5.1 ANTIBACTERIAL DRUGS

5.1 Antibacterial Drugs

The most recent Guidelines for Primary and Secondary Care 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.

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

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

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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

RED Cefiderocol 1g powder for concentrate for for solution [Fetcroja®]

(on advice of Consultant Microbiologist only)

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 Ceftazidime injection 500mg, 1g, 2g

RED Ceftriaxone injection 250mg, 1g

RED Cefuroxime injection 250mg, 750mg, 1.5g

RED Ceftolozane/tazobactam (Zerbax®) On advice of Consultant Microbiologist only

5.1.2.2 Carbapenems

RED Meropenem (on advice of Consultant Microbiologist only) injection 500mg, 1g

RED Meropenem with vaborbactam powder for concentrate for solution for infusion 1g/1g

[consultant microbiologist recommendation only]

5.1.2.3 Other beta-lactam antibiotics

Pseudomonal colonisation in cystic fibrosis - paediatric use only

RED Aztreonam 75mg powder + solvent for nebuliser solution (Cayston®)

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5.1.3 Tetracyclines - see section13.6.2 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

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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)

RED Tobramycin IV for use in paediatrics [cystic fibrosis]

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 250mg, tablets 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

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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.

Clostridiodes difficile infection - NICE NG199

Vancomycin [oral] - 1st line

GREEN Vancomycin capsules 125mg,

Fidaxomicin - 2nd line

AMBER Fidaxomicin 200mg tablets (Consultant Microbiologist Initiation only)

Click here for stock availability in community pharmacy

Chloramphenicol

RED Chloramphenicol injection 1g

Polymyxins

Colistimethate sodium DPI is recommended as an option for treating chronic pseudomonas lung infections in cystic fibrosis

as per NICE (TAG276) only if:

> they would clinically benefit from continued colistimethate sodium but do not tolerate it in its nebulised form and

thus tobramycin therapy would be considered and

> the manufacturer provides colistimethate sodium DPI with the discount agreed as part of the patient access scheme

to primary, secondary and tertiary care in the NHS

RED Colistimethate sodium dry powder

(Colobreathe® inhalation powder capsules)

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

Colistemethate for nebulisation

Colomycin in Bronchiectesis [non Cystic Fibrosis] – 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)

Cystic fibrosis

RED Colistimethate sodium, powder for reconstitution 1million-unit & 2 million-unit vial [NHS England Commissioned]

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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)

Rifaximin as second line antibacterial treatment for the treatment of Small Intestinal Bacterial Overgrowth

To be initiated by specialist and prescribing retained within secondary care.

RED Rifaximin [Targaxan® 550mg tablets, Xifaxanta® 200mg tablets]

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) see prescribing information sheet

tablets 600mg

RED infusion 2mg/mL (600mg/300mL)

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

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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 Terizidone 250mg capsules (for use when cycloserine is unavailable 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), NHS England Commissioned

tablets 300 (rifampicin 300mg, isoniazid 150mg)

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.

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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 - See patient information leaflet

tablets 250mg, 500mg

suspension 125mg/5ml, 250mg/5mL

RED Ciprofloxacin infusion 100mg/50mL, 200mg/100mL, 400mg/200mL

GREEN Ofloxacin tablets 200mg

GREEN Levofloxacin tablets 250mg

RED Delafloxacin [Quofenix - [for use only on advice of microbiologist]

300mg powder for concentration for solution for infusion

tablets 450mg

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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 *[PRESCRIBE BY BRAND HIPREX®]

(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 must be swallowed whole, do not crush. [Ref: Newt guidelines]

Long- acting capsules should be swallowed whole. Do not open, crush, or chew the long-acting/Modified Release

capsule. (ref: Newt guidelines).
Non-MR capsule can be opened in swallowing difficulties and mixed with water for administration

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 confirm.

*To help avoid an upset stomach, give nitrofurantoin with some food or milk.

Tablets must be swallowed whole, do not crush. [Ref: Newt guidelines]

AMBER Nitrofurantoin Liquid 25mg/5ml- only if confirmed by sensitivities in paediatric patients

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

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the but is information currently held in the public domain, members of public seeking advice

on medicine-related matters are advised to speak with their GP, pharmacist, nurse or contact NHS111 Service.

Email: info.elmmb@nhs.net