Penicillin G Sodium

Drug overview for PENICILLIN G SODIUM (penicillin g sodium):

Generic name: PENICILLIN G SODIUM (pen-ih-SILL-in GEE)
Drug class: Beta-Lactams
Therapeutic class: Anti-Infective Agents

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

Penicillin G potassium and penicillin G sodium are used parenterally when rapid and high concentrations of penicillin G are required, as in the treatment of endocarditis, meningitis, pericarditis, septicemia, severe pneumonia, or other serious infections caused by organisms susceptible to penicillin G. For additional information on the uses of penicillin G potassium and penicillin G sodium, see Uses in the Natural Penicillins General Statement 8:12.16.04.

DRUG IMAGES

PENICILLIN G NA 5 MILLION UNIT

The following indications for PENICILLIN G SODIUM (penicillin g sodium) have been approved by the FDA:

Indications:
Abdominal actinomycosis
Actinomycosis
Anthrax septicemia
Aspiration pneumonia
Botulism
Cervicofacial actinomycosis
Clostridium perfringens empyema
Congenital neurosyphilis
Cutaneous anthrax
Diphtheria
Enterococcal endocarditis
Enterococcus septicemia
Erysipeloid
Erysipelothrix endocarditis
Fusospirochetal pharyngitis
Gas gangrene caused by Clostridium perfringens
Gastrointestinal anthrax
Granulomatosis infantiseptica
Inhaled anthrax
Listeria endocarditis
Listeria meningitis
Lung abscess
Meningitis due to anthrax
Meningococcal meningitis
Meningococcemia
Necrotizing fasciitis Streptococcus infection
Necrotizing pneumonia
Neonatal group B streptococcal septicemia
Neonatal meningitis
Neonatal pneumonia
Neurosyphilis
Pasteurella multocida endocarditis
Pasteurella multocida osteomyelitis
Pasteurellosis
Pneumococcal meningitis
Pneumococcus endocarditis
Primary genital syphilis
Pulmonary actinomycosis
Rat-bite fever
Scarlet fever
Secondary syphilis
Sepsis of newborn
Skin and skin structure Streptococcus pyogenes infection
Streptococcal endocarditis
Streptococcal meningitis
Streptococcal pneumonia
Streptococcal toxic shock syndrome
Streptococcus empyema
Streptococcus myositis
Streptococcus pericarditis
Symptomatic congenital syphilis
Tetanus
Upper respiratory infection due to Neisseria meningitidis

Professional Synonyms:
Abdominal actinomycotic infection
Actinomycotic infection
Actinophytosis
Anthracemia
Anthrax meningitis
Anthrax pneumonia
Bacterial sepsis of newborn
Cerebral anthrax
Cervicofacial actinomycotic infection
Clostridium perfringens gas gangrene
Diphtheritis
Disseminated infantile listeriosis
Empyema due to Clostridium perfringens
Empyema due to Streptococcus
Endocarditis due to enterococcus
Endocarditis due to Erysipelothrix rhusiopathiae
Endocarditis due to Listeria monocytogenes
Endocarditis due to Pasteurella multocida
Endocarditis due to Streptococcus
Fusospirochetal infection of the oropharynx
Gangrenous erysipelas due to Streptococcus
Gangrenous pneumonia
Gas gangrene due to Clostridium perfringens
GI anthrax
Infection caused by Erysipelothrix rhusiopathiae
Infectious disease with painful voluntary muscle spasms
Inhalational anthrax
Intestinal anthrax
Intoxication with Clostridium botulinum toxin
Juvenile neurosyphilis
Late congenital neurosyphilis
Lumpy jaw
Meningeal anthrax
Meningitis due to Listeria monocytogenes
Meningitis due to listeriosis
Meningococcal septicemia
Myositis due to Streptococcus
Necrotic pneumonia
Necrotizing erysipelas due to Streptococcus
Necrotizing fasciitis due to Streptococcus
Neonatal group B streptococcal sepsis
Neonatal sepsis
Osteomyelitis due to Pasteurella multocida
Pasteurella infection
Pericarditis due to Streptococcus
Pneumococcal endocarditis
Pneumonia due to Streptococcus species
Pneumonia due to Streptococcus spp.
Pulmonary abscess
Pulmonary actinomycotic infection
Pyogenic bone infection due to Pasteurella multocida
Pyothorax due to Clostridium perfringens
Pyothorax due to Streptococcus
Rag-Sorter's disease
Ragpicker's disease
Ragsorter's disease
Rat-bite disease
Scarlatina
Sepsis due to Enterococcus
Septicemia due to anthrax
Septicemia due to Enterococcus
Septicemia due to Neisseria meningitidis
Skin & skin soft tissue Streptococcus pyogenes infection
Skin infection due to Bacillus anthracis
Sodoku
Sokosho
Streptococcal infection of the pericardium
Streptococcus pneumoniae meningitis
Streptococcus species empyema
Syphilitic chancre
Syriac ulcer
Thoracic actinomycosis
Toxic shock syndrome due to Streptococcus
TSS due to Streptococcus
URI due to Neisseria meningitidis
Vincent's angina
Wool-Sorter's disease
Wool-Sorter's pneumonia
Woolsorter's disease

The following dosing information is available for PENICILLIN G SODIUM (penicillin g sodium):

Dosing
Administration
PENICILLIN G SODIUM
PENICILLIN G SODIUM

Dosage of penicillin G potassium and penicillin G sodium usually is expressed in terms of penicillin G units, but also has been expressed as mg of penicillin G.

Dosage of IM or IV penicillin G potassium or sodium for pediatric patients should be individualized and generally is based on weight and the severity of the infection.

The manufacturers state that penicillin G potassium or sodium should not be used in pediatric patients requiring less than 1 million penicillin G units per dose.

