NHS Greater Glasgow & Clyde Area Drug and Therapeutics Committee
Greater Glasgow and Clyde Prescribing
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5 Infections

5.1 Antibacterial drugs

5.1.1 Penicillins

5.1.1.1 Benzylpenicillin and phenoxymethylpenicillin

Preferred list
BENZYLPENICILLIN

Prescribing Notes:

Generally given by slow IV injection and use in primary care will be limited.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/3708.htm

PHENOXYMETHYLPENICILLIN

Prescribing Notes:

The alternative name is penicillin V. Used widely in bacterial tonsillitis, otitis media and cellulitis.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/3710.htm

5.1.1.2 Penicillinase-resistant penicillins

Preferred list
FLUCLOXACILLIN

Prescribing Notes:

Penicillinase-resistant penicillin used widely in cellulitis, otitis externa and impetigo.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/3718.htm

Total Formulary
TEMOCILLIN (injection)

Restrictions: Restricted to specialist use only on the advice of a microbiologist or an infectious disease physician as second line therapy in severely-ill patients with confirmed ESBL- or AmpC related infections.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/PHP3320-temocillin.htm?q=temocillin&t=search&ss=text&p=2#_hit

5.1.1.3 Broad-spectrum penicillins

Preferred list
AMOXICILLIN

Prescribing Notes:

Broad spectrum penicillin with a wide range of indications including chest infections, otitis media, urinary tract infections and prophylaxis of endocarditis.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/3724.htm

CO-AMOXICLAV

Restrictions: Excludes Augmentin Duo®.Inappropriate use of co-amoxiclav is associated with an increased risk of infections such as Clostridium difficile and MRSA. The risk of cholestatic jaundice with co-amoxiclav is six times that seen with amoxicillin and is more common in men and the over 65s. Therefore, co-amoxiclav should be reserved for infections suspected of being due to amoxicillin resistant beta-lactamase producing strains.

Prescribing Notes:

Duration of therapy should not normally exceed 14 days. See Primary Care and Acute infection guidelines for appropriate uses in adults. Co-amoxiclav is a mixture of amoxicillin and clavulanic acid. Care should be taken as to which product should be used in paediatric patients due to the different amounts of clavulanic acid. Consult the BNF for Children for details.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/3737.htm

5.1.1.4 Antipseudomonal penicillins

Total Formulary
PIPERACILLIN AND TAZOBACTAM

Restrictions: Restricted to specialist initiation. Brand include Tazocin®. Recommended for use on the advice of a microbiologist or an infectious disease physician as second line therapy in severely ill patients with multi-resistant organisms.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/202628.htm

5.1.1.5 Mecillinams

Total Formulary
PIVMECILLINAM

Restrictions: Restricted to use on advice of microbiology only.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/81581.htm

5.1.10 Antileprotic drugs

Total Formulary
DAPSONE

Restrictions: Restricted to specialist initiation.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/3926.htm

5.1.11 Metronidazole and tinidazole

Preferred list
METRONIDAZOLE

Prescribing Notes:

A useful antibiotic for anaerobic infections. Patients should be counselled to avoid alcohol whilst taking this medicine because of the potential disulfiram-like reaction.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/3932.htm

5.1.12 Quinolones

Preferred list
CIPROFLOXACIN

Prescribing Notes:

Ciprofloxacin should be prescribed by mouth in preference to IV where possible, as oral dosing gives similar concentrations to IV administration. The exception is when the oral route is compromised (e.g. nil by mouth, reduced absorption, unconsciousness, vomiting or mechanical swallowing disorder). Ciprofloxacin is active against many Gram positive and Gram negative bacteria and is a useful second or third line agent for urinary tract infections and infections of the GI tract, though it should not be used empirically. The NHSGGC Infection Management guidelines can provide advice on when use is appropriate. CSM advice for quinolones has been issued. Refer to BNF for further details.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/3945.htm

Total Formulary
NORFLOXACIN

Restrictions: Restricted to specialist initiation. Restricted to prophylactic use only for spontaneous bacterial peritonitis in line with the GGC management of decompensated liver disease guidelines (unlicenced indication).

