netFormulary NHS
Nottinghamshire Area Prescribing Committee
Joint Formulary
 Search
 Formulary Chapter 5: Infections - Full Chapter
Notes:

Intravenous antibiotics are more expensive than oral equivalents, some are very expensive. They put patients at risk of IV cannula infections. Oral antibiotics are usually fairly cheap. IM injections are rarely if ever indicated.

Course lengths:
Prescriptions for oral antibiotics for in-patients should be reviewed at or before five days. Prescriptions for intravenous antibiotics should be reviewed at or before 48 hours after which the patient should be considered for an oral antibiotic if there is an equivalent available (see IV to oral switch policy). For uncomplicated urinary tract infections three days treatment is usually sufficient in adult women. Complicated infections require longer treatment.

When initiating therapy with agents marked with Restricted, you must seek Microbiology/Infectious Diseases advice.

The restricted antimicrobials may be prescribed without discussion with microbiology if they are being used for an approved indication as specified. Use outside these indications (and any use for some antimicrobials) requires DOCUMENTED approval from one of the medical microbiologists or Infectious Diseases Physician prior to prescribing.

Chapter Links...
 Details...
05.01.07  Expand sub section  Some other antibacterials
Dalbavancin
View adult BNF View SPC online View childrens BNF
Restricted Drug Restricted
Red

Infusion

  • NUH OPAT service only: Restricted antibiotic: see local guidelines [NUH guideline]
 
   
Pristinamycin
View adult BNF View SPC online View childrens BNF
Restricted Drug Restricted
Red

Tablets (unlicensed)

NUH only.  Approved for:

  • Treatment of bone and joint infections as well as deep soft tissue infections within the OPAT specialty only on microbiology recommendation only.
  • Treatment of M. genitalium infection on GU Medicine specialist advice only (consultant/SAS)

- Restricted antimicrobial: see NUH restricted antimicrobials list [NUH guideline]

 
   
Rifaximin (Xifaxanta®)
(C.Diff and SIBO)
View adult BNF View SPC online View childrens BNF
Formulary
Red
Tablets (200mg)
  • NUH only: management of recurrent C.Difficile as per local policy
  • NUH only: Small Intestinal Bacterial Overgrowth
    (unlicensed indications)
    Non-formulary, Awaiting submission for Traveller's diarrhoea and Pouchitis 
  • Link  Link to reviews
    Link  NICE evidence summary: Rifaximin for pouchitis
       
    05.01.07  Expand sub section  Chloramphenicol
    Chloramphenicol
    (Systemic)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    Capsule, injection
  • Restricted antibiotic: see local guidelines
  • See local guidelines. [SFH guideline][NUH guideline
  •    
    05.01.07  Expand sub section  Fosfomycin
    Fosfomycin
    View adult BNF View SPC online View childrens BNF
    Formulary

    Sachets

    Amber Traffic Light  Amber 3 (initiate as per APC guideline) for UTIs according to guidelines. See primary care or local guidelines [SFH guidelines][NUH guideline]

    Intravenous infusion (Fomicyt®)

    Red Traffic Light NUH only Restricted antibiotic: see local guidelines. [NUH guideline]

     
    Link  Link to reviews
    Link  NICE Evidence summary: Fosfomycin for resistant urinary tract infections
    Link  NUH Memo: Adult dosing, preparation and administration of Fomicyt® brand
       
    05.01.07  Expand sub section  Fusidic acid
    Sodium fusidate
    Formulary
    Amber 2

    Tablet, suspension

    • For use in Staphylococcus aureus infections, in combination with other agents
    • The syrup form is fusidic acid, the tablet form is sodium fusidate. Remember dose conversion when switching between tablets and syrup (500mg sodium fusidate tablets= 750mg fusidic acid syrup). See table of liquid medicines requiring dose adjustment
    • Fusidic acid 250mg/5ml syrup is expensive. See unexpectedly expensive medicines list 
    • Injection discontinued 2013
    • See local guidelines. [SFH guideline][NUH guideline]
     
    Link  MHRA safety update on interaction with statins, Sept 11
       
    05.01.07  Expand sub section  Vancomycin and teicoplanin to top
    Teicoplanin (Targocid®)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    Injection
  • See local guidelines. [SFH guideline][NUH guideline]
  • When used in line with the Community IV antibiotic pathway (APC Jan 15) 
  •    
    Vancomycin
    (Oral)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Amber 3

