| Formulary Chapter 5: Infections - Full Chapter
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| Notes: |
Prescribers must follow the relevant local and national guidance when treating an infection. Some anti-infectives require approval from the local Trust microbiology team for use, consult local guidance for further information.
Not all anti-infectives listed in this chapter will be available in all localities; availability will be guided by local need and resistance patterns.
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| Chapter Links... |
 Blackpool Teaching Hospitals: Antimicrobial Formulary |
| East Lancashire Primary Care: Antimicrobial guide primary care |
| East Lancashire Secondary Care: Antimicrobial guide secondary care |
| Greater Preston, Chorley and South Ribble/LSCFT/Morecambe Bay Primary Care: NICE Summary of antimicrobial prescribing guidance - managing common infections |
| Lancashire Teaching Hospitals Secondary Care: Tap on the bugs app (App store) |
| Lancashire Teaching Hospitals Secondary Care: Tap on the bugs app (Google) |
| University Hospitals of Morecambe Bay: Antimicrobial guide secondary care |
| West Lancashire Primary Care: Pan Mersey antimicrobial guide |
| British Association for Sexual Health and HIV |
| Dapsone for the treatment of Dermatitis Herpetiformis, other dermatoses and Vasculitis shared care guideline |
| LSCMMG Recurrent UTI Prophylactic Antibiotic Pathway |
| NICE CG165: Hepatitis B (chronic): diagnosis and management |
| NICE CG97: Lower urinary tract symptoms in men: management |
| NICE NG109: Urinary tract infection (lower): antimicrobial prescribing |
| NICE NG112: Urinary tract infection (recurrent): antimicrobial prescribing |
| NICE NG113: Urinary tract infection (catheter-associated): antimicrobial prescribing |
| NICE NG120: Cough (acute): antimicrobial prescribing |
| NICE NG125: Surgical site infections: prevention and treatment |
| NICE NG19: Diabetic foot problems: prevention and management |
| NICE NG191: COVID-19 rapid guideline: managing COVID-19 |
| NICE NG240: Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management |
| WHO: AWaRe classification of antibiotics for evaluation and monitoring of use, 2023 |
| NICE NG51: Sepsis: recognition, diagnosis and early management |
| NICE NG78: Cystic fibrosis: diagnosis and management |
| Details... |
| 05.01.07 |
Some other antibacterials |
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Methenamine Hippurate
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Formulary
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Tablets 1g
For prevention of recurrent lower urinary tract infections (UTI) in women, in line with NG112.
Methenamine should only be used for prophylaxis and not for treatment.
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 NICE NG112: Urinary tract infection (recurrent): antimicrobial prescribing
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Nitrofurantoin
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Formulary
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Modified release capsules 100mg
Capsules 50mg
Liquid 25mg/5ml (paediatric use only, on approval by consultant microbiologist)
For patients with NG tubes or swallowing difficulties, please seek pharmacy advice.
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MHRA: Nitrofurantoin now contraindicated in most patients with an estimated glomerular filtration rate (eGFR) of less than 45 ml/min/1.73m2
MHRA: Nitrofurantoin: reminder of the risks of pulmonary and hepatic adverse drug reactions
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| 05.01.07 |
Chloramphenicol |
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Chloramphenicol
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Formulary
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Capsules 250mg
Injection 1g
On advice of Microbiology only.
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| 05.01.07 |
Fosfomycin |
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Fosfomycin (Monuril®)
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Formulary
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Oral solution sachets 3g
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Fosfomycin injection
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Formulary
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On advice of Microbiology only.
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| 05.01.07 |
Fusidic acid |
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Sodium fusidate injection
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Formulary
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Infusion 500mg
On advice of Microbiology only.
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MHRA: Systemic fusidic acid and interaction with statins
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| 05.01.07 |
Glycopeptide antibacterials |
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Dalbavancin
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Formulary
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Powder for concentrate for solution for infusion 500mg
On advice of Microbiology only.
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Oritavancin
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Formulary
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Powder for concentrate for solution for infusion 400mg
On advice of Microbiology only.
Management of patients with skin and soft tissue infections
RED for the following indications:
Treatment of acute, complicated bacterial skin and skin structure infections (ABSSSI) in adults, with confirmed drug-resistant gram-positive infection, who are eligible for early discharge.