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/3956.htm

LEVOFLOXACIN

Restrictions: Restricted to specialist initiation. Restricted to second line use by hospital specialists for penicillin allergic patients with community or hospital acquired pneumonia or for cystic fibrosis patients intolerant of ciprofloxacin where a quinolone is required.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/69969.htm

LEVOFLOXACIN (nebuliser solution)

Restrictions: Restricted to specialist initiation and use as third-line treatment option after colistimethate sodium (first line) and tobramycin (second line).

MOXIFLOXACIN

Restrictions: Restricted to specialist initiation. Treatmrnt of community acquired pneumonia (CAP) is restricted to use on the advice of microbiologists or specialists in infectious diseases. Restricted to second line use by hospital specialists for cystic fibrosis patients intolerant of ciprofloxacin where a quinolone is required.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/127959.htm

OFLOXACIN

Restrictions: Restricted to use in the treatment of pelvic inflammatory disease and epididimitis.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/3958.htm

5.1.13 Urinary-tract infections

Preferred list
TRIMETHOPRIM

Prescribing Notes:

Trimethoprim should be considered the first line choice for uncomplicated UTIs.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/3960.htm

5.1.2 Cephalosporins, carbapenems, and other beta-lactams

5.1.2.1 Cephalosporins

Preferred list
CEFALEXIN

Prescribing Notes:

Approximately 10% of patients with hypersensitivity to penicillins will also be allergic to cephalosporins.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/3789.htm

CEFOTAXIME (INJECTION)

Restrictions: Restricted to specialist initiation.

Prescribing Notes:

Approximately 10% of patients with hypersensitivity to penicillins will also be allergic to cephalosporins.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/3772.htm

CEFTRIAXONE

Prescribing Notes:

Approximately 10% of patients with hypersensitivity to penicillins will also be allergic to cephalosporins. This can be given by deep IM injection or IV injection/infusion.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/3784.htm

CEFUROXIME (INJECTION)

Restrictions: Restricted to specialist initiation.

Prescribing Notes:

Approximately 10% of patients with hypersensitivity to penicillins will also be allergic to cephalosporins.

For use after cataract surgery please refer to chapter 11.3.1 

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/3786.htm

Total Formulary
CEFACLOR

Prescribing Notes:

Avoid using oral cephalosporins as a step down following IV use.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/3763.htm

CEFRADINE

Restrictions: Restricted to specialist initiation.

Prescribing Notes:

Avoid using oral cephalosporins as a step down following IV use.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/3797.htm

CEFTAZIDIME

Restrictions: Restricted to specialist initiation.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/3780.htm

CEFIXIME

Restrictions: Restricted to prescribing by specialists as per Sandyford treatment protocol.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/3768.htm

CEFTAROLINE FOSAMIL (infusion)

Restrictions: Included on the Formulary only for the treatment of complicated skin and soft tissue infections in adults. It is restricted to specialist use only on the advice of local microbiologists or specialists in infectious disease in accordance with the prescribing notes below.

Prescribing Notes:

 It is Formulary for use in patients with known or suspected meticillin resistant Staphylococcus aureus (MRSA) infection in the following settings:

  • For Gram-positive only infections where vancomycin iv is inappropriate/has not been tolerated or treatment modification is required; and daptomycin iv or linezolid iv is normally used.
  • For polymicrobial Gram-positive and common Gram-negative pathogens, where vancomycin iv in combination with gentamicin iv is inappropriate/has not been tolerated or treatment modification is required; and daptomycin iv in combination with gentamicin iv, or linezolid iv in combination with gentamicin iv, or tigecycline iv is normally used.

