Chapter 5 page number 1 Chapter 5 Infections First line drugs Drugs recommended in both primary and secondary care. Second line drugs Alternatives (often in specific conditions) in both primary and secondary care. Specialist initiated drugs Secondary care, authorised independent prescribers or GPs with special interest initiation. Suitable for continuation by primary care. Shared care agreements may be applicable. Secondary care only drugs Drugs only suitable for secondary care use and initiated by appropriate team or specialist. Primary care prescribers should not be asked to prescribe. Primary & Secondary Care Notes Secondary Care 5.1 Antibacterial drugs See Drug Colour Coding The empirical prescribing of antibacterial drugs should always be guided by local primary and secondary care guidelines. Do not use antibiotics unnecessarily. Use can predispose to colonisation/infection with resistant organisms or precipitate Clostridium difficile infection. See Antibacterial prescribing notes See also GWH Post-splenectomy antibiotic guidelines and associated GP letters. Selection of an antibiotic requires balancing its benefit against risk. Particular care should be taken in prescribing antibiotics in pregnancy, in renal or liver impairment and in the elderly. Consider individual allergic reactions. Patients who have had a life threatening reaction to penicillin should NOT be prescribed penicillins or cephalosporins. Advice on prescribing antibiotics in penicillin allergy can be obtained from Antibiotic prescribing in penicillin allergy. This formulary chapter contains those antimicrobial agents authorised for empirical use, and also those antibiotics restricted to use by microbiology recommedation in the 3T s clinical area. Agents not listed in this forumlary should not be prescribed for patients without discussion with local microbiologists and may require specific application and approval from the Trust or PCT. Intravenous antibiotics should be reviewed every 48 hours and changed to oral equivalents (where available) in a timely manner according to the local IV to oral intravenous switch policy. The following documents should be used in conjunction with this formulary when determining which antibacterial agents to prescribe: Primary care guidelines Secondary care guidelines and approved list As far as possible, the Trust guidelines avoid the use of cephalosporins, quinolones and other antibiotics suspected of contributing to Clostridium difficile infection. However it should be borne in mind that all antibiotics can contribute to Clostridium difficile infections and it is therefore important not to prescribe antibiotics unnecessarily or to extend courses without clinical justification. 5.1.1 Penicillins Phenoxymethylpenicillin oral Amoxicillin oral preparation For guidance on use of antibiotics and vaccinations for prophylaxis in asplenic patients, see trust guidelines. Amoxicillin injection Co-amoxiclav injection Flucloxacillin injection Flucloxacillin oral Piperacillin and tazobactam (Tazocin): only for neutropenic sepsis, severe HAP or sepsis of unknown origin in patients with renal impairment, as per GWH guidelines.
Chapter 5 page number 2 Co-amoxiclav oral Benzylpenicillin injection Benzathine benzylpenicllin injection May be first or second line, depending on indication and whether using in primary or secondary care please refer to guidelines Do not use combinations of antibiotics that cover similar organisms NB Co-amoxiclav and Metronidazole do not need to be routinely used together to cover anaerobic infections. First line in primary care for suspected meningococcal disease Only available as unlicensed preparation. Pivmecillinam ONLY for second-line treatment of UTI in patients whose microbiological cultures shows sensitivity to Pivmecillinam or in whom first-line options are contraindicated. 5.1.2 Cephalosporins and other beta-lactams Please note the following cephalosporins should ONLY be prescribed in line with Wiltshire, Swindon & BaNES Guidelines for Antibiotic Prescribing in the Community (primary care), Trust Antibiotic Guidelines (secondary care) or on the specific recommendations of a GWH Microbiologist. Cefalexin Ceftazidime Cefixime Cefotaxime Ceftriaxone Cefuroxime: NOT ROUTINELY STOCKED AT GWH Aztreonam : microbiological/paediatric consultant advice only. GWH 5.1.2.2 Carbapenems Use is restricted within secondary care guidelines Ertapenem/ Meropenem: microbiology advice only Imipenem with cilastatin/ Doripenem microbiology advice only NOT ROUTINELY STOCKED AT GWH 5.1.3 Tetracyclines Avoid in children youger than 12 years and in breastfeeding women deposition of tetracyclines in growing bones and teeth causes staining and dental hypoplasia. Doxycycline Oxytetracycline: see chapter 13.6.2 Lymecycline: see chapter 13.6.2 Demeclocycline see chapter 6.5.2 Note second line choice for dermatology patients; see section 13.6.2 Second line treatment for animal bites in penicillin allergy in primary care. Tigecycline: microbiology advice only.