    Capsule, injection used orally (certain brands licensed), oral solution (unlicensed)

     
       
    Vancomycin
    (IV)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Red
    Injection
  • See local guidelines. [SFH guideline][NUH guideline]
  • NUH only Vancomycin Prefilled Syringe (125mg in 30mL) approved for continuous infusion within the Neonatal Units as per guideline. Unlicensed medicine - named patient use only. 
  •    
    05.01.07  Expand sub section  Daptomycin
    Daptomycin (Cubicin®)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    Infusion
  • Regular CPK monitoring required
  • See local guidelines. [SFH guideline][NUH guideline
  • Link  Link to reviews
       
    05.01.07  Expand sub section  Linezolid
    Linezolid
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Amber 2

    Tablet, Infusion

    • Restricted antibiotic - microbiologist recommendation only
    • Oral bioavailability ~100%. SFH - Use IV only where strictly necessary
    • CHM advice: Full blood counts to be monitored weekly (see SPC for details - click yellow link below the drug name)
    • CHM advice: Severe optic neuropathy may occur rarely, particularly if linezolid is used for longer than 28 days. Advise patients to report any visual symptoms immediately. Patients who require >28 days therapy should have regular formal visual assessments
    • See local guidelines. [SFH guideline][NUH guideline]
     
    Link  Linezolid and SSRIs FAQ
    Link  Link to reviews
       
    05.01.07  Expand sub section  Polymyxins
    Colistimethate
    View adult BNF View SPC online View childrens BNF
    Formulary
    Red
    Tablet, Syrup, Injection
  • Restricted antibiotic: see local guidelines 
  • Link  Link to reviews
    Link  UKMI: Safety Assessment for Different Formulations
       
    Colistimethate for nebulisation (Colomycin®)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2
    High Cost Medicine

    Injection (Colomycin® brand licensed for nebulisation)

    • Approved for CF and non-CF bronchiectasis on specialist initiation.
    • High cost medicine when used in cystic fibrosis only.
    • SFH: All patients on nebulised antibiotics must be referred to a respiratory specialist nurse.
    • SFH Patient Information Leaflet found here
     
    Link  Link to reviews
    Link  NICE ESUOM25: Non-cystic fibrosis bronchiectasis: colistimethate sodium
    Link  Notts APC guideline for non-CF bronchiectasis
    Link  SFH: Policy for the prescription, administering and monitoring of nebulised antibiotics in adults
       
    Colistimethate inhaler (Colobreathe®)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    High Cost Medicine
    Homecare

    Inhalation powder, hard capsule with inhaler

    • Available for use in line with NICE for:
      - NUH:treating pseudomonas lung infection in cystic fibrosis NICE TA276
    • For non-cystic fibrosis bronchiectasis use Colomycin® brand.
    • Available through homecare for NUH patients. Please contact pharmacy medicines homecare team for further information
     
    Link  MHRA: Colobreathe: risk of capsule breakage—new instructions for use
    Link  NICE: Cystic fibrosis (pseudomonas lung infection) - colistimethate sodium and tobramycin (TA276)
       
    Colistimethate (Promixin®)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    High Cost Medicine
    Homecare

    Nebule


    Red Traffic Light  For new patients. Not routinely commissioned for indications other than cystic fibrosis - contact pharmacy (at SFH 3163) for more information.
    Amber Traffic Light  For existing patients already receiving supplies from primary care. Repatriation of these patients is not expected.

    • Requires a different nebuliser to the Colomycin brand of colistin which has a shorter administration time. Approximately twice the price of Colomycin.
    • For non-cystic fibrosis bronchiectasis use Colomycin® brand.
    • Available through homecare for NUH patients. Please contact pharmacy medicines homecare team for further information
     
