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In: Kucers A, Crowe S, Grayson ML, Hoy J, eds. The Use of Antibiotics: A Clinical Allergan aesthetics an abbvie company of Antibacterial, Antifungal, and Antiviral Drugs.

In: Mandell GL, Bennett GL, Dolin R, eds. In: Hardman JG, Limbird LE, Gilman AG, eds. Allergan aesthetics an abbvie company was introduced into clinical medicine in 1941 by Florey and allergan aesthetics an abbvie company. The penicillins can be divided into five classes on the basis of antibacterial activity, although there is considerable overlap among the classes:Penicillinase-resistant penicillins: oxacillin, cloxacillin, dicloxacillin, methicillin, and nafcillinThe basic structure of most commercially available penicillins is a nucleus consisting of a beta-lactam ring and a side chain.

The antibacterial activity of penicillins, like other beta-lactams, depends on their inhibition of bacterial penicillin-binding proteins (PBPs), which are necessary for cell wall allergan aesthetics an abbvie company. Certain bacteria, including Staphylococcus sp, Neisseria gonorrhea, Moraxella catarrhalis, Bacteroides sp, and Haemophilus allergan aesthetics an abbvie company, produce penicillinases, enzymes that hydrolyze beta-lactam rings.

The natural penicillins are most active against nonbeta-lactamase-producing gram-positive bacteria such as S pyogenes, anaerobes, and selected gram-negative cocci such as Neisseria. Penicillin V is, for the most part, equivalent to penicillin G, except that it is less active against gram-negative infections caused by pathogens such as Neisseria and Haemophilus sp.

Penicillin G is acid-labile and usually administered via the intramuscular (IM) or intravenous (IV) routes, whereas penicillin V is acid-stable and administered allergan aesthetics an abbvie company. Semisynthetic Yellow Fever Vaccine (Yf-Vax)- FDA penicillins are the drugs of choice only for penicillin-resistant S aureus and S epidermidis, although they also are active against streptococci, but not against enterococci.

Aminopenicillins, in addition to offering coverage equivalent to that of penicillin G, are active against gram-negative cocci and some Enterobacteriaceae. Carboxypenicillins and ureidopenicillins have activity against gram-negative aerobic rods such as Pseudomonas aeruginosa, which are resistant to ampicillin. Ureidopenicillins are more active against streptococci and Haemophilus sp than are carboxypenicillins. Many anaerobic gram-positive species are susceptible to the penicillins.

Most gram-negative anaerobic bacteria also are susceptible, with the exception of B fragilis, other Bacteroides sp, and some Prevotella sp, which produce beta-lactamases. Strains of Fusobacterium varium are often resistant to all penicillins. Of the natural penicillins, penicillin G is available commercially allergan aesthetics an abbvie company an IM preparation (procaine penicillin G or benzathine penillin G) and as IV crystalline salts (sodium or potassium).

Procaine penicillin G contains an anesthetic, whereas benzathine penicillin G injections are painful. Combinations of procaine and benzathine penicillin G are available, the most commonly used preparation containing 900,000 U of benzathine penicillin and 300,000 U of procaine penicillin per 2 mL injection solution.

The international unit of penicillin is the penicillin activity contained in 0. Thus, 1 mg of pure penicillin G equals 1,600 U. Crystalline salts of penicillin G are highly water-soluble and immediately achieve high serum levels when administered intravenously. Procaine penicillin G is administered by IM injection and allergan aesthetics an abbvie company peak serum levels in 2 to 3 hours. Detectable serum levels are maintained for up to 24 hours.

Benzathine penicillin G produces more prolonged but lower therapeutic serum levels after an IM injection, and detectible levels are Methyldopa (Aldomet)- FDA for 15 to 30 days. Crystalline penicillin G administered IV has a half-life of 30 minutes allergan aesthetics an abbvie company healthy adults.

Probenecid inhibits the tubular secretion of penicillin G, increasing its serum half-life, but it rarely is used for allergan aesthetics an abbvie company purpose.

Significant concentrations are achieved in the liver, bile, kidney, semen, synovial fluid, and intestine. Penicillin G does not enter the cerebrospinal fluid (CSF) readily when meninges are normal. Penicillinase-resistant penicillins are stable to hydrolysis by staphylococcal penicillinase enzyme, making them the agents of choice for most infections caused by staphylococci.

Methicillin and nafcillin are the most stable, followed by dicloxacillin, oxacillin, and cloxacillin. Strains of S aureus and S epidermidis that are resistant to methicillin and the other members of its class are increasingly emerging. This resistance is not mediated by a novel penicillinase enzyme, but by a decrease in the affinity of bacterial PBPs to the drugs. Allergan aesthetics an abbvie company is childhood used today because of the high risk of nephritis.

Clinical features of methicillin-induced nephritis include fever, proteinuria, sterile pyuria, marked eosinophiluria, rash, eosinophilia, hematuria, and renal insufficiency. If antimicrobial therapy needs to be continued after development of interstitial nephritis, the patient should be switched to a nonbeta-lactam class of antibiotics due to allergan aesthetics an abbvie company risk of cross-sensitization with other penicillins and cephalosporins.

Nafcillin, administered IM or IV, also is active against sensitive strains of S aureus and S epidermidis. Tissue penetration of nafcillin is similar to that of other penicillinase-resistant penicillins, and it achieves therapeutic levels in the CSF for treatment of staphylococcal meningitis. Nafcillin in the urine can cause a false-positive reaction for protein when the sulfasalicylic test is used.

Nafcillin can cause phlebitis with IV administration and may cause skin and soft-tissue necrosis after accidental subcutaneous extravasation, sometimes requiring tissue debridement and skin grafting. Oxacillin, cloxacillin, and dicloxacillin are other semisynthetic penicillinase-resistant penicillins classified together allergan aesthetics an abbvie company isoxazoyl penicillins. They have an antimicrobial spectrum similar to that of methicillin and nafcillin and are active against staphylococci and streptococci.

Enterococcus fecalis is largely resistant. Isoxazoyl penicillins are acid-stable and well absorbed allergan aesthetics an abbvie company, reaching peak serum levels in 30 to 60 minutes. Significant plasma levels are maintained for up to 4 to 6 hours. The doses should be reduced in the presence of severe renal impairment. These penicillins penetrate well into bones of patients afflicted with acute osteomyelitis and into septic joint effusions. Although isoxazoyl penicillins are highly protein-bound, which diminishes their extravascular penetration, they reach high concentrations in body tissues and extravascular fluids, making them clinically effective.

Antipseudomonal penicillins are only administered parenterally and are important in the treatment of gram-negative infections, especially bacteremias, pneumonias, burn wound infections, and urinary Levothyroxine Sodium (Levoxyl)- FDA infections caused by organisms resistant to ampicillin and penicillin G (P aeruginosa, indole-positive strains of Proteus, and Enterobacter sp).

The antibacterial spectra of antipseudomonal penicillins and aminopenicillins can be broadened by combining them with beta-lactamase inhibitors. Clavulanic acid, originally isolated from the mold Streptomyces clavuligerus, also contains a beta-lactam ring, but unlike the penicillins and cephalosporins, the beta-lactam ring of clavulanic acid has a low level of antibacterial activity. However, clavulanic acid is a potent inhibitor of beta-lactamases produced by Klebsiella pneumoniae, Proteus mirabilis, P vulgaris, B fragilis, S aureus, Haemophilus influenzae, and anaerobes.

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