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5.0 Infections

5.0 Infections

The list below purely represents those formulations stocked within ELHT.  Traffic lights have been assigned to these drugs, although there are additional recommendations on what grade of staff may initiate or recommend them within secondary care.  Please refer to the most up to date East Lancashire Antimicrobial Guidelines for such information before prescribing any of these antimicrobials. 

The most recent editions can be found below:

Antimicrobial Guidelines in Primary Care

Antimicrobial Guidelines for Secondary Care

NICE Visual Summaries: Antimicrobial Prescribing

For further guidance refer to local Consultant Microbiologists or contact your pharmacist.

Information Leaflet - Uncomplicated Urinary Tract Infection

Information Leaflet - 'Treating your infection' (self-care)

5.1.1 Penicillins

5.1.1.1 Benzylpenicillin and phenoxymethylpenicillin
GREEN       Benyzylpenicillin (Penicillin G) injection 600mg, 1.2g
GREEN      Phenoxymethylpenicillin (PenicillinV)                  
                   tablets 250mg
                   oral solution 125mg/5ml, 250mg/5mL
 
5.1.1.2 Penicillinase-resistant penicillins
GREEN      Flucloxacillin              
                  capsules 250mg, 500mg
                  oral solution 125mg/5ml, 250mg/5mL

RED           Flucloxacillin injection 250mg, 500mg, 1g

RED           Temocillin
                   Powder for solution (1g)
                   Use in urosepsis where use of gentamicin not possible and on advice of consul
                   consultant microbiologist for resistant gram negative bacteria.

RED           Ceftazidime-avibactam
                   Powder for solution for infusion  2g/0.5g
                   Treatment of multi-drug resistant organisms in adult patients with limited
                   treatment options.
                   (on advice of consultant microbiologist only, hospital use only)
 
5.1.1.3 Broad-spectrum penicillins
GREEN      Amoxicillin
                   capsules 250mg, 500mg
                   suspension 125mg/5ml, 250mg/5mL
                   sachet (sugar free) 3g

RED           Amoxicillin injection 500mg, 1g 

GREEN      Co-amoxiclav
                   tablets 250/125, 500/125
                   suspension 250/62, 125/31

RED           Co-amoxiclav injection 500/100, 1000/200

5.1.1.4 Antipseudomonal penicillins
RED           Tazocin injection 4.5g 
 
5.1.1.5 Mecillinams
GREEN       Pivmecillinam (alternative 1st line agent in UTI)
                    tablets 200mg  (on advice of Consultant Microbiologist only)
                    Not for prophylaxis. See MicroGuide Adult Antimicrobial Guidelines
 
 

5.1.2 Cephalosporins, carbapenems and other beta-lactams

5.1.2.1 Cephalosporins
GREEN      Cefaclor
                   tablets m/r 375mg
                   suspension 125mg/5mL, 250mg/5mL
GREEN      Cefalexin
                   capsules 250mg, 500mg
                   syrup 125mg/5mL, 250mg/5mL
GREEN      Cefixime tablets 200mg
 
Cefotaxime may be used in primary care for use when meningococcal disease is suspected and benzylpenicillin cannot be given,  as long as this does not delay the urgent transfer to hospital. (See antimicrobial guidelines)
GREEN      Cefotaxime (Paediatrics only) Injection 250mg, 500mg,1g
 
RED           Cefradine injection 1gram
RED           Ceftazidime injection 500mg, 1g, 2g
RED           Ceftriaxone injection 250mg, 1g
RED           Cefuroxime injection 250mg, 750mg, 1.5g     
 
5.1.2.2 Carbapenems
RED           Meropenem (on advice of Consultant Microbiologist onlyinjection 500mg, 1g


5.1.3 Tetracyclines – see section 13.6.2 for use in acne

GREEN     Doxycycline capsules 50mg, 100mg
GREEN     Doxycycline dispersible 100mg (Vibramycin-D) 
                  (an option when swallowing difficulties)
GREEN     Lymecycline capsules 408mg
GREEN     Minocycline tablets 50mg, 100mg (not for use in acne- see section 13.6.2 for acne)
GREEN     Oxytetracycline tablets 250mg
GREEN     Tetracycline tablets 250mg


Tigecycline

Tigecycline should only be initiated on the direct advice of a microbiologist, and should be prescribed at registrar/consultant level for the management of complicated skin/soft tissue or intra-abdominal infections.  It should be used to replace the use of more costly double/triple combinations where these are inappropriate, ineffective or not tolerated. All prescriptions should be endorsed ‘microbiologist approved’ and given a review date by the microbiologist which initially must be no more than 5 days from commencement. 