Use must be on the advice of local microbiologists and must be reserved for the treatment of patients who would otherwise be required to have a prolonged inpatient stay due to unsuitability for OPAT.
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LSCMMG: Oritavancin NMR
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Teicoplanin
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Formulary
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injection 200mg, 400mg
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Vancomycin
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Formulary
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Capsules 125mg
Liquid 250mg/5mL (unlicensed special)
ORAL use - Powder for solution 500mg, 1g (in exceptional cases patients can be discharged on powder for solution orally - seek pharmacy advice to ensure safe transfer of care)
INTRAVENOUS use - Powder for solution 500mg, 1g
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Lancashire and South Cumbria Critical Care - Vancomycin Guideline
MHRA: Prescribing medicines in renal impairment: using the appropriate estimate of renal function to avoid the risk of adverse drug reactions
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| 05.01.07 |
Daptomycin |
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| 05.01.07 |
Linezolid |
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Linezolid
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Formulary
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Tablets 600mg
On advice of Microbiology only.
Severe optic neuropathy may occur rarely, particularly if linezolid is used for longer than 28 days.
Haematopoietic disorders (including thrombocytopenia, anaemia, leucopenia, and pancytopenia) have been reported in patients receiving linezolid. It is recommended that full blood counts are monitored weekly.
For the treatment of pneumonia or complicated skin and soft tissue infections on the recommendation of a microbiologist when used for up to 14-days
**Please refer to attached prescriber information sheet for more detail prior to prescribing**
Dosage and administration
Consultant microbiologists will request GPs to prescribe up to 14 days of treatment in the community ONLY.
If more than 14 days of treatment is required, either as an initial course or if an extension to the initial 14-day course is required, the patient must be referred back into secondary care.
The recommended dose of oral linezolid is 600 mg every 12 hours usually for 10–14 consecutive days (up to 28 days of treatment may be supplied by specialists).
Information for prescribers - to be read in conjunction with the SPC
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LSCMMG: Linezolid
LSCMMG: Linezolid Prescriber Information Sheet
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Linezolid injection
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Formulary
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Intravenous infusion 600mg/300ml
On advice of Microbiology only.
Severe optic neuropathy may occur rarely, particularly if linezolid is used for longer than 28 days.
Haematopoietic disorders (including thrombocytopenia, anaemia, leucopenia, and pancytopenia) have been reported in patients receiving linezolid. It is recommended that full blood counts are monitored weekly.
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| 05.01.07 |
Quinupristin and dalfopristin |
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| 05.01.07 |
Polymyxins |
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Colistimethate
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Formulary
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Injection 1 million units, 2 million units
Inhalation powder capsules 1,662,500unit
On advice of Microbiology only.
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NICE TA276: Colistimethate sodium and tobramycin dry powders for inhalation for treating pseudomonas lung infection in cystic fibrosis
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Colistimethate for nebulisation (Colomycin®)
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Formulary
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Injection 1million unit (Colomycin®)
Bronchiectesis (non cystic fibrosis)
On advice of Microbiology only.
Training and education regarding use of nebuliser to be provided by specialist.
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LSCMMG: Colistimethate for nebulisation (Colomycin®) - Prescribing Information Sheet
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| 05.01.07 |
Rifaximin |
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Rifaximin
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Formulary
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Tablets 550mg tablets (Targaxan®), 200mg tablets (Xifaxanta®)
Second line antibacterial treatment for the treatment of small intestinal bacterial overgrowth.
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LSCMMG: Rifaximin
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Rifaximin (Targaxan®)
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Formulary
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Tablets 550 mg
Prevention of episodes of hepatic encephalopathy in people aged 18 years or older.
Preventing episodes of overt hepatic encephalopathy (NICE TA337).
Recommended for preventing episodes of hepatic encephalopathy in people aged 18 years or older.
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NICE TA337: Rifaximin for preventing episodes of overt hepatic encephalopathy
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| 05.01.07 |
Fidaxomicin |
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Fidaxomicin
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Formulary
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Tablets 200mg
Treatment of Clostridium difficile infections (CDI) also known as C. difficile-associated diarrhoea (CDAD) in adults.
Fidaxomicin should be initiated by a microbiologist or under microbiologist recommendation.