Chapter 5 page number 3 5.1.4 Aminoglycosides Gentamicin Tobramycin nebulised solution (Tobi): specialist prescribing. Colistimethate Colistimethate 5.1.5 Macrolides Azithromycin Clarithromycin oral preps. Stat doses for insertion/removal of catheters. For information on gentamicin, framecitin, gramicidin and neomycin in topical ENT, see section 12.1 See MHRA Drug Safety Update Nov17 for further information and advice on the potential for histamine-related adverse drug reactions with some batches. See NICE TA276 For use in bronchiectasis and existing CF patients (usually nebulised). See NICE TA276 For use in new CF patients (usually nebulised). See NICE TA276 For treatment of Chlamydia trachomatis Azithromycin is available OTC post positive sample. For further information see: www.clamelle.co.uk Available on PGD at participating pharmacies in Swindon PCT through Contraceptive and Sexual Health Service. Second line treatment of otitis media in primary care: if penicillin allergic. First line macrolide in primary care.first line treatment for Helicobacter pylori. Gentamicin once daily dosing except endocarditis,paediatric mennigitis patients or on microbiology recommendation. Refer to trust guidelines for information on therapeutic drug monitoring. See MHRA Drug Safety Update Nov17 for further information and advice on the potential for histamine-related adverse drug reactions with some batches. Gentamicin 0.3 % eye drops Gentamicin 1.5% eye drops preservative free see section 11.3.1 Amikacin injection paediatric consultant/microbiology advice only. Monitoring of drug levels is required. Clarithromycin injection: only for use in severe community aquired pneumonia or as IV alternative to oral erythromycin. Erythromycin 0.5 % eye ointment (unlicensed) Treatment of suspected Chlamydia in Neonates. To be assessed by paediatricians. See 11.3.1 Erythromycin oral Erythromycin topical : See section 13.6.1 Azithromycin 5.1.6 Clindamycin Clindamycin oral preps Clindamycin topical First line macrolide in secondary care Alternative in pregnancy to clarithromycin or as a second line treatment of Chlamydia in primary care. Erythromycin oral preparation for the treatment of acne: See section 13.6.2 Specialist initiation only for treatment of bronchiectatics with recurrent Pseudomonas exacerbations. Treatment of cellulitis in penicillin allergic patients in primary care. See chapter 13.6.1 Clindamycin injection and oral : microbiology advice only.
Chapter 5 page number 4 5.1.7 Other antibacterials Chloramphenicol ophthalmic Fusidic acid/sodium fusidate topical Vancomycin oral (capsules) Fusidic acid oral preps Teicoplanin Chloramphenicol injection Fidaxomicin Rifaximin See section 11.3.1 See section 13.10.1.1 & 2 First line topically for impetigo only for small localised legions. Only for treatment of Clostridium difficile associated diarrhoea. Initiation on microbiology advice only. See MHRA safety alert on interactions with statins. Initiation in secondary care only as per guidelines. See GWH guidelines for dosing and therapeutic drug monitoring requirements Only for use in meningitis in severe penicillin allergy in primary care Epiglottitis and supraglottitis if penicillin allergic, or on microbiology advice. For use only on the advice of microbiology or the Clostridium difficile team For use in the prevention of recurrent episodes of hepatic encephalopathy ONLY on the advice of Consultant Liver Specialist / Consultant Gastroenterologist, in accordance with NICE TA 337. See 3Ts prescribing guidance on the treatment of hepatic encephalopathy for further advice on place in therapy. See also 3Ts SCA on Rifaximin for hepatic encephalopathy. Fusidic acid injection: On microbiologicay advice only. See MHRA safety alert on interactions with statins. Linezolid oral and infusion: microbiology advice only. Vancomycin injection: see GWH guidelines for dosing and therapeutic drug monitoring requirements Daptomycin Injection microbiology advice only. Quinupristin with Dalfopristin (Synercid) Injection microbiology advice only. Promixin For use in paediatrics only following initiation by specialist centre Fosfomycin IV For use on the recommendation of a Consultant Microbiologist only. 5.1.8 Sulphonamides and trimethoprim Trimethoprim oral Co-trimoxazole oral For prophylaxis of PJP (Pneumocystis carinii/ jiroveci pneumonia); see section 5.4.8 Trimethoprim Inj: microbiology advice only. Cotrimoxazole injection: For treatment of PJP (Pneumocystis carinii/ jiroveci pneumonia) only. Sulphamethoxypyridazine unlicensed use in dermatology for blistering disease. 15% sulphacetamide in alcohol For use by specialist dermatologists only for nail infections.