MHRA Advice for healthcare professionals: 
        > Reformulated tigecycline is incompatible with amphotericin B, amphotericin B lipid complex and                        diazepam.
These medicines should not be given simultaneously with the new tigecycline formulation through the same Y- site.
       > Tigecycline must not be mixed with other products for which compatibility data are not available.
       > Please remember that the original formulation is also incompatible with some medicines.
RED           Tigecycline injection 50mg   


5.1.4 Aminoglycosides

AMBER     Gentamicin injection 10mg/mL, 80mg/2mL
AMBER     Neomycin tablets 500mg
RED          Tobramycin (Bramitob®) nebuliser solution 300mg - for cystic fibrosis in children only.
RED          Tobramycin  dry powder for inhalation for treating pseudomonas lung infections in cystic fibrosis  
                  as per  NICE (TAG276) 
NOTE:      Tobramycin is RED Traffic Light where prescribing has been initiated on or after 1st April 2013.
                 Where prescribing was initiated prior to April 1st 2013 the traffic light status may remain AMBER
                 until  repatriation of patients has been agreed by NHS England, local commissioners and providers.

5.1.5 Macrolides 

GREEN       Azithromycin
                   tablets 250mgtablets 500mg  
                   capsules 500mg   
                   suspension 200mg/5mL
GREEN      Clarithromycin
                   tablets 250mg
                   suspension 125mg/5ml, 250mg/5mL
RED             Clarithromycin injection 500mg 
GREEN      Erythromycin
                   tablets e/c 250mg
                   suspension 125mg/5mL, 250mg/5mL

5.1.6 Clindamycin
GREEN      Clindamycin
                   capsules 75mg, 150mg

RED           Clindamycin injection 600mg/4mL

5.1.7 Some other antibacterials


Fosfomycin
Fosfomycin GP pathway protocol updated 0916 [361 KB]   
AMBER     Fosfomycin 3g sachets (prescribe as Monuril®) 
                   Only to be given on advice of consultant microbiologist -Refer to pathway above

RED           Fosfomycin injection (Fomicyt®)
                  On advice of consultant microbiologist only. 
 
Chloramphenicol 
RED           Chloramphenicol injection 1g
 
Colistimethate sodium
RED           Colistimethate sodium dry powder - pseudomonas lung infections in Cystic Fibrosis NICE (TAG276)
Colistimethate is Red Traffic Light where prescribing has been initiated on or after 1st April 2013.
Where prescribing was initiated prior to April 1st 2013 the traffic light status may remain amber until repatriation of        patients has been agreed by NHS England, local commissioners and providers 
Colomycin in non CF Bronchiectesis – is recommended when long term nebulised therapy is being considered.
Delivered by nebulisation/inhalation. Specialist initiation. Training and education regarding use of nebuliser to be provided
by specialist. 

AMBER     Colistimethate injection 1million unit (Colomycin)*
 
See Prescribing Information Sheet
   
AMBER     Gentamicin injection  10mg/mL, 80mg/2mL  (2nd line alternative to colistin) 
                   (delivered by inhalation/nebulisation)
 
Fidaxomicin 
AMBER      Fidaxomicin 200mg tablets (Consultant Microbiologist Initiation only)
 
Fusidic acid
GREEN      Sodium fusidate
                   tablets 250mg
                   suspension (fusidic acid) 250mg/5mL

RED            Sodium fusidate infusion 500mg (on advice of Consultant Microbiologist only)

Rifaximin
AMBER      Rifaximin tablets 550mg (NICE TAG337)
 
Vancomycin and teicoplanin
GREEN       Vancomycin capsules 125mg,
RED            Vancomycin injection 500mg, 1g
AMBER      Teicoplanin injection 200mg, 400mg
 
