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 Formulary Chapter 5: Infections - Full Chapter
Notes:
The development of this chapter for the George Eliot Formulary is in progress
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05.01  Antibacterial drugs
05.01  GEH Antibiotic Guidelines
 note 

Please see link below for current GEH antibiotic guidelines.

GEH Antibiotic Guidelines

05.01.01  Penicillins
 note 

The penicillins are bactericidal and act by interfering with bacterial cell wall synthesis. They diffuse well into body tissues and fluids, but penetration into the cerebrospinal fluid is poor except when the meninges are inflamed. They are excreted in the urine in therapeutic concentrations.

Diarrhoea frequently occurs during oral penicillin therapy. It is most common with broad spectrum penicillins, which can cause antibiotics associated colitis.

The most important side-effect of the penicillins is hypersensitivity which causes rashes and anaphylaxis which can be fatal.

05.01.01.01  Benzylpenicillin and phenoxymethylpenicillin
 note 

Benzylpenicillin sodium remains an important and useful antibiotic but is inactivated by bacterial beta-lactamases. Benzylpenicillin is inactivated by gastric acid and absorption from the GI tract is low; therefore it must be given by injection.

Phenoxymethylpenicillin (Penicillin V) has a similar antibacterial spectrum to benzylpenicillin sodium, but is less active. It is gastric acid stable, so is suitable for oral administration. It should not be used for serious infections because absorption can be unpredictable and plasma concentrations variable.

Benzylpenicillin
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Formulary
  • Also known as Penicillin G
  • Available injection
 
   
Phenoxymethylpenicillin
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Formulary
  • Also know as Penicillin V
  • Available as
    • Tablets
    • Oral solution
 
   
Benzylpenicillin Benzathine IM injection
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Restricted Drug Restricted
  • Available as 2.4 Mega Unit injection
  • For GUM clinic only for the treatment of early syphilis and late latent syphilis
 
   
05.01.01.02  Penicillinase-resistant penicillins to top
 note 

Most staphylococci are now resistant to benzylpenicilline because they produce penicillinases. Flucloxacillin, however, is not inactivated by these enzymes and is thus effective in infections caused by penicillin-resistant staphylococci, which is the sole indication for its use. Flucloxacillin is acid stable and can, therefore, be given by mouth as well as by injection. Flucloxacillin is well absorbed from the gut.

Flucloxacillin
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Formulary
  • Available as:
    • Capsules
    • Injection
    • Oral solution
 
Link  UKMI Q&A: Can 2g flucloxacillin be given as a slow IV
   
05.01.01.03  Broad-spectrum penicillins
Amoxicillin
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Formulary
  • Available as :
    • Tablets
    • Injection
    • Oral solution
 
   
Co-Amoxiclav
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Formulary
  • Available as:
    • Tablets
    • Injection
    • Oral solution
 
   
05.01.01.04  Antipseudomonal penicillins
Piperacillin and Tazobactam (Tazocin®)
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Formulary
  • Available as injection
  • Reintroduced to antibiotic guidelines September 2018
 
   
05.01.01.05  Mecillinams
05.01.02  Cephalosporins, carbapenems and other beta-lactums
05.01.02  Cephalosporins to top
 note 

The cephalosporins are broad-spectrum antibiotics wihich are used for the treatment of septicaemia, pneumonia, meningitis, biliary-tract infections, peritonitis and UTIs. The pharmacology of the cephalosporins is similar to that of the penicillins, excretion being principally renal. Cephalosporins penetrate the CSF poorly unless meninges are inflamed.

The principal side effect of the cephalosporins is hypersensitivity and about 0.5-6.5% of penicillin-sensitive patients will also be allergic to the cephalosporins.

Patients with a history of immediate hypersensitivigy to penicillin and other beta-lactams should not receive a cephalosporin. Cephalosporins should be used with caution in patients with sensitivity to penicillin and other beta-lactams.

05.01.02  Carbapenams
 note 

The carbapenams are beta-lactam antibacterials with a broad spectrum of activity which includes many Gram-positive and Gram-negative bacteria and anaerobes.

Avoid if history of immediate hypersensitivity reaction to beta-lactam antibacterials. Use with caution in patients with sensitivity to beta-lactam antibacterials.

