Penicillin G Benzathine and Penicillin G Procaine
Medically reviewed by Drugs.com. Last updated on Dec 23, 2019.
(pen i SIL in jee BENZ a theen & pen i SIL in jee PROE kane)
- Pen G Benz/Pen G Procaine
- Penicillin G Procaine and Benzathine Combined
- Penicillin G Procaine/Benzath
Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product
Injection, suspension [prefilled syringe]:
600,000 units: Penicillin G benzathine 300,000 units and penicillin G procaine 300,000 units per 1 mL (1 mL) [DSC]
1,200,000 units: Penicillin G benzathine 600,000 units and penicillin G procaine 600,000 units per 2 mL (2 mL)
2,400,000 units: Penicillin G benzathine 1,200,000 units and penicillin G procaine 1,200,000 units per 4 mL (4 mL) [DSC]
Bicillin C-R 900/300: 1,200,000 units: Penicillin G benzathine 900,000 units and penicillin G procaine 300,000 units per 2 mL (2 mL)
Brand Names: U.S.
- Bicillin C-R
- Bicillin C-R 900/300
- Antibiotic, Penicillin
Inhibits bacterial cell wall synthesis by binding to one or more of the penicillin-binding proteins (PBPs); which in turn inhibits the final transpeptidation step of peptidoglycan synthesis in bacterial cell walls, thus inhibiting cell wall biosynthesis. Bacteria eventually lyse due to ongoing activity of cell wall autolytic enzymes (autolysins and murein hydrolases) while cell wall assembly is arrested.
IM: Released slowly
Highest levels in the kidney; lesser amounts in liver, skin, intestines
Time to Peak
Serum: IM: Within 3 hours
Special Populations: Renal Function Impairment
Excretion of the drug is considerably delayed in neonates, children, and individuals with renal function impairment.
Use: Labeled Indications
Pneumococcal infections: Treatment of moderately severe pneumonia and otitis media due to susceptible Pneumococcus spp. (eg, Streptococcus pneumoniae)
Streptococcal infections, group A: Treatment of moderately severe to severe infections, without associated bacteremia, of the upper respiratory tract, scarlet fever, erysipelas, and skin and soft tissue infections due to group A streptococci
Note: Bicillin C-R 900/300 is only indicated in pediatric patients.
Limitations of use: Not considered appropriate for the treatment of sexually transmitted diseases, including syphilis, gonorrhea, yaws, bejel, and pinta. When high, sustained serum levels are required, use alternative penicillin preparations.
Hypersensitivity to penicillin(s), procaine, or any component of the formulation
Note: Bicillin C-R 900/300 is only indicated in pediatric patients.
Pneumococcal infections (except meningitis): IM: 1.2 million units on day 1; may be repeated every 2 or 3 days until afebrile for 48 hours.
Streptococcal infections, group A: IM: 2.4 million units in a single dose. Note: Alternatively, 50% of the total dose can be administered on day 1 and 50% on day 3. For treatment of group A streptococcal pharyngitis in adults, penicillin G benzathine (Bicillin L-A) is preferred (IDSA [Shulman 2012]).
Refer to adult dosing.
Pneumococcal infections (except meningitis): Infants and Children: IM:
Bicillin C-R: 600,000 units on day 1; may repeat every 2 to 3 days until afebrile for 48 hours
Bicillin C-R 900/300: 1.2 million units on day 1; may repeat every 2 or 3 days until afebrile for 48 hours
Streptococcal infections, group A:
Infants, Children: IM:
<14 kg: 600,000 units in a single dose
14 to 27 kg: 900,000 units to 1.2 million units in a single dose
Bicillin C-R 900/300: 1.2 million units in a single dose
Children and Adolescents (>27 kg): IM:
Bicillin C-R: Refer to adult dosing.
Bicillin C-R 900/300: 1.2 million units in a single dose
Note (Bicillin C-R only): Alternatively, 50% of the total dose can be administered on day 1 and 50% on day 3.
Rheumatic fever, primary prevention (Bicillin C-R 900/300) (off-label use): Infants and Children 6 months to 12 years and Adolescents ≤14 years: IM: 1.2 million units as a single dose (Bass 1976; Gerber 2009). Note: The efficacy of this regimen for heavier adolescents is unknown.