The American Academy of Pediatrics (AAP) states that the usual dosage of IV or IM penicillin G potassium or sodium in neonates 7 days of age or younger is 25,000-50,000 units/kg every 12 hours. In neonates 8-28 days of age, AAP recommends a dosage of 25,000-50,000 units/kg every 8 hours. Higher dosages may be necessary for the treatment of meningitis in neonates.

In pediatric patients beyond the neonatal period, AAP states that the usual dosage of IV or IM penicillin G potassium or sodium is 100,000-150,000 units/kg daily given in 4 equally divided doses for the treatment of mild to moderate infections or 200,000-300,000 units/kg daily given in 4-6 equally divided doses for the treatment of severe infections. AAP states that the highest dosage recommended for pediatric patients beyond the neonatal period should be used for the treatment of meningitis.

In patients with impaired renal function, doses and/or frequency of administration of penicillin G may need to be modified in response to the degree of impairment.

The manufacturers state that dosage of IM or IV penicillin G potassium or sodium should be adjusted in patients with severe renal impairment. These manufacturers and others recommend that patients with creatinine clearance less than 10 mL/minute per 1.73 m2 receive a loading dose of penicillin G using the usually recommended dose followed by 50% of the usually recommended dose given every 8-10 hours.

In uremic patients with creatinine clearance greater than 10 mL/minute per 1.73 m2, the manufacturers and others recommend a loading dose of penicillin G using the usually recommended dose followed by 50% of the usually recommended dose given every 4-5 hours.

Alternatively, some clinicians suggest that if the usual dosing interval for penicillin G potassium or sodium in patients with normal renal function (creatinine clearance greater than 50 mL/minute) is every 6 or 8 hours, then the usual dose should be given every 8-12 hours in those with creatinine clearance of 10-50 mL/minute or every 12-18 hours in those with creatinine clearance less than 10 mL/minute.

Some clinicians suggest a maximum daily dosage of 4-10 million penicillin G units in adults with severe renal failure.

In patients with impaired hepatic function in addition to impaired renal function, further dosage reductions may be advisable.

No enhanced Administration information available for this drug.

Dosing information for PENICILLIN G SODIUM
DRUG LABEL	DOSING TYPE	DOSING INSTRUCTIONS
PENICILLIN G NA 5 MILLION UNIT	Maintenance	Adults infuse 5 million units over 1-2 hour(s) by intravenous route every 6 hours

Generic dosing information for PENICILLIN G SODIUM
DRUG LABEL	DOSING TYPE	DOSING INSTRUCTIONS
PENICILLIN G NA 5 MILLION UNIT	Maintenance	Adults infuse 5 million units over 1-2 hour(s) by intravenous route every 6 hours

The following drug interaction information is available for PENICILLIN G SODIUM (penicillin g sodium):

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 3 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
Selected Cephalosporins & Penicillins/Probenecid SEVERITY LEVEL: 3-Moderate Interaction: Assess the risk to the patient and take action as needed. MECHANISM OF ACTION: Probenecid impairs the clearance of some cephalosporins and penicillins via inhibition of renal anion transporters in the proximal tubule.(49) It has also been hypothesized that probenecid may affect tissue distribution of cephalosporins.(1-5) CLINICAL EFFECTS: The concurrent administration of probenecid may result in increased maximum concentration (Cmax), area-under-curve (AUC), and half-life of the cephalosporin or penicillin.(49) While this may improve antibiotic efficacy,(46-48) increased levels may also increase the risk for antibiotic-associated nephrotoxicity.(4) PREDISPOSING FACTORS: Underlying renal dysfunction may increase the risk for nephrotoxicity. PATIENT MANAGEMENT: In patients receiving the combination to improve antibiotic efficacy, monitor for antibiotic adverse effects and consider monitoring renal function. In patients receiving probenecid therapy to prevent or treat hyperuricemia, exposure to the antibiotic will be increased. A decrease in antibiotic dose or frequency may be required. The US manufacturer of piperacillin-tazobactam states probenecid should not be coadministered with piperacillin-tazobactam unless the benefit outweighs the risk.(50) DISCUSSION: Concurrent use of probenecid with a cephalosporin or penicillin may cause an increase in the Cmax, AUC, and an increased elimination half life of the antibiotic.(6-8,49) This may be beneficial or necessary in difficult to treat infections,(46-48) but an increased risk for adverse effects should be expected. Antibiotics not dose adjusted for concurrent use with probenecid may be associated with an increased risk for adverse effects, such as nephrotoxicity. Probenecid administered concurrently with piperacillin-tazobactam prolongs the half-life of piperacillin by 21% and tazobactam by 71%. In a study in 8 healthy males, concurrent administration of probenecid (1 g) with piperacillin (1 g IM) increased piperacillin's Cmax and AUC by 30% and 60%. Renal clearance was reduced by 40%.(51) The cephalosporins affected by probenecid include cefazolin,(9-11) cephacetrile,(12,13) cephaloglycin,(14,15) cephalexin,(16-21) cephradine, (22-23) cefoxitin,(24-28) cefadroxil(29), cefaclor,(23) cefamandole,(30) ceftizoxime,(31,32) cefuroxime,(33,34) cefprozil,(35) cefonicid,(36) cefmetazole,(37) cefmenoxime,(38) and cefditoren.(39) Probenecid has been shown not to affect moxalactam,(4,40,41) ceforanide, (4,42), cefoperazone, ceftazidime(4,34,43) or ceftriaxone.(4)	PROBENECID, PROBENECID-COLCHICINE

Severe List
Clostridioides difficile infection

The following adverse reaction information is available for PENICILLIN G SODIUM (penicillin g sodium):

Overview
Severe
Less Severe

Adverse reaction overview.

