5.0.1 Prescribing guidelines
There
is no ideal antibacterial, antifungal or antiviral agent and the selection of
the most effective drug depends upon the known or suspected pathogen, the site
of infection, host factors and potential drug side effects. Antibiotics should
not be used for simple viral infections such as pharyngitis.
The majority of infections in neonates and children are caused by the same
organisms as in adults, and in most cases they are treated in a similar way.
Paediatric doses are adjusted according to age and size, and further details
can be found in the BNF for
Children.
Antibiotics should be used singly where possible, rather than in combination,
and those given intravenously should be changed to oral as soon as clinical
circumstances permit.
Broad spectrum antibiotics such as cefuroxime, cefotaxime, caftazidime,
ceftriaxone, ciprofloxacin and moxifloxacin should only be prescribed for
clinical conditions as outlined in this formulary or following discussion with
a Consultant Medical Microbiologist.
Empiric overuse and prolonged administration of antibiotics must be avoided in
order to reduce the risk of side-effects, including Clostridium difficile diarrhoea, and also to reduce the likeliness
of the emergence of antibiotic resistant organisms.
A microbiological diagnosis may not be available when treatment is started.
Samples should always be collected before treatment begins and therapy should
be reviewed when results are obtained.
Duration of antimicrobial therapy depends on the type of infection and the
patient’s response, but as a guide most acute infections will respond to a
5-day course. Uncomplicated infections of the urinary tract generally require
only 3days treatment. However severe or
complicated infections may require longer than 5days. Unnecessarily prolonged therapy is both
hazardous (e.g. increased risk of side effects, secondary infections etc.) and
expensive and is likely to lead to bacterial resistance in the hospital.
Allergic reactions may occur with any drug but they are more common with
penicillins. For penicillin allergy enquiries should always be made regarding
the nature of the allergy. For the purposes of the Formulary penicillin allergy
has been separated into:
"low risk" – patients describing a
‘mild’ rash to penicillins, can receive cephalosporins, imipenem or meropenem
unless a reaction to these antibiotics has been experienced. However, hypersensitivity may occur with
these agents and thus caution should be observed when prescribing (see BNF
5.1.1).
"high risk" – patients describing anaphylaxis, severe rash or
other life threatening reactions should not receive a penicillin, cephalosporin
imipenem or meropenem.
Advice on therapy can be obtained from a Consultant Medical Microbiologist
(NDDH ext 3199 or bleep 193) or Medicines Information (NDDH ext 2393). For drug
interactions see the BNF.
5.0.2 Antimicrobial assays
Serum levels of gentamicin, tobramycin and vancomycin are
measured by the Microbiology Lab which should be contacted (NDDH ext 2347)
before samples are sent. Assays for other antimicrobials (on a clotted blood
sample) may be available by special arrangement.
• Gentamicin and Tobramycin
The dosing regimen of choice for gentamicin and tobramycin is to give the
drug once daily at a dose of 4.5mg per kg per day. Monitor the trough level
before the second dose and await result before administration of this dose. If
the trough level is less than 1mg/l (less than 2mg/l for neonates) the dose is maintained;
if above this level discussion between the clinical team and a Consultant
Medical Microbiologist should occur. If renal function is stable reassay every
48 to 72 hours (dose can be given before result known). There are a few
clinical conditions requiring gentamicin to be given in divided doses eg
infective endocarditis (discuss with Consultant Medical Microbiologist re
appropriate dose regimen and monitoring).
• Vancomycin
The trough level should be monitored before the third or fourth dose. The trough
should be 5-15mg/l (for severe infections (10-15mg/l). Trough levels should be
remeasured every 48-72hrs if renal function remains stable.
5.0.3 Special circumstances
5.0.3.1 Renal impairment
See BNF, Appendix 3.
Link to creatinine
clearance calculator using the Cockcroft and Gault formula:
5.0.3.2 Hepatic impairment
See BNF, Appendix 2.
5.0.3.3 Pregnancy
See BNF, Appendix 4.
5.0.3.4 Breast feeding
See BNF, Appendix 5.
5.0.4 Recommended antibacterial drugs
The treatments recommended here are prudent initial choices according to the
most likely organisms. They need to be reviewed when culture results become
available, and according to changes in clinical circumstances. Doses are given
for adults with normal renal and hepatic function. Modified doses quoted for
children are derived from the BNF and the RCPCH’s Medicines for
Children. Experienced advice should also be sought to confirm that they are
right for the clinical situation.
Some antibiotic agents need to be reserved for specific clinical indications
and these are detailed within the formulary.
Prescribing of these restricted agents outwith this guidance requires
the approval of a Consultant Medical Microbiologist. The restricted agents are:- aztreonam,
cefotaxime, ceftazidime, ceftriaxone,
ciprofloxacin iv, co-trimoxazole, imipenem, meropenem, linezolid,
rifampicin iv, and Tazocin®.
The co-prescribing of metronidazole with co-amoxiclav is not required in the
majority of clinical situations as co-amoxiclav is a broad spectrum antibiotic
with activity against anaerobes. The use
of metronidazole as first-line treatment for Clostridium difficile diarrhoea may occasionally warrant concurrent
use with co-amoxiclav.
5.0.4.1 Respiratory infections in children
Pneumonia in babies up to 3 months
In neonates and babies up to 3 months of age, likely organisms include coliforms,
Staph aureus, Streptococci and H influenzae.
Initial treatment:
cefotaxime iv; dose: 50mg/kg every 8 to 12 hrs; 50mg/kg every 6
hours in severe infections,
plus:
gentamicin iv; dose: 4 to 5mg/kg every 24hrs under 4 weeks; 7mg/kg
every 24hrs in those 4 weeks to 18yrs,
plus:
clarithromycin iv if Chlamydia or Mycoplasma are suspected; dose:
7.5mg/kg daily every 12 hrs.
Pneumonia in children
Likely organisms include: in children from 3 months to 5yrs of age, Strep
pneumoniae, H influenzae, viruses, Chlamydia, and Mycoplasma;
in children over 5yrs, Strep pneumoniae, Mycoplasma, Staph
aureus.
Initial treatment:
amoxicillin sugar free suspension; dose: 3mths – 1yr 125mg three
times a day; 1yr – 5yr 250mg three times a day; 5yr – 12yr 500mg three times a
day.
plus:
clarithromycin orally; dose: < 8kg, 7.5mg/kg twice daily;
8-11kg, 62.5mg twice daily; 12-19kg, 125mg twice daily; 20-29kg, 187.5mg twice
daily; 30-40kg, 250mg twice daily; these doses being doubled for severe
infections.
When intravenous treatment is needed:
benzylpenicillin iv; dose: 50mg/kg daily every 4 to 6 hrs,
plus:
clarithromycin iv; dose: 7.5mg/kg every 12hrs.
5.0.4.2 Respiratory infections in
adults
Acute bronchitis in healthy adults.
Likely organisms: Mycoplasma, Chlamydia. Initial
treatment:
doxycyline caps; dose: 200mg initially then 100mg daily for 5
days,
or:
clarithromycin tabs; dose: 500mg twice daily for 5 days.
Acute exacerbations of chronic bronchitis.
Likely organisms: Strep pneumoniae, H influenzae, M
catarrhalis.
Initial treatment:
amoxicillin caps; dose: 500mg – 1g every 8hrs,
or
doxycycline caps; dose: 200mg initially then 100mg daily.
or in those sufficiently unwell needing iv therapy:
amoxicillin inj; dose: 500mg – 1g
every 6hrs,
plus:
ciprofloxacin inj; dose: 400mg every 12hrs.
Community acquired pneumonia.
See guidelines and use early warning score.
Community acquired pneumonia -
Hospital treated, not severe:
Likely organisms: Strep pneumoniae,
H influenzae, Mycoplasma, Chlamydia.
Initial treatment in most cases:
amoxicillin caps; dose: 500mg to 1g every 8hrs,
plus (if not classical picture of pneumococcal pneumonia):
clarithromycin tabs; dose: 500mg every 12hrs.
If penicillin allergic:
clarithromycin tabs; 500mg every
12hrs.
If iv treatment needed:
amoxicillin inj; dose: 500mg – 1g every 6hrs,
plus if required:
clarithromycxin inj; dose: 500mg every 12hrs.
