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Penicillin G (Parenteral/Aqueous)

Pronunciation

(pen i SIL in jee, pa REN ter al, AYE kwee us)

Index Terms

  • Aqueous Crystalline Penicillin G
  • Benzylpenicillin Potassium
  • Benzylpenicillin Sodium
  • Crystalline Penicillin
  • Penicillin G Potassium
  • Penicillin G Sodium

Dosage Forms

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Solution, Intravenous, as potassium:

Generic: 20,000 units/mL (50 mL); 40,000 units/mL (50 mL); 60,000 units/mL (50 mL)

Solution Reconstituted, Injection, as potassium:

Pfizerpen-G: 5,000,000 units (1 ea); 20,000,000 units (1 ea)

Pfizerpen-G: 5,000,000 units (1 ea); 20,000,000 units (1 ea) [pyrogen free]

Generic: 5,000,000 units (1 ea); 20,000,000 units (1 ea)

Solution Reconstituted, Injection, as potassium [preservative free]:

Generic: 20,000,000 units (1 ea)

Solution Reconstituted, Injection, as sodium:

Generic: 5,000,000 units (1 ea)

Brand Names: U.S.

  • Pfizerpen-G

Pharmacologic Category

  • Antibiotic, Penicillin

Pharmacology

Interferes with bacterial cell wall synthesis during active multiplication, causing cell wall death and resultant bactericidal activity against susceptible bacteria

Distribution

Poor penetration across blood-brain barrier, despite inflamed meninges

Relative diffusion from blood into CSF: Poor unless meninges inflamed (exceeds usual MICs)

CSF:blood level ratio: Inflamed meninges: 2% to 6%

Excretion

Urine (58% to 85% as unchanged drug)

Time to Peak

Serum: IV: Immediately after infusion

Half-Life Elimination

Neonates: <6 days of age: 3.2 hours; ≥14 days of age: 1.4 hours

Adults: Normal renal function: 31 to 50 minutes

End-stage renal disease (ESRD): 6 to 20 hours (Aronoff 2007)

Special Populations: Renal Function Impairment

Excretion is delayed.

Special Populations: Hepatic Function Impairment

When combined with impaired renal function, elimination is further delayed.

Special Populations: Elderly

Renal clearance may be delayed (caused by decreased renal function).

Use: Labeled Indications

Serious gram-positive infections: Treatment of septicemia, empyema, pneumonia, pericarditis, endocarditis, and meningitis caused by Streptococcus pyogenes (group A beta-hemolytic streptococcus), other beta-hemolytic streptococci including groups C, H, G, L and M, Streptococcus pneumoniae and Staphylococcus species (nonpenicillinase-producing strains)

Anthrax: Treatment of anthrax caused by Bacillus anthracis

Actinomycosis: Treatment of actinomycosis (cervicofacial disease and thoracic and abdominal disease) caused by Actinomyces israelii

Clostridial infections: Treatment of botulism (adjunctive therapy to antitoxin), gas gangrene, and tetanus (adjunctive therapy to human tetanus immune globulin) caused by Clostridium spp.

Diphtheria: Treatment of diphtheria (adjunctive therapy to antitoxin and prevention of the carrier state) caused by Corynebacterium diphtheriae

Erysipelothrix endocarditis: Treatment of erysipelothrix endocarditis caused by Erysipelothrix rhusiopathiae

Fusospirochetosis: Treatment of fusospirochetosis, including severe infections of the oropharynx [Vincent], lower respiratory tract and genital area, caused by Fusobacterium spp. and spirochetes

Listeria infections: Treatment of listeria infections, including meningitis and endocarditis, caused by Listeria monocytogenes

Meningococcal infection: Treatment of meningococcal meningitis and/or septicemia caused by Neisseria meningitidis

Pasteurella infections: Treatment of pasteurella infections, including bacteremia and meningitis, caused by Pasteurella multocida