IM: Administer by deep IM injection at a slow, steady rate in the dorsogluteal region (upper outer quadrant of the buttock) or ventrogluteal region (anterolateral thigh). When repeated doses are indicated, vary the injection site. Do not inject near an artery or a nerve; permanent neurological damage or gangrene may result. Do not mix with other IV solutions. Do not administer IV, intravascularly, or intra-arterially.
Store at 2°C to 8°C (36°F to 46°F); do not freeze. Extended storage information at room temperature may be available; contact product manufacturer to obtain current recommendations.
Acemetacin: May increase the serum concentration of Penicillins. Monitor therapy
BCG (Intravesical): Antibiotics may diminish the therapeutic effect of BCG (Intravesical). Avoid combination
BCG Vaccine (Immunization): Antibiotics may diminish the therapeutic effect of BCG Vaccine (Immunization). Monitor therapy
Cholera Vaccine: Antibiotics may diminish the therapeutic effect of Cholera Vaccine. Management: Avoid cholera vaccine in patients receiving systemic antibiotics, and within 14 days following the use of oral or parenteral antibiotics. Avoid combination
Dichlorphenamide: Penicillins may enhance the hypokalemic effect of Dichlorphenamide. Monitor therapy
Lactobacillus and Estriol: Antibiotics may diminish the therapeutic effect of Lactobacillus and Estriol. Monitor therapy
Methotrexate: Penicillins may increase the serum concentration of Methotrexate. Monitor therapy
Mycophenolate: Penicillins may decrease serum concentrations of the active metabolite(s) of Mycophenolate. This effect appears to be the result of impaired enterohepatic recirculation. Monitor therapy
Nitisinone: May increase the serum concentration of OAT1/3 Substrates. Monitor therapy
Pretomanid: May increase the serum concentration of OAT1/3 Substrates. Monitor therapy
Probenecid: May increase the serum concentration of Penicillins. Monitor therapy
Sodium Picosulfate: Antibiotics may diminish the therapeutic effect of Sodium Picosulfate. Management: Consider using an alternative product for bowel cleansing prior to a colonoscopy in patients who have recently used or are concurrently using an antibiotic. Consider therapy modification
Teriflunomide: May increase the serum concentration of OAT1/3 Substrates. Monitor therapy
Tetracyclines: May diminish the therapeutic effect of Penicillins. Monitor therapy
Tolvaptan: May increase the serum concentration of OAT1/3 Substrates. Management: Patients being treated with the Jynarque brand of tolvaptan should avoid concomitant use of OAT1/3 substrates. Concentrations and effects of the OAT1/3 substrate would be expected to increase with any combined use. Consider therapy modification
Typhoid Vaccine: Antibiotics may diminish the therapeutic effect of Typhoid Vaccine. Only the live attenuated Ty21a strain is affected. Management: Vaccination with live attenuated typhoid vaccine (Ty21a) should be avoided in patients being treated with systemic antibacterial agents. Use of this vaccine should be postponed until at least 3 days after cessation of antibacterial agents. Consider therapy modification
Vitamin K Antagonists (eg, warfarin): Penicillins may enhance the anticoagulant effect of Vitamin K Antagonists. Monitor therapy
May interfere with urinary glucose tests using cupric sulfate (Benedict's solution, Clinitest®); may inactivate aminoglycosides in vitro; positive Coombs' [direct], increased protein
Also see individual agents.
<1%, postmarketing, and/or case reports: Central nervous system disease (Hoigne syndrome), Clostridioides difficile associated diarrhea
ALERT: U.S. Boxed WarningAppropriate administration:
Not for IV use. Do not inject IV or admix with other IV solutions. There have been reports of inadvertent IV administration of penicillin G benzathine, which has been associated with cardiorespiratory arrest and death. Prior to administration of this drug, carefully read the Warnings, Adverse Reactions, and Administration and Dosage sections of the labeling.
Concerns related to adverse effects:
• Anaphylactic/hypersensitivity reactions: Serious and occasionally severe or fatal hypersensitivity (anaphylactic) reactions have been reported in patients on penicillin therapy, especially with a history of beta-lactam hypersensitivity (including cephalosporins), history of sensitivity to multiple allergens. Use with caution in asthmatic patients. If a serious reaction occurs, treatment with supportive care measures and airway protection should be instituted immediately.
• Fibrosis and atrophy: Quadriceps femoris fibrosis and atrophy have been reported following repeated IM injections of penicillins into the anterolateral thigh.
