	Cellulitis and acute lymphangitis
L03.0	Cellulitis and acute lymphangitis of finger and toe
L03.01	Cellulitis of finger
L03.011	Cellulitis of right finger
L03.012	Cellulitis of left finger
L03.019	Cellulitis of unspecified finger
L03.03	Cellulitis of toe
L03.031	Cellulitis of right toe
L03.032	Cellulitis of left toe
L03.039	Cellulitis of unspecified toe
L03.1	Cellulitis and acute lymphangitis of other parts of limb
L03.11	Cellulitis of other parts of limb
L03.111	Cellulitis of right axilla
L03.112	Cellulitis of left axilla
L03.113	Cellulitis of right upper limb
L03.114	Cellulitis of left upper limb
L03.115	Cellulitis of right lower limb
L03.116	Cellulitis of left lower limb
L03.119	Cellulitis of unspecified part of limb
L03.2	Cellulitis and acute lymphangitis of face and neck
L03.21	Cellulitis and acute lymphangitis of face
L03.211	Cellulitis of face
L03.22	Cellulitis and acute lymphangitis of neck
L03.221	Cellulitis of neck
L03.3	Cellulitis and acute lymphangitis of trunk
L03.31	Cellulitis of trunk
L03.311	Cellulitis of abdominal wall
L03.312	Cellulitis of back [any part except buttock]
L03.313	Cellulitis of chest wall
L03.314	Cellulitis of groin
L03.315	Cellulitis of perineum
L03.316	Cellulitis of umbilicus
L03.317	Cellulitis of buttock
L03.319	Cellulitis of trunk, unspecified
L03.8	Cellulitis and acute lymphangitis of other sites
L03.81	Cellulitis of other sites
L03.811	Cellulitis of head [any part, except face]
L03.818	Cellulitis of other sites
L03.9	Cellulitis and acute lymphangitis, unspecified
L03.90	Cellulitis, unspecified
L08.9	Local infection of the skin and subcutaneous tissue, unspecified
N48.22	Cellulitis of corpus cavernosum and penis
Staphylococcus aureus skin and skin structure infection
B95.6	Staphylococcus aureus as the cause of diseases classified elsewhere
H60.1	Cellulitis of external ear
H60.10	Cellulitis of external ear, unspecified ear
H60.11	Cellulitis of right external ear
H60.12	Cellulitis of left external ear
H60.13	Cellulitis of external ear, bilateral
J34.0	Abscess, furuncle and carbuncle of nose
L02	Cutaneous abscess, furuncle and carbuncle
L02.0	Cutaneous abscess, furuncle and carbuncle of face
L02.02	Furuncle of face
L02.03	Carbuncle of face
L02.1	Cutaneous abscess, furuncle and carbuncle of neck
L02.12	Furuncle of neck
L02.13	Carbuncle of neck
L02.2	Cutaneous abscess, furuncle and carbuncle of trunk
L02.22	Furuncle of trunk
L02.221	Furuncle of abdominal wall
L02.222	Furuncle of back [any part, except buttock]
L02.223	Furuncle of chest wall
L02.224	Furuncle of groin
L02.225	Furuncle of perineum
L02.226	Furuncle of umbilicus
L02.229	Furuncle of trunk, unspecified
L02.23	Carbuncle of trunk
L02.231	Carbuncle of abdominal wall
L02.232	Carbuncle of back [any part, except buttock]
L02.233	Carbuncle of chest wall
L02.234	Carbuncle of groin
L02.235	Carbuncle of perineum
L02.236	Carbuncle of umbilicus
L02.239	Carbuncle of trunk, unspecified
L02.3	Cutaneous abscess, furuncle and carbuncle of buttock
L02.32	Furuncle of buttock
L02.33	Carbuncle of buttock
L02.4	Cutaneous abscess, furuncle and carbuncle of limb
L02.42	Furuncle of limb
L02.421	Furuncle of right axilla
L02.422	Furuncle of left axilla
L02.423	Furuncle of right upper limb
L02.424	Furuncle of left upper limb
L02.425	Furuncle of right lower limb
L02.426	Furuncle of left lower limb