05.01.02.01  Cephalosporins
Cefalexin
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Formulary
  • Available as:
    • Capsules
    • Oral solution
 
   
Cefotaxime
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Formulary
  • Available as injection
  • Used in the treatment of Spontaneous Bacterial Peritonitis in Cirrhosis as per trust guidelines
 
   
Ceftriaxone
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Formulary
  • Available as injection
 
   
05.01.02.02  Carbapenems
Ertapenem
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Restricted Drug Restricted
  • Available as injection
  • Please refer to Trust antibiotic guidelines or contact antibiotic pharmacist bleep 5038 for advice
 
   
Meropenem
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Restricted Drug Restricted
  • Available as injection
  • Please refer to Trust antibiotic guidelines or contact antibiotic pharmacist bleep 5038 for advice
 
   
05.01.03  Tetracyclines
 note 

The tetracyclines are broad spectrum antibiotics whose value has decreased owing to to increasing bacterial resistance.

Tetracyclines should not be given to pregnant women; effects on skeletal developement have been documented in the first trimester in animal studies. Administration during the second or third trimester mau cause discolouration of the child's teeth, and maternal hepatotoxicity has been reported with large parenteral doses. Tetracyclines should not be given to women who are breast-feeding (although absorption and therefore discolouration of teeth in the infant is probably prevented by chelation with calcium in milk).

Doxycycline
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Formulary
  • Available as:
    • Capsules
    • Dispersibele tablet
 
   
Lymecycline (Tetralysal® 300)
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Formulary
  • Available as capsules
  • For dermatology use
 
   
Oxytetracycline
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Formulary
  • Available as tablets
  • For dermatology use
 
   
05.01.03  Tigecycline to top
 note 

Tigecycline is a glycylcycline antibacterial structurally related to the tetracyclines. Tigecycline is active against Gram-positive and Gram-negative bacteria, including tetracycline-resistant organisms, and some anaerobes. It is aslo active against MRSA and vancomycin-resistant enterococci.

Tigecycline
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Restricted Drug Restricted
  • Available as injection
  • Restricted use - on microbiology advice only.
  • Contraindicated in patients hypersensitive to tetracyclines.
 
   
05.01.04  Aminoglycosides
 note 

The aminoglycosides are not absorbed from the gut (although there is a risk of absorption in inflammatory bowel disease and liver failure) and must therefore be given by injection for systemic infections.

Gentamicin is the aminoglycoside of choice in the UK and is used widely for the treatment of serious infections. It has a broad spectrum but is inative against anaerobes and has poor activity against haemolytic streptococci and pneumococci. When given for the 'blind' therapy of undiagnosed serious infections it is usually given with conjunction with another antibiotic.

Loading and maintenance doses of gentamicin may be calculated on the basis of the patient's weight and renal function; adjustments are then made according to serum-gentamicin concentrations. High doses are occasionally indicated for serious infections, especially in the neonate, in the patient with cystic fibrosis, or in the immunocompromised patient. Whenever possible treatment should not exceed 7 days.

Serum concentration monitoring avoids both excessive and subtherapeutic concentrations thus preventing toxicity and ensuring efficacy. Serum-aminoglycoside concentrations should be monitored in patients receiving parenteral aminoglycoside and must be determined in the elderly, in obesity, and in cystic fibrosis, or if high doses are being given, or if there is renal impairment.

Gentamicin
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Formulary
  • Available as injection
 
   
Amikacin
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Restricted Drug Restricted
  • Available as injection
 
   
Tobramycin
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Restricted Drug Restricted
  • Available as injection
 
   
05.01.05  Macrolides
 note 

The macrolides have an antibacterial spectrum that is similar but not identical to that of penicillin; they are thus an alternative in penicillin-allergic patients. They are active against many penicillin resistant staphylococci, but some are now also resistant to the macrolides.

Erythromycin causes nausea, vomiting and diarrhoea in some patients; in mild to moderate infections this can be avoided by giving a lower dose, but if a more serious infection is suspected, higher doses are needed.

With azithromycin plasma concentrtaions are very low, but tissue concentrations are much higher. It has a long tissue half-life and once daily dosage is recommended.

Clarithromycin is an erythromycin derivative with slightly greater activity than the parent compound, tissue concentrations are higher than with erythromycin. It is given twice daily.

