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If the infection is more severe, intravenous penicillin G may be used.В CellulitisВ is a more extensive infection, which may be due to a number of different streptococci orВ Staphylococcus aureus .

A penicillinase-resistant penicillin should be used empirically, either orally or intravenously, depending upon the severity of infection.

More severe skin infections, including necrotizing fasciitis, can be caused by group A streptococcus (streptococcal gangrene), along with other organisms, such as anaerobes and gram-negative rods.

In skin infections caused by streptococcus, aggressive therapy with penicillin G has been utilized yet is still associated with morbidity and mortality (27).

It is thought that the high organism inoculum seen in these infections is indicative of an increased number of organisms that are not actively replicating, against which penicillin is less effective (224). There is experimental data to suggest that penicillin in combination with clindamycin may be more effective, since clindamycin’s mechanism of action is cell cycle independent (223,В 224).

Gas gangrene is a complication of a surgical or traumatic wound that can result in severe pain, skin discoloration, and edema.В Clostridium perfringens В and other Clostridial species are the common causative organisms.

WhileВ surgical debridementВ is a cornerstone of therapy, antibiotic treatment is essential. The drug of choice is penicillin G intravenously 10-24 mu daily in divided doses (57). Decreased susceptibility ofВ Clostridium perfringens В has been seenВ in vitro В however (151), and some animal model studies have demonstrated poorer results in the penicillin treated animals versus animals that received other antibiotics such asВ metronidazoleВ or clindamycin (222).

The clinical significance of these findings is unclear, but some clinicians are using combinations of penicillin G and another agent for treatment of this serious infection. NaturallyВ occurring cutaneous anthrax, caused byВ Bacillus anthracis В spores, can occur in patients exposed to wool (128). Intravenous penicillin G (1MU q 4-6 hours) has been demonstrated to effectively result in negative cultures of previously positive blister fluid (196) and is considered the treatment of choice. Oral penicillin VK is often used in patients after receiving an animal bite, particularly a cat bite. Antimicrobial prophylaxis is often indicated after such bites as the infection rate is high and is often caused byВ Pasteurella multocida В (143).

Penicillin VK’s coverage against this organism is good and a dosage of 250-500 mg every 6 hours for 10 days is often utilized.

The oral flora of a cat or dog can also includeВ Staphylococcus aureus В and anaerobes; therefore some clinicians may choose amoxicillin/clavulanic acid to cover other possible organisms adequately. Human oral flora includesВ Staphylococcus aureus ,В Eikenella corrodens , and anaerobes, therefore these bites should be treated with amoxicillin/clavulanic acid.

Other traumatic wounds may require antimicrobial prophylaxis, as well.

In a study of 599 patients with traumatic wounds of the hands or feet with underlying bone, tendon, or joint lesions, a penicillin G injection was compared with 6 days of oral penicillin VK or no

treatment

Patients receiving intravenous penicillin G were significantly less likely to develop infection versus no treatment and patients receiving oral therapy had more gastrointestinal complaints.

A single dose of penicillin G may be a useful alternative as prophylaxis in these patients (146). Treatment of acute pyelonephritis depends upon urine gram-stain and culture results.В AmoxicillinВ may be used for treatment ofВ enterococcalВ infection, but cephalosporins are probably a better choice for coverage ofВ Staphylococcus В (e.g.В Staphylococcus saprophyticus ). In the past,В ampicillinВ and amoxicillin were drugs of choice for treatment of E. coli В infection, however it is reported that 25-35% of isolates are now resistant (112). If use of a penicillin compound is desired, a combination beta-lactam/beta-lactamase inhibitor can be used (either orally or intravenously).

Lower urinary tract infection can be treated with single dose therapy and amoxicillin 3g is a regimen that has been used (173), but because of increasing resistance, other agents may be more desirable. Some experts suggest that with single dose or a 3-day course of therapy, the beta-lactams are inferior to other agents such asВ trimethoprim-sulfamethoxazoleВ at early and late follow-up (215). Penicillin G can be used as an adjunct to therapy for the treatment ofВ inhalational,В gastrointestinal, or oropharyngeal anthraxВ resulting from bioterrorism, however it should not be used as a sole agent (115).

Data from an outbreak in late 2001 resulting from intentional anthrax infection noted that the isolates ofВ Bacillus anthracis were producers of constitutive and inducible beta-lactamases and non betalactamase stable penicillins, and are not likely to be clinically effective (46).

Penicillin G continues to be indicated for naturally occurring infections (10).

Amoxicillin may also be used as an option for completion of therapy for cutaneous anthrax after treatment withВ ciprofloxacinВ orВ doxycyclineВ and after clinical improvement is documented (115). Amoxicillin may be used for completion of a 60-day course of anthrax post exposure prophylaxis at a dosage of 500 mg three times daily in patients who have received a fluoroquinoloneВ or doxycycline for 14-21 days and if there are contraindications to use of those drugs, e.g.

In infants and young children with sickle cell disease, oral penicillin VK is recommended as prophylaxis againstВ pneumococcal infectionВ at a dose of 125mg twice daily, starting before the child is 4 months of age.

Oral penicillin VK is also recommended for children with functional or anatomical asplenia (7). Yaws, causedВ byВ Treponema pallidum , subspeciesВ pertenue В effects persons in tropical or subtropical areas and is characterized by skin and bone lesions.

Treatment of choice is a single dose of BPG 1.2 mu for individuals aged 10 or over and 600,000u for younger children.

Other treponemal diseases includeВ pinta, which manifests as unsightly skin lesions, and bejel, or endemic syphilis, which causes lesions of skin and bone and is not transmitted by sexual contact.

BPG 1.2MU as a single dose is effective for both these diseases (51). Leptospirosis, transmitted from animals and caused by the spirocheteВ Leptospira interrogans , can manifest as a self-limited form (anicteric) or a more severe form of multi-organ dysfunction (icteric).

Mild disease can be treated with oral ampicillin (500-750mg q6h), amoxicillin (500mg q6h), or doxycycline (81). In moderate to severe disease, intravenous penicillin G (1.5mu q6h) has been shown to improve symptoms and shorten hospital stay (251).

For prophylaxis, doxycycline, but not penicillin, is recommended (81).

Lyme disease, caused byВ Borrelia burgdorferi , is treated with amoxicillin 500 mg qid or doxycycline (59). Length of therapy is usually 10 days for mild (localized) infection and 20-30 days forВ disseminated diseaseВ (e.g.

In patients with objective neurologic abnormalities or high degree atrioventricular heart block, intravenous therapy with penicillin G (5 mu qid), ceftriaxone, or cefotaxime may be used (58,В 183,В 221).

Doses of intravenous penicillin G 3g every 6 hours were studied in patients with neuroborreliosis and were found to attain concentrations of 0.5 Вµg/mL in the CSF 2-3 hours after dosing.

This concentration was determined to be appropriate to sufficiently treat neuroborreliosis (123).