Rat bite fever: Treatment of rat bite fever (including Haverhill fever) caused by Spirillum minus or S. moniliformis

Syphilis: Treatment of syphilis (congenital and neurosyphilis) caused by Treponema pallidum

Contraindications

Hypersensitivity to any penicillin or any component of the formulation

Dosing: Adult

Usual dosage range: IM, IV: 12 to 24 million units/day in divided doses every 4 to 6 hours

Indication-specific dosing:

Actinomyces species: IV:

Cervicofacial disease: 1 to 6 million units/day in divided doses every 4 to 6 hours

Thoracic and abdominal disease: 10 to 20 million units/day in divided doses every 4 to 6 hours

Anthrax: IV: Minimum 8 million units/day in divided doses every 6 hours; higher doses may be required depending on the susceptibility of the organism.

Clostridium species: IV:

Manufacturer’s labeling: Botulism, gas gangrene, tetanus: 20 million units/day in divided doses every 4 to 6 hours; adjunctive therapies for botulism and tetanus (eg, botulinum antitoxin, tetanus immune globulin) are also recommended.

Alternate recommendations: Skin and soft tissue necrotizing infections (off-label use): 2 to 4 million units every 4 to 6 hours; use in combination with clindamycin and continue until further debridement is not necessary, patient has clinically improved, and patient is afebrile for 48 to 72 hours (IDSA [Stevens 2014])

Diphtheria (adjunctive therapy to antitoxin and for prevention of carrier state): IV: 2 to 3 million units/day in divided doses every 4 to 6 hours for 10 to 12 days

Endocarditis, treatment: IV:

Enterococcus, native or prosthetic valve (penicillin-susceptible/gentamicin-susceptible strains) (off-label dose): 18 to 30 million units/day as continuous infusion or in divided doses every 6 hours with concomitant gentamicin. Duration of therapy: 4 weeks (native valve and symptoms present <3 months); 6 weeks (native valve and symptoms present ≥3 months or prosthetic valve) (AHA [Baddour 2015).

Enterococcus, native or prosthetic valve (penicillin-susceptible/streptomycin-susceptible/gentamicin-resistant strains) (off-label dose): 18 to 30 million units/day as continuous infusion or in divided doses every 6 hours with concomitant streptomycin. Duration of therapy: 4 weeks (native valve and symptoms present <3 months); ≥6 weeks (native valve and symptoms present ≥3 months or prosthetic valve) (AHA [Baddour 2015).

Erysipelothrix rhusiopathiae: 12 to 20 million units/day in divided doses every 4 to 6 hours for 4 to 6 weeks

Listeria monocytogenes: 15 to 20 million units/day in divided doses every 4 to 6 hours for 4 weeks

Viridans group streptococcus (VGS) and S. bovis (off-label dose) (AHA [Baddour 2015]):

Native valve: Highly penicillin-susceptible (MIC ≤0.12 mcg/mL): 12 to 18 million units/day as continuous infusion or in divided doses every 4 or 6 hours for 4 weeks or 12 to 18 million units/day as continuous infusion or in divided doses every 6 hours for 2 weeks with concomitant gentamicin

Native valve: Relatively penicillin-resistant (MIC >0.12 to <0.5 mcg/mL): 24 million units/day as continuous infusion or in divided doses every 4 or 6 hours for 4 weeks with concomitant gentamicin for the first 2 weeks

Prosthetic valve: Highly penicillin-susceptible (MIC ≤0.12 mcg/mL): 24 million units/day as continuous infusion or in divided doses every 4 or 6 hours for 6 weeks (with or without concomitant gentamicin for the first 2 weeks)

Prosthetic valve: Relatively or fully penicillin-resistant (MIC >0.12 mcg/mL): 24 million units/day as continuous infusion or in divided doses every 4 or 6 hours with concomitant gentamicin for 6 weeks

Erysipelas (off-label dose): IV: 10 to 20 million units/day in divided doses every 4 to 6 hours; switch to oral penicillin when patient is afebrile (Bonnetblanc 2003)