No enhanced Common Adverse Effects information available for this drug.

There are 36 severe adverse reactions.

More Frequent	Less Frequent
None.	Anaphylaxis Dyspnea Exfoliative dermatitis Hypotension Kounis syndrome Serum sickness

Rare/Very Rare
Abnormal desquamation Abnormal hepatic function tests Acute generalized exanthematous pustulosis Agranulocytosis Altered mental status Angioedema Cholestasis Clostridioides difficile infection Crystalluria DRESS syndrome Eosinophilia Facial edema Hemolytic anemia Hepatitis Hyperreflexia Hypokalemia Increased risk of bleeding due to coagulation disorder Interstitial nephritis Laryngismus Leukopenia Myoclonus Neutropenic disorder Pancytopenia Phlebitis after infusion Renal failure Seizure disorder Stevens-johnson syndrome Thrombocytopenic disorder Thrombophlebitis Toxic epidermal necrolysis

Rare/Very Rare

Abnormal desquamation
Abnormal hepatic function tests
Acute generalized exanthematous pustulosis
Agranulocytosis
Altered mental status
Angioedema
Cholestasis
Clostridioides difficile infection
Crystalluria
DRESS syndrome
Eosinophilia
Facial edema
Hemolytic anemia
Hepatitis
Hyperreflexia
Hypokalemia
Increased risk of bleeding due to coagulation disorder
Interstitial nephritis
Laryngismus
Leukopenia
Myoclonus
Neutropenic disorder
Pancytopenia
Phlebitis after infusion
Renal failure
Seizure disorder
Stevens-johnson syndrome
Thrombocytopenic disorder
Thrombophlebitis
Toxic epidermal necrolysis

There are 12 less severe adverse reactions.

More Frequent	Less Frequent
Diarrhea Headache disorder Nausea Oral candidiasis Vomiting Vulvovaginal candidiasis	Pruritus of skin Skin rash Stomatitis

Rare/Very Rare
Fever Injection site sequelae Urticaria

The following precautions are available for PENICILLIN G SODIUM (penicillin g sodium):

Pediatric
Pregnant
Lactation
Geriatric

No enhanced Pediatric Use information available for this drug.

Contraindicated

None

Severe Precaution

None

Management or Monitoring Precaution

None

Reproduction studies evaluating penicillin G in mice, rats, and rabbits have not revealed evidence of impaired fertility or harm to the fetus. Although experience with use of penicillins during pregnancy has not shown any evidence of adverse effects on the fetus, there are no adequate or controlled studies using penicillin G in pregnant women. Some clinicians state that penicillin G is considered low risk and safe for use during pregnancy.

The drug is included in the US Centers for Disease Control and Prevention (CDC) recommendations for the treatment of syphilis during pregnancy. The manufacturers state that penicillin G potassium or sodium should be used during pregnancy only when clearly needed.

Penicillin G is distributed into milk. Some clinicians state that penicillin G is usually considered compatible with breast-feeding. The manufacturers and others state that penicillin G potassium or sodium 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 G SODIUM (penicillin g sodium)'s list of indications:

Abdominal actinomycosis
A42.1	Abdominal actinomycosis
Actinomycosis
A42	Actinomycosis
A42.0	Pulmonary actinomycosis
A42.1	Abdominal actinomycosis
A42.2	Cervicofacial actinomycosis
A42.7	Actinomycotic sepsis
A42.8	Other forms of actinomycosis
A42.81	Actinomycotic meningitis
A42.82	Actinomycotic encephalitis
A42.89	Other forms of actinomycosis
A42.9	Actinomycosis, unspecified
Anthrax septicemia
A22.7	Anthrax sepsis
Aspiration pneumonia
J69	Pneumonitis due to solids and liquids
J69.0	Pneumonitis due to inhalation of food and vomit
J69.1	Pneumonitis due to inhalation of oils and essences
J69.8	Pneumonitis due to inhalation of other solids and liquids
O29.01	Aspiration pneumonitis due to anesthesia during pregnancy
O29.011	Aspiration pneumonitis due to anesthesia during pregnancy, first trimester
O29.012	Aspiration pneumonitis due to anesthesia during pregnancy, second trimester
O29.013	Aspiration pneumonitis due to anesthesia during pregnancy, third trimester
O29.019	Aspiration pneumonitis due to anesthesia during pregnancy, unspecified trimester
O74.0	Aspiration pneumonitis due to anesthesia during labor and delivery
O89.01	Aspiration pneumonitis due to anesthesia during the puerperium
P24.01	Meconium aspiration with respiratory symptoms
P24.11	Neonatal aspiration of (clear) amniotic fluid and mucus with respiratory symptoms
P24.21	Neonatal aspiration of blood with respiratory symptoms
P24.31	Neonatal aspiration of milk and regurgitated food with respiratory symptoms
P24.81	Other neonatal aspiration with respiratory symptoms
Botulism
A05.1	Botulism food poisoning
A48.5	Other specified botulism
A48.51	Infant botulism
A48.52	Wound botulism
Cervicofacial actinomycosis
A42.2	Cervicofacial actinomycosis
Clostridium perfringens empyema
B96.7	Clostridium perfringens [c. perfringens] as the cause of diseases classified elsewhere
Congenital neurosyphilis
A50.40	Late congenital neurosyphilis, unspecified
A50.41	Late congenital syphilitic meningitis
A50.42	Late congenital syphilitic encephalitis
A50.43	Late congenital syphilitic polyneuropathy
A50.44	Late congenital syphilitic optic nerve atrophy
A50.45	Juvenile general paresis
A50.49	Other late congenital neurosyphilis
Cutaneous anthrax
A22.0	Cutaneous anthrax
Diphtheria
A36	Diphtheria
A36.0	Pharyngeal diphtheria
A36.1	Nasopharyngeal diphtheria
A36.2	Laryngeal diphtheria
A36.3	Cutaneous diphtheria
A36.8	Other diphtheria
A36.81	Diphtheritic cardiomyopathy
A36.82	Diphtheritic radiculomyelitis
A36.83	Diphtheritic polyneuritis
A36.84	Diphtheritic tubulo-interstitial nephropathy
A36.85	Diphtheritic cystitis
A36.86	Diphtheritic conjunctivitis
A36.89	Other diphtheritic complications
A36.9	Diphtheria, unspecified
Enterococcal endocarditis
B95.2	Enterococcus as the cause of diseases classified elsewhere
I33.0	Acute and subacute infective endocarditis
Enterococcus septicemia
A41.81	Sepsis due to enterococcus
Erysipeloid
A26	Erysipeloid
A26.0	Cutaneous erysipeloid
A26.7	Erysipelothrix sepsis
A26.8	Other forms of erysipeloid
A26.9	Erysipeloid, unspecified
Erysipelothrix endocarditis
A26.8	Other forms of erysipeloid
I33.0	Acute and subacute infective endocarditis
Fusospirochetal pharyngitis
A69.1	Other vincent's infections
Gas gangrene caused by clostridium perfringens
A48.0	Gas gangrene
Gastrointestinal anthrax
A22.2	Gastrointestinal anthrax
Granulomatosis infantiseptica
P37.2	Neonatal (disseminated) listeriosis
Inhaled anthrax
A22.1	Pulmonary anthrax
Listeria endocarditis
A32.82	Listerial endocarditis
Listeria meningitis
A32.1	Listerial meningitis and meningoencephalitis
A32.11	Listerial meningitis
A32.12	Listerial meningoencephalitis
Lung abscess
J85.1	Abscess of lung with pneumonia
J85.2	Abscess of lung without pneumonia
Meningitis due to anthrax
A22.8	Other forms of anthrax
Meningococcal meningitis
A39.0	Meningococcal meningitis
Meningococcemia
A39.1	Waterhouse-friderichsen syndrome
A39.2	Acute meningococcemia
A39.3	Chronic meningococcemia
A39.4	Meningococcemia, unspecified
Necrotizing fasciitis streptococcus infection
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
M72.6	Necrotizing fasciitis
Necrotizing pneumonia
J85.0	Gangrene and necrosis of lung
Neonatal group B streptococcal septicemia
P36.0	Sepsis of newborn due to streptococcus, group B
Neonatal meningitis
A32.1	Listerial meningitis and meningoencephalitis
A32.11	Listerial meningitis
A32.12	Listerial meningoencephalitis
G00.2	Streptococcal meningitis
G00.8	Other bacterial meningitis
Neonatal pneumonia
P23	Congenital pneumonia
P23.1	Congenital pneumonia due to chlamydia
P23.2	Congenital pneumonia due to staphylococcus
P23.3	Congenital pneumonia due to streptococcus, group B
P23.4	Congenital pneumonia due to escherichia coli
P23.5	Congenital pneumonia due to pseudomonas
P23.6	Congenital pneumonia due to other bacterial agents
P23.8	Congenital pneumonia due to other organisms
P23.9	Congenital pneumonia, unspecified
Neurosyphilis
A50.4	Late congenital neurosyphilis [juvenile neurosyphilis]
A50.40	Late congenital neurosyphilis, unspecified
A50.41	Late congenital syphilitic meningitis
A50.42	Late congenital syphilitic encephalitis
A50.43	Late congenital syphilitic polyneuropathy
A50.44	Late congenital syphilitic optic nerve atrophy
A50.45	Juvenile general paresis
A50.49	Other late congenital neurosyphilis
A52.1	Symptomatic neurosyphilis
A52.10	Symptomatic neurosyphilis, unspecified
A52.11	Tabes dorsalis