L02.429	Furuncle of limb, unspecified
L02.43	Carbuncle of limb
L02.431	Carbuncle of right axilla
L02.432	Carbuncle of left axilla
L02.433	Carbuncle of right upper limb
L02.434	Carbuncle of left upper limb
L02.435	Carbuncle of right lower limb
L02.436	Carbuncle of left lower limb
L02.439	Carbuncle of limb, unspecified
L02.5	Cutaneous abscess, furuncle and carbuncle of hand
L02.52	Furuncle hand
L02.521	Furuncle right hand
L02.522	Furuncle left hand
L02.529	Furuncle unspecified hand
L02.53	Carbuncle of hand
L02.531	Carbuncle of right hand
L02.532	Carbuncle of left hand
L02.539	Carbuncle of unspecified hand
L02.6	Cutaneous abscess, furuncle and carbuncle of foot
L02.62	Furuncle of foot
L02.621	Furuncle of right foot
L02.622	Furuncle of left foot
L02.629	Furuncle of unspecified foot
L02.63	Carbuncle of foot
L02.631	Carbuncle of right foot
L02.632	Carbuncle of left foot
L02.639	Carbuncle of unspecified foot
L02.8	Cutaneous abscess, furuncle and carbuncle of other sites
L02.82	Furuncle of other sites
L02.821	Furuncle of head [any part, except face]
L02.828	Furuncle of other sites
L02.83	Carbuncle of other sites
L02.831	Carbuncle of head [any part, except face]
L02.838	Carbuncle of other sites
L02.9	Cutaneous abscess, furuncle and carbuncle, unspecified
L02.92	Furuncle, unspecified
L02.93	Carbuncle, unspecified
L03.01	Cellulitis of finger
L03.011	Cellulitis of right finger
L03.012	Cellulitis of left finger
L03.019	Cellulitis of unspecified finger
L03.03	Cellulitis of toe
L03.031	Cellulitis of right toe
L03.032	Cellulitis of left toe
L03.039	Cellulitis of unspecified toe
L03.1	Cellulitis and acute lymphangitis of other parts of limb
L03.11	Cellulitis of other parts of limb
L03.111	Cellulitis of right axilla
L03.112	Cellulitis of left axilla
L03.113	Cellulitis of right upper limb
L03.114	Cellulitis of left upper limb
L03.115	Cellulitis of right lower limb
L03.116	Cellulitis of left lower limb
L03.119	Cellulitis of unspecified part of limb
L03.2	Cellulitis and acute lymphangitis of face and neck
L03.21	Cellulitis and acute lymphangitis of face
L03.211	Cellulitis of face
L03.22	Cellulitis and acute lymphangitis of neck
L03.221	Cellulitis of neck
L03.3	Cellulitis and acute lymphangitis of trunk
L03.31	Cellulitis of trunk
L03.311	Cellulitis of abdominal wall
L03.312	Cellulitis of back [any part except buttock]
L03.313	Cellulitis of chest wall
L03.314	Cellulitis of groin
L03.315	Cellulitis of perineum
L03.316	Cellulitis of umbilicus
L03.317	Cellulitis of buttock
L03.319	Cellulitis of trunk, unspecified
L03.8	Cellulitis and acute lymphangitis of other sites
L03.81	Cellulitis of other sites
L03.811	Cellulitis of head [any part, except face]
L03.818	Cellulitis of other sites
L03.9	Cellulitis and acute lymphangitis, unspecified
L03.90	Cellulitis, unspecified
L08.89	Other specified local infections of the skin and subcutaneous tissue
L08.9	Local infection of the skin and subcutaneous tissue, unspecified
N48.22	Cellulitis of corpus cavernosum and penis
Streptococcus acute otitis media
B95.0	Streptococcus, group a, as the cause of diseases classified elsewhere
B95.4	Other streptococcus as the cause of diseases classified elsewhere
B95.5	Unspecified streptococcus as the cause of diseases classified elsewhere
H66.0	Acute suppurative otitis media