Azithromycin
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Formulary
  • Available as:
    • Tablets
    • Capsules
    • Oral solution
  • SPECIALIST INITIATED FOR PROPHYLAXIS IN EXACERBATIONS OF COPD

 

 
   
Clarithromycin
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Formulary
  • Available as:
    • Tablets
    • Injection
    • Oral solution
 
   
Erythromycin
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Formulary
  • Available as:
    • Tablets
    • Oral solution
    • Injection Restricted Drug 
 
   
05.01.06  Clindamycin
 note 

Clindamycin is active against gram-positive cocci, including streptococci and penicillin-resistant staphylococci and also against many anaerobes. It is well concentrated in bone and excreted in bile and urine.

Clindamycin has been associated with antibiotic-associated colitis, which may be fatal. Although antibiotic-associated colitis can occur with most antibacterials, it occurs more frequently with clindamycin. If C.difficile infection is suspected or confirmed, discontinue the antibiotic if appropriate. Seek specialist advice if the antibiotic cannot be stopped and the diarrhoea is severe.

Clindamycin
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Formulary
  • Available as:
    • Tablets
    • Injection
 
   
05.01.07  Some other antibacterials
05.01.07  Chloramphenicol to top
 note 

Chloramphenicol is a potent broad spectrum antibiotic, it is associated with serious haematological side effects when given systemically and should therefore be reserved for the treatment of life-threatening infections.

Chloramphenicol
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Formulary
  • Available at injection
 
   
05.01.07  Fusidic acid
 note 

Fusidic acid and its salts are narrow-spectrum antibiotics used for staphylococcal infections.

Sodium fusidate
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Formulary
  • Available as tablets
 
   
05.01.07  Vancomycin and teicoplanin
 note 

The glycopeptide antibiotic vancomycin has bactericidal activity against aerobic and anaerobic Gram-positive bacteria.

With IV use manufacturer advises initial doses should be based on body weight; subsequent dose adjustments should be based on serum vancomycin concentrations to achieve targeted therapeutic concentrations. Frequency of monitoring depends on the clinical situation and response to treatment.

The glycopeptide antibiotic teicoplanin has bactericidal activity against aerobic and anaerobic Gram positive bacteria including multi-resistant staphylococci. Teicoplanin is similar to vancomycin, but has a significantly longer duration of action, allowing once daily administration after the loading dose.

Vancomycin
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Formulary
  • Available as:
    • Capsules
    • Injection to be used orally
    • Injection
  • For inpatients on oral vancomycin please adminster the injection orally - please see link below for guidance on preparation
 
Link  GEH Vancomycin - preparing oral doses from vials
Link  GEH Vancomycin Prescription Chart (page 1)
Link  Vancomycin Prescription Chart (page 2)
   
Teicoplanin (Targocid®)
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Restricted Drug Restricted
  • Available as injection
  • To be used only on microbiology advice
 
   
05.01.07  Daptomycin
 note 

Daptomycin is a lipopeptide antibacterial with a spectrum of activity similar to vancomycin but its efficacy against enterococci has not been established It needs to be given with other antibacterials for mixed infections involving Gram-negative bacteria and some anaerobes.

Daptomycin (Cubicin®)
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Restricted Drug Restricted
  • Available as injection
  • To be used only on microbiology advice
 
   
05.01.07  Linezolid
 note 

Linezolid an oxazolidinone antibacterial, is active acainst Gram-positive bacteria including MRSA and glycopeptide resistant enterococci. Resistance to linezolid can develop with prolonged treatment or if the dose is less than that recommended. Linezolid is not active against common Gram-negative organisms; it must be given in combination with other antibacterials for mixed infections that also involve Gram-negative organisms.

Linezolid
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Restricted Drug Restricted
  • Available as:
    • Tablets
    • Injection

Severe optic neuropathy may occur rarely, particularly if linezolid is used for longer than 28 days:

  • patients should be warded to report symptoms of visual impairment
  • patients experiencing new visual symptoms should be evaluated promptly, and referred to an opthalmologist if necessary
  • visual function should be monitored regularly if treatment is required for longer than 28 days.

Haematopoietic disorders (including thrombocytopenia, anaemia, leucopenia and pancytopenia) have been reported in patients receiving linezolid. It is recommended that FBC are monitored weekly. Close monitoring is recommended in patients who:

  • receive treatment for more than 10-14 days
  • have pre-existing myelosuppression
  • are receiving drugs that may have adverse effects on haemoglobin, blood counts or platelet funciton
  • have severe renal impairment

If significant myelosuppression occurs, treatment should be stopped unless it is considered essential, in which case intensive monitoring of blood counts and appropriate management should be implemented.

