Chest
Volume 112, Issue 6, December 1997, Pages 1657-1664
Journal home page for Chest

Reviews
Penicillin Dosing for Pneumococcal Pneumonia

https://doi.org/10.1378/chest.112.6.1657Get rights and content

Most textbook authors still endorse penicillin G as the specific antibiotic of choice for pneumococcal pneumonia. However, problems with early precise etiologic diagnosis of pneumonia and the emergence of drug-resistant pneumococci cause penicillin to be seldom used for this purpose today. A third explanation for the infrequent use of penicillin is lack of clear consensus dosing guidelines. Emergence of pneumococci resistant to the newer cephalosporins and concerns about overuse of vancomycin, however, have prompted renewed interest in the development of precise, rapid methods for diagnosis of pneumococcal pneumonia with the implication that penicillin might be used more frequently. We review several issues concerning penicillin dosing: intermittent vs continuous therapy, high dose vs low dose, relationship of dose to resistance, and cost-effective pharmacology. An optimum “high-dose” regimen for life-threatening pneumococcal pneumonia in a 70-kg adult consists of a 3 million unit (mu) loading dose followed by continuous infusion of 10 to 12 mu of freshly prepared drug every 12 h. The maintenance dose should be reduced in elderly patients and in patients with renal failure according to the following formula: dose (mu/24 h=4+[creatinine clearance÷7]). This regimen provides a penicillin serum level of 16 to 20 µg/mL, which should suffice for all but the most highly resistant strains (minimum inhibitory concentration ≥4 µg/mL). Newer cephalosporins and vancomycin can be reserved for patients with suspected meningitis or endocarditis or for localities in which highly resistant pneumococci are known to be prevalent.

Section snippets

Historical Overview

Doses of penicillin used in the early 1940s were minuscule by today's standards. The classic studies on the pharmacokinetics of penicillin G given IV were done with 20,000 to 40,000 Florey units.38 By 1945, a recommended regimen for severe pneumococcal pneumonia consisted of 25,000 U IV every 3 h (q3h) for two doses, then 10,000 U IM q3h for two doses.39 By 1946, it was noted that “sometimes the drip method is preferred to the intramuscular route by the scientific clinician but seldom is it

Dosing Considerations

Four issues pertaining to IV penicillin G therapy will be considered: intermittent vs continuous infusion; high dose vs low dose; the relationship of dose to resistance; and cost.

References (99)

  • FarthingMJG et al.

    Infectious diseases, tropical medicine and STDs

  • MandelGL et al.

    Principles and practice of infectious diseases: antimicrobial therapy 1995/1996

    (1995)
  • Med Lett

    (1996)
  • RodnichJE et al.

    Pulmonary infections

  • SanfordJP et al.

    Guide to antimicrobial therapy

    (1996)
  • MastersPA et al.

    Community-acquired pneumonia

    Louis

    (1993)
  • AustrianR

    Pneumococcal infections

  • DaleDC et al.

    Scientific American CD ROM 5

    (1996)
  • DumaRJ

    Pneumococcal pneumonia

  • MusherDM

    Streptococcus pneumoniae

  • SeatonA et al.

    Pneumonia

  • JohnsonCC et al.

    Pyogenic bacterial pneumonia

    Textbook of respiratory medicine. 2nd ed

    (1994)
  • BerkowR et al.

    The Merck manual of diagnosis and therapy

    (1992)
  • HenkelTJ et al.

    Treatment of infectious diseases

  • LipchikRJ

    Pneumonia

  • GreenwoodBM

    Pneumococcal infection

  • WeiserJN

    Pneumococcus

  • NiedermanMS et al.

    Respiratory tract infections

  • IsadaCM et al.

    Infectious disease handbook

    (1997)

    Cleveland

    (1996)
  • SchwartzB et al.

    Streptococcal infections

  • ChambersHF

    Infectious diseases: bacterial and chlamydial

  • NeuHC

    Pneumonia

  • OrtqvistA

    Antibiotic treatment of community-acquired pneumonia in clinical practice: a European perspective

    J Antimicrob Chemother

    (1995)
  • SinghKP et al.

    Pneumococcal bacteraemia in south Auckland: a 5 year review with emphasis on prescribing practices

    NZ Med J

    (1992)
  • NiedermanMS et al.

    Guidelines for the initial management of adults with community-acquired pneumonia: diagnosis, assessment of severity, and initial antimicrobial therapy

    Am Rev Respir Dis

    (1993)
  • FeinAM et al.

    Guidelines for the initial management of community-acquired pneumonia: savory recipe or cookbook for disaster

    Am J Respir Crit Care Med

    (1995)
  • BartlettJG et al.

    Community-acquired pneumonia

    N Engl J Med

    (1995)
  • SloasMM et al.

    Cephalosporin treatment failure in penicillin- and cephalosporin-resistant Streptococcus pneumoniae meningitis

    Pediatr Infect Dis J

    (1992)
  • BontenJM et al.

    Epidemiology of colonisation of patients and environment with vancomycin-resistant enterococci

    Lancet

    (1996)
  • BartlettJG

    Update in infectious diseases

    Ann Intern Med

    (1997)
  • Defining the public health impact of drug-resistant Streptococcus pneumoniae: report of a working group

    MMWR

    (1996)
  • PallaresR et al.

    Resistance to penicillin and cephalosporin and mortality from severe pneumococcal pneumonia in Barcelona, Spain

    N Engl J Med

    (1995)
  • AustrianR

    Confronting drug-resistant pneumococci [editorial]

    Ann Intern Med

    (1994)
  • JerniganDB et al.

    Minimizing the impact of drug-resistant Streptococcus pneumoniae (DRSP): a strategy from the DRSP working group

    JAMA

    (1996)
  • RammelkampCH et al.

    The absorption, excretion, and distribution of penicillin

    J Clin Invest

    (1943)
  • TillettWS et al.

    The treatment of lobar pneumonia with penicillin

    J Clin Invest

    (1945)
  • GosseAH

    Chest infections

  • BennettIL

    Pneumococcal infections

  • BrewinA et al.

    High-dose penicillin therapy and pneumococcal pneumonia

    JAMA

    (1974)
  • Cited by (0)

    View full text