Community acquired pneumonia - Hospital treated, severe:
co-amoxiclav iv; dose: 1.2g every 8hrs,
plus:
clarithromycin iv; dose: 500mg every 12hrs, changing to oral amoxicillin
and clarithromycin with clinical
improvement.
Review need for iv therapy on post take ward round and daily thereafter.
If “low risk” penicillin allergic:
cefuroxime iv; dose: 1.5g every 8hrs,
plus:
clarithromycin iv; dose: 500mg every 12hrs.
If “high risk” penicillin allergic:
discuss with Consultant Medical Microbiologist.
Non ventilator associated hospital acquired pneumonia,
aspiration pneumonia.
Likely organisms: Strep pneumoniae, H influenzae, Staph
aureus, coliforms.
Empirical therapy will vary with individual cases, but initial appropriate therapy:
co-amoxiclav tabs; dose: 625mg every 8hrs,
or:
co-amoxiclav inj; dose: 1.2g every 8hrs.
For severe disease:
co-amoxiclav inj; dose: 1.2g every 8hrs,
plus:
ciprofloxacin tabs; dose: 750mg every 12hrs.
or (if indicated):
ciprofloxacin inj; dose: 400mg every 12hrs.
Pleural infection, lung abcess and empyema.
Community acquired:
co-amoxiclav inj; dose: 1.2g every 8hrs.
or if "low risk" penicillin allergy (see
5.0.1)
cefuroxime inj; dose: 1.5g every 8 hrs,
plus:
metronidazole tabs; dose: 400mg every 8 hrs.
or if "high risk" penicillin allergy (see
5.0.1)
clindamycin inj/caps; dose 300 - 600mg every 6 hrs,
plus:
ciprofloxacin tabs; dose: 750mg every 12 hrs,
or
ciprofloxacin inj; dose: 400mg every 12 hrs.
Hospital acquired:
imipenem inj; dose: 500mg every 6 hrs,
plus:
vancomycin inj; dose: 500mg – 1g every 12 hrs.
or if high risk penicillin allergy (see 5.0.1)
discuss with Consultant Medical Microbiologist.
NB please refer all cases of lung abscess and empyema to the Chest Physician
or Consultant Medical Microbiologist.
Pulmonary tuberculosis
Organisms: Myco tuberculosis, Myco bovis.
NB please refer all cases to the Chest Physician.
If it is necessary to start empirical treatment then use quadruple therapy with
Rifater (rifampicin 120mg, isoniazid 50mg and pyrazinamide
300mg per tab) plus ethambutol.
Dose: see BNF.
All patients should have an infection control risk assessment.
5.0.4.3 Eye infections
Conjunctivitis
• Babies under 3 months
Likely organisms: N gonorrhoeae, Staph aureus, Strep
pneumoniae, Chlamydia.
Initial treatment:
chloramphenicol eye drops; dose: one drop every 30-60mins.
If the response is poor Chlamydia should be considered and treated with:
erythromycin 0.5% eye ointment [unlicensed];
dose: apply two or three times a day and continue for 48hrs after
healing;
plus:
clarithromycin orally; dose: 7.5mg/kg twice daily.
N gonorrhoeae, if present, needs systemic treatment.
• Babies over 3 months
Likely organisms: Staph aureus, haemolytic Strep, Strep
pneumoniae, H influenzae .
Initial treatment:
chloramphenicol eye drops; dose: one drop every 30-60mins.
• Adults
Likely organisms: Staph aureus, haemolytic Strep, Strep
pneumoniae.
Initial treatment:
chloramphenicol eye drops; dose: one drop every 1-2hrs.
For confirmed infection with Chlamydia:
erythromycin 0.5% eye ointment; dose: apply two or three times a
day and continue for 48hrs after healing;
plus:
clarithromycin orally; dose: 500mg twice daily.
Genital infection should be excluded.
Viral infections
Viral conjunctivitis needs no specific treatment.
For herpes simplex keratitis (see 11.3)
Corneal
ulcer
Likely organisms: mixed infection including Staph aureus, Streptococci,
coliforms, Pseudomonas, and
require specialist treatment advice.
Initial treatment:
cefuroxime eye drops 5% (prepared at NDDH pharmacy); dose: one
drop every 30min for 24-48hrs reduced to one drop every 2hrs with clinical
improvement;
plus:
gentamicin (forte) eye drops 1.5%; dose: one drop every 30min for
24-48hrs reduced to one drop every 2hrs with clinical improvement;
or:
chloramphenicol eye drops; dose: one drop every 30min for 24-48hrs
reduced to one drop every 2hrs with clinical improvement.
Orbital cellulitis
Likely organisms: Staph aureus, Strep pneumoniae, Haemolytic
Strep, plus H influenzae in children.
Initial treatment:
cefuroxime iv; dose: 1.5g every 8hrs,
plus:
flucloxacillin iv; dose: 1g every 6 hrs,
Please discuss further management with a Consultant Medical Microbiologist..
5.0.4.4
ENT and mouth infections
Acute tonsillitis
Likely organisms: Strep pyogenes.
Initial treatment:
penicillin V tabs; dose: 500mg every 6hrs for 5 days, or for 10
days to prevent rheumatic fever if the throat swab is positive,
or, if there is penicillin allergy:
clarithromycin tabs; dose: 500mg twice daily for 5 days, continued
for 10 days if the throat swab is positive.
Acute epiglottitis
Likely organism: H influenzae.
Initial treatment:
cefotaxime iv; dose: 1.5g every 8hrs for 48hrs,
or, if there is "high risk" penicillin allergy (see 5.0.1)
chloramphenicol iv; dose: 1g every 4hrs for 48hrs.
These treatments should be followed by: rifampicin caps; dose:
600mg (20mg/kg in those aged 3-12months) once daily for 4 days. For prevention
of infection in household contacts (see
5.0.5).
Acute otitis media
Likely organisms: Strep pneumoniae, H
influenzae, viruses.
Most infections are caused by viruses and the majority of uncomplicated cases
will resolve without antibacterial treatment.
In severe cases initial treatment:
amoxicillin iv or clarithromycin iv if penicillin allergic.
Acute sinusitis
Likely organisms: H influenzae, Strep pyogenes, Strep
pneumoniae, Staph aureus.
Initial treatment:
doxycycline caps; dose: 200mg initially then 100mg daily for 7
days.
or:
amoxicillin caps dose: 500mg every 8hrs for 7 days.
or:
clarithromycin tabs; dose: 500mg every 12hrs for 7 days.
Peritonsillar abscess
Likely organisms: Staph aureus, Strep
pyogenes, anaerobes.
Initial treatment:
co-amoxiclav iv; dose: 1.2g every
8hrs for 5 days,
or for penicillin allergic:
clindamycin caps; dose: 300mg every
6hrs for 5 days.
Otitis externa
Likely organisms: Staph aureus, Pseudomonas, Aspergillus.
Initial treatment:
Sofradex® drops; dose: 2-3 drops 3-4 times daily.
or:
Otosporin® drops; dose: 2-3 drops 3-4 times daily.
If an abscess/cellulitis present:
flucloxacillin caps; dose: 500mg every 6hrs,
plus: (if pseudomonas suspected)
ciprofloxacin tabs; dose: 750mg every 12hrs.
Dental abscess
Likely organisms: mouth flora, mainly anaerobes.
Initial treatment:
amoxicillin caps; dose: 500mg every 6hrs for 5 days.
or:
metronidazole tabs; dose: 400mg every 8hrs for 5 days.
Gingivitis
Likely organism: Vincent's organism.
Initial treatment:
amoxicillin caps; dose: 500mg every 6hrs for 3 days or until
symptoms resolve.
or:
metronidazole tabs; dose: 400mg every 8hrs for 3 days or until
symptoms resolve.
5.0.4.5
Cardiovascular infections
Infective
endocarditis
Likely organisms in congenital and post rheumatic valve lesions, prosthetic
heart valves, drug users and others at special risk: Strep viridans, Staph
aureus, coagulase negative Staph, enterococci, Pseudomonas,
fungi.