Fusospirochetosis (including Vincent disease): IV: 5 to 10 million units/day in divided doses every 4 to 6 hours

Leptospirosis (off-label use): IV: 1.5 million units every 6 hours for 7 days (Panaphut 2003, Suputtamongkol 2004, Watt 1988)

Lyme neuroborreliosis (off-label use): IV: 3 to 4 million units every 4 hours (Halperin 2007, Halperin 2013)

Meningitis: IV:

Listeria: 15 to 20 million units/day in divided doses every 4 to 6 hours for 2 weeks

Meningococcus: 24 million units/day in divided doses every 2 hours

Neurosyphilis: IV:

Manufacturer’s labeling: 2 to 4 million units every 4 hours for 10 to 14 days; after completion, additional therapy with benzathine penicillin G may be warranted

Alternate recommendations includes ocular syphilis (off-label dose): 18 to 24 million units/day in divided doses every 4 hours (or by continuous infusion) for 10 to 14 days (CDC [Workowski 2015])

Osteomyelitis, native vertebral (off-label use) (IDSA [Berbari 2015]): IV:

Enterococcus spp (penicillin-susceptible) or streptococci (beta-hemolytic): 20 to 24 million units/day as a continuous infusion or in divided doses every 4 hours for 6 weeks. Note: In patients with infective endocarditis due to penicillin-susceptible Enterococcus spp, the addition of an aminoglycoside for 4 to 6 weeks is recommended.

Propionibacterium acnes: 20 million units/day as a continuous infusion or in divided doses every 4 hours for 6 weeks

Pasteurella infections (bacteremia, meningitis): IV: 4 to 6 million units/day in divided doses every 4 to 6 hours for 2 weeks

Prosthetic joint infection (off-label use): IV:

Enterococcus spp (penicillin-susceptible), streptococci (beta-hemolytic): 20 to 24 million units/day as a continuous infusion every 24 hours or in divided doses every 4 hours for 4 to 6 weeks (Osmon 2013); Note: For penicillin-susceptible Enterococcus spp, consider addition of aminoglycoside.

Propionibacterium acnes: 20 million units/day as a continuous infusion every 24 hours or in divided doses every 4 hours for 4 to 6 weeks (Osmon 2013)

Rat bite fever (including Haverhill fever): IV: 12 to 20 million units/day in divided doses every 4 to 6 hours for 3 to 4 weeks

Streptococcus infections: IV:

Group B streptococcus, maternal dose (neonatal prophylaxis) (off-label use): 5 million units x 1 dose, then 2.5 to 3.0 million units every 4 hours until delivery (CDC 2010)

Skin infections, including skin and soft tissue necrotizing infections (off-label use): 2 to 4 million units every 4 to 6 hours; use in combination with clindamycin for necrotizing infections and continue until further debridement is not necessary, patient has clinically improved, and patient is afebrile for 48 to 72 hours (IDSA [Stevens 2014])

Group A streptococcus invasive infection, severe: 3 to 4 million units every 4 hours with clindamycin for 10 to 14 days (Walker 2014)

Streptococcal pneumonia: IV: 12 to 24 million unit/day in divided doses every 4 to 6 hours. Note: Only recommended for S. pneumoniae when MIC is <2 mcg/mL (Mandell 2007).

Whipple disease (off-label use): IV: 2 to 4 million units every 4 hours for 2 to 4 weeks, followed by oral trimethoprim/sulfamethoxazole monotherapy or oral doxycycline and hydroxychloroquine for 1 year (Bures 2013)

Dosing: Geriatric

Refer to adult dosing.

Dosing: Pediatric

Usual dosage range: IM, IV: Infants, Children, and Adolescents: 100,000 to 300,000 units/kg/day in divided doses every 4 to 6 hours (maximum dose: 24 million units/day) (Red Book [AAP 2015])

Indication-specific dosing:

Community-acquired pneumonia (CAP) (off-label dose) (IDSA/PIDS 2011): IV: Infants >3 months, Children, and Adolescents: Note: May consider addition of vancomycin or clindamycin to empiric therapy if community-acquired MRSA suspected. In children ≥5 years, a macrolide antibiotic should be added if atypical pneumonia cannot be ruled out.