Dalbavancin
RED            Dalbavancin 500mg powder for concentrate for infusion
 
Linezolid
AMBER     Linezolid (on advice of Consultant Microbiologist only)
                   tablets 600mg
RED           infusion 2mg/mL (600mg/300mL)
Polymyxins
RED           Colistin injection 1million unit (Colomycin)
RED           Colistin nebuliser powder for solution 1million unit (Promixin®)
RED           Fidaxomicin tablets 200mg

5.1.8 Sulphonamides and trimethoprim 

AMBER     Co-trimoxazole
                   tablets 480mg, 960mg
                   suspension 240/5ml, 480/5mL
RED           Co-trimoxazole injection 480mg/5mL, 960mg/10mL

GREEN      Trimethoprim
                   tablets 100mg, 200mg
                   suspension 50mg/5mL

5.1.9 Antituberculous drugs

All cases of suspected tuberculosis or other mycobacterial disease must be discussed with a respiratory physician.

RED           Capreomycin 1g powder for solution                                        (NHS England Commissioned)          
RED           Cycloserine capsules 250mg                                                       (NHS England Commissioned) 
RED           Ethambutol tablets 100mg, 400mg                                            (NHS England Commissioned) 
RED           Isoniazid   tablets 100mg,  elixir 50mg/5mL                              (NHS England Commissioned) 
RED           Isoniazid injection 50mg/2mL
RED           Pyrazinamide tablets 500mg                                                       (NHS England Commissioned)
RED            Rifampicin injection 600mg
RED           Rifater® tablets (rifampicin 120mg, isoniazid 50mg, pyrazinamide 300mg)  
                                                                                                                            (NHS England Commissioned)
RED           Rifinah® tablets 150 (rifampicin 150mg, isoniazid 100mg),                                
                                  tablets 300 (rifampicin 300mg, isoniazid 150mg)     (NHS England Commissioned)
RED           Voractiv® tablets (Rifampicin150mg, isoniazid 75mg, pyrazinamide 400mg, ethambutol 275mg)


Rifampicin
for Non-TB, licensed indications 

AMBER      Rifampicin                                                                                      (NHS England Commissioned)
                    capsules 150mg, 300mg, syrup 100mg/5mL     (Rifadin®, Rimactane®)      

   Prescribing should routinely be retained by specialists within secondary care to ensure optimal treatment.

5.1.10 Antileprotic drugs

AMBER     Dapsone tablets 50mg     

5.1.11 Metronidazole and tinidazole

GREEN        Metronidazole 
                    tablets 200mg, 400mg
                    suspension 200mg/5mL
                    suppositories 500mg, 1gram
RED            Metronidazole infusion 500mg/100mL


5.1.12  Quinolones

GREEN      Ciprofloxacin
                   tablets 250mg, 500mg
                   suspension 125mg/5ml, 250mg/5mL
RED           Ciprofloxacin infusion 100mg/50mL, 200mg/100mL, 400mg/200mL


GREEN
 
     Ofloxacin tablets 200mg

5.1.13 Urinary-tract infections

Please consult Antimicrobial Guidelines in Primary Care

NICE Visual Summaries: Antimicrobial Prescribing
 

Information Leaflet - Uncomplicated Urinary Tract Infection

Urinary Tract Infections in Adults
GREEN      Nitrofurantoin*
                  100 mg M/R capsules (1st Line choice)
                  50mg capsules 
                  100mg tablets
                  50mg tablets
GREEN      Trimethoprim tablets (alternative 1st line agent, if low risk of resistance)
GREEN      Pivmecillinam (alternative 1st line agent)
GREEN      Methenamine Hippurate 
                   (Recurrent UTI, 3rd line use ONLY in recurrent UTI in non-pregnant women 
                    - 2 in 6 months or > 3 in a year;) 
                   1g tablets
To help avoid an upset stomach, give nitrofurantoin with some food or milk. Tablets 
 may be swallowed whole, or crushed or broken, and mixed with food. If using the long-
 acting capsule, it should be swallowed whole. Do not open, crush, or chew the long-acting  capsule.