Please discuss all cases of suspected infective endocarditis with a Consultant
Medical Microbiologist before initiating treatment. Initial empirical treatment
before culture results known:
benzylpencillin iv; dose: 1.2g every 4hrs,
plus:
gentamicin iv; dose: 1mg/kg every 8hrs.
if presentation acute:
flucloxacillin iv; dose: 2g every 4hrs.
plus:
gentamicin iv; dose: 1mg/kg every 8hrs.
if prosthetic valve or MRSA suspected or penicillin
allergy:
vancomycin iv; dose: 1g every 12hrs
plus:
rifampicin caps; dose: 300-600mg twice daily
plus:
gentamicin iv; dose: 1mg/kg every 8hrs.
5.0.4.6
Gastrointestinal infections
Acute
gastroenteritis
Acute gastroenteritis is usually treated by adequate rehydration (see
9.2.1.2). Patients with
diarrhoea should be isolated – see the Infection Control Manual.Antibiotics
should be used only for persistent and severe infection.
•
Salmonella and Shigella.
ciprofloxacin tabs; dose: 500mg twice
daily for 2-5 days.
•
Campylobacter
clarithromycin tabs; dose: 250mg twice
daily for 5 days.
or:
ciprofloxacin tabs; dose: 500mg
twice daily for 5 days.
Cl difficile associated diarrhoea
metronidazole tabs; dose: 400mg every
8hrs for 7-10 days.
For
those patients who cannot tolerate oral medication prescribe metronidazole iv
500mg every 8hrs.
Acute cholangitis / cholecystitis /
biliary sepsis
Likely organisms: coliforms, Pseudomonas, enterococci.
Tazocin iv ; dose; 4.5g every
8hrs – NB contains penicillin
Low risk penicillin allergic
cefuroxime iv; dose; 1.5g every
8hrs
plus
metronidazole iv; dose; 500mg every
8hrs
High
risk penicillin allergic
Seek
advice from Consultant Medical Microbiologist
iv to oral switch
co-amoxiclav oral; dose; 625mg every
8hrs
penicillin
allergic
ciprofloxacin oral; dose; 500mg every
12hrs
plus
metronidazole oral; dose; 400mg every
8hrs
Diverticulitis
amoxicillin iv; dose: 500mg every
6hrs,
plus:
gentamicin iv; dose: 4.5mg/kg
once daily (check level before second dose see 5.0.2)
plus:
metronidazole; dose: 1g rectally
every 8hrs or 500mg iv every 8hrs.
Lower abdominal sepsis / perforation
amoxicillin iv; dose: 1g every 6hrs,
plus:
gentamicin iv; dose: 4.5mg/kg
once daily (check level before second dose see 5.0.2)
plus:
metronidazole; dose: 1g rectally
every 8hrs or 500mg iv every 8hrs
iv to oral switch
co-amoxiclav oral; dose; 625mg every
8hrs
penicillin allergic
ciprofloxacin oral; dose; 500mg every
12hrs
plus
metronidazole oral; dose; 400mg every
8hrs
5.0.4.7
Septicaemia
• Adults
Likely organisms if
source unknown: Staph, haemolytic Strep, enterococci, coliforms, anaerobes, Pseudomonas.
Community acquired:
flucloxacillin iv; dose: 2g
every 6hrs,
plus:
amoxicillin iv; dose: 1g
every 6hrs,
plus:
gentamicin iv; dose:
4.5mg/kg once daily (check level before second dose see
5.0.2)
If serum creatinine > 200 micromols/litre use imipenem alone (dose dependent
on renal function).
"Low risk" penicillin allergy
(see 5.0.1)
imipenem
iv; dose: 500mg every 6hrs.
"High risk" penicillin allergy
(see 5.0.1)
vancomycin iv; dose: 1g every 12hrs,
plus:
rifampicin caps; dose: 300-600mg every
12 hrs.
plus:
gentamicin iv; dose: 4.5mg/kg once daily (check level before second dose see 5.0.2)
Hospital acquired:
imipenem iv; dose: 500mg every 6hrs.
plus if
MRSA risk:
vancomycin
iv; dose: 1g every12hrs.
"High risk" penicillin allergy (see 5.0.1)
vancomycin iv; dose: 1g every 12hrs,
plus:
rifampicin caps; dose: 300-600mg every 12 hrs.
plus:
gentamicin iv; dose: 4.5mg/kg once daily (check level before second dose see 5.0.2).
• Babies and children
Likely organisms if source unknown: coliforms, Strep, Staph, Pseudomonas,
Listeria.
Initial treatment:
benzylpencillin iv; dose: preterm neonates and neonate under 7 days 25mg/kg
every 12 hrs; neonates 1-4 weeks, 25mg/kg every 8 hrs; child 1month-18yrs,
25mg/kg every 6 hrs; these doses should be doubled in severe illness,
plus:
gentamicin iv; dose: for those up to 4 weeks,
4 to 5mg/kg every 24hrs; for those aged 4weeks-12yrs, 7mg/kg every 24hrs,
plus:
flucoxacillin iv; dose: 1 month – 18years, 12.5 - 25mg every 6 hrs (max 1g
every 6 hrs); may be doubled in severe illness.
• Neutropenic patients
Likely organisms: Staph
aureus and epidermidis, Strep viridans,
coliforms, Pseudomonas, enterococci.
Initial treatment, pending results of blood cultures:
Tazocin® iv; dose: 4.5g every 8hrs,
plus:
gentamicin iv; dose; 4.5mg/kg once daily (check level before second dose see 5.0.2).
If serum creatinine > 200 micromols/litre use meropenem alone (dose
dependent on renal function).
"Low risk" penicillin allergy
meropenem
iv; dose: 1g every 8hrs.
"High risk" penicillin allergy
discuss with Consultant Medical Microbiologist.
Suspected line infection:
meropenem iv; dose; 1g every 8hrs,
plus:
vancomycin iv; dose; 1g every 12hrs.
• Septicaemia in haemodialysis patients.
Likely organisms MRSA plus those listed above
Initial treatment
vancomycin iv: dose: 1g stat dose
plus:
gentamicin iv: dose: 240mg stat dose
Further doses according to levels taken at dialysis. Please discuss all cases
with the Renal Unit at the Renal Devon & Exeter Hospital and review lines.
5.0.4.8
CNS infections
Please discuss all cases with a Consultant Medical Microbiologist
Meningitis
• babies under 3 month
Likely organisms in neonates: E coli,
Group B Strep, Listeria; in babies aged 1-3 months: E coli,
Group B Strep, H influenzae, Listeria, N meningitidis,
Strep pneumoniae.
Initial treatment:
amoxicillin iv; dose: neonate under 7 days 50mg/kg every 12 hrs,
neonate 7 – 28 days 50mg/kg every 8 hours, child 1 month – 18 years 50mg/kg
every 4 – 6 hrs (max 2g every 4 hrs)
plus:
cefotaxime iv; dose: neonate
under 7 days 25mg/kg every 12 hrs, neonate 7 – 21 days 25mg/kg every 8 hours,
neonate 21 – 28 days 50mg/kg every 6 - 8 hours, child 1 month – 18 years
50mg/kg every 6 hours (max 12g daily)
• babies older than 3 month
Likely organisms: Strep pneumoniae,
H influenzae, N meningitidis.
Initial treatment:
cefotaxime iv; dose: child 1 month – 18 years 50mg/kg every 6
hours (max 12g daily),
or, if there is severe pencillin allergy:
choramphenicol iv; dose: 1 month – 18 years 12.5mg/kg every 6
hrs.
Babies and children treated for N meningitidis meningitis should be
given rifampicin before discharge; dose: for babies aged
3-12months, 5mg/kg every 12hrs for 2 days; over 1 year, 10mg/kg every 12hrs for
2 days. Household contacts should all be given prophylaxis (see 5.0.5.1).
Children treated for H influenzae type B meningitis should be given rifampicin
before discharge; dose: < 3months 10mg/kg once daily for 4 days;
> 3months 20mg/kg once daily (max 600mg daily) for 4 days. Household
contacts need to be given prophylaxis only if they have children under 4yrs (see 5.0.5.1).
• Adults
Likely organisms: Strep pneumoniae,
N meningitidis.
Initial treatment:
cefotaxime iv; dose: 2-3g every 6hrs.
or, if "high risk" penicillin allergy (see 5.0.1)
chloramphenicol iv; dose: 1g every 4hrs.