• Methemoglobinemia: Has been reported with local anesthetics, including procaine; clinically significant methemoglobinemia requires immediate treatment along with discontinuation of the anesthetic and other oxidizing agents. Onset may be immediate or delayed (hours) after anesthetic exposure. Patients with glucose-6-phosphate dehydrogenase deficiency, congenital or idiopathic methemoglobinemia, cardiac or pulmonary compromise, exposure to oxidizing agents or their metabolites, or infants <6 months of age are more susceptible and should be closely monitored for signs and symptoms of methemoglobinemia (eg, cyanosis, headache, rapid pulse, shortness of breath, lightheadedness, fatigue).
• Procaine sensitivity: If there is a history of hypersensitivity to procaine, test with 0.1 mL of procaine 1% or 2% solution. If erythema, wheal, flare, or eruption occurs, patient may be sensitive to procaine; do not use penicillin G procaine in these patients. Treat sensitivity with supportive measures, including antihistamines.
• Superinfection: Prolonged use may result in fungal or bacterial superinfection, including Clostridioides (formerly Clostridium) difficile-associated diarrhea (CDAD) and pseudomembranous colitis; CDAD has been observed >2 months postantibiotic treatment.
• Renal impairment: Use with caution in patients with renal impairment. Monitor renal function periodically, especially with high-dose or prolonged therapy.
Concurrent drug therapy issues:
• Drug-drug interactions: Potentially significant interactions may exist, requiring dose or frequency adjustment, additional monitoring, and/or selection of alternative therapy. Consult drug interactions database for more detailed information.
• Appropriate administration: [US Boxed Warning]: Not for IV use; cardiopulmonary arrest and death have occurred from inadvertent IV administration. Do not mix with other IV solutions. Administer by deep IM injection only. Injection into or near an artery or nerve could result in severe neurovascular damage or permanent neurological damage or gangrene possibly requiring amputation, necrosis/sloughing at or surrounding the injection site, or other serious complications.
• Limitations of use: Not considered appropriate for the treatment of sexually transmitted diseases, including syphilis, gonorrhea, yaws, bejel, and pinta. When high, sustained serum levels are required, use alternative penicillin preparations.
• Choice of preparation: Penicillin G benzathine-penicillin G procaine (eg, Bicillin C-R) is not the same preparation as penicillin G procaine. Dispensing errors have occurred (CDC 2005).
• Prolonged use: Extended duration of therapy or use associated with high serum concentrations (eg, in renal insufficiency) may be associated with an increased risk for some adverse reactions (neutropenia, hemolytic anemia, serum sickness).
Hypersensitivity reactions with first dose, injection-site reactions, periodic renal and hematologic function tests with prolonged therapy
Adverse events have not been observed in animal reproduction studies. Maternal use of penicillins has generally not resulted in an increased risk of adverse fetal effects. See individual agents
• Discuss specific use of drug and side effects with patient as it relates to treatment. (HCAHPS: During this hospital stay, were you given any medicine that you had not taken before? Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? How often did hospital staff describe possible side effects in a way you could understand?)
• Patient may experience diarrhea. Have patient report immediately to prescriber bruising; bleeding; signs of kidney problems (unable to pass urine, blood in the urine, change in amount of urine passed, or weight gain); signs of methemoglobinemia (blue or gray color of the lips, nails, or skin; abnormal heartbeat; seizures; severe dizziness or passing out; severe headache; fatigue; loss of strength and energy; or shortness of breath); chills; sore throat; edema; joint pain; severe dizziness; passing out; injection site irritation, lump, dark scab, or hard area; severe loss of strength and energy; numbness, tingling, or weakness; or signs of Clostridioides (formerly Clostridium) difficile (C. diff)-associated diarrhea (abdominal pain or cramps, severe diarrhea or watery stools, or bloody stools) (HCAHPS).
• Educate patient about signs of a significant reaction (eg, wheezing; chest tightness; fever; itching; bad cough; blue skin color; seizures; or swelling of face, lips, tongue, or throat). Note: This is not a comprehensive list of all side effects. Patient should consult prescriber for additional questions.
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Always consult your healthcare provider to ensure the information displayed on this page applies to your personal circumstances.
More about penicillin g benzathine / procaine penicillin
- Side Effects
- During Pregnancy
- Dosage Information
- Drug Interactions
- En Español
- Drug class: natural penicillins