 (ref: Newt guidelines)

Urinary Tract Infections in Paediatrics
GREEN               1st line   Trimethoprim liquid
GREEN               2nd line Nitrofurantoin tablets 50mg*
GREEN               3rd line Cefalexin liquid
       NB In order to allow the correct dose to be administered nitrofurantoin liquid
       maybe used in paediatrics if sensitivities/microbiology advice confirm.
 
AMBER               Nitrofurantoin Liquid - on advice of microbiology only

 To help avoid an upset stomach, give nitrofurantoin with some food or milk. Tablets 
 may be swallowed whole, or crushed or broken, and mixed with food. If using the long-
 acting capsule, it should be swallowed whole. Do not open, crush, or chew the long-acting  capsule.
(ref: Newt guidelines)

**SEE 'MICROGUIDE' FOR MOST UP TO DATE INFORMATION**

Treatment of Oral Candidiasis in adults

First line:
Fluconazole* 50mg (capsules) orally once daily
     Course duration 7 days
*Fluconazole has clinically significant interactions with other medicines - check these before prescribing* 
 
Second line when fluconazole is contraindicated
Nystatin suspension 100,000units/mL  dose 4ml every 6 hours
     Course duration 7 days
__________________________________________________________________________

GREEN      Amphotericin lozenges 1mg
RED           Amphotericin
                   Injection liposomal 50mg (on advice of Consultant Microbiologist only)
                   Injection complex 50mg   (on advice of Consultant Microbiologist only)

GREEN      Fluconazole
                   capsules 50mg, 150mg, 200mg
                   suspension 50mg/5ml,  200mg/5mL
RED           Fluconazole
                   injection 50mg/25mL
                   infusion 200mg/100mL

RED           Flucytosine
                   infusion 10mg/mL 250mL (on advice of Consultant Microbiologist only)

GREEN      Itraconazole 
                   capsules 100mg
                   liquid 50mg/5mL

GREEN      Ketoconazole tablets 200mg

GREEN      Miconazole oral gel 24mg/mL

GREEN      Nystatin suspension 100,000u/mL

GREEN      Terbinafine tablets 250mg

RED           Voriconazole
                  Tablets 50mg, 200mg
                  Suspension 200mg/5mL
                  Intravenous infusion 200mg

RED           Micafungin intravenous infusion 50mg and 100mg (paediatric use only)

RED             Anidulafungin intravenous infusion 100mg (adult use)

RED           Posaconazole suspension 200mg/5mL

5.3.1 HIV Infection

Please refer to Lancashire Formulary for AntiRetroviral Therapy (ART) - click here

Nucleoside reverse transcriptase inhibitors

RED           Abacavir tablets 300mg                                                                                      (NHS England Commissioned)  
RED           Abacavir with Lamivudine tablets 300mg, 600mg ( Kivexa®)                          (NHS England Commissioned)
RED           Zidovudine 300mg, lamivudine 150mg (Combivir®)                                          (NHS England Commissioned)   
RED           Didanosine                                                                                                           (NHS England Commissioned)  
                   tablets 25mg,  capsules e/c 250mg, 400mg
RED           Lamivudine tablets 100mg,150mg                                                                   (NHS England Commissioned)  
RED           Tenofovir tablets 245mg                                                                                    (NHS England Commissioned)  
RED           Tenovir 245mg, emtricitabine 200mg tablets (Truvada®)                                (NHS England Commissioned)  
RED           Zidovudine                                                                                                            (NHS England Commissioned)  
                   capsules 100mg, 250mg
                   syrup 50mg/5mL

Protease inhibitors

RED           Atazanavir capsules 150mg, 200mg, 300mg               Second line use only   (NHS England Commissioned)
RED           Darunavir tablets 75mg, 150mg, 400mg, 600mg                                            (NHS England Commissioned) 
                  Second line use only oral suspension 100mg/mL   
RED           Fosamprenavir tablets 700mg                                                                            (NHS England Commissioned)  
RED           Glecaprevir with pibrentasvir   NICE TA499                                                     (NHS England Commissioned)
RED           Indinavir capsules 200mg                                                                                    (NHS England Commissioned) 
RED           Kaletra® tablets (lopinavir 200mg, ritonavir 50mg)                                        (NHS England Commissioned)   
RED           Nelfinavir tablets 250mg                                                                                     (NHS England Commissioned)   
RED           Ritonavir capsules 100mg                                                                                   (NHS England Commissioned)  
RED           Saquinavir capsules 200mg                                                                                 (NHS England Commissioned)   