If
patient over 50 years of age consider the addition of:
amoxicillin iv; dose: 2g every 4 hrs.
Cerebral abscess
Likely organisms: mixed organisms, including Staph, Strep , coliforms
and anaerobes.
Initial treatment:
cefotaxime iv; dose: 2-3g every 6hrs,
plus:
metronidazole; dose: 1g rectally or 500mg iv every 8hrs.
5.0.4.9
Obstetric and GU infections
Likely organisms for
infection associated with ruptured membranes, caesarean section, postnatal
metritis and septic abortion with mild symptoms: coliforms , anaerobes,
Strep, Streptococcus Staph.
Initial treatment:
co-amoxiclav tabs 625mg; dose: 1 tab every 8hrs.
or for “low-risk” penicillin allergy:
cefuroxime iv; dose: 750mg every 8hrs,
plus:
metronidazole; dose: 1g rectally or 500mg every 8hrs.
Clarithromycin iv or orally should be added if Chlamydia is
suspected.
Septic abortion with severe symptoms
Likely organisms: coliforms,E coli Clostridium perfringens and
other anaerobes, Strep, Staph.
Initial treatment:
amoxicillin iv; dose: 1g every 6hrs,
plus:
gentamicin iv; dose: 4.5mg/kg once daily (check level before second
dose (see
5.0.2),
plus:
metronidazole; dose: 1g rectally or 500mg iv every 8hrs.
Also:
flucloxacillin iv may be needed; dose: 500mg-1g every 6hrs.
Acute salpingitis and pelvic inflammatory disease
Likely organisms: Chlamydia, N gonorrhoeae, Streptococci,
coliforms , anaerobes.
Initial treatment:
doxycycline caps; dose: 100mg every 12hrs,
plus:
ceftriaxone inj; dose: 1g single dose,
plus:
metronidazole tabs; dose: 400mg every 8hrs.
In pregnancy:
ceftriaxone inj; dose: 1g sinle dose,
Acute pyelonephritis
Likely organisms: coliforms, enterococci, Staph,
Pseudomonas.
Initial treatment:
amoxicillin iv; dose: 1g every 6hrs,
plus:
gentamicin iv; dose: 4.5mg/kg once daily (check level before second
dose (see
5.0.2),
or:
ciprofloxacin tabs; dose: 500-750mg every 12hrs for 10-14 days.
Urinary Tract Infection (uncomplicated)
Likely organisms: coliforms, enterococci, Staph.
First line:
trimethoprim tabs; dose: 200mg every 12hrs for 3 days in
females; 200mg every 12hrs for 7 days in males.
First line in pregnacy:
cefradine caps; dose: 500mg every
6hrs for 7 days
Second line:
cefradine caps; dose: 500mg every
6hrs for 3 days in females; 500mg every 6hrs for 7 days in males.
Prostatitis
Likely organisms: mixed coliforms, enterococci, Staph,
Strep.
Initial treatment:
ciprofloxacin tabs; dose: 500mg every 12hrs.
or:
trimethoprim tabs; dose: 200mg every 12hrs for 14 days or more.
If Chlamydia is suspected: add doxycycline caps; dose:
100mg every 12hrs to above.
Gonococcal urethritis:
Treatment (notify genitourinary clinic):
cefixime 400mg; dose: 400mg single
dose
or:
ciprofloxacin tabs; dose: 500mg
single dose.
Chlamydial urethritis:
Treatment (notify genitourinary clinic):
doxycycline caps; dose: 100mg twice daily for 7 days.
5.0.4.10 Skin
and soft tissue infection
Community
acquired wound infection and impetigo
Likely organisms: Staph aureus,
haemolytic Strep.
Initial treatment:
amoxicillin caps; dose: 500mg every
6hrs,
plus:
flucloxacillin caps; dose: 500mg every 6hrs.
or if penicillin allergic
clarithromycin tabs; dose: 500mg twice daily.
In severe cases treatment should be given iv.
Cellulitis and erysipelas
Likely organisms: haemolytic Strep, Staph
aureus.
Initial treatment:
amoxicillin caps; dose: 500mg every 6hrs,
plus:
flucloxacillin caps; dose: 500mg every 6hrs.
or if penicillin allergic:
clarithromycin tabs; dose: 500mg
twice daily.
In severe cases:
benzylpenicillin iv; dose: 1.2 – 2.4g
every 4hrs,
plus:
flucloxacillin iv; dose: 1 - 2g every
6hrs.
Check MRSA status and obtain advice from
Consultant Medical Microbiologist if MRSA positive.
Bites
• animal
Likely organisms: Pasteurella multocida, Staph aureus, mixed anaerobes,
Capnocytophaga canimorsus (DF-2), and risk of rabies in those returning from
other countries.
Initial treatment:
co-amoxiclav tabs 625mg; dose: 1 tab
every 8hrs.
Treatment should be iv in severe cases.
• human
Likely organisms: mixed organisms including Staph, Strep, anaerobes; also risk
of blood borne viruses (see innoculation injury policy).
Initial treatment:
co-amoxiclav tabs 625mg; dose: 1 tab
every 8 hrs.
for penicillin allergic patients
ciprofloxacin tabs; dose: 500mg twice daily
plus:
clindamycin caps; dose: 300mg
every 6hrs.
5.0.4.11 Bone
and joint infections
Acute
osteomyelitis or septic arthritis
• adults
Likely organisms: Staph aureus, haemolytic Strep.
Initial treatment:
benzylpencillin iv; dose: 2.4g every 4hrs,
plus:
flucloxacillin iv; dose: 2g every 6hrs.
or if "low risk" penicillin allergy
cefuroxime iv; dose: 1.5g every 8hrs.
or if "high risk" penicillin allergy
clindamycin iv or orally; dose: 600mg every 6hrs.
• children of all ages
Likely organisms: Staph aureus, haemolytic Strep, H
influenzae.
Initial treatment:
cefuroxime iv; dose: for children 1 month to 12 years 20mg/kg
every 8hrs,
plus:
flucloxacillin iv; dose: for children 1 month to 12 years 12.5 –
25mg/kg every 6hrs.
plus, if Staph aureus infection is present:
fusidic acid suspension 250mg in 5ml; dose: age up to 1yr, 15mg/kg
every 8hrs; 1-5yrs, 250mg every 8hrs; 5-12yrs, 500mg every 8hrs.
Please discuss with a Consultant
Medical Microbiologist
5.0.5
Preventive use of antibiotics
Prophylactic
antibiotics should be used if the risk of infection is unacceptable. When the
risk results from a surgical treatment, antibiotic schedules are planned to
give peak blood levels at the time of the procedure and thus should be given at
induction of anaesthesia.
5.0.5.1
Meningitis
Meningococcus
Secondary cases of meningococcal meningitis should be prevented
amongst household and kissing contacts who should receive:
rifampicin syrup; dose: 5mg/kg every 12hrs for 2 days in those
under 1yr; 10mg/kg every 12hrs for 2 days in those aged 1-14yrs;
rifampicin caps; dose: 600mg every 12hrs for 2 days in those over 14yrs;
ciprofloxacin tabs; dose: 500mg as a single dose in adults.
The same treatment should also be given to the affected individual. Caution:
rifampicin renders oral contraceptives less effective; it should be avoided in
pregnancy and expert advice sought.
Haemophilus influenzae type B
Playgroup contacts under 4yrs of age, and also household members if
there are children of under 4yrs, need be treated to prevent secondary cases of
Haemophilus influenzae type B meningitis:
rifampicin syrup; dose: once daily for 4 days: < 3months
10mg/kg; > 3 months 20mg/kg (max 600mg).
Caution: rifampicin, see above.
5.0.5.2
Epiglottitis
Secondary
prevention of Haemophilus influenzae disease, including epiglottitis, is
the same as for Haemophilus meningitis.
5.0.5.3
Splenectomy and sickle cell disease
To prevent
infection with Pneumococcus following splenectomy, or in those with
sickle cell disease:
penicillin V; dose: 1month - 6yrs, 125mg every 12hrs; 6-12yrs,
250mg every 12hrs; >12yrs, 500mg every 12hrs.
if cover also needed for H. influenzae in children
amoxicillin; dose: <5yrs 125mg every 12hrs; 5 - 12yr 250mg every 12hrs.
