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 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.

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 Details...
05.02  Expand sub section  Antifungal drugs
Lipid-complex amphotericin (Abelcet®)
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Restricted Drug Restricted
Red
High Cost Medicine

Infusion

  • Available at NUH only - see restricted antimicrobials list
 
Link  NUH haematology guidelines
Link  NUH microbiology guidelines
   
Liposomal amphotericin (AmBisome®)
View adult BNF View SPC online View childrens BNF
Restricted Drug Restricted
Red
High Cost Medicine

Infusion

Available at NUH only:

  • Approved for use, via the nebulised route, as prophylaxis against COVID-19 associated pulmonary aspergillosis (CAPA) in mechanically-ventilated ITU patients with COVID-19 infection. Unlicensed indication - named patient use only.
 
Link  NUH guidelines - see restricted antimicrobials list
Link  NUH haematology guidelines
Link  SFH: Information about IV filters
   
Amphotericin (Fungizone®)
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Restricted Drug Restricted
Red

Approved Clinical Indications:

  • For intravitreal use and for eye/ear drop preparation only
  • Use via intrathecal route on the advice of consultant microbiologist only (NUH only).
  • NB: other amphotericin preparations are used for iv administration
 
Link  MHRA: potentially fatal adverse reaction if amphotericin products confused
Link  NPSA alert on injectable amphotericin
   
Fluconazole
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Formulary
Green
Capsule (50mg, 150mg, 200mg), Oral suspension (expensive), Infusion.
  • NUH: infusion restricted - see trust guidelines
  • See link for interactions of fluconazole. 
  • Link  Mouthcare products available for adults at SFH
    Link  NUH guidelines
    Link  UKMI Q&A: Can oral fluconazole be used with breastfeeding?
       
    Flucytosine (Ancotil®)
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    Restricted Drug Restricted
    Red

    Tablets 500mg (Unlicensed medicine - named patient use only)

    Available at NUH only:

    • Restricted for proven systemic yeast infections. Discuss with microbiologist - Serum assays required to minimise toxicity.
     
    Link  NUH guidelines
    Link  NUH restricted antimicrobials list
       
    Griseofulvin
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    Formulary
    Green
    Tablet
  • For scalp and dermatophyle infections in children 
  •    
    Isavuconazole (Cresemba®)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    Capsules, Powder for Infusion
  • Available at NUH only - see restricted antimicrobials list
    IV isavuconazole must be administered using a giving set with an in-line filter – See NUH antimicrobial website for further information.
     
  •    
    Itraconazole
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    Formulary
    Green
    Capsule, Liquid 
    Link  NUH guidelines
    Link  UKMI Q&A: Which medicines require extra care when switching between liquid and tablet/capsule formulations?
       
    Posaconazole (IV) (Noxafil®)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    High Cost Medicine
    NUH only
    Infusion
  • Restricted for use in adult patients on recommendation of microbiology or in line with haematology guidelines
    See Microbiology guidelines - restricted agent or Haematology guidelines
     
  • Link  Posaconazole tablet and oral suspension not interchangeable - HCP letter
       
    Posaconazole (oral) (Noxafil®)
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    Restricted Drug Restricted
    Red
    High Cost Medicine

    Suspension 200mg in 5mL

     
    Link  Link to reviews
    Link  NUH monitoring information
    Link  NUH restricted antimicrobials list
    Link  Posaconazole tablet and oral suspension not interchangeable - HCP letter
    Link  UKMI Q&A: Which medicines require extra care when switching between liquid and tablet/capsule formulations?
       
    Terbinafine
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    Formulary
    Green

    Tablet

    • For use in severe tinea infections where oral therapy is appropriate as per APC antimicrobial guidance.
    • Tablets disperse in water if needed. See here for general advice on dispersing tablets.
     
       
    Voriconazole (Vfend®)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    High Cost Medicine

    Tablet, Suspension, Infusion

     
    Link  MHRA: reminder of risk of liver toxicity, phototoxicity, and squamous cell carcinoma
    Link  NUH monitoring information
    Link  NUH restricted antimicrobials list
       
    05.02  Expand sub section  Drugs used in fungal infections
    05.02.01  Expand sub section  Triazole antifungals
    05.02.02  Expand sub section  Imidazole antifungals
    05.02.03  Expand sub section  Polyene antifungals to top
    05.02.04  Expand sub section  Echinocandin antifungals
    Caspofungin
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    High Cost Medicine

    Infusion

    • At NUH: First line echinocandin. Approved for use in paediatric patients and adult haematology See Haematology guidelines or Microbiology guidelines
    • At SFH: Approved to be used for neutropenic patients with approval of consultant haematologist and microbiologist. Contact High Cost Drugs Team ext 4567 for more information. See local guideline below.
    • See local guidelines. [SFH guideline][NUH guideline]
     
    Anidulafungin (Ecalta®)
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    Restricted Drug Restricted
    Red
    High Cost Medicine

    Infusion

    • Approved for use in adults. Not licensed in under 18s.
    • Second line  echinodandin where caspofungin is deemed inappropriate e.g moderate to severe liver impairment (Child Pugh score >7) . First line use in haematology remains caspofungin [NUH guideline] [SFH guideline]
     
    Link  Link to reviews
       
    Micafungin (Mycamine®)
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    Restricted Drug Restricted
    Red
    High Cost Medicine

    Infusion

    • At NUH: removed from formulary as of 6th June 2016.
    • At SFH: not routinely stocked. Available on Microbiologist request only.
    • See local guidelines. [SFH guideline][NUH guideline]
    • Prescriber checklist available via the SPC - see risk materials tab at the top of the SPC.
     
    Link  Link to reviews
       
    05.02.05  Expand sub section  Other antifungals
     ....
     Non Formulary Items
    Ketoconazole  (Nizoral®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    Discontinued due to hepatotoxicity concerns (November 2013).
    Link  Discontinuation notification
     
      
    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

      

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