 
   
05.01.07  Polymyxins to top
Colistimethate for nebulisation (Colomycin®)
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Formulary
  • Available as injection (Colomycin® brand licensed for nebulisation)
 
   
05.01.07  Rifaximin
Rifaximin (Targaxan®)
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Formulary
Amber SC
  • Available as tablets
  • For use in recurrent hepatic encephalopathy as per NICE TA337
 
Link  NICE TA337: Rifaximin for preventing episodes of overt hepatic encephalopathy
Link  Rifaxamin - Shared Care Agreement
   
05.01.07  Fidaxomicin
Fidaxomicin
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Restricted Drug Restricted
  • Available as tablets
  • Restricted for the treatment of C.difficile as per trust guidelines
 
   
05.01.08  Sulphonamides and trimethoprim
 note 

Sulfamethoxazole and trimethoprim are used in combination (as co-trimoxazole) because of their synergistic activity (the importance of the sulfonamides has decreased as a result of increasing bacterial resistance and their replacement by antibacterials which are generally more active and less toxic). Co-trimoxazole is the drug of choice in the prophylaxis and treament of Pneumocystis jirovecii (Pneumocystic carinii) pneumonia. It should only be considered for use in acute exacerbations of chronic bronchitis and infections of the urinary tract when there is bacteriological evidence of sensitivity to co-trimoxazole and good reason to prefer this combination to a single antibacterial; similarly it should only be used in acute otitis media in children when there is good reason to prefer it.

Co-trimoxazole is associated with rare but serious side effects, discontinue immediately if blood disorders or rash develop.

Co-trimoxazole
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Formulary
  • Available as:
    • Tablets
    • Oral solution
    • Injection
 
Link  UKMI Q&A: How to prepare and administer intravenous co-trimoxazole in fluid restricted patients?
   
Trimethoprim
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Formulary
  • Available as:
    • Tablets
    • Oral solution
  • 2nd line treatment for UTI
 
   
05.01.09  Antituberculosis drugs
 note 

Active tuberculosis is treated in two phases - an initial phase using for drugs and a continuation phase using two drugs in fully sensitive cases. There are two regimens recommneded for the treatment of TB in the UK; variations occur in other countries. Either the unsupervised regimen or the supervised regimen should be used. Compliance with therapy is a major determinant of its success.

Initial phase

The concurrent use of four drugs during the initial phase is designed to reduce the bacterial population as rapidly as possible and prevent the emergence of drug-resistant bacterial. The drugs are best given as fixed-dose, combination preparations unless one of the components cannot be given because of resistance or intolerance. The treatment of choice for the initial phase is the daily use of rifampicin, ethambutol, pyrizinamide and isoniazid (with pyridoxine for prophylaxis of isoniazid induced neuropathy). This initial phase of treatment should be continued for 2 months.

Continuation phase

After the initial phase, daily treatment is continued for a further four months with rifampicin and isoniazid (preferably given as a combination product) with pyridoxine.

Please refer to table in BNF 'recommended dosage for standard unsupervised 6-month treatment' & 'recommended dosage for intermittent supervised 6-month treatment'.

Major causes of treatment failure are incorrect prescribing by the physician and inadequate compliance by the patient.

Ethambutol
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Formulary
  • Available as tablets
  • Patients who cannot understand warnings about visual side-effects should, if possible, be given an alternative drug. In particular, ethambutol should be used with caution in children until they are at least 5 years old and capable of reporting symptomatic visual changes accurately.
  • Ocular toxicity is more common where excessive dosage is sued or if the patient's renal function is impaired. Early discontinuation of the drug is almost always followed by recover of eyesight.
  • The earliest features of ocular toxicity are subjective and patients should be advised to discontinue therapy immediately if they develop deterioration in vison and promptly seek further advice.
 
   
Isoniazid
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Formulary
  • Available as tablets
  • Peripheral neuropathy is more likely to occur where there are pre-existing risk factors such as diabetes, alcohol dependence, chronic renal failure, pregnancy, malnutrition and HIV infection. In patients at increased risk of peripheral neuropathy, pyridoxine whould be given prophylactically from the start.
  • Patients/carers should be told how to recognise signs of liver disorder, and advised to discontinue treatment and seek immediate medical attention if symptoms such as persistent nausea, vomiting, malaise or jaundice develop.
 