Ceftaroline is also licensed for the treatment of community acquired pneumonia, but this indication has not been reviewed by SMC and is therefore non-Formulary

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/PHP18798-ceftaroline-fosamil.htm?q=ceftaroline&t=search&ss=text&p=1#_hit

CEFTOBIPROLE (ZEVTERA) (infusion)

Restrictions: Restricted to use only on the advice of a Microbiologist or Infectious Disease specialist for use in the treatment of Hospital-acquired pneumonia (excluding ventilator-associated pneumonia) when activity is required against suspected methicillin-resistant Staphylococcus aureus (MRSA) and Gram-negative pathogens (including Pseudomona aeruginosa, Escherichia coli and Klebsiella pneumoniae) and when combination treatment that includes vancomycin or teicoplanin is inappropriate or has not been tolerated, or when treatment modification is required, i.e. as an alternative to linezolid-based regimen

Prescribing Notes:

Ceftobiprole is an Alert Antimicrobial

5.1.2.2 Carbapenems

Total Formulary
ERTAPENEM

Restrictions: Restricted to specialist initiation. Restricted to second or third line treatment of community-acquired intra-abdominal infections resistant to current conventional treatments. Treatment of diabetic foot infections of the skin and soft tissue is restricted to use by specialists managing diabetic foot infection on the advice of a microbiologist. The indication of prophylaxis of surgical site infection following elective colorectal surgery in adults remains non-Formulary. The use for other infections should only be on the advice of a microbiologist or infectious disease physician.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/119728.htm

IMIPENEM CILASTIN

Restrictions: Restricted to specialist initiation. Restricted to use on microbiological and infectious disease physician advice only.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/3802.htm

MEROPENEM

Restrictions: Restricted to specialist initiation. Restricted to use on microbiological and infectious disease physician advice only.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/33501.htm

5.1.2.3 Other beta-lactam antibiotics

Total Formulary
AZTREONAM (injection)

Restrictions: Restricted to specialist initiation. Restricted to use on microbiological and infectious disease physician advice only. Aztreonam nebules for the suppresive therapy of Pseudomonas aeruginosa infections in adults with cystic fibrosis is not recommended for use by the SMC and is non-Formulary.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/3800.htm

AZTREONAM (CAYSTON) (NEBULES)

Restrictions: Restricted to specialist initiation for use as suppressive therapy of chronic pulmonary infections due to Pseudomonas aeriginosa in patients with cystic fibrosis (age 6 and above) when inhaled colistemethate sodium and inhaled tobramycin are not tolerated or not providing satisfactory therapeutic benefit (measured as a 2% decline in forced expiratory volume in 1 second (FEV1)

BNF Link: https://www.medicinescomplete.com/mc/bnf/current/PHP3423-cayston.htm?q=aztreonam&t=search&ss=text&p=5#PHP3423-cayston

5.1.3 Tetracyclines

Preferred list
OXYTETRACYCLINE

Prescribing Notes:

This antibiotic is also used for the treatment of acne (chapter 13.6)

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/3827.htm

DOXYCYCLINE

Prescribing Notes:

Doxycycline is no more effective than oxytetracycline and is several times more expensive. Uses include sinusitis and pelvic inflammatory disease.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/3816.htm

Total Formulary
TIGECYCLINE

Restrictions: Restricted to specialist initiation. Restricted to second or third line use under the advice of local microbiologists or specialists in infectious diseases.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/129711.htm

5.1.4 Aminoglycosides

Preferred list
GENTAMICIN

Prescribing Notes:

Restricted to specialist initiation. Gentamicin should be prescribed in line with local guidelines and is subject to dose adjustment in line with therapeutic drug monitoring.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/3832.htm

Total Formulary
TOBRAMYCIN (Nebules)

Restrictions: Restricted to specialist initiation as second-line use after colistimethate (colistin).

Prescribing Notes:

All available brand of nebulised tobramycin are included in the Formulary.  Prescribers are asked to use the preparation with the lowest acquisition cost taking into account of patient tolerability.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/202643.htm

TOBRAMYCIN (TOBI PODHALER) (POWDER FOR INHALATION)

Restrictions: Restricted to specialist initiation as second-line use after colistimethate (colistin).