A52.12	Other cerebrospinal syphilis
A52.13	Late syphilitic meningitis
A52.14	Late syphilitic encephalitis
A52.15	Late syphilitic neuropathy
A52.16	Charcot's arthropathy (tabetic)
A52.17	General paresis
A52.19	Other symptomatic neurosyphilis
A52.2	Asymptomatic neurosyphilis
A52.3	Neurosyphilis, unspecified
Pasteurella multocida endocarditis
A28.0	Pasteurellosis
I33.0	Acute and subacute infective endocarditis
Pasteurella multocida osteomyelitis
A28.0	Pasteurellosis
H05.02	Osteomyelitis of orbit
H05.021	Osteomyelitis of right orbit
H05.022	Osteomyelitis of left orbit
H05.023	Osteomyelitis of bilateral orbits
H05.029	Osteomyelitis of unspecified orbit
M46.2	Osteomyelitis of vertebra
M46.20	Osteomyelitis of vertebra, site unspecified
M46.21	Osteomyelitis of vertebra, occipito-atlanto-axial region
M46.22	Osteomyelitis of vertebra, cervical region
M46.23	Osteomyelitis of vertebra, cervicothoracic region
M46.24	Osteomyelitis of vertebra, thoracic region
M46.25	Osteomyelitis of vertebra, thoracolumbar region
M46.26	Osteomyelitis of vertebra, lumbar region
M46.27	Osteomyelitis of vertebra, lumbosacral region
M46.28	Osteomyelitis of vertebra, sacral and sacrococcygeal region
M86	Osteomyelitis
M86.0	Acute hematogenous osteomyelitis
M86.00	Acute hematogenous osteomyelitis, unspecified site
M86.01	Acute hematogenous osteomyelitis, shoulder
M86.011	Acute hematogenous osteomyelitis, right shoulder
M86.012	Acute hematogenous osteomyelitis, left shoulder
M86.019	Acute hematogenous osteomyelitis, unspecified shoulder
M86.02	Acute hematogenous osteomyelitis, humerus
M86.021	Acute hematogenous osteomyelitis, right humerus
M86.022	Acute hematogenous osteomyelitis, left humerus
M86.029	Acute hematogenous osteomyelitis, unspecified humerus
M86.03	Acute hematogenous osteomyelitis, radius and ulna
M86.031	Acute hematogenous osteomyelitis, right radius and ulna
M86.032	Acute hematogenous osteomyelitis, left radius and ulna
M86.039	Acute hematogenous osteomyelitis, unspecified radius and ulna
M86.04	Acute hematogenous osteomyelitis, hand
M86.041	Acute hematogenous osteomyelitis, right hand
M86.042	Acute hematogenous osteomyelitis, left hand
M86.049	Acute hematogenous osteomyelitis, unspecified hand
M86.05	Acute hematogenous osteomyelitis, femur
M86.051	Acute hematogenous osteomyelitis, right femur
M86.052	Acute hematogenous osteomyelitis, left femur
M86.059	Acute hematogenous osteomyelitis, unspecified femur
M86.06	Acute hematogenous osteomyelitis, tibia and fibula
M86.061	Acute hematogenous osteomyelitis, right tibia and fibula
M86.062	Acute hematogenous osteomyelitis, left tibia and fibula
M86.069	Acute hematogenous osteomyelitis, unspecified tibia and fibula
M86.07	Acute hematogenous osteomyelitis, ankle and foot
M86.071	Acute hematogenous osteomyelitis, right ankle and foot
M86.072	Acute hematogenous osteomyelitis, left ankle and foot
M86.079	Acute hematogenous osteomyelitis, unspecified ankle and foot
M86.08	Acute hematogenous osteomyelitis, other sites
M86.09	Acute hematogenous osteomyelitis, multiple sites
M86.1	Other acute osteomyelitis
M86.10	Other acute osteomyelitis, unspecified site
M86.11	Other acute osteomyelitis, shoulder
M86.111	Other acute osteomyelitis, right shoulder
M86.112	Other acute osteomyelitis, left shoulder
M86.119	Other acute osteomyelitis, unspecified shoulder
M86.12	Other acute osteomyelitis, humerus
M86.121	Other acute osteomyelitis, right humerus
M86.122	Other acute osteomyelitis, left humerus
M86.129	Other acute osteomyelitis, unspecified humerus
M86.13	Other acute osteomyelitis, radius and ulna
M86.131	Other acute osteomyelitis, right radius and ulna
M86.132	Other acute osteomyelitis, left radius and ulna
M86.139	Other acute osteomyelitis, unspecified radius and ulna
M86.14	Other acute osteomyelitis, hand
M86.141	Other acute osteomyelitis, right hand
M86.142	Other acute osteomyelitis, left hand
M86.149	Other acute osteomyelitis, unspecified hand
M86.15	Other acute osteomyelitis, femur
M86.151	Other acute osteomyelitis, right femur
M86.152	Other acute osteomyelitis, left femur
M86.159	Other acute osteomyelitis, unspecified femur
M86.16	Other acute osteomyelitis, tibia and fibula
M86.161	Other acute osteomyelitis, right tibia and fibula
M86.162	Other acute osteomyelitis, left tibia and fibula
M86.169	Other acute osteomyelitis, unspecified tibia and fibula
M86.17	Other acute osteomyelitis, ankle and foot
M86.171	Other acute osteomyelitis, right ankle and foot
M86.172	Other acute osteomyelitis, left ankle and foot
M86.179	Other acute osteomyelitis, unspecified ankle and foot
M86.18	Other acute osteomyelitis, other site
M86.19	Other acute osteomyelitis, multiple sites
M86.2	Subacute osteomyelitis
M86.20	Subacute osteomyelitis, unspecified site
M86.21	Subacute osteomyelitis, shoulder
M86.211	Subacute osteomyelitis, right shoulder
M86.212	Subacute osteomyelitis, left shoulder
M86.219	Subacute osteomyelitis, unspecified shoulder
M86.22	Subacute osteomyelitis, humerus
M86.221	Subacute osteomyelitis, right humerus
M86.222	Subacute osteomyelitis, left humerus
M86.229	Subacute osteomyelitis, unspecified humerus
M86.23	Subacute osteomyelitis, radius and ulna
M86.231	Subacute osteomyelitis, right radius and ulna
M86.232	Subacute osteomyelitis, left radius and ulna
M86.239	Subacute osteomyelitis, unspecified radius and ulna
M86.24	Subacute osteomyelitis, hand
M86.241	Subacute osteomyelitis, right hand
