Bicillin L-A

Bicillin L-A

 [bi-sil´in]
trademark for preparations of penicillin g benzathine, an antibiotic.

penicillin G benzathine

Bicillin L-A, Permapen

Pharmacologic class: Penicillin

Therapeutic class: Anti-infective

Pregnancy risk category B

Action

Inhibits biosynthesis of cell-wall mucopeptide; kills penicillin-susceptible bacteria during active multiplication stage

Availability

Suspension for I.M. injection: 600,000 units/ml in 1-, 2-, and 4-ml prefilled syringes

Indications and dosages

Upper respiratory infections

Adults: 1.2 million units I.M. as a single dose

Children weighing 27 kg (60) or more: 900,000 units I.M. as a single dose

Infants and children weighing less than 27 kg (60 lb): 300,000 to 600,000 units I.M. as a single dose

Early syphilis (primary, secondary, or latent)

Adults: 2.4 million units I.M. as a single dose

Children: 50,000 units/kg I.M. as a single dose, increased as needed up to adult dosage

Congenital syphilis

Children younger than age 2: 50,000 units/kg I.M. as a single dose

Late (tertiary) syphilis and neurosyphilis

Adults: 2.4 million units I.M. q week for up to 3 weeks, after aqueous penicillin G or procaine penicillin therapy

Gummas and cardiovascular syphilis

Adults: 2.4 million units I.M. q week for 3 weeks

Yaws, bejel, and pinta

Adults: 1.2 million units I.M. as a single dose

Prophylaxis of rheumatic fever and glomerulonephritis

Adults: After acute attack, 1.2 million units I.M. q month or 600,000 units q 2 weeks

Contraindications

• Hypersensitivity to penicillins, beta-lactamase inhibitors (piperacillin/tazobactam), or benzathine

Precautions

Use cautiously in:
• severe renal insufficiency, significant allergies, asthma
• pregnant or breastfeeding patients.

Administration

• Before giving, ask patient about allergy to penicillin, beta-lactamase inhibitors, and benzathine. Be aware that cross-sensitivity to cephalosporins and imipenem also may occur.

Do not give intravenously
• Inject deep I.M. into upper outer quadrant of buttock in adult or mid-lateral thigh in infant or small child. Don't inject into gluteal muscle in child younger than age 2. Rotate injection sites with repeated doses.

Keep epinephrine and emergency equipment at hand in case of anaphylaxis.
• Be aware that Hoigne's syndrome (transient bizarre behavior and neurologic reactions) may immediately follow I.M. injection.
• Know that in syphilis treatment, Jarisch-Hersheimer reaction (fever, chills, headache, sweating, malaise, hypotension or hypertension) may occur 2 to 12 hours after therapy begins and usually subsides within 24 hours.

Adverse reactions

CNS: headache, lethargy, hallucinations, anxiety, neuropathy, fatigue, nervousness, tremors, euphoria, asthenia, Hoigne's syndrome, cerebrovascular accident, seizures, coma

CV: hypotension, pulmonary hypertension, vasodilation, vasovagal reaction, syncope, palpitations, tachycardia, cardiac arrest, pulmonary embolism

EENT: blurred vision, vision loss, laryngeal edema

GI: nausea, vomiting, diarrhea, epigastric distress, abdominal pain, colitis, blood in stool, glossitis, pseudomem-branous colitis

GU: hematuria, proteinuria, urogenic bladder, erectile dysfunction, priapism, nephropathy, renal failure

Hematologic: hemolytic anemia, leukopenia, thrombocytopenia

Metabolic: hypernatremia, hyper-kalemia

Respiratory: dyspnea, hypoxia, apnea, pulmonary embolism

Skin: rash, urticaria, sweating

Other: fever, superinfection, injection site reactions and pain, Jarisch-Hersheimer reaction, anaphylaxis, serum sickness

Interactions

Drug-drug.Aspirin, probenecid: increased penicillin blood level Erythromycins, tetracyclines: decreased antimicrobial activity of penicillin

Hormonal contraceptives: decreased contraceptive efficacy

Drug-diagnostic tests.Alanine aminotransferase, blood urea nitrogen, creatinine, eosinophils, granulocytes, hemoglobin, platelets, potassium, white blood

cells: increased levels

Direct Coombs' test: positive result

Sodium: decreased level

Urine glucose, urine protein: false-positive results

Patient monitoring

Watch closely for anaphylaxis and serum sickness.
• In long-term therapy, monitor electrolyte levels and CBC with white cell differential; watch for electrolyte imbalances and blood dyscrasias.
• Assess neurologic status, especially for seizures and decreasing level of consciousness.

Watch for evidence of superinfection and pseudomembranous colitis.

Patient teaching

Teach patient to recognize anaphylaxis symptoms and to contact emergency medical services immediately if these occur.

Tell patient drug may cause diarrhea. Instruct him to immediately report severe, persistent diarrhea, and fever.
• Urge patient to complete entire course of therapy as prescribed, even after symptoms improve.
• Advise patient to contact prescriber if infection symptoms get worse.
• Tell female patient that drug may make hormonal contraceptives ineffective. Advise her to use barrier birth control if she wishes to avoid pregnancy.
• As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs and tests mentioned above.

References in periodicals archive ?
Bicillin L-A is recommended for treating syphilis and upper respiratory tract infections caused by susceptible streptococci (2).
Despite a change in package color in 2002 to distinguish Bicillin C-R from Bicillin L-A (3), the proprietary names and package appearances remained similar for the two formulations (Figure).
Therefore, whether treatment failures that occurred among those treated with Bicillin C-R represent an excess over what would be expected had they been treated with Bicillin L-A cannot be determined without additional data.
in November 2004, King Pharmaceuticals distributed a letter to clinicians, professional societies, and STD programs throughout the United States, alerting them to the potential for confusing Bicillin C-R with Bicillin L-A, the appropriate use of each formulation, changes in product labels, and mechanisms for reporting inadvertent use of Bicillin C-R for treatment of syphilis.
Bicillin L-A (penicillin G benzathine injectable suspension) is the only currently approved penicillin G benzathine product indicated for use in sexually transmitted infections such as syphilis.
The company has received postmarketing reports from several STD clinics in the United States where Bicillin C-R was used instead of Bicillin L-A to treat patients with syphilis.
The company is changing the packaging and syringe labels of Bicillin C-R to highlight the distinction between that product and Bicillin L-A.
Apparently, the clinic ordered Bicillin L-A by telephone but received Bicillin C-R instead.
Yet 56% of the survey respondents were unaware of the potential confusion between Bicillin C-R and Bicillin L-A.
Besides having similar proprietary names, the package and label for Bicillin C-R and Bicillin L-A have similar lettering and colors.
During December 1997-May 1998, 150 doses of Bicillin C-R were shipped to county A's STD clinic after orders for Bicillin L-A were placed by telephone.
Although the five pregnant women were located and treated with Bicillin L-A, four infants were treated for congenital syphilis because their mothers had not been treated adequately at least 30 days before delivery.