       
    05.01.07  Expand sub section  Rifaximin
    Rifaximin (Targaxan®)
    (Encephalopathy)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2
    Tablets (550mg).
  • For use in recurrent hepatic encephalopathy. Option as per NICE TA337
  • See Xifaxanta® entry for management of recurrent C.Difficile, Small Intestinal Bacterial Overgrowth, pouchitis (unlicensed indications) and travellers diarrhoea.
  • Tablets disperse in water if needed. They do not dissolve well, so make sure all of the drug is recovered (it also tastes very bitter). See here for general advice on dispersing tablets. 
  • Link  Link to reviews
    Link  NUH: Guideline for the management of Clostridium difficile infection and antibiotic-associated diarrhoea in adults
       
    05.01.07  Expand sub section  Fidaxomicin to top
    Fidaxomicin (Dificlir®)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2
    High Cost Medicine

    Tablets

    • Microbiologist recommendation only for the treatment of recurrent clostridium difficile as per antimicrobial guidelines.
    • Low anticipated numbers per year in primary care (<5)
    • Very expensive (10 day course approx £1350)
    • Fidaxomicin is licensed in UK and available via standard wholesalers, but is unlikely to be stocked in community pharmacies. Supplies may be obtained from hospital pharmacy departments if undue delay in initiation is anticipated
     
    Link  Link to reviews
    Link  PHE: management and treatment of Clostridium difficile infection May 2013
    Link  Primary care antimicrobial guidelines
       
     ....
     Non Formulary Items
    Bezlotuxumab  (Zinplava®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    No formal assessment
    Link  Link to reviews
     
    Oritavancin  (Orbactiv®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
  • No formal submission
  •  
    Tedizolid  (Sivextro®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
  • No formal submission
  •  
      
    Key
    note Notes
    Section Title Section Title (top level)
    Section Title Section Title (sub level)
    First Choice Item First Choice item
    Non Formulary Item Non Formulary section
    Restricted Drug
    Restricted Drug
    Unlicensed Drug
    Unlicensed
    Track Changes
    Display tracking information
    click to search medicines.org.uk
    Link to adult BNF
    click to search medicines.org.uk
    Link to children's BNF
    click to search medicines.org.uk
    Link to SPCs
    SMC
    Scottish Medicines Consortium
    Cytotoxic Drug
    Cytotoxic Drug
    CD
    Controlled Drug
    High Cost Medicine
    High Cost Medicine
    Cancer Drugs Fund
    Cancer Drugs Fund
    NHSE
    NHS England
    Homecare
    Homecare
    CCG
    CCG

    Traffic Light Status Information

    Status Description

    Grey

    Grey / Non-Formulary: Medicines, which the Nottinghamshire APC has actively reviewed and does not recommend for use at present due to limited clinical and/or cost effective data.
    Grey / Non-Formulary (undergoing assessment): Work is ongoing and will be reviewed at a future APC meeting.
    Grey / Non-Formulary (no formal assessment): APC has not formally reviewed this medicine or indication because it had never been requested for formulary inclusion. Often used for drugs new to market.
      

    Red

    Medicines which should normally be prescribed by specialists only. eg hospital only.
    For patients already receiving prescriptions in primary care - continue. No new patients to receive prescriptions in primary care.
      

    Amber 1

    Medicines that should be initiated by a specialist and prescribed by primary care prescribers only under a shared care protocol, once the patient has been stabilised.
    Prior agreement must be obtained by the specialist from the primary care provider before prescribing responsibility is transferred. The shared care protocol must have been agreed by the relevant secondary care trust Drugs and Therapeutics Committee(s) (DTC) and approved by the Nottinghamshire APC.
      

    Amber 2

    Medicines suitable to be prescribed in primary care / general practice after specialist* recommendation or initiation.
    A supporting prescribing guideline may be requested which must have been agreed by the relevant secondary care trust DTCs and approved by the Nottinghamshire APC.
    *Specialist is defined by the APC as a clinician who has undertaken an appropriate formal qualification or recognised training programme within the described area of practice
      

    Amber 3

    Primary care/ non specialist may initiate as per APC guideline.
    The supporting prescribing guideline must have been agreed by the relevant secondary care trust D&TC(s) and approved by the Nottinghamshire APC.
      

    Green

    Medicines suitable for routine use within primary care.
    Can be initiated within primary care within their licensed indication, in accordance with nationally recognised formularies, for example the BNF, BNF for Children, Medicines for Children or Palliative Care Formulary. Primary care prescribers take full responsibility for prescribing.   

    OTC

      

    netFormulary