   
Pyrazinamide
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Formulary
  • Available as tablets
  • Patients/carers should be told how to recognise signs of liver disorder and advised to discontinue treatment and seek immediate medical attention if symptoms such as persistent nausea, vomiting, malaise or jaundice develop.
 
   
Rifabutin (Mycobutin®)
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Formulary
  • Available as capsules
 
   
Rifampicin
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Formulary
  • Available as:
    • Capsules
    • Oral solution
    • Injection
  • Patients/carers should be advised that rifampicin discolours soft contact lenses.
  • Patients/carers should be told how to recognise signs of liver disorder, and advised to discontinue treatment and seek immediate medical attention if symptoms such as persistant nausea, vomiting, malaise or jaundice develop.
 
   
Rifampicin and Isoniazid (Rifinah® 300)
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Formulary
  • Available as tablets
 
   
Rifampicin and Isoniazid (Rifinah® 150)
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Formulary
  • Available as tablets
 
   
Rifampicin and Isoniazid and Pyrazinamide (Rifater®)
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Formulary
  • Available as tablets
 
   
05.01.11  Metronidazole to top
 note 

Metronidazole is an antimicrobial drug with high activity against anaerobic bacteria and protozoa.

Metronidazole is well absorbed orally and the intravenous route is normally reserved for severe infections. Metronidazole by the rectal route is an effective alternative to the intravenous route when oral administration is not possible.

Metronidazole
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Formulary
  • Available as:
    • Tablets
    • Oral solution
    • Suppositories
    • Injection
  • Oral solution is not suitable for any patients with an enteral tube that does not end in the stomach (NJ/PEJ/PEGJ) - in such instances use tablets which will crush and disperse in water.
 
   
05.01.12  Quinolones
 note 

The CSM has warned that quinolones may induce convulsions in patients with or withoug a history of convulsions; taking NSAIDs at the same time may also induce them

Tendon damage (including rupture) has been reported rarely in patients receiving quinolones. Tendon rupture may occur within 48 hours of starting treatment; cases have also been reported several months after stopping a quinoone. Healthcare professionals are reminded that:

  • quinolones are contra-indicated in patietns with a history of tendon disorders related to quinolone use
  • patients over 60 years of age are more prone to tendon damage
  • the risk of tendon damage is increased by the concomitant use of corticosteroids
  • if tendinits is suspected, the quinolone should be discontinued immediately.

Quinolones cause arthropathy in the weight-bearing joints of immature animals and are therefore generally not recommended in children and growing adolescents. However, the significance of this effect in humans is uncertain and in some specific circumstances short term use of ciprofloxacin may be justified in children.

Please see link below for new restrictions following review of disabling and potentially long-lasting side effects:

https://www.ema.europa.eu/documents/press-release/fluoroquinolone-quinolone-antibiotics-prac-recommends-restrictions-use_en.pdf

Ciprofloxacin
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Formulary
  • Available as:
    • Tablets
    • Oral solution
    • Injection
  • Oral solution should not be used for administration via enteral feeding tubes as the beads can cause blockages. Instead disperse tablets, also stop the feed for one hour prior and post administration otherwise absorption of ciprofloxacin is markedly reduced.
 
Link  New prescribing restrictions following review of disabling and potentially long-lasting side effects
   
05.01.13  Urinary-tract infections
 note 

Urinary tract infection is more common in women than in men; when it occurs in men there is frequently an underlying abnormality of the renal tract.

Uncomplicated UTI

  • If a patient presents with clinical signs/symptoms of UTI or urosepsis please ensure that an MSU sample is sent for routine microscopy and culture.
  • Please DO NOT treat patients for UTI purely on the basis of a positive urine dip result.
  • Urine dip test is only useful to RULE OUT urinary tract infection.
  • If patient has recurrent UTIs, please discuss that case with Microbiology and DO NOT prescribe prophylactic antibiotics.

UTI in Pregnancy

  • Send MSU for culture
  • Treat for 7 days with an oral antibiotic according to results of sensitivity tests.