RED           Elbasvir-grazoprevir tablets 50mg, 100mg   NICE TA 413                              (NHS England Commissioned


Non-nucleoside reverse transcriptase inhibitors

RED           Efavirenz, tablets 600mg, capsules 200mg                                                              (NHS England Commissioned)   
RED           Etravirine tablets 100mg, 200mg       Third line use only                                  (NHS England Commissioned)   
RED           Nevirapine tablets 200mg                                                                                    (NHS England Commissioned)   


Other antiretrovirals

RED           Raltegravir tablets 400mg                                                                                    (NHS England Commissioned)   
RED           Maraviroc tablets 150mg, 300mg (Celsentri®)                                                  (NHS England Commissioned)


5.3.2 Herpesvirus infections

5.3.2.1 Herpes simplex and varicella-zoster infection

GREEN      Aciclovir
                   tablets 200mg, 400mg, 800mg
                   suspension 200mg/5mL
                   injection 250mg/10mL, 500mg/20mL, 1000mg/40mL
AMBER     Famciclovir (second line use only)
                   tablets 125mg, 250mg, 750mg

5.3.2.2 Cytomegalovirus infection

Valganciclovir is used in the treatment of reactivated CMV in immunosuppressed patients treated with MabCampath® as per protocols at Manchester Royal Infirmary.

RED           Ganciclovir injection 500mg vial                                                                         (NHS England Commissioned) 
RED           Valganciclovir tablets 450mg                                                                               (NHS England Commissioned) 
RED           Foscarnet Sodium (Foscavir®)                                                                             (NHS England Commissioned)  
                  (cytomegalovirus retinitis in AIDS patients)
RED            Cidofovir capsules 250mg (Vistide®)                                                                  (NHS England Commissioned)  
                  (cytomegalovirus retinitis in AIDS patients)

5.3.3    Viral Hepatitis

As per NICE guidance – see BNF.
RED         Adefovir dipivoxil tablets 10mg (Herpsera®)                                                       (NHS England Commissioned)  
 
Entecavir - within its marketing authorisation, is recommended as an option for the treatment of people with chronic HBeAg-positive or HBeAg-negative hepatitis B in whom antiviral treatment is indicated. This guidance does not apply to people with chronic hepatitis B who also have hepatitis C, hepatitis D or HIV.
 
RED          Entecavir                                                                                                              (NHS England Commissioned) 
                 tablets 500microgram, 1mg
                 oral solution 50microgram/ml
AMBER    Tenofovir tablets 245mg
 
NICE TAG252 and NICE TAG253 approve the use of Telaprevir and Boceprevir for the treatment of Hepatitis C,                   genotype 1
RED         Telaprevir (Invico®) tablets                                                                               (NHS England Commissioned)     
RED         Boceprevir (Victrelis®) tablets                                                                         (NHS England Commissioned)      
 
NICE TAG300 recommends the use of Peginterferon alfa in combination with ribavirin as an option to treat chronic hepatitis C in children and young people
RED          Peginterferon alfa and ribavirin in combination                                          (NHS England Commissioned)  


5.3.3.2  Chronic Hepatitis C       

NHS England have issued a policy statement for treatment of chronic Hepatitis C in patients with cirrhosis which sets out treatments that will be routinely commissioned.  The statement is available here.

The statement supports the use of Viekirax and Exviera and this is acknowledged.
 