Empiric treatment or S. pneumoniae (moderate-to-severe; MICs to penicillin ≤2.0 mcg/mL) (preferred): 200,000 to 250,000 units/kg/day in divided doses every 4 to 6 hours

Group A Streptococcus (moderate-to-severe) (preferred): 100,000 to 250,000 units/kg/day in divided doses every 4 to 6 hours

Diphtheria (adjunctive therapy to antitoxin and for prevention of carrier state): IV: 150,000 to 250,000 units/kg/day in divided doses every 6 hours for 7 to 10 days.

Lyme neuroborreliosis (off-label use): IV: 200,000 to 400,000 units/kg/day in divided doses every 4 hours (Halperin 2013)

Meningitis: IV: Note: Dosing varies based on organism being treated.

Group B streptococcus: Infants: 450,000 to 500,000 units/kg/day divided every 6 hours (Red Book [AAP 2015])

S. pneumoniae: Infants, Children, and Adolescents: 250,000 to 400,000 units/kg/day divided every 4 to 6 hours (Red Book [AAP 2015])

Other susceptible organisms: Infants, Children, and Adolescents: 300,000 units/kg/day divided every 4 to 6 hours; maximum daily dose: 24 million units/day (Tunkel 2004)

Meningococcal disease: IV: Infants, Children, and Adolescents: 300,000 units/kg/day in divided doses every 4 to 6 hours; maximum daily dose: 12 million units/day (Red Book [AAP 2015])

Neurosyphilis: IV: 200,000 to 300,000 units/kg/day divided every 4 to 6 hours for 10 to 14 days (maximum dose: 24 million units/day) (Red Book [AAP 2015])

Skin and soft tissue necrotizing infections due to Clostridium species (off-label use): IV: 60,000 to 100,000 units/kg every 6 hours; use in combination with clindamycin and continue until further debridement is not necessary, patient has clinically improved, and patient is afebrile for 48 to 72 hours (IDSA [Stevens 2014])

Streptococcal skin infections, including skin and soft tissue necrotizing infections (off-label use): IV: 60,000 to 100,000 units/kg every 6 hours; use in combination with clindamycin for necrotizing infections and continue until further debridement is not necessary, patient has clinically improved, and patient is afebrile for 48 to 72 hours (IDSA [Stevens 2014])

Syphilis (congenital): IV:

Manufacturer’s labeling (after the newborn period): 50,000 units/kg/dose every 4 to 6 hours for 10 to 14 days

Alternate recommendations (off-label dose) (CDC [Workowski 2015]):

Neonates: 50,000 units/kg/dose every 12 hours for first 7 days of life, then every 8 hours for a total of 10 days. If more than one day of therapy is missed, the entire course needs to be restarted.

Infants ≥30 days and Children: 50,000 units/kg/dose every 4 to 6 hours for 10 days

Dosing: Renal Impairment

Manufacturer's labeling:

Uremic patients with CrCl >10 mL/minute/1.73 m2: Administer a usual recommended dose followed by 50% of the usual recommended dose every 4 to 5 hours

CrCl <10 mL/minute/1.73 m2: Administer a normal dose followed by 50% of the normal dose every 8 to 10 hours

Alternate recommendation:

GFR >50 mL/minute: No dosage adjustment necessary (Aronoff 2007).

GFR 10-50 mL/minute: Administer 75% of the normal dose (Aronoff 2007).

GFR <10 mL/minute: Administer 20% to 50% of the normal dose (Aronoff 2007).