Chapter 5 page number 5 5.1.9 Antituberculosis drugs Rifampicin See GWH guidelines. 5.1.10 Antileprotic drugs All anti TB treatments will be under the direction of a respiratory consultant. For current guidance on treatment of tuberculosis, refer to NICE guidance CG33 (March 2006) http://www.nice.org.uk/guidance/cg33 For treatment of multi resistant TB seek advice from microbiology or GWH respiratory physician: Dr Onyirioha: hospital ext 6500/bleep 2023. Respiratory secretaries: hospital ext 4766/4768. 5.1.11 Metronidazole and tinidazole Metronidazole oral See hospital guidelines for use in treatment of Clostridium difficile associated diarrhoea. For use in confirmed TB only under the direction of a respiratory consultant: Rifinah Rifater Pyrazinamide Isoniazid Ethambutol Other may be considered on specialist advice in MDR or XDR cases of TB. Dapsone: on microbiology advice. For use in dermatology or for treatment of PJP (see 5.4.8), on specialist advice only Clofazimine: For use in dermatology on specialist advice only. Metronidazole injection Metronidazole topical praparations: See section 13.10.1.1 & 2 Tinidazole microbiology advice only. (see also 5.4.4) 5.1.12 Quinolones Use is restricted within primary and secondary care guidelines. Ciprofloxacin 0.3% See formulary section 12.1 drops (Ciloxan ): Ciprofloxacin oral For use only in specific indications according to GWH guidelines, primary care guidelines, or on microbiology recommendation. Ofloxacin Use in primary care for treatment of PID or acute prostatitis only. 5.1.13 Urinary tract infections Nitrofurantoin Do not use in patients with a history of or with suspected renal failure. Please see MHRA Drug Safety Update August 2013. Now contraindicated in most patients with egfr of less than 45ml/min/1.73m2. Please see MHRA Drug Safety Update Sept 2014. Ciprofloxacin injection: Use to be restricted as per hospital antibiotic guidelines. Moxifloxacin Consultant ophthalmologist or microbiology advice only. GWH Fosfomycin For prescribing on the advice of consultant microbiologist only. Refer Fosfomycin Guidelines for details of prescribing and supply by community pharmacy in primary care. See NICE evidence summary for additional information.