M86.242	Subacute osteomyelitis, left hand
M86.249	Subacute osteomyelitis, unspecified hand
M86.25	Subacute osteomyelitis, femur
M86.251	Subacute osteomyelitis, right femur
M86.252	Subacute osteomyelitis, left femur
M86.259	Subacute osteomyelitis, unspecified femur
M86.26	Subacute osteomyelitis, tibia and fibula
M86.261	Subacute osteomyelitis, right tibia and fibula
M86.262	Subacute osteomyelitis, left tibia and fibula
M86.269	Subacute osteomyelitis, unspecified tibia and fibula
M86.27	Subacute osteomyelitis, ankle and foot
M86.271	Subacute osteomyelitis, right ankle and foot
M86.272	Subacute osteomyelitis, left ankle and foot
M86.279	Subacute osteomyelitis, unspecified ankle and foot
M86.28	Subacute osteomyelitis, other site
M86.29	Subacute osteomyelitis, multiple sites
M86.3	Chronic multifocal osteomyelitis
M86.30	Chronic multifocal osteomyelitis, unspecified site
M86.31	Chronic multifocal osteomyelitis, shoulder
M86.311	Chronic multifocal osteomyelitis, right shoulder
M86.312	Chronic multifocal osteomyelitis, left shoulder
M86.319	Chronic multifocal osteomyelitis, unspecified shoulder
M86.32	Chronic multifocal osteomyelitis, humerus
M86.321	Chronic multifocal osteomyelitis, right humerus
M86.322	Chronic multifocal osteomyelitis, left humerus
M86.329	Chronic multifocal osteomyelitis, unspecified humerus
M86.33	Chronic multifocal osteomyelitis, radius and ulna
M86.331	Chronic multifocal osteomyelitis, right radius and ulna
M86.332	Chronic multifocal osteomyelitis, left radius and ulna
M86.339	Chronic multifocal osteomyelitis, unspecified radius and ulna
M86.34	Chronic multifocal osteomyelitis, hand
M86.341	Chronic multifocal osteomyelitis, right hand
M86.342	Chronic multifocal osteomyelitis, left hand
M86.349	Chronic multifocal osteomyelitis, unspecified hand
M86.35	Chronic multifocal osteomyelitis, femur
M86.351	Chronic multifocal osteomyelitis, right femur
M86.352	Chronic multifocal osteomyelitis, left femur
M86.359	Chronic multifocal osteomyelitis, unspecified femur
M86.36	Chronic multifocal osteomyelitis, tibia and fibula
M86.361	Chronic multifocal osteomyelitis, right tibia and fibula
M86.362	Chronic multifocal osteomyelitis, left tibia and fibula
M86.369	Chronic multifocal osteomyelitis, unspecified tibia and fibula
M86.37	Chronic multifocal osteomyelitis, ankle and foot
M86.371	Chronic multifocal osteomyelitis, right ankle and foot
M86.372	Chronic multifocal osteomyelitis, left ankle and foot
M86.379	Chronic multifocal osteomyelitis, unspecified ankle and foot
M86.38	Chronic multifocal osteomyelitis, other site
M86.39	Chronic multifocal osteomyelitis, multiple sites
M86.4	Chronic osteomyelitis with draining sinus
M86.40	Chronic osteomyelitis with draining sinus, unspecified site
M86.41	Chronic osteomyelitis with draining sinus, shoulder
M86.411	Chronic osteomyelitis with draining sinus, right shoulder
M86.412	Chronic osteomyelitis with draining sinus, left shoulder
M86.419	Chronic osteomyelitis with draining sinus, unspecified shoulder
M86.42	Chronic osteomyelitis with draining sinus, humerus
M86.421	Chronic osteomyelitis with draining sinus, right humerus
M86.422	Chronic osteomyelitis with draining sinus, left humerus
M86.429	Chronic osteomyelitis with draining sinus, unspecified humerus
M86.43	Chronic osteomyelitis with draining sinus, radius and ulna
M86.431	Chronic osteomyelitis with draining sinus, right radius and ulna
M86.432	Chronic osteomyelitis with draining sinus, left radius and ulna
M86.439	Chronic osteomyelitis with draining sinus, unspecified radius and ulna
M86.44	Chronic osteomyelitis with draining sinus, hand
M86.441	Chronic osteomyelitis with draining sinus, right hand
M86.442	Chronic osteomyelitis with draining sinus, left hand
M86.449	Chronic osteomyelitis with draining sinus, unspecified hand
M86.45	Chronic osteomyelitis with draining sinus, femur
M86.451	Chronic osteomyelitis with draining sinus, right femur
M86.452	Chronic osteomyelitis with draining sinus, left femur
M86.459	Chronic osteomyelitis with draining sinus, unspecified femur
M86.46	Chronic osteomyelitis with draining sinus, tibia and fibula
M86.461	Chronic osteomyelitis with draining sinus, right tibia and fibula
M86.462	Chronic osteomyelitis with draining sinus, left tibia and fibula
M86.469	Chronic osteomyelitis with draining sinus, unspecified tibia and fibula
M86.47	Chronic osteomyelitis with draining sinus, ankle and foot
M86.471	Chronic osteomyelitis with draining sinus, right ankle and foot
M86.472	Chronic osteomyelitis with draining sinus, left ankle and foot
M86.479	Chronic osteomyelitis with draining sinus, unspecified ankle and foot
M86.48	Chronic osteomyelitis with draining sinus, other site
M86.49	Chronic osteomyelitis with draining sinus, multiple sites
M86.5	Other chronic hematogenous osteomyelitis
M86.50	Other chronic hematogenous osteomyelitis, unspecified site
M86.51	Other chronic hematogenous osteomyelitis, shoulder
M86.511	Other chronic hematogenous osteomyelitis, right shoulder
M86.512	Other chronic hematogenous osteomyelitis, left shoulder
M86.519	Other chronic hematogenous osteomyelitis, unspecified shoulder
M86.52	Other chronic hematogenous osteomyelitis, humerus
M86.521	Other chronic hematogenous osteomyelitis, right humerus
M86.522	Other chronic hematogenous osteomyelitis, left humerus
M86.529	Other chronic hematogenous osteomyelitis, unspecified humerus