NB antibiotic prophylaxis is not fully reliable. Pneumococcal vaccine, Haemophilus
influenzae type B vaccine (Hib) and Meningococcal Group C conjugate
vaccine should be offered ideally before splenectomy (see 14.4).
5.0.5.4
Rheumatic fever
• age 1month
-6yrs
To prevent recurrence of rheumatic fever in those aged 1month - 6yrs:
penicillin V orally; dose: 125mg every 12hrs.
or:
clarithromycin orally; dose: < 8kg, 7.5mg/kg twice daily; 8-11kg,
62.5mg twice daily; 12-19kg, 125mg twice daily.
• age over 6yrs
To prevent recurrence of rheumatic fever in those over 6yrs:
penicillin V orally; dose: 250mg every 12hrs.
or:
clarithromycin orally; dose: 12-19kg, 125mg twice daily; 20-29kg,
187.5mg twice daily; 30-40kg, 250mg twice daily.
Prevention of secondary case of group A streptococcal infection
• adults
penicillin V orally; dose:
250-500mg every 6hrs for 10 days.
• age < 1yr
penicillin V orally; dose: 6.25mg
every 6hrs
• age 1 - 5yrs
penicillin V orally; dose: 125mg
every 6hrs
• age 6 – 12 yrs
penicillin V orally; dose: 250mg
every 6hrs
for patients penicillin allergic
• adults and children > 8yrs
erythromycin orally; dose: 250-500mg every 6hrs for 10 days.
• age < 2yr
erythromycin orally; dose: 125mg
every 6hrs
• age 2 - 8yrs
erythromycin orally; dose: 250mg
every 6hrs
or
adults
azithromycin [unlicensed indication];
dose: 500mg once daily for 5 days
• children age > 6mths
azithromycin [unlicensed indication];
dose: 12mg/kg once daily (max 500mg
once daily).
5.0.5.6
Infective endocarditis and dental or invasive procedures
Prevention of
infective endocarditis is necessary for those with heart valves lesions, septal
defect, patent ductus, prosthetic valve or history of endocarditis undergoing:
• dental work such as extractions, scaling or periodontal procedures;
• bronchoscopy, instrumentation or surgery to the upper respiratory tract;
• ERCP, gastroscopy, colonoscopy or abdominal surgery;
• cystoscopy, TURP and other genitourinary procedures or surgery;
• gynaecological and obstetric procedures.
See BNF for guidance.
Prophylaxis for surgical procedures
When antibiotics are used prophylactically in surgery, the great majority of
patients should receive only a single prophylactic dose of each agent
prescribed.
If known to be MRSA carrier add vancomycin
iv 1g or teicoplanin iv 10mg per kg (max 800mg) to prophylactic antibiotics
at induction. HF
- ch14 main.htm - vaccines
5.0.5.7
Vascular grafts
For insertion
of vascular grafts where the operative field is clean:
co-amoxiclav iv; dose: 1.2g at induction.
If “low risk” penicillin allergic:
cefuroxime iv; dose: 1.5g
plus:
metronidazole iv; dose: 500mg.
If “high risk” penicillin allergic:
discuss with Consultant Medical Microbiologist.
5.0.5.8
Orthopaedic procedures
cefuroxime iv; dose:
750mg-1.5g at induction. This may be repeated if needed.
If “high risk” penicillin allergic:
discuss with Consultant Medical Microbiologist.
5.0.5.9 Lower
limb amputation
For lower
limb amputation with a clean operative field:
co-amoxiclav iv; dose: 1.2g at induction.
or:
benzylpenicillin iv; dose: 1.2g,
plus:
metronidazole iv; dose: 500mg at induction.
For lower limb amputation with a dirty operative field:
gentamicin iv; dose: 120mg, should also be given at induction.
5.0.5.10 ERCP
For
endoscopic retrograde cholangiopancreatography, in cases with no specific risk:
ciprofloxacin tabs; dose: 750mg 90mins before the procedure.
5.0.5.11
Upper gastrointestinal surgery
For upper
gastrointestinal surgery, gall bladder surgery or invasive procedures:
co-amoxiclav iv; dose: 1.2g at induction.
If “low risk” penicillin allergic:
cefuroxime iv; dose: 1.5g
plus:
metronidazole iv; dose: 500mg.
If “high risk” penicillin allergic:
discuss with Consultant Medical Microbiologist.
5.0.5.12
Colo-rectal surgery
co-amoxiclav
iv; dose: 1.2g single dose at induction. If there is excessive blood
loss (>1.5 litres) during operation or duration of surgery > 4hrs, then
repeat dose.
If “low risk” penicillin allergic:
cefuroxime iv; dose: 1.5g
plus:
metronidazole iv; dose: 500mg.
If “high risk” penicillin allergic:
discuss with Consultant Medical Microbiologist.
5.0.5.13
Urological surgery
For
urological surgery or invasive procedures:
amoxicillin iv; dose: 1g,
plus:
gentamicin iv; dose: 120mg at or just before induction,
or:
ciprofloxacin tabs; dose: 750mg 90min before the procedure.
5.0.5.14
Gynaecological procedures and caesarean sections:
co-amoxiclav
iv; dose: 1.2g at induction.
If “low risk” penicillin allergic:
cefuroxime iv; dose: 1.5g
plus:
metronidazole iv; dose: 500mg.
If “high risk” penicillin allergic:
discuss with Consultant Medical Microbiologist.
5.0.6 MRSA
Treatment
should be decided in conjunction with Consultant Medical Microbiologist.
First line therapy:
vancomycin iv; dose: 500mg to 1g
every 12hrs with level before the third dose (see 5.0.2).
5.0.7 Viral
prophylaxis
Prevention of
Varicella zoster in those at risk:
Varicella Zoster immunoglobulin
and antivirals may indicated. Please discuss
need with a Consultant Medical Microbiologist.
Prevention of recurrent infection with Herpes simplex:
aciclovir tabs: dose: 400mg every 12hrs; 400mg every 6hrs in the
immuno-compromised.
5.1
Antibacterials
5.1.1.
Penicillins
5.1.1.1
Benzyl /phenoxymethyl penicillins
First choice
(orally): Phenoxymethylpencillin tabs: (penicillin V) 250mg [20
tabs £0.88]. Dose: 250-500mg every 6hrs, 1hr before meals.:
Phenoxymethylpenicillin syrup: 125mg/5ml [100ml £1.29]; 250mg/5ml [100ml
£1.52].
First choice (parenterally): Benzylpenicillin injection: (penicillin
G) 600mg (1 megaunit) [20 vials £19.00]; 1.2g [20 vials £37.80]. Dose:
600mg by im or slow iv injection every 6hrs increased to 1.2g every 6hrs or
more frequently if needed; for bacterial endocarditis 1.2-2.4g every 4hrs by
slow iv injection.
5.1.1.2
Penicillinase-resistant penicillins
First choice:
Flucloxacillin caps: 250mg [20 caps £1.45]; 500mg [20 caps £2.59]. Dose:
250-500mg every 6hrs, 1hr before meals.
Flucloxacillin syrup: 125mg/5ml [100ml £3.13]; 250mg in 5ml [100ml £8.51].
Flucloxacillin injection: 250mg [20 vials £24.60]; 500mg [20 vials £49.00];
1g [20 vials £98.00]. Dose: by slow iv injection 250mg-1g every 6hrs; by
im injection 250mg every 6hrs.
5.1.1.3 Broad
spectrum penicillins
First choice
(orally): Amoxicillin caps: 250mg [15 caps £0.81]; 500mg [15 caps £1.04]. Dose:
250-500mg every 8hrs.
Amoxicillin syrup: 125mg/5ml [100ml £1.33]; 250mg/5ml [100ml £1.48].
Amoxicillin sachets: 3g [1 sachet £3.39]. Dose: 3g once, repeated
if needed.
First choice (parenterally): Amoxicillin injection: 500mg [20 vials
£11.80]; 1g [20 vials £23.60]. Dose: by
iv injection 500mg every 8hrs, increased to 1g every 6hrs in severe
infections; by im injection 500mg
every 8 hrs.
Also:
Co-amoxiclav tabs: 375mg (amoxicillin 250mg plus clavulanic acid 125mg) [15
tabs £2.05]. Dose: 1 tab every 8hrs.