Chapter 5 page number 6 5.2 Antifungal Drugs Studies suggest that lipid-based amphotericin (Ambisome) is less nephrotoxic than conventional amphotericin. However liposomal amphotericin is significantly more expensive, and due to the paucity of randomised trials showing its efficacy against proven invasive disease its use is limited to: - haematology patients, or immunosuppressed patients - those requiring prolonged therapy. - Patients who have failed on conventional therapy (> 500mg conventional dose) - concomitant use of nephrotoxic agents. - those with pre-existing renal impairment (creatinine clearance < 60ml/min). - those with a rapidly rising or significant increase in creatinine or other signs of severe toxicity related to conventional amphotericin use. Secondary care treatment of invasive fungal infections is based on positive cultures and advice from microbiology and mycology from the reference laboratory in Bristol. Nystatin oral suspension Amphotericin injection Fluconazole oral Clotrimazole -pessaries -cream Itraconazole Posaconazole Miconazole (Daktarin oral gel) Primary care for vaginal candidiasis. secondary care for treatment and prophylaxis of oral candida. Use liquid preparation. Primary care: for nail infections. Secondary care initiated only: Prophylaxis in haematology patients. Caution in patients at high risk of heart failure. For prophylactic use only in haematology patients who cannot tolerate itraconazole. See MHRA Drug Safety Update Sept 16 for further safety information and advice. Available OTC See MHRA Drug Safety Update June 2016 for further information and advice on the potential for topical miconazole, including oral gel, to seriously interact with warfarin. See MHRA Drug Safety Update Sept 17 for information on the contraindication of over-thecounter miconazole oral gel in patients taking wafarin, and advice to healthcare professionals wishing to prescribe this combination. Fluconazole IV For serious systemic candida infections. Flucytosine On microbiology advice only. Micafungin Use ONLY in accordance with Trust antifungal guidelines or on the advice of a Consultant Microbiologist. Anidulafungin Use ONLY in accordance with Trust antifungal guidelines or on the advice of a Consultant Microbiologist. Caspofungin On microbiology advice only. Voriconazole on microbiology advice only. See MHRA Drug Safety Update for information on risk of liver toxicity, phototoxicity and squamous cell carcinoma for the skin. Terbinafine Amorolfine nail laquer For nail infections (see skin chapter 13.10.2) For nail infections (see skin chapter 13.10.2)
Chapter 5 page number 7 5.3 Antiviral Drugs 5.3.1 HIV Infection refer to British HIV Guidelines at http://www.bhiva.org/ For information on drug interactions see the Liverpool University site at http://www.hiv-druginteractions.org/ Nucleoside reverse transcriptase inhibitors Lamivudine Abacavir Didanosine (Videx ) Emtricitabine (Emtriva ) Stavudine Tenofovir Zidovudine Combination nucleoside reverse transcriptase inhibitors Zidovudine/Lamivudine Abacavir/Lamivudine Abacavir/Lamivudine/ Zidovudine (Trizivir ) Emtricitabine/ Tenofovir disoproxil fumarate (Truvada ) Emtricitabine/ Tenofovir alafenamide fumarate (Descovy ) Protease inhibitors Atazanavir Darunavir (Prezista ) Fosamprenovir (Telzir ) Indinavir Ritonavir See MHRA Drug Safety Update Dec 16 for further information and advice on risk of serious adverse effect. Saquinavir Tipranivir (Aptivus ) Combination protease inhibitors See MHRA Drug Safety Update Dec 16 for further information and advice on risk of serious adverse effect. Atazanavir/ Cobicistat (EvoTaz ) Darunavir /Cobicistat (Rezolsta ) Non-nucleoside reverse transcriptase inhibitors Lopinavir/Ritonavir (Kaletra )
Chapter 5 page number 8 Efavirenz Nevirapine Etravirine Rilpivirine
Chapter 5 page number 9 Combination nucleoside reverse transcriptase inhibitors and non-nucleoside reverse transcriptase inhibitors Efavirenz/Entricitabine/Tenofovir disoproxil fumarate (Atripla ) Emtricitabine/Rilpivirine /Tenofovir disoproxil fumarate (Eviplera ) Emtricitabine/Rilpivirine/ Tenofovir alafenamide fumarate (Odefsey ) Other antiretrovirals Maraviroc Raltegravir Dolutegravir (Tivicay ) Dolutegravir / Lamivudine (Triumeq ) Elvitegravir/ Emtricitabine/ Tenofovir alafenamide fumarate / Cobicistat (Genvoya ) See MHRA Drug Safety Update Dec 16 for further information and advice on risk of serious adverse effect. 5.3.2 Herpesvirus and varicella zoster infections Aciclovir Elvitegravir/ Emtricitabine/ Tenofovir disoproxil fumarate / Cobicistat (Stribild ) See MHRA Drug Safety Update Dec 16 for further information and advice on risk of serious adverse effect. Aciclovir IV Aciclovir 3% eye ointment See section 11.3.3 5.3.2.2 Cytomegalovirus infection Treatment options will be based on virology and advice from Bristol Reference Laboratory Cidofovir injection Microbiology recommendation only. NOT ROUTINELY STOCKED AT GWH Ganciclovir injection Valganciclovir Microbiology recommendation only. NOT ROUTINELY STOCKED AT GWH 5.3.3 Viral Hepatitis Foscarnet injection: Microbiology recommendation only. GWH