Sofosbuvir -is recommended as an option for treating chronic hepatitis C in adults, as specified in  NICE TA330
RED          Sofosbuvir (Sovaldi®) tablets                                                                            (NHS England Commissioned)      
 
Sofosbuvir-velpatasvir - is recommended as an option for treating chronic hepatitis C in adults, as specified in attached table, only if the company provides the drug with the discount agreed in the simple discount agreement. NICE TA430
RED          Sofosbuvir-velpatasvir (Epclusa)                                                                       (NHS England Commissioned)     
 
RED          Sofosbuvir-velpatasvir-voxilaprevir is recommended as an option for treating chronic hepatitis C in adults, 
                 only if it is used as specified in the attached table and the company provides the drug at the same price or
                 lower than that agreed with the Commercial Medicines Unit as per NICE TA507   
                                                                                                                                                  (NHS England Commissioned)  
Simeprevir - in combination with peginterferon alfa nd ribavirin is recommended as a possible treatment for adults with genotype 1 or 4 chronic hepatitis C - NICE TA331 
 
RED          Simeprevir (Olysio®) capsules                                                                           (NHS England Commissioned)  
RED          Ledispar-sofosbuvir (Harvoni®)                                                                        (NHS England Commissioned) 
                  tablets 90mg, 400mg    
 
Daclatasvir - is recommended as a possible treatment for adults with some types (called genotypes) of chronic   hepatitis C , depending on their level of fibrosis. NICE TA364
 RED        Daclatasvir (Daklinza®)                                                                                      (NHS England Commissioned)  
                 tablets 30mg, 60mg
 
Ombitasvir- paritaprevir-ritonavir with or without dasabuvir is recommended, within its marketing authorisation, as an option for treating genotype 1 or 4 chronic hepatitis in adults - NICE TA365 
RED          Ombitasvir–paritaprevir–ritonavir (Viekirax®)                                              (NHS England Commissioned)  
                  tablets 12.5mg, 75mg, 50mg  
RED          Ribavirin tablets 200mg                                                                                   (NHS England Commissioned)   


5.3.4     Influenza

Oseltamavir and zanamivir are to be used in line with NICE guidance and local emergency planning agreements.  Endorse prescription SLS.

GREEN     Oseltamivir
                  capsules 75mg
                  suspension 60mg/5mL

GREEN     Zanamivir inhaler 5mg blisters x 4

5.3.5     Respiratory syncytial virus

Palivizumab is to be used in line with National Joint Committee of Vaccination and Immunisation guidance in the following circumstances:

1. Children under the age of 2 years with chronic lung disease who

  • Have recieved oxygen for >28 days after birth;
  • Are receiving home oxygen therapy

2. Infants less than 6 months of age who have left to right shunt haemodynamically significant congenital heart disease and /or pulmonary hypertension. 

Supply of palivizumab should always be from pharmacy to individual patients; it should never be issued as stock.  This allows recharging of the costs of palivizumab to the CCGs under ‘payment by results’ by allowing the tracing of all supplies.

RED          Palivizumab injection 50mg, 100mg                                                                        (NHS England Commissioned)  

5.4.1 Antimalarials

Malaria prophylaxis
Drugs for malaria are not to be prescribed n the NHS.
Chloroquine and proguanil are available to purchase over the counter.  

Mefloquine (Lariam®), Atovaquone with proguanil hcl (Malarone®) and Doxycycline require a private prescription.

OTC/Self care           Chloroquine Phosphate (Avloclor®)  
                                    tablets 250mg (equivalent to 155mg base)
OTC/Self care           Proguanil tablets 100mg (Paludrine®) 
OTC/Self care           Doxycycline - See section 5.1.3 (private prescription only)
 
RED                            Primaquine tablets 7.5mg, 15mg (named patient basis)
GREEN                       Quinine Sulphate tablets 200mg, 300mg


5.4.2 Amoebicides

GREEN                     Metronidazole
                                  tablets 200mg, 400mg
                                  suspension 200mg/5mL 

5.4.4 Antigiardial drugs

GREEN                       Metronidazole
                                 tablets 200mg, 400mg
                                 suspension 200mg/5mL

5.4.8 Drugs for pneumocystis pneumonia

RED                              Pentamidine nebuliser Solution 60mg/mL

5.5.1 Drugs for threadworms

GREEN       Mebendazole
                    tablets 100mg
                    suspension 100mg/5mL
GREEN       Pripsen® sachets (piperazine 4g, sennosides 15.3mg)


5.5.4 Drugs for hookworms


GREEN      Mebendazole
                   tablets 100mg
                   suspension 100mg/5mL