End-stage renal disease on intermittent hemodialysis (IHD) (administer after hemodialysis on dialysis days) (Heintz 2009): Administer a normal dose followed by either 25% to 50% of normal dose every 4 to 6 hours or 50% to 100% of normal dose every 8 to 12 hours. For mild-to-moderate infections, administer 0.5 to 1 million units every 4 to 6 hours or 1 to 2 million units every 8 to 12 hours. For neurosyphilis, endocarditis, or serious infections, administer up to 2 million units every 4 to 6 hours; administer after dialysis on dialysis days or supplement with 500,000 units after dialysis. Note: Dosing dependent on the assumption of 3 times weekly, 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 to 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 to 6 hours

CVVHD: Loading dose of 4 million units, followed by 2 to 3 million units every 4 to 6 hours

CVVHDF: Loading dose of 4 million units, followed by 2 to 4 million units every 4 to 6 hours

Dosing: Hepatic Impairment

No dosage adjustment provided in manufacturer’s labeling. However, the manufacturer’s labeling recommends further adjustment of doses adjusted for renal impairment in patients with both renal and hepatic impairment.

Reconstitution

Intermittent IV infusion: 5 million unit vial: Add 8.2 mL SWFI or NS for a final concentration of 500,000 units/mL; add 3.2 mL for a final concentration of 1,000,000 units/mL. Dilute further to 50,000 to 145,000 units/mL prior to infusion.

Continuous IV infusion: 20 million unit vial: Add 11.5 mL SWFI or NS for a final concentration of 1,000,000 units/mL. Dilute further in 1 to 2 L of infusion solution and administer over a 24-hour period.

Intramuscular: 5 million unit vial: Add 8.2 mL SWFI or NS for a final concentration of 500,000 units/mL; add 3.2 mL for a final concentration of 1,000,000 units/mL. Dilute further, up to 100,000 units/mL, for less discomfort. If larger doses are needed, consider IV infusion.

Intrapleural: If fluid is aspirated, administer local infusion in a volume equal to 25 to 50% of the amount of fluid aspirated. If fluid is not aspirated, prepare as directed for IM injection and infuse locally.

Administration

IM; Administer IM by deep injection in the upper outer quadrant of the buttock

IV: Note: The 20 million unit dosage form may be administered by continuous IV infusion only.

Intermittent IV: Infuse over 15 to 30 minutes.

Dietary Considerations

Some products may contain potassium and/or sodium.

Compatibility

Penicillin G potassium: Stable in dextran 6% in dextrose, dextran 6% in NS, D5LR, D51/4NS, D51/2NS, D5NS, D5W, D10W, LR, 1/2NS, NS, hetastarch 6%; incompatible with dextran 70 6% in dextrose, dextran 40 10% in dextrose.

Compatibility in syringe: Incompatible with metoclopramide.

Penicillin G sodium: Stable in dextran 40 10%; incompatible with fat emulsion 10%.

Storage

Penicillin G potassium powder for injection should be stored below 86°F (30°C). Following reconstitution, solution may be stored for up to 7 days under refrigeration. Premixed bags for infusion should be stored at -20°C or -4°F; frozen bags may be thawed at 25°C (77°F) or in a refrigerator (5°C [41°F]). Once thawed, solution is stable for 14 days at 5°C (41°F) or for 24 hours at 25°C (77°F). Do not refreeze once thawed.

Penicillin G sodium powder for injection should be stored below 30°C (86°F). Once reconstituted, the manufacturer recommends refrigeration (2°C to 8°C [36°F to 46°F]) and use within 3 days of reconstitution. After further dilution to 2,500 to 50,000 units/mL in either D5W or NS (in PVC bags or elastomeric pump containers), one study demonstrated stability when stored under refrigeration for up to 21 days (Hossain 2014).