Antibiotics that are regarded as suitable for use in pregnancy include: cefalexin and amoxicillin (once sensitivity results are available). Nitrofurantoin; do not use close to term as can cause haemolysis in patients with G6PD deficiency. Foetal erythrocytes have little reduced glutatione and there is a theoretical possibility that haemolysis may occur. Trimethoprim; do not use in first trimester or if the pregnant patient is folate-deficient, has a predisposition to folate-deficiency, or is taking another folate antagonist such as an anti-epileptic of proguanil.

Complicated UTI

  • A complicated UTI is defined as a UTI in the presence of an underlying structural abnormality of the renal tract.
  • Urine cultures should be sent to guide targeted antibiotic therapy in all cases.

Catheter-assiciated UTI

  • Patients with a urinary catheter in-situ may have asymptomatic bacteriuria.
  • Unless patient is symptomatic of catheter-associated UTI or systemically septic please DO NOT institure empiric antibiotic treatment.
  • DO NOT initialte antibiotic treatment based on a positive dipstick result only.
  • Please ensure that:
    • catheters are only inserted for appropriate indications
    • catheters are in-situ for only as long as needed
    • catheter insertion is undertaken with aseptic technique
    • following catheter insertion, a closed drainage system is maintained
    • unobstructed urine flow is maintained
    • hand hygeine and standard IP&C precautions are taken when handling the catheter.

Antimicrobial selection should be based upon the culture results when available

Nitrofurantoin
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First Choice
  • Available as:
    • Modified release capsules (preference)
    • Tablets/Capsules
    • Oral solution
  • Oral solution is very expensive, please crush and disperse the standard release tablets where possible
  • Avoid if patients creatinine clearance is <45ml/min.
 
Trimethoprim
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Second Choice

See section 5.1.8

 
   
05.02  Antifungal drugs
05.02.01  Triazole antifungals
 note 

Triazole antifungal drugs have a role in the prevention and systemic treatment of fungal infections. Fluconazole is very well absorbed after oral administration. It also achieves good penetration into the CSF to treat fungal meningitis. Fluconazole is excreted largely unchaged in the urine and can be used to treat candida.

Fluconazole
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Formulary
  • Available as:
    • Capsules
    • Oral solution
    • Injection
 
   
05.02.02  Imidazole antifungals to top
 note 

The imidazole antifungals include clotrimazole which is used for the local treatment of vaginal candidiasis and for dermatophyte infections. Miconazole can be used locally for oral infections; it is also effective in intestinal infections. Systemic absorption may follow use of miconazole oral gel and may result in significant drug interactions.

05.02.03  Polyene antifungals
 note 

The polyene antifungals include amphotericin and nystatin; neither drug is absorbed when given by mouth. Nystatin is used for oral, oropharyngeal and perioral infections by local application in the mouth. Amphotericin by IV infusion is used for the treatment of systemic fungal infections and is active against most fungi and yeasts. It is highly protein bound penetrates poorly into body fluids and tissues. When given parenterally amphotericin is toxic and side effects are common (lipid formulations are significantly less toxic).

Amphotericin (AmBisome®)
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Restricted Drug Restricted
  • Available as injection
 
   
05.02.04  Echinocandin antifungals
 note 

The echinocandin antifungals include caspofungin, they are only active against Aspergillus spp. and Candiada spp. Echinocandins are not effective against fungal infections of the CNS.

Caspofungin (Cancidas®)
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Restricted Drug Restricted
  • Available as injection
 
   
05.02.05  Other antifungals
05.03  Antiviral drugs
Zanamivir 10mg/ml solution for infusion (Dectova ®)
(20ml vial)
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Formulary
Amber SC
High Cost Medicine

https://www.gov.uk/government/publications/influenza-treatment-and-prophylaxis-using-anti-viral-agents

Dominant circulating strain has a higher risk of Oseltamivir resistance, eg A(H1N1)pdm09

Complicated Influenza

Consider Zanamivir IV if patients:

- cannot use inhaled Zanamivir

- have severe complicated illness such as multi-organ failure

- note: commence as soon as possible and usually within 6 days

Or

Dominant circulating strain has a lower risk of Oseltamivir resistance, eg A(H1N1)pdm09

Complicated Influenza

Consider switching to Zanamivir if:

- Poor clinical response

-evidence of gastrointestinal dysfunction

-subtype testing confirms a strain with potential Oseltamivir resistance, eg A(H1N1)pdm09

 
   
05.03.01  HIV infection to top
 note 

Treatment aims to prevent the mortality and morbidity associated with chronic HIV infection whilst minimising drug toxicity. Although it should be started before the immune system is irreversibly damaged, the need for early drug treatment should be balanced against the risk of toxicity. Commitment to treatment and strict adherence over many years are required; the regimen chosen should take into account convenience and patient tolerance. Treatment also reduces the risk of HIV transmission to sexual partners, but the risk is not eliminated completely.