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/3847.htm

AMIKACIN

Restrictions: Restricted to specialist initiation. Restricted to use on microbiological and infectious disease physician advice only.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/64687.htm#_64687

DALBAVANCIN

Restrictions: For details of restrictions please see Prescribing Notes below.

Prescribing Notes:

Restricted to use on the advice of local microbiologists and infectious disease specialists only in the following situations:

  • in accordance with OPAT service clinical management pathway for second-line use or when meticillin-resistant Staphylococcus aureus (MRSA) infection is suspected AND when the patient is initially hospitalised due to ABSSSI, requires intravenous antibiotics, but is eligible for early discharge as soon as their medical condition does not require durther inpatient treatment.

Please note: this is a PROTECTED ANTIBIOTIC and relevant paper work should be completed.

NEOMYCIN

Restrictions: Restricted to specialist initiation.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/3841.htm

NETILMICIN

Restrictions: Restricted to specialist initiation. Restricted to use on microbiological and infectious disease physician advice only.

5.1.5 Macrolides

Preferred list
CLARITHROMYCIN

Restrictions: Excludes Clarosip®.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/3861.htm

ERYTHROMYCIN

Prescribing Notes:

Erythromycin has a spectrum of activity similar to penicillin, which makes it a useful alternative for penicillin allergic patients for many infections.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/3850.htm

Total Formulary
AZITHROMYCIN (tablets, oral suspension, IV infusion)

Restrictions: Oral formulations are only Formulary for indications which require its powerful anti-chlamydial effect. Azithromycin IV infusion is restricted to use for the treatment of community acquired pneumonia (CAP) and pelvic inflammatory disease (PID) only on the advice of a microbiologist or infectious disease physician when the oral route of administration is compromised. It is considered an Alert Antimicrobial.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/3859.htm

5.1.6 Clindamycin

Total Formulary
CLINDAMYCIN

Prescribing Notes:

Excludes vaginal cream.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/3864.htm

5.1.7 Some other antibacterials

Total Formulary
CHLORAMPHENICOL

Restrictions: Restricted to specialist initiation.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/3867.htm

COLISTIMETHATE SODIUM (COLOBREATHE) (dry powder inhaler)

Restrictions: Restricted to specialist initiation where nebulised colistimethate is not tolerated and tobramycin is being considered.

COLISTIMETHATE SODIUM (COLISTIN) (nebules)

Restrictions: For restrictions please see prescribing notes below

Prescribing Notes:

  • Restricted to specialist initiation. Restricted to use on microbiological and infectious disease physician advice only.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/215404.htm#_215404

DAPTOMYCIN

Restrictions: Restricted to specialist initiation. Restricted to use in patients not responding to or intolerant of a glycopeptide. Use for for VRE, VISA and VRSA2 or known or suspected MRSA infection is restricted to the advice of a microbiologist or specialist in infectious diseases.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/129715.htm

FIDAXOMICIN (DIFICLIR) (tablets)

Restrictions: Fidaxomicin is restricted to use for the treatment of adults with microbiologically proven recurrence of Clostridium difficile infection (CDI) only on the advice of Consultant microbiologists or Consultants in Infectious Diseases. An Alert Antibiotic form must be completed prior to issue from pharmacy. It is non-formulary for use in adults with first episode of CDI or as empirical treatment in CDI.

FOSFOMYCIN (MONURIL) (granules)

Restrictions:

Restricted to use on the advice of microbiologists or infectious disease physicians when laboratory results indicate sensitivity and according to local primary care or acute sector treatment protocols.

  • The primary care protocol for use can be accessed on StaffNet by clicking HERE
  • The acute care protocol for use can be accessed on StaffNet by clicking HERE

Prescribing Notes:

Formulary indications:

  • Treatment of extended-spectrum beta-lactamases (ESBL) lower urinary tract infection (LUTI) in non-septic men as an oral alternative to current intravenous treatments.
  • Treatment of extended-spectrum beta-lactamases (ESBL) lower urinary tract infection (LUTI) in non-pregnant women as an oral alternative to current intravenous treatments.
  • Treatment of acute lower uncomplicated urinary tract infections, caused by pathogens sensitive to fosfomycin in adult and adolescent females.
  • Prophylactic treatment in diagnostic and surgical transurethral procedures.