Co-amoxiclav tabs: 625mg (amoxicillin 500mg plus clavulanic acid 125mg)
[15 tabs £4.25]. Dose: 1 tab every 8hrs.
Co-amoxiclav dispersible tabs: 375mg [15 tabs £7.01]. Dose: 1 tab every 8hrs.
Co-amoxiclav sugar free syrup: 125/31mg in 5ml [100ml £3.14]; 250/62mg in
5ml [100ml £4.30].
Also:
Co-amoxiclav injection: 600mg [15 vials £18.15]; 1.2g [15 vials £36.30].
Dose: by iv injection over 5mins 1.2g every 8hrs.
5.1.1.4
Anti-pseudomonal pencillins
Consultant
Medical Microbiologist’s Recommendation Only:
Piperacillin with tazobactam (Tazocin®): 2g/250mg [15 vials
£114.75]; 4g/500mg [15 vials £227.55]. Dose: by slow iv injection in 3
or 4 divided doses, 100-150mg/kg/day increased in severe infections to
200-300mg/kg/day.
5.1.2
Cephalosporins and other beta lactams
First choice:
Cefradine caps: 250mg [20 caps £4.26]; 500mg [20 caps £5.49]. Dose:
250-500mg every 6hrs.
Cefradine syrup: 250mg/5ml
[100ml £3.77]. (prescribe cefalexin
syrup if cefradine syrup unavailable).
Cefradine injection: 500mg [20 vials £17.76]. Dose: 500mg-1g by
iv or im injection every 6hrs.
Consultant Medical Microbiologist’s Recommendation Only:
Aztreonam injection: 1g [15 vials £143.85], 2g [15 vials £288.00]. Dose:
1-2g every 8hrs by iv injection.
Cefotaxime injection: 500mg [15 vials
£32.10]; 1g [15 vials £64.65]; 2g [15 vials £128.55]. Dose: 1-2g by iv injection every 8hrs.
Ceftazidime injection: 500mg [15 vials £66.00]; 1g [15 vials £127.50];
2g [15 vials £268.50]; 3g [15 vials £386.40]. Dose: 1-2g every 8hrs by
iv injection.
Ceftriaxone injection: 250mg [5 vials
£12.75]; 1g [5 vials £50.85]; 2g [5 vials £101.80]. Dose: see BNF.
Cefuroxime injection: 250mg [15 vials
£14.10]; 750mg [15 vials £35.10]; 1.5g [15 vials £70.50]. Dose: 750mg-1.5g by
iv injection every 8hrs.
Imipenem with Cilastatin (Primaxin®
500mg) iv injection: 500mg [15 vials £180.00]. Dose: by iv infusion over
30 to 60 mins 500mg every 6 to 8hrs.
Meropenem injection: 500mg [15 vials £128.93]; 1g [15 vials £257.85]. Dose:
by iv injection over 5 mins 500mg-1g
every 8hrs.
5.1.3
Tetracyclines
Caution:
Tetracyclines should not be given to children <12yrs, pregnant or breast
feeding women.
First choice (orally): Oxytetracycline tabs: 250mg [20 tabs 75p]. Dose:
250-500mg every 6hrs, taken 1hr before meals and not at the same time as
milk, antacids, calcium or magnesium salts.
Also:
Doxycycline caps: 50mg [6 caps 39p]; 100mg [6 caps 42p]. Dose: 200mg
initially then 100mg daily.
Doxycycline disp. tabs: 100mg [6 tabs £3.68]
5.1.4
Aminoglycosides
Serum levels
of all aminoglycosides should be monitored regularly (see
5.0.2). Doses are needed at less frequent intervals in the elderly and in those
with renal failure. Caution: Hearing should be checked clinically or by
audiogram before an aminoglycoside is given, especially if treatment is likely
to be prolonged.
First choice: Gentamicin injection: 20mg
in 2ml [15 vials £27.00]; 80mg in 2ml [15 amps £23.10]. Dose: single daily
dosing: by IV infusion over 20 to 30 mins, 4.5mg/kg once daily, adjusted
according to trough level. Note: once daily treatment is not sufficiently
evaluated in neonates, pregnancy, infective endocarditis and impaired renal
function (serum creatinine > 200 micromols/litre.
NB. iv bolus injections of gentamicin should be given over at least 3 minutes.
Also:
Tobramycin
injection: 80mg in 2ml [15 vials £62.40]. Dose
& warnings: see gentamicin above.
Neomycin sulphate tabs: 500mg [40 tabs
£8.26]. Dose: 1g every 4hrs.
Note: Oral neomycin is not absorbed so it cannot be used
for systemic infections.
5.1.5
Macrolides
First choice (orally): Clarithromycin
tabs: 250mg [10 tabs £2.34]; 500mg [10 tabs £4.47]; Dose: 250-500mg every 12hrs.
Clarithromycin suspension: 125mg/5ml
[70ml £5.58]; 250mg/5ml [70ml £11.16].
Also:
Erythromycin tabs: 250mg [20 tabs £1.32]. Dose:
250-500mg every 6hrs.
Erythromycin syrup: 125mg/5ml [100ml £1.79]; 250mg/5ml [100ml £2.39].
For uncomplicated genital chlamydia infections and non-gonococcal urethritis
Azithromycin tabs: 250mg [4 tabs £8.81].
Dose: 1g as a single dose
Azithromycin syrup: 200mg/5ml [15ml
£5.06, 30ml £13.80].
First
choice (parenterally): Clarithromycin injection: 500mg [10 vials £94.50]. Dose: by intravenous infusion into
larger proximal vein, 500mg twice daily. Reconstitute with 10ml water for
injection then add to 250ml sodium chloride 0.9% or glucose 5% and give over 60
minutes.
5.1.6
Clindamycin
Clindamycin
caps: 150mg [20 caps £18.23]. Dose: 150-300mg ever 6hrs.
Also:
Clindamycin injection: 600mg in 4ml [20 amps £247.00]. Dose: by deep
im injection or iv infusion 300mg to 600mg every 6hrs.
5.1.7 Other
antibiotics
Chloramphenicol
caps: 250mg [20 caps £125.67]. Dose: 50mg/kg/day in 4 divided doses.
Chloramphenicol injection: 1g [20 vials £27.80]. Dose:
50mg/kg/day in 4 divided doses.
Vancomycin injection: 500mg [20 vials £161.00]; 1g [20 vials £322.20]. Dose:
1g infused over at least 1hr every 12hrs. Note: serum levels must be
monitored.
Vancomycin caps: 125mg [20 caps £63.08]. Dose: 125mg every 6hrs. Note:
Oral vancomycin is not absorbed so cannot be used for systemic infection.
Colistin injection: 1 megaunit [30 vials £50.37]; 2 megaunit [30 vials
£92.79]. Dose: by im injection, iv injection or iv infusion, 2 megaunits
every 8hrs; by nebulisation, 1 megaunit every 12hrs if wt above 40kg,
500,000 units every 12hrs if wt below 40kg.
Sodium fusidate tabs: 250mg [30 tabs £16.50]. Dose: 500mg every
8hrs.
Fusidic acid suspension 250mg in 5ml [100ml £13.46]. Dose: 750mg
(15ml) every 8hrs. NB fusidic acid is
incompletely absorbed and doses recommended for suspension are proportionately
higher than those for sodium fusidate tablets.
Consultant Medical Microbiologist’s Recommendation Only:
Linezolid tabs: 600mg [20 tabs
£890.00]. Dose: 600mg every 12 hours for 10 – 14 days.
Linezolid iv infusion: 600mg [20x300ml iv bags £890.00]. Dose:
600mg given over 30 – 120 mins,every 12 hours for 10 – 14 days.
Teicoplanin inj: 200mg [7 vials £24.99]; 400mg [7 vials £42.70]. Dose:
by im or iv injection or iv infusion initially 400mg every 12 hours for 3 doses
then 200mg to 400mg daily (higher doses may be required in patients over 85kg
and in severe burns, endocarditis or MRSA).
5.1.8
Trimethoprim
First choice:
Trimethoprim tabs: 100mg [10
tabs 35p]; 200mg [10 tabs 64p]. Dose: 200mg every 12hrs.
Also:
Trimethoprim suspension; 50mg/5ml [100ml £1.60].