Chapter 5 page number 10 5.3.3.1 Chronic Hepatitis B Treatment of viral hepatitis B is covered by NICE Clinical Guideline CG165 and NICE Technology Appraisals TA96, TA153, TA154 and TA173. Tenofovir ONLY for initiation by Consultant Gastroenterologist specialising in liver disease. Entecavir ONLY for initiation by Consultant Gastroenterologist specialising in liver disease. Interferon Alfa 2a ONLY for initiation by Consultant Gastroenterologist specialising in liver disease. 5.3.3.2 Chronic Hepatitis C Treatment of viral hepatitis C is covered by NICE Technology Appraisals: TA75, TA106, TA200, TA252, TA253, TA300, TA330, and TA331 Please see MHRA Drug Safety Update Jan 17 for further information and advice on risk of Hepatitis B reactivation and risk of interaction with Vitamin K antagonists. Please note prescribing for patients with chronic hepatitis C is via tertiary centres ONLY. 5.3.4 Influenza Refer to NICE Guidelines TA168 and HPA guidelines for use in epidemic or pandemic influenza outbreaks. Oseltamivir Give within 48 hours of onset of symptoms/exposure. Preferred drug in breast feeding. Use at GWH following pandemic influenza guidance. Zanamivir Give within 36 hours of onset of symptoms/ exposure. Preferred drug during pregnancy. 5.3.5 Respiratory syncytial virus Palivizumab On advice of consultant neonatologists only. Ribavirin Only after seeking microbiologist advice. GWH 5.4 Antiprotozoal Drugs 5.4.1 Antimalarials Prophylactic agents including Proguanil hydrochloride with Atovaquone (Malarone ), Chloroquine, Mefloquine, Proguanil and Doxycycline are available on private prescriptions only. For advice on treatment of malaria, contact GWH microbiology or London Hospital for Tropical diseases on 020 7380 9234. For advice on malarial prophyaxis, the following resources are available: www.travax.nhs.uk (requires nhs login) http://www.fitfortravel.nhs.uk/ Pharmacy Medicines Information 01793 60(5029). Health Protection Agency Malaria 020 7636 3924 World Health Organisation emims Travel Tables (requires user login) BNF advice on antimalarial prophylaxis. Mepacrine unlicensed use in dermatology. Quinine hydrochloride injection See MHRA Drug Safety Update Nov 17 for further information and advice on dose-dependent QTprolonging effects and updated medicine interactions.
Chapter 5 page number 11 5.4.2 Amoebicides Diloxanide Furoate Prescribe if positive microscopy or serology. Metronidazole 5.4.4 Antigiardial drugs Metronidazole Tinidazole 5.4.8 Drugs for pneumocystis pneumonia Please refer to hospital treatment guidelines for Pneumocystis jirovecii (formerly carnii) Only after seeking microbiologist advice: Cotrimoxazole injection Clindamycin Primaquine Dapsone Trimethoprim Trimetrexate Atovaquone Pentamidine isetionate
Chapter 5 page number 12 5.5 Anthelmintics 5.5.1 Drugs for threadworms Mebendazole Recommended for all children >6 months and adults. Repeat in 2/52 if infestation persists. Piperazine Only use in children aged 3-6 months only. 5.5.2 Ascaricides seek microbiologist/dermatologist specialist advice. 5.5.3 Drugs for tapeworm infections seek microbiologist/dermatologist specialist advice. 5.5.4 Drugs for hookworms seek microbiologist/dermatologist specialist advice. 5.5.5 Schistosomicides seek microbiologist/dermatologist specialist advice. 5.5.6 Filaricides seek microbiologist/dermatologist specialist advice. Ivermectin 5.5.7 Drugs for cutaneous larva migrans seek microbiologist/dermatologist specialist advice. 5.5.8 Drugs for strongyloidiasis seek microbiologist/dermatologist specialist advice. Albendazole References: Primary care - Wilts & Swindon Guidelines for Antibiotic Prescribing in the Community Secondary care - Acute Trust Antibiotic Prescribing Supporting individual antibiotic treatment guidelines are available on request. Contact GWH Antibiotic Team.