Drug Interactions

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. Avoid combination

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

Probenecid: May increase the serum concentration of Penicillins. Management: Avoid the routine use of penicillins and probenecid, but this combination may be used advantageously in select cases with careful monitoring. Monitor for toxic effects of penicillins if probenecid is initiated or the dose is increased. Consider therapy modification

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 OAT3 Substrates. Monitor therapy

Tetracycline Derivatives: May diminish the therapeutic effect of Penicillins. 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

Test Interactions

False-positive or negative urinary glucose determination using Clinitest®; positive Coombs' [direct]; false-positive urinary and/or serum proteins by certain test methods

Adverse Reactions

Frequency not defined.

Cardiovascular: Localized phlebitis, local thrombophlebitis

Central nervous system: Coma (high doses), hyperreflexia (high doses), myoclonus (high doses), seizure (high doses)

Dermatologic: Contact dermatitis, skin rash

Endocrine & metabolic: Electrolyte disturbance (high doses)

Gastrointestinal: Pseudomembranous colitis

Hematologic & oncologic: Neutropenia, positive direct Coombs test (rare, high doses)

Hypersensitivity: Anaphylaxis, hypersensitivity reaction (immediate and delayed), serum sickness

Immunologic: Jarisch-Herxheimer reaction

Local: Injection site reaction

Renal: Acute interstitial nephritis (high doses), renal tubular disease (high doses)

Warnings/Precautions

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) or 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.

• Neurovascular damage: Avoid intra-arterial administration or injection into or near major peripheral nerves or blood vessels since such injections may cause severe and/or permanent neurovascular damage.

• Superinfection: Prolonged use may result in fungal or bacterial superinfection, including C. difficile-associated diarrhea (CDAD) and pseudomembranous colitis; CDAD has been observed >2 months postantibiotic treatment.

Disease-related concerns:

• Renal impairment: Use with caution in patients with renal impairment; dosage adjustment recommended. In the presence of concomitant hepatic impairment, further dosage adjustment may be needed.

• Seizure disorders: Use with caution in patients with a history of seizure disorder; high levels, particularly in the presence of renal impairment, may increase risk of seizures.

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

Special populations:

• Neonates: Neonates may have decreased renal clearance of penicillin and require frequent dosage adjustments depending on age.

Other warnings/precautions:

• Electrolyte imbalance: Product contains sodium and potassium; high doses of IV therapy may alter serum levels. If high doses (eg, >10 million units) are used, administer at a slower rate (eg, >30 minutes for intermittent IV infusion).

Monitoring Parameters

Periodic electrolyte, hepatic, renal, cardiac and hematologic function tests during prolonged/high-dose therapy; observe for signs and symptoms of anaphylaxis during first dose

Pregnancy Risk Factor

B

Pregnancy Considerations

Adverse events have not been observed in animal reproduction studies. Penicillin G crosses the placenta. Maternal use of penicillins has generally not resulted in an increased risk of adverse fetal effects. Penicillin G is the drug of choice for treatment of syphilis during pregnancy and penicillin G (parenteral/aqueous) is the drug of choice for the prevention of early-onset Group B Streptococcal (GBS) disease in newborns (consult current guidelines) (CDC (RR-10) 2010; CDC [Workowski 2015]). When IV therapy is required for anthrax infection in pregnant and postpartum women, penicillin G may be used as an alternative agent (Meaney-Delman 2014).

Patient Education

• 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 nausea, vomiting, mouth sores, tongue discoloration, or injection site irritation. Have patient report immediately to prescriber signs of high potassium (abnormal heartbeat, confusion, dizziness, passing out, weakness, shortness of breath, numbness or tingling feeling), severe dizziness, passing out, severe loss of strength and energy, jaundice, muscle pain, joint pain, abdominal pain, bruising; bleeding; twitching, seizures, urinary retention, change in amount of urine passed, or signs of Clostridium difficile (C. diff)-associated diarrhea (stomach pain or cramps, very loose 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.

Intended Use and Disclaimer: Should not be printed and given to patients. This information is intended to serve as a concise initial reference for health care professionals to use when discussing medications with a patient. You must ultimately rely on your own discretion, experience, and judgment in diagnosing, treating, and advising patients.

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