M86.53	Other chronic hematogenous osteomyelitis, radius and ulna
M86.531	Other chronic hematogenous osteomyelitis, right radius and ulna
M86.532	Other chronic hematogenous osteomyelitis, left radius and ulna
M86.539	Other chronic hematogenous osteomyelitis, unspecified radius and ulna
M86.54	Other chronic hematogenous osteomyelitis, hand
M86.541	Other chronic hematogenous osteomyelitis, right hand
M86.542	Other chronic hematogenous osteomyelitis, left hand
M86.549	Other chronic hematogenous osteomyelitis, unspecified hand
M86.55	Other chronic hematogenous osteomyelitis, femur
M86.551	Other chronic hematogenous osteomyelitis, right femur
M86.552	Other chronic hematogenous osteomyelitis, left femur
M86.559	Other chronic hematogenous osteomyelitis, unspecified femur
M86.56	Other chronic hematogenous osteomyelitis, tibia and fibula
M86.561	Other chronic hematogenous osteomyelitis, right tibia and fibula
M86.562	Other chronic hematogenous osteomyelitis, left tibia and fibula
M86.569	Other chronic hematogenous osteomyelitis, unspecified tibia and fibula
M86.57	Other chronic hematogenous osteomyelitis, ankle and foot
M86.571	Other chronic hematogenous osteomyelitis, right ankle and foot
M86.572	Other chronic hematogenous osteomyelitis, left ankle and foot
M86.579	Other chronic hematogenous osteomyelitis, unspecified ankle and foot
M86.58	Other chronic hematogenous osteomyelitis, other site
M86.59	Other chronic hematogenous osteomyelitis, multiple sites
M86.6	Other chronic osteomyelitis
M86.60	Other chronic osteomyelitis, unspecified site
M86.61	Other chronic osteomyelitis, shoulder
M86.611	Other chronic osteomyelitis, right shoulder
M86.612	Other chronic osteomyelitis, left shoulder
M86.619	Other chronic osteomyelitis, unspecified shoulder
M86.62	Other chronic osteomyelitis, humerus
M86.621	Other chronic osteomyelitis, right humerus
M86.622	Other chronic osteomyelitis, left humerus
M86.629	Other chronic osteomyelitis, unspecified humerus
M86.63	Other chronic osteomyelitis, radius and ulna
M86.631	Other chronic osteomyelitis, right radius and ulna
M86.632	Other chronic osteomyelitis, left radius and ulna
M86.639	Other chronic osteomyelitis, unspecified radius and ulna
M86.64	Other chronic osteomyelitis, hand
M86.641	Other chronic osteomyelitis, right hand
M86.642	Other chronic osteomyelitis, left hand
M86.649	Other chronic osteomyelitis, unspecified hand
M86.65	Other chronic osteomyelitis, thigh
M86.651	Other chronic osteomyelitis, right thigh
M86.652	Other chronic osteomyelitis, left thigh
M86.659	Other chronic osteomyelitis, unspecified thigh
M86.66	Other chronic osteomyelitis, tibia and fibula
M86.661	Other chronic osteomyelitis, right tibia and fibula
M86.662	Other chronic osteomyelitis, left tibia and fibula
M86.669	Other chronic osteomyelitis, unspecified tibia and fibula
M86.67	Other chronic osteomyelitis, ankle and foot
M86.671	Other chronic osteomyelitis, right ankle and foot
M86.672	Other chronic osteomyelitis, left ankle and foot
M86.679	Other chronic osteomyelitis, unspecified ankle and foot
M86.68	Other chronic osteomyelitis, other site
M86.69	Other chronic osteomyelitis, multiple sites
M86.8	Other osteomyelitis
M86.8x	Other osteomyelitis
M86.8x0	Other osteomyelitis, multiple sites
M86.8x1	Other osteomyelitis, shoulder
M86.8x2	Other osteomyelitis, upper arm
M86.8x3	Other osteomyelitis, forearm
M86.8x4	Other osteomyelitis, hand
M86.8x5	Other osteomyelitis, thigh
M86.8x6	Other osteomyelitis, lower leg
M86.8x7	Other osteomyelitis, ankle and foot
M86.8x8	Other osteomyelitis, other site
M86.8x9	Other osteomyelitis, unspecified sites
M86.9	Osteomyelitis, unspecified
Pasteurellosis
A28.0	Pasteurellosis
Pneumococcal meningitis
G00.1	Pneumococcal meningitis
Pneumococcus endocarditis
B95.3	Streptococcus pneumoniae as the cause of diseases classified elsewhere
I33.0	Acute and subacute infective endocarditis
Primary genital syphilis
A51.0	Primary genital syphilis
Pulmonary actinomycosis
A42.0	Pulmonary actinomycosis
Rat-bite fever
A25	Rat-bite fevers
A25.0	Spirillosis
A25.1	Streptobacillosis
A25.9	Rat-bite fever, 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
Secondary syphilis
A51.3	Secondary syphilis of skin and mucous membranes
A51.31	Condyloma latum
A51.32	Syphilitic alopecia
A51.39	Other secondary syphilis of skin
A51.4	Other secondary syphilis
A51.41	Secondary syphilitic meningitis
A51.42	Secondary syphilitic female pelvic disease
A51.43	Secondary syphilitic oculopathy
A51.44	Secondary syphilitic nephritis
A51.45	Secondary syphilitic hepatitis
A51.46	Secondary syphilitic osteopathy
A51.49	Other secondary syphilitic conditions
Sepsis of newborn
P36	Bacterial sepsis of newborn
P36.0	Sepsis of newborn due to streptococcus, group B
P36.1	Sepsis of newborn due to other and unspecified streptococci
P36.10	Sepsis of newborn due to unspecified streptococci
P36.19	Sepsis of newborn due to other streptococci
P36.2	Sepsis of newborn due to staphylococcus aureus
P36.3	Sepsis of newborn due to other and unspecified staphylococci
P36.30	Sepsis of newborn due to unspecified staphylococci
P36.39	Sepsis of newborn due to other staphylococci
P36.4	Sepsis of newborn due to escherichia coli
P36.5	Sepsis of newborn due to anaerobes
P36.8	Other bacterial sepsis of newborn
P36.9	Bacterial sepsis of newborn, unspecified
Skin and skin structure strep. pyogenes infection