H66.00	Acute suppurative otitis media without spontaneous rupture of ear drum
H66.001	Acute suppurative otitis media without spontaneous rupture of ear drum, right ear
H66.002	Acute suppurative otitis media without spontaneous rupture of ear drum, left ear
H66.003	Acute suppurative otitis media without spontaneous rupture of ear drum, bilateral
H66.004	Acute suppurative otitis media without spontaneous rupture of ear drum, recurrent, right ear
H66.005	Acute suppurative otitis media without spontaneous rupture of ear drum, recurrent, left ear
H66.006	Acute suppurative otitis media without spontaneous rupture of ear drum, recurrent, bilateral
H66.007	Acute suppurative otitis media without spontaneous rupture of ear drum, recurrent, unspecified ear
H66.009	Acute suppurative otitis media without spontaneous rupture of ear drum, unspecified ear
H66.01	Acute suppurative otitis media with spontaneous rupture of ear drum
H66.011	Acute suppurative otitis media with spontaneous rupture of ear drum, right ear
H66.012	Acute suppurative otitis media with spontaneous rupture of ear drum, left ear
H66.013	Acute suppurative otitis media with spontaneous rupture of ear drum, bilateral
H66.014	Acute suppurative otitis media with spontaneous rupture of ear drum, recurrent, right ear
H66.015	Acute suppurative otitis media with spontaneous rupture of ear drum, recurrent, left ear
H66.016	Acute suppurative otitis media with spontaneous rupture of ear drum, recurrent, bilateral
H66.017	Acute suppurative otitis media with spontaneous rupture of ear drum, recurrent, unspecified ear
H66.019	Acute suppurative otitis media with spontaneous rupture of ear drum, unspecified ear
H66.4	Suppurative otitis media, unspecified
H66.40	Suppurative otitis media, unspecified, unspecified ear
H66.41	Suppurative otitis media, unspecified, right ear
H66.42	Suppurative otitis media, unspecified, left ear
H66.43	Suppurative otitis media, unspecified, bilateral
H66.9	Otitis media, unspecified
H66.90	Otitis media, unspecified, unspecified ear
H66.91	Otitis media, unspecified, right ear
H66.92	Otitis media, unspecified, left ear
H66.93	Otitis media, unspecified, bilateral
Tonsillitis due to streptococcus pyogenes
J03.0	Streptococcal tonsillitis
J03.00	Acute streptococcal tonsillitis, unspecified
J03.01	Acute recurrent streptococcal tonsillitis
Upper respiratory pneumococcal infection
B95.3	Streptococcus pneumoniae as the cause of diseases classified elsewhere
J00	Acute nasopharyngitis [common cold]
J01	Acute sinusitis
J01.0	Acute maxillary sinusitis
J01.00	Acute maxillary sinusitis, unspecified
J01.01	Acute recurrent maxillary sinusitis
J01.1	Acute frontal sinusitis
J01.10	Acute frontal sinusitis, unspecified
J01.11	Acute recurrent frontal sinusitis
J01.2	Acute ethmoidal sinusitis
J01.20	Acute ethmoidal sinusitis, unspecified
J01.21	Acute recurrent ethmoidal sinusitis
J01.3	Acute sphenoidal sinusitis
J01.30	Acute sphenoidal sinusitis, unspecified
J01.31	Acute recurrent sphenoidal sinusitis
J01.4	Acute pansinusitis
J01.40	Acute pansinusitis, unspecified
J01.41	Acute recurrent pansinusitis
J01.8	Other acute sinusitis
J01.80	Other acute sinusitis
J01.81	Other acute recurrent sinusitis
J01.9	Acute sinusitis, unspecified
J01.90	Acute sinusitis, unspecified
J01.91	Acute recurrent sinusitis, unspecified
J02	Acute pharyngitis
J02.0	Streptococcal pharyngitis