5.1.8.2
Co-trimoxazole
Co-trimoxazole should be limited to
the role of drug of choice in treatment and prophylaxis of Pneumocystis carinii pneumonia; it is also indicated for
toxoplasmosis and nocardiasis.
Co-trimoxazole: 480mg tablets [28
tabs £13.13]; 480mg in 5ml injection [5ml amp £1.58].
5.1.9 Antituberculous drugs
First choice:
Rifater® tabs: (rifampicin 120mg plus isoniazid 50mg plus
pyrazinamide 300mg) [30 tabs £6.59]. Dose: see BNF.
Also:
Ethambutol tabs: 100mg [20 tabs £4.11]; 400mg [20 tabs £15.26]. Dose:
see BNF.
Isoniazid tabs: 100mg [15 tabs £4.44]. Dose: 300mg daily.
Isoniazid injection 50mg in 2ml [30 amps £331.20].
Pyrazinamide tabs: 500mg [unlicensed]. Dose: 500mg every 8hrs.
Rifampicin caps: 150mg [10 caps £1.88]; 300mg [10 caps £4.18]. Dose:
600mg daily.
Rifampicin syrup: 100mg in 5ml [120ml £3.56].
Rifampicin plus isoniazid tabs: 150mg plus 100mg (Rifinah®
150) [15 tabs £2.84]; 300mg plus 150mg (Rifinah® 300, Rimactizid®
300) [10 tabs £3.75]. Dose: see BNF.
For expert use:
Rifampicin injection: 600mg [10 vials £76.70].
5.1.11
Metronidazole
First choice:
Metronidazole tabs: 200mg [15 tabs 76p]; 400mg [15 tabs 87p]. Dose:
see BNF.
Also:
Metronidazole suspension: 200mg/5ml [100ml £8.03]. Dose: see BNF.
Metronidazole suppositories: 500mg [15 suppos £18.51]; 1g [15 suppos
£27.51]. Dose: 1g every 8hrs for 3 days then 1g every 12hrs.
Also:
Metronidazole infusion: 500mg in 100ml [15 bags £18.30]. Dose:
500mg every 8hrs.
5.1.12 Quinolones
Ciprofloxacin tabs: 100mg [6 tabs
£1.26]; 250mg [10 tabs £1.04]; 500mg [10 tabs £1.16]; 750mg [10 tabs £1.90].
Dose: 250-750mg every 12hrs.
For UTIs Dose: 100mg every 12hrs for 3
days
Also:
Ciprofloxacin suspension: 250mg in 5ml [100ml £16.50]. Dose: 250-750mg every 12hrs.
For expert use:
Ciprofloxacin injection: 100mg in 50ml [10 = £80.00]; 200mg in 100ml [10 =
£150.00]; 400mg in 200ml [10 = £220.00]. Dose:
200 - 400mg twice daily by iv infusion over at least 30mins.
5.1.13
Nitrofurantoin
Nitrofurantoin
tabs: 50mg [20 tabs £1.77]; 100mg [20 tabs £0.96]. Dose: 50-100mg every
6hrs.
NB. patients should be made aware that if they develop symptoms of a dry
cough or breathlessness they should inform their doctor immediately.
5.2
Antifungals
Amphotericin
lozenges: (see 12.3.2).
Clotrimazole cream: 1%; vaginal cream 2%; vaginal cream 10%; pessaries
500mg: (see 7.2.2.1).
Fluconazole caps: 50mg [7 caps £1.00]; 150mg [1 cap £0.94]; 200mg [7
caps £1.93]; suspension 50mg/5ml [35ml £16.61]; 200mg/5ml [35ml £66.42]; infusion 50mg/25ml [7 = £52.14]; 200mg/100ml [7 = £204.96]. Dose:
Vaginal candidiasis and candidal balanitis, by mouth, a single dose of 150mg.
Mucosal candidiasis (except genital), by mouth, 50mg daily (100mg daily in
unusually difficult infections) given for 7–14 days in oropharyngeal
candidiasis (max. 14 days except in severely immunocompromised patients); for
14 days in atrophic oral candidiasis associated with dentures; for 14–30 days
in other mucosal infections (e.g. oesophagitis, candiduria, non-invasive
bronchopulmonary infections.
Tinea pedis, corporis, cruris, pityriasis versicolor, and dermal candidiasis,
by mouth, 50 mg daily for 2–4 weeks (for up to 6 weeks in tinea pedis);
max. duration of treatment 6 weeks.
Invasive candidal infections (including candidaemia and disseminated
candidiasis) and cryptococcal infections (including meningitis), by mouth or
intravenous infusion, 400mg on first day then 200–400mg daily; max. 800mg daily
in severe infections [unlicensed maximum dose]; treatment continued according
to response (at least 8 weeks for cryptococcal meningitis).
Prevention of relapse of cryptococcal meningitis in AIDS patients after
completion of primary therapy, by mouth, 200mg daily or by intravenous
infusion, 100–200mg daily.
Prevention of fungal infections in immunocompromised patients, by mouth or by
intravenous infusion, 50–400mg daily adjusted according to risk; 400mg daily if
high risk of systemic infections e.g. following bone-marrow transplantation;
commence treatment before anticipated onset of neutropenia and continue for 7
days after neutrophil count in desirable range
Miconazole cream: 2%: (see 13.10.2).
Nystatin oral suspension: 100,000 units/ml (see 12.3.2).
Nystatin tabs: 500,000 units [20 tabs
£1.56]. Dose: for intestinal candiasis
only, 1 tab every 6hrs.
For expert use:
Amphotericin liposomal infusion: (AmBisome®)
50mg [vial £96.69]. Dose: as advised by
Consultant Medical Microbiologist.
Itraconazole caps: 100mg [14 caps
£13.12]; 50mg/5ml oral liquid[150ml £46.72]. Dose: see BNF.
5.3 Antiviral
drugs
5.3.1 HIV
Infection
For Expert Use Only
Nucleoside reverse transcriptase inhibitors
Abacavir (Ziagen®): 300mg [60tabs
£221.81].
Didanosine (Videx®): 25mg [60tabs £25.56]; 125mg [30EC caps £49.16];
200mg [30EC caps £78.65];250mg [30EC caps £98.31]; 400mg [30 EC caps £157.30].
Lamivudine (Epivir®): 150mg [60tabs £152.14]; 300mg [30tabs
£167.21].
Stavudine (Zerit®): 20mg
[56caps £142.28]; 30mg [56caps £149.30]; 40mg [56caps £153.70].
Tenofovir (Viread®): 245mg [30tabs £255.00].
Tenofovir with emtricitabine (Truvada®): 245mg/200mg [30tabs
£418.50].
Zidovudine (Retrovir®): 100mg [100caps £110.98]; 250mg [40caps
£110.98]; 50mg/5ml oral solution [200ml £22.20]; 200mg/20ml iv infusion [vial
£11.14].
Ziovudine with lamivudine (Combivir®): 300mg/150mg [60tabs £318.60].
Protease inhibitors
Atazanavir (Reyataz®): 150mg
[60caps £303.38]; 200mg [60caps £303.38]; 300mg [30caps £303.38].
Indinavir (Crixivan®): 200mg [360caps £181.02]; 400mg [180caps
£181.02].
Lopinavir with ritonavir (Kaletra®): 200mg/50mg [180tabs £307.39];
400mg/100mg in 5ml oral solution [300ml £307.39].
Nelfinavir (Viracept®): 250mg [300tabs £262.51].
Ritonavir (Norvir®): 100mg [84caps £94.35]; 400mg/5ml oral solution
[450ml £403.20].
Saquinavir (Invirase®): 200mg [270caps £230.70]; 500mg [120tabs
£256.33].
Non-nucleoside reverse transcriptase inhibitors
Efavirenz (Sustiva®): 50mg [30caps £16.73]; 200mg [90caps £200.27];
600mg [30tabs £200.27]; oral solution 30mg/ml [180ml £53.84].
Nevirapine (Viramune®): 200mg [60tabs £170.00].
Other antiretrovirals
Raltegravir (Isentress): 400mg [60tabs £647.29].
