Dosing: Adult Actinomyces species: I.V.: 10-20 million units/day divided every 4-6 hours for 4-6 weeks
Clostridium perfringens: I.V.: 24 million units/day divided every 4-6 hours with clindamycin
Corynebacterium diphtheriae: I.V.: 2-3 million units/day in divided doses every 4-6 hours for 10-12 days
Erysipelas: I.V.: 1-2 million units every 4-6 hours
Erysipelothrix: I.V.: 2-4 million units every 4 hours
Fascial space infections: I.V.: 2-4 million units every 4-6 hours with metronidazole
Leptospirosis: I.V.: 1.5 million units every 6 hours for 7 days
Listeria: I.V.: 15-20 million units/day in divided doses every 4-6 hours for 2 weeks (meningitis) or 4 weeks (endocarditis)
Lyme disease (meningitis): I.V.: 20 million units/day in divided doses
Neurosyphilis: I.V.: 18-24 million units/day in divided doses every 4 hours (or by continuous infusion) for 10-14 days (CDC, 2006; CDC, 2009; CDC, 2010)
Streptococcus:Brain abscess: I.V.: 18-24 million units/day in divided doses every 4 hours with metronidazole
Endocarditis or osteomyelitis: I.V.: 3-4 million units every 4 hours for at least 4 weeks
Pregnancy (prophylaxis GBS): I.V.: 5 million units x 1 dose, then 2.5 million units every 4 hours until delivery (ACOG, 2002; CDC, 2002)
Skin and soft tissue: I.V.: 3-4 million units every 4 hours for 10 days
Toxic shock: I.V.: 24 million units/day in divided doses with clindamycin
Streptococcal pneumonia: I.V.: 2-3 million units every 4 hours
Whipple's disease: I.V.: 2 million units every 4 hours for 2 weeks, followed by oral trimethoprim/sulfamethoxazole or doxycycline for 1 year
Relapse or CNS involvement: 4 million units every 4 hours for 4 weeks
Dosing: PediatricSusceptible infections: I.M., I.V.:
Infants ≥1 month and Children: 100,000-400,000 units/kg/day in divided doses every 4-6 hours (maximum dose: 24 million units/day)
Meningitis (gonococcal): I.V.: 250,000 units/kg/day in 4 divided doses
Moderate infections: I.M., I.V.: 100,000-250,000 units/kg/day in 4 divided doses
Neurosyphilis: I.V.: 200,000-300,000 units/kg/day divided every 4-6 hours for 10-14 days (maximum dose: 24 million units/day)
Severe infections: I.M., I.V.: 250,000-400,000 units/kg/day in divided doses every 4-6 hours (maximum dose: 24 million units/day)
Syphilis (congenital): I.V.:
Infants: 50,000 units/kg every 12 hours for first 7 days of life, then every 8 hours for a total of 10 days (CDC, 2010)
Children: 50,000 units/kg every 4-6 hours for 10 days (CDC, 2010)
Dosing: Geriatric Refer to adult dosing.
Dosing: Renal Impairment Uremic patients with Clcr >10 mL/minute/1.73 m2: Administer full loading dose followed by 1/2 of the loading dose given every 4-5 hours
Clcr <10 mL/minute/1.73 m2: Administer full loading dose followed by 1/2 of the loading dose given every 8-10 hours
Intermittent hemodialysis (IHD) (administer after hemodialysis on dialysis days): Administer normal loading dose followed by either 25% to 50% of normal dose every 4-6 hours or 50% to 100% of normal dose every 8-12 hours. For mild-to-moderate infections, administer 0.5-1 million units every 4-6 hours or 1-2 million units every 8-12 hours. For neurosyphilis, endocarditis, or serious infections, administer up to 2 million units every 4-6 hours; administer after dialysis on dialysis days or supplement with 500,000 units after dialysis (Heintz, 2009). Note: Dosing dependent on the assumption of 3 times/week, complete IHD sessions.
Continuous renal replacement therapy (CRRT) (Heintz, 2009; Trotman, 2005): Drug clearance is highly dependent on the method of renal replacement, filter type, and flow rate. Appropriate dosing requires close monitoring of pharmacologic response, signs of adverse reactions due to drug accumulation, as well as drug concentrations in relation to target trough (if appropriate). The following are general recommendations only (based on dialysate flow/ultrafiltration rates of 1-2 L/hour and minimal residual renal function) and should not supersede clinical judgment:
CVVH: Loading dose of 4 million units, followed by 2 million units every 4-6 hours
CVVHD: Loading dose of 4 million units, followed by 2-3 million units every 4-6 hours
CVVHDF: Loading dose of 4 million units, followed by 2-4 million units every 4-6 hours