J02.9	Acute pharyngitis, unspecified
J03	Acute tonsillitis
J03.0	Streptococcal tonsillitis
J03.00	Acute streptococcal tonsillitis, unspecified
J03.01	Acute recurrent streptococcal tonsillitis
J03.9	Acute tonsillitis, unspecified
J03.90	Acute tonsillitis, unspecified
J03.91	Acute recurrent tonsillitis, unspecified
J04	Acute laryngitis and tracheitis
J04.0	Acute laryngitis
J04.1	Acute tracheitis
J04.10	Acute tracheitis without obstruction
J04.11	Acute tracheitis with obstruction
J04.2	Acute laryngotracheitis
J04.3	Supraglottitis, unspecified
J04.30	Supraglottitis, unspecified, without obstruction
J04.31	Supraglottitis, unspecified, with obstruction
J05	Acute obstructive laryngitis [croup] and epiglottitis
J05.0	Acute obstructive laryngitis [croup]
J05.1	Acute epiglottitis
J05.10	Acute epiglottitis without obstruction
J05.11	Acute epiglottitis with obstruction
J06	Acute upper respiratory infections of multiple and unspecified sites
J06.0	Acute laryngopharyngitis
J06.9	Acute upper respiratory infection, unspecified
Upper respiratory streptococcal infection
B95.0	Streptococcus, group a, as the cause of diseases classified elsewhere
B95.3	Streptococcus pneumoniae as the cause of diseases classified elsewhere
B95.4	Other streptococcus as the cause of diseases classified elsewhere
B95.5	Unspecified streptococcus as the cause of diseases classified elsewhere
J00	Acute nasopharyngitis [common cold]
J01	Acute sinusitis
J01.0	Acute maxillary sinusitis
J01.00	Acute maxillary sinusitis, unspecified
J01.01	Acute recurrent maxillary sinusitis
J01.1	Acute frontal sinusitis
J01.10	Acute frontal sinusitis, unspecified
J01.11	Acute recurrent frontal sinusitis
J01.2	Acute ethmoidal sinusitis
J01.20	Acute ethmoidal sinusitis, unspecified
J01.21	Acute recurrent ethmoidal sinusitis
J01.3	Acute sphenoidal sinusitis
J01.30	Acute sphenoidal sinusitis, unspecified
J01.31	Acute recurrent sphenoidal sinusitis
J01.4	Acute pansinusitis
J01.40	Acute pansinusitis, unspecified
J01.41	Acute recurrent pansinusitis
J01.8	Other acute sinusitis
J01.80	Other acute sinusitis
J01.81	Other acute recurrent sinusitis
J01.9	Acute sinusitis, unspecified
J01.90	Acute sinusitis, unspecified
J01.91	Acute recurrent sinusitis, unspecified
J02	Acute pharyngitis
J02.0	Streptococcal pharyngitis
J02.9	Acute pharyngitis, unspecified
J03	Acute tonsillitis
J03.0	Streptococcal tonsillitis
J03.00	Acute streptococcal tonsillitis, unspecified
J03.01	Acute recurrent streptococcal tonsillitis
J03.9	Acute tonsillitis, unspecified
J03.90	Acute tonsillitis, unspecified
J03.91	Acute recurrent tonsillitis, unspecified
J04	Acute laryngitis and tracheitis
J04.0	Acute laryngitis
J04.1	Acute tracheitis
J04.10	Acute tracheitis without obstruction
J04.11	Acute tracheitis with obstruction
J04.2	Acute laryngotracheitis
J04.3	Supraglottitis, unspecified
J04.30	Supraglottitis, unspecified, without obstruction
J04.31	Supraglottitis, unspecified, with obstruction
J05	Acute obstructive laryngitis [croup] and epiglottitis
J05.0	Acute obstructive laryngitis [croup]
J05.1	Acute epiglottitis
J05.10	Acute epiglottitis without obstruction
J05.11	Acute epiglottitis with obstruction
J06	Acute upper respiratory infections of multiple and unspecified sites
J06.0	Acute laryngopharyngitis
J06.9	Acute upper respiratory infection, unspecified