B95.0	Streptococcus, group a, as the cause of diseases classified elsewhere
B95.4	Other streptococcus as the cause of diseases classified elsewhere
L08.89	Other specified local infections of the skin and subcutaneous tissue
L08.9	Local infection of the skin and subcutaneous tissue, unspecified
Streptococcal endocarditis
B95.0	Streptococcus, group a, as the cause of diseases classified elsewhere
B95.1	Streptococcus, group b, 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
I33.0	Acute and subacute infective endocarditis
Streptococcal meningitis
G00.1	Pneumococcal meningitis
G00.2	Streptococcal meningitis
Streptococcal pneumonia
J13	Pneumonia due to streptococcus pneumoniae
J15.3	Pneumonia due to streptococcus, group B
J15.4	Pneumonia due to other streptococci
Streptococcal toxic shock syndrome
A48.3	Toxic shock syndrome
B95.0	Streptococcus, group a, as the cause of diseases classified elsewhere
Streptococcus empyema
B95.0	Streptococcus, group a, as the cause of diseases classified elsewhere
B95.1	Streptococcus, group b, 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
J86	Pyothorax
J86.0	Pyothorax with fistula
J86.9	Pyothorax without fistula
Streptococcus myositis
B95.0	Streptococcus, group a, as the cause of diseases classified elsewhere
B95.1	Streptococcus, group b, 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
M60.0	Infective myositis
M60.00	Infective myositis, unspecified site
M60.000	Infective myositis, unspecified right arm
M60.001	Infective myositis, unspecified left arm
M60.002	Infective myositis, unspecified arm
M60.003	Infective myositis, unspecified right leg
M60.004	Infective myositis, unspecified left leg
M60.005	Infective myositis, unspecified leg
M60.009	Infective myositis, unspecified site
M60.01	Infective myositis, shoulder
M60.011	Infective myositis, right shoulder
M60.012	Infective myositis, left shoulder
M60.019	Infective myositis, unspecified shoulder
M60.02	Infective myositis, upper arm
M60.021	Infective myositis, right upper arm
M60.022	Infective myositis, left upper arm
M60.029	Infective myositis, unspecified upper arm
M60.03	Infective myositis, forearm
M60.031	Infective myositis, right forearm
M60.032	Infective myositis, left forearm
M60.039	Infective myositis, unspecified forearm
M60.04	Infective myositis, hand and fingers
M60.041	Infective myositis, right hand
M60.042	Infective myositis, left hand
M60.043	Infective myositis, unspecified hand
M60.044	Infective myositis, right finger(s)
M60.045	Infective myositis, left finger(s)
M60.046	Infective myositis, unspecified finger(s)
M60.05	Infective myositis, thigh
M60.051	Infective myositis, right thigh
M60.052	Infective myositis, left thigh
M60.059	Infective myositis, unspecified thigh
M60.06	Infective myositis, lower leg
M60.061	Infective myositis, right lower leg
M60.062	Infective myositis, left lower leg
M60.069	Infective myositis, unspecified lower leg
M60.07	Infective myositis, ankle, foot and toes
M60.070	Infective myositis, right ankle
M60.071	Infective myositis, left ankle
M60.072	Infective myositis, unspecified ankle
M60.073	Infective myositis, right foot
M60.074	Infective myositis, left foot
M60.075	Infective myositis, unspecified foot
M60.076	Infective myositis, right toe(s)
M60.077	Infective myositis, left toe(s)
M60.078	Infective myositis, unspecified toe(s)
M60.08	Infective myositis, other site
M60.09	Infective myositis, multiple sites
Streptococcus pericarditis
B95.0	Streptococcus, group a, as the cause of diseases classified elsewhere
B95.1	Streptococcus, group b, 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
I30.1	Infective pericarditis
Symptomatic congenital syphilis
A50	Congenital syphilis
A50.0	Early congenital syphilis, symptomatic
A50.01	Early congenital syphilitic oculopathy
A50.02	Early congenital syphilitic osteochondropathy
A50.03	Early congenital syphilitic pharyngitis
A50.04	Early congenital syphilitic pneumonia
A50.05	Early congenital syphilitic rhinitis
A50.06	Early cutaneous congenital syphilis
A50.07	Early mucocutaneous congenital syphilis
A50.08	Early visceral congenital syphilis
A50.09	Other early congenital syphilis, symptomatic
A50.2	Early congenital syphilis, unspecified
A50.3	Late congenital syphilitic oculopathy
A50.30	Late congenital syphilitic oculopathy, unspecified
A50.31	Late congenital syphilitic interstitial keratitis
A50.32	Late congenital syphilitic chorioretinitis
A50.39	Other late congenital syphilitic oculopathy
A50.4	Late congenital neurosyphilis [juvenile neurosyphilis]
A50.40	Late congenital neurosyphilis, unspecified
A50.41	Late congenital syphilitic meningitis
A50.42	Late congenital syphilitic encephalitis
A50.43	Late congenital syphilitic polyneuropathy
A50.44	Late congenital syphilitic optic nerve atrophy
A50.45	Juvenile general paresis
A50.49	Other late congenital neurosyphilis
A50.5	Other late congenital syphilis, symptomatic
A50.51	Clutton's joints
A50.52	Hutchinson's teeth
A50.53	Hutchinson's triad
A50.54	Late congenital cardiovascular syphilis
A50.55	Late congenital syphilitic arthropathy
A50.56	Late congenital syphilitic osteochondropathy
A50.57	Syphilitic saddle nose
A50.59	Other late congenital syphilis, symptomatic
A50.7	Late congenital syphilis, unspecified
A50.9	Congenital syphilis, unspecified
Tetanus
A33	Tetanus neonatorum
A34	Obstetrical tetanus
A35	Other tetanus
Upper respiratory neisseria meningitidis infection
A39.89	Other meningococcal infections