FOSFOMYCIN (IV infusion)

Restrictions: Restricted to use only on the advice of a microbiologist or infectious disease physician for multi-resistant organisms.

Prescribing Notes:

Fosfomycin IV is classed as an Alert Antibiotic.

BNF Link: https://www.medicinescomplete.com/mc/bnf/current/PHP34804-fosfomycin.htm?q=fosfomycin&t=search&ss=text&p=3#PHP34804-fosfomycin

LINEZOLID

Restrictions: Restricted to specialist use only. Restricted to hospital-based use on the advice of a microbiologist or infectious disease physician. Prolonged use (>2 weeks) must be avoided.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/106106.htm

RIFAXIMIN (TARGAXAN) (tablets)

Restrictions: Use for the reduction in recurrence of episodes of overt hepatic encephalopathy (HE) in patients ≥18 years of age is restricted to initiation by a consultant gastroenterologist.

Prescribing Notes:

Rifaximin is considered to be most useful in a highly selective group of patients with hepatic encephalopathy who are resistant to other standard therapies such as lactulose and dietary measures.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/PHP33134-targaxan.htm?q=rifaximin&t=search&ss=text&p=3#PHP33134-targaxan

SODIUM FUSIDATE

Restrictions: Restricted to specialist initiation.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/3870.htm

TEDIZOLID PHOSPHATE (SIVEXTRO) (tablets, IV infusion)

Restrictions: Restricted to use only on the advice of microbiologists and specialists in infectious diseases for use in patients with ABSSSI caused by Gram-positive Staphylococcus aureus (specifically methicillin-resistant Staphylococcus aureus [MRSA] isolates) as an alternative oxazolidinone antibacterial.

Prescribing Notes:

This is an Alert Antimicrobial.

TEICOPLANIN

Restrictions: Restricted to specialist initiation. Restricted to use on microbiological and infectious disease physician advice only. Vancomycin is the first line glycopeptide.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/3878.htm

VANCOMYCIN

Restrictions: Restricted to specialist initiation. Restricted to use on microbiological and infectious disease physician advice only. Vancomycin is the first line glycopeptide.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/3876.htm

5.1.8 Sulfonamides and trimethoprim

Preferred list
TRIMETHOPRIM

Prescribing Notes:

Used primarily for urinary tract infections.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/3894.htm

Total Formulary
CO-TRIMOXAZOLE

Restrictions: Restricted to specialist initiation. The CSM has recommended that co-trimoxazole be restricted to use in Pneumocystis carinii pneumonia, toxoplasmosis and nocardiasis. It should only be used in urinary or respiratory tract infections where there is bacterial evidence of sensitivity and good reason to prefer the combination to a single antibiotic.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/3884.htm

5.1.9 Antituberculosis drugs

Total Formulary
RIFAMPICIN, ISONIAZID AND PYRAZINAMIDE (RIFATER)

Restrictions: Restricted to specialist initiation.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/3918.htm

RIFAMPICIN AND ISONIAZID (RIFINAH)

Restrictions: Restricted to specialist initiation.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/201680.htm

STREPTOMYCIN

Restrictions: Restricted to specialist initiation.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/3923.htm

ETHAMBUTOL

Restrictions: Restricted to specialist initiation.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/3905.htm#_3905

ISONIAZID

Restrictions: Restricted to specialist initiation.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/3907.htm

RIFABUTIN

Restrictions: Restricted to specialist initiation. Restricted to patients with mycobacterial infections resistant to conventional anti-tuberculosis drugs.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/14338.htm

RIFAMPICIN

Prescribing Notes:

Recommended for the prevention of secondary cases of meningococcal meningitis and Haemophilus influenza type B infection.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/3913.htm