Post
Exposure Prophylaxis Packs
5.3.2 Herpesvirus
infections
First choice:
Aciclovir tabs: 200mg [25 tabs £4.01]; 400mg [25 tabs £3.61]; 800mg [35
tabs £9.21]. Dose: for herpes simplex 200mg (400mg in the
immunocompromised) 5 times daily, usually for 5 days; for herpes zoster
800mg 5 times daily for 7 days.
Also:
Aciclovir suspension: 200mg in 5ml [125ml £31.32].
Aciclovir injection: 250mg [15 vials £152.25]; 500mg [15 vials £282.15].
Dose: by iv infusion over 1hr, for herpes simplex or recurrent
varicella-zoster 5mg/kg every 8hrs; for primary varicella-zoster or recurrent
disease in the immunocompromised and in herpes simplex encephalitis, 10mg/kg
every 8hrs.
5.3.3 Viral
hepatitis
Chronic Hepatitis B
Peginterferon alfa-2a (see
8.2.4) is used for the treatment of chronic hepatitis B (see NICE
guidance above) and may be preferable to interferon alfa. The use of peginterferon alfa-2a and interferon
alfa is limited by a response rate of less than 50% and relapse is frequent.
Treatment should be discontinued if no improvement occurs after 3–4 months. The
manufacturers of peginterferon alfa-2a and interferon alfa contraindicate use
in decompensated liver disease but low doses can be used with great caution in
these patients. Although interferon alfa is contra-indicated in patients
receiving immunosuppressant treatment (or who have received it recently),
cautious use of peginterferon alfa-2a may be justified in some cases.
Chronic Hepatitis C
Before starting treatment, the genotype of the infecting hepatitis C virus
should be determined and the viral load measured as this may affect choice of
treatment regimen. A combination of ribavirin and peginterferon
alfa (see
8.2.4) is used for the treatment of chronic hepatitis C. The combination
of ribavirin and interferon alfa is less
effective than the combination of peginterferon alfa and ribavirin.
Peginterferon alfa alone should be used if ribavirin is contra-indicated or not tolerated. Ribavirin monotherapy is ineffective.
NICE guidance (peginterferon alfa, interferon alfa, and ribavirin for chronic hepatitis C)
NICE has recommended (January 2004) that the combination of peginterferon alfa
and ribavirin should be used for treating moderate to severe chronic hepatitis C in
patients aged over 18 years:
(a) not previously treated with interferon alfa or peginterferon alfa;
(b) treated previously with interferon alfa alone or in combination with ribavirin;
(c) whose condition did not respond to peginterferon alfa alone or responded
but subsequently relapsed.
Peginterferon alfa alone should be used if ribavirin is contra-indicated or not tolerated. Interferon alfa for either
monotherapy or combined therapy should be used only if neutropenia and
thrombocytopenia are a particular risk. Patients receiving interferon alfa may
be switched to peginterferon alfa.
The duration of treatment depends on genotype and viral load. See above link
for full guidance.
Ribavirin: 200mg tabs (Copegus®) [42 tabs
£111.11]; 200mg caps (Rebetol®)
[42 caps £81.90]. Dose: Chronic hepatitis C
(in combination with peginterferon alfa, NB prescribe Copegus® with
Pegasys® and Rebetol® withViraferonPeg®),
body-weight under 65kg, 400mg twice daily; body-weight 65–85kg, 400mg in the
morning and 600mg in the evening; body-weight over 85kg, 600mg twice daily;
5.3.4 Influenza
Discuss with a Consultant Medical Microbiologist for
up to date information regarding management in outbreak settings.
First choice: Oseltamivir caps: 75mg [10caps £15.72]. Dose: (treatment) 75mg every 12 hours for 5
days; (prevention) 75mg once daily for at least 7 days for post-exposure
prophylaxis; for up to 6 weeks during an epidemic.
Oseltamivir suspension: 60mg/5ml [75ml £15.72].
5.3.5 Respiratory syncytial virus
Palivizumab is a monoclonal antibody licensed
for preventing serious lower respiratory-tract disease caused by respiratory
syncytial virus in children at high risk of the disease; it should be
prescribed under specialist supervision and on the basis of the likelihood of
hospitalisation. Palivizumab should be considered for children under 6 months
with haemodynamically significant left-to-right shunt congenital heart disease
or who have pulmonary hypertension. It should also be considered for children
under 2 years either with chronic lung disease requiring oxygen at home
(or have been on prolonged oxygen treatment) or with severe congenital
immunodeficiency. Palivizumab can also be used for the first 6–12 months of
life in a child born at under 35 weeks gestation who is considered by the
specialist to be at special risk of hospitalisation.
Palivizumab injection (Synagis®):
50mg [1 vial £360.40]; 100mg [1 vial £663.11]. Dose: by
intramuscular injection (preferably in anterolateral thigh),
15mg/kg once a month during season of RSV risk (child undergoing cardiac bypass
surgery, 15mg/kg as soon as stable after surgery, then once a month during
season of risk); injection volume over 1ml should be divided between more than
one site.
5.4
Antiprotozoal drugs
5.4.1 Antimalarials
For expert use:
Chloroquine phosphate: 250mg tabs (= 150mg chloroquine base) [10 tabs
61p]; Dose: see BNF.
Chloroquine sulphate: 68mg in
5ml syrup (= 50mg/5ml chloroquine base) [100ml £4.60]. Dose: see BNF.
Paludrine®/Avloclor® travel pack: (14 tabs
chloroquine plus 98 tabs primaquine) [7 week supply £8.79]
Primaquine tabs: 7.5mg (unlicensed prep) [20 tabs £18.40]. Dose:
see BNF.
Quinine dihydrochloride injection: 600mg in 2ml [10 amps £54.60]. Dose:
see BNF.
Quinine sulphate tabs: 200mg [10 tabs 71p]; 300mg [10 tabs 70p]. Dose:
see BNF.
5.4.2
Amoebicides
First choice: Metronidazole tabs: 400mg [21tabs £1.06] (see 5.1.11). Dose: 400mg
every 8hrs for 7 days followed by diloxanide furoate 500mg every 8hrs for 10
days.
For expert use:
Diloxanide tabs: 500mg [30tabs
£42.95]. Dose: 500mg every 8hrs for 10 days.
5.4.3 Trichomonas
First choice: Metronidazole tabs: 200mg [10 tabs 50p] (see 5.1.11). Dose: see BNF.
5.4.4 Giardia
First choice: Metronidazole tabs: 200mg [30 tabs £1.51] (see 5.1.11). Dose: 2g daily for 3
days or 400mg every 8hrs for 5 days.
5.4.8 Pneumocystis pneumonia
Co-trimoxazole injection: 480mg in 5ml [5ml amp £1.58]. Dose: see BNF.
Co-trimoxazole tablets: 480mg [28tabs £13.13].
Also:
Pentamidine injection: 300mg [vial
£30.45].
Pentamidine nebuliser solution: 300mg in 5ml [bottle £32.15].
5.5.Anthelmintics
5.5.1 Threadworm
First choice: Mebendazole tabs: 100mg [2 tabs 45p]. Dose: for adults and children
over 2yrs 100mg as a single dose repeated after 2-3 weeks.
Caution: mebendazole should be avoided in pregnancy, lactation and in
children under 2yrs.
Also:
Mebendazole suspension: 100mg in 5ml [30ml £1.59].
Also:
Piperazine 4g plus sennoside 15.3mg sachet: (Pripsen®) [2
sachets £1.73]. Dose: for adults and children over 6yrs, 1 sachet
repeated after 14 days.
5.5.2 Ascaris
First choice: Mebendazole tabs: 100mg [6 tabs £1.36] (see 5.5.1). Dose: 100mg twice
daily for 3 days.
5.5.3 Tapeworm
First choice: Niclosamide tabs: 500mg (unlicensed). Dose: 4 tabs as a single dose.
5.5.4 Hookworms
First choice: Mebendazole tabs: 100mg [6 tabs £1.36] (see 5.5.1). Dose: 100mg
twice daily for 3 days.
5.5.5-7 Schistosoma, filariae, Guinea worm
Expert advice needed.
5.5.8 Strongyloides
Thiabendazole tabs: 500mg (unlicensed). Dose: 25mg/kg (max 1.5g) every 12hrs for 3
days.
Also:
Albendazole tabs: 400mg (unlicensed). Dose: 400mg daily for 3 days
repeated after 3 weeks if needed.