Fidaxomicin (Dificlir®) to be considered as an option for use following a first or second relapse. i.e. as second or third line therapy.
Fidaxomicin to also be considered for patients with severe CDI who are considered to be at high risk for recurrence as per the Public Health England Guidance. e.g. elderly patients with multiple comorbidities who are receiving concomitant antibiotics and those not responding to oral vancomycin.
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Key |
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Restricted Drug |
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Unlicensed |
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Link to adult BNF
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Link to children's BNF
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Link to SPCs
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Scottish Medicines Consortium |
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Cytotoxic Drug |
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Controlled Drug |
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High Cost Medicine |
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Cancer Drugs Fund |
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NHS England |
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Homecare |
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ICB |
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Low carbon footprint |
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Medium carbon footprint |
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High carbon footprint |
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| Status |
Description |
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Green:
Appropriate for initiation and ongoing prescribing in both primary and secondary care.
Generally, little or no routine drug monitoring is required. |
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Green (Restricted):
Appropriate for initiation and ongoing prescribing in both primary and secondary care provided:
Additional criteria specific to the medicine or device are met, or
The medicine or device is used following the failure of other therapies as defined by the relevant LSCMMG pathway.
Generally, little or no routine drug monitoring is required.
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Red medicines:
Medicine is supplied by the hospital for the duration of the treatment course.
Primary care initiation or continuation of treatment is not recommended unless exceptional circumstances such as specialist GP.
Red medicines are those where primary care prescribing is not recommended. These treatments should be initiated by specialists only and prescribing retained within secondary care. They require specialist knowledge, intensive monitoring, specific dose adjustments or further evaluation in use. If however, a primary care prescriber has particular specialist knowledge or experience of prescribing a particular drug for a particular patient it would not always be appropriate for them to expect to transfer that prescribing responsibility back to secondary care. There should be a specific reason and a specific risk agreement, protocol and service set up to support this.
Primary care prescribers may prescribe RED medicines in exceptional circumstances to patients to ensure continuity of supply while arrangements are made to obtain ongoing supplies from secondary care. |
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Amber level 0:
Suitable for prescribing in primary care following recommendation or initiation by a specialist.
Little or no specific monitoring required.
Patient may need a regular review, but this would not exceed that required for other medicines routinely prescribed in primary care.
Brief prescribing document or information sheet may be required.
Primary care prescribers must be familiar with the drug to take on prescribing responsibility or must get the required information.
When recommending or handing over care, specialists should ask primary care prescribers to take over prescribing responsibility, and should give enough information about the indication, dose, monitoring requirements, use outside product licence and any necessary dose adjustments to allow them to confidently prescribe. |
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Amber level 1 (with shared care):
Suitable for prescribing in primary care following recommendation or initiation by a specialist.
Minimal monitoring required.
Patient may need a regular review, but this would not exceed that required for other medicines routinely prescribed in primary care.
Full prior agreement about patient’s on-going care must be reached under the shared care agreement.
Primary care prescribers are advised not to take on prescribing of these medicines unless they have been adequately informed by letter of their responsibilities with regards monitoring, side effects and interactions and are happy to take on the prescribing responsibility. A copy of locally approved shared care guidelines should accompany this letter which outlines these responsibilities. Primary care prescribers should then tell secondary care of their intentions as soon as possible by letter so that arrangements can be made for the transfer of care. |
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Amber level 2 (with shared care and enhanced service):
Initiated by specialist and transferred to primary care following a successful initiation period.
Significant monitoring required on an on-going basis.
Full prior agreement about patient’s on-going care must be reached under the shared care agreement.
Suitable for enhanced service.
These medicines are considered suitable for GP prescribing following specialist initiation of therapy, as per shared care document which will be sent out with the request to prescribe, with on-going communication between the primary care prescriber and specialist. Amber Level 2 medicines require significant monitoring for which an enhanced service may be suitable. (Subject to local commissioning agreements). |
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Do not prescribe: NOT recommended for use by the NHS in Lancashire and South Cumbria.
Includes medicines that NICE has not recommended for use and terminated technology appraisals, unless there is a local need. |
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Grey medicines:
Medicines which have not yet been reviewed or are under the review process.
GPs and specialists are recommended not to prescribe these drugs.
This category includes drugs where funding has not yet been agreed.
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Refer to local guidance. |
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