The optimum time for initiating antiretroviral treatment depends primarily on the CD4 cell count. The timing and choice of treatment should also take account of clinical symptoms, comorbidities and the possible effect of antiretroviral drugs on factors such as the risk of CV events. Treatment includes a combination of drugs known at 'highly active antretroviral therapy'.

Lamivudine and Dolutegravir (Dovato ®)
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Formulary
Amber SC
NHS England
  • Available as tablets
  • Manufacturer recommends Dolutegravir should not be prescribed to women who are trying to become pregnant and should be excluded in women of child bearing potential with pregnancy testing before commencement.
  • Women of child bearing potential should be advised to use effective contraception throughout treatment.
  • If pregnancy is confirmed in the first Trimesterwhilst a woman is taking Dolutegravir, switch to an alternative treatment unless there is no suitable alternative.

 

Two drug regimen and is non inferior to the three drug regimen

Less Renal toxicity

Lower cardiovascular risk

Low resistance

Good Tolerability

Small size tablet for compliance

 
   
05.03.01  Nucleoside reverse transcriptase inhibitors
Abacavir
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Formulary
  • Available as tablets
  • Life-threatening hypersensitivity reactions have ben reported - characterised by fever or rash and possibly nausea, vomithing, diarrhoea, abdominal pain, dyspnoea, cough, lethargy, malaise, headache and myalgia; less frequently mouth ulceration, oedema, hypotension, sore throat, acute respiratory distress syndrome, anaphylaxis, parasthesia, arthralgia, conjunctivitis, lymphadenopathy, lymphocytopenia and renal failure; rarely myolysis. Laboratory abnormalities may include raised LFTs and CK; symptoms usually appear in the first 6 weeks, but may occur at any time.
  • Discontinue immediately if any symptom of hypersensitivity develops and do not rechallenge (risk of more severe reaction).
 
   
Abacavir and Lamivudine (Kivexa®)
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Formulary
  • Available as tablets
 
   
Abacavir with Lamivudine and DolutegravirBlack Triangle (Triumeq®)
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Formulary
  • Available as tablets
  • If a dose is more than 20 hours late, the missed dose should not be taken an the next dose should be taken at the normal time.
 
Link  MHRA/CHM advice: Dolutegravir (Tivicay, Triumeq, Juluca): signal of increased risk of neural tube defects; do not prescribe to women seeking to become pregnant; exclude pregnancy before initiation and advise use of effective contraception
   
Bictegravir with Emtricitabine and Tenofovir Alafenamide (Biktarvy ®)
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Formulary
  • Available as tablets
  • Manufacturer advises if a missed dose is more than 18 hours late, the missed dose should not be taken and the next dose should be taken at the normal time
 
   
Darunavir with Cobicistat, Emtricitabine and Tenofovir Alafenamide (Symtuza ® )
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Formulary
Amber SC
High Cost Medicine
NHS England
  • Available in tablets
  • Pharmacokinetic data show mean exposure of Darunavir boosted with Cobicistat (available in combination in Rezolasta and Symtuza) to be lower during 6-12 weeks postpartum. Low Darunavir exposure may be associated with an increased risk of HIV-1 transmission to the unborn child.
 
   
Elvitegravir with cobicistat, emtricitabine and tenofovir alafenamideBlack Triangle (Genvoya®)
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Formulary
  • Available as tablets
  • Manufacturer advises effective contraception in women of childbearing potential; if using a hormonal contraceptive, it must contain drospirenone or norgestimate as the progestogen and at least 30mcg ethinylestradiol.
  • If a dose is more than 18 hours late, the missed dose should not be taken and the next dose should be taken at the normal time.
  • Patients and carers should be counselled on the effects on driving and performance of skilled tasks due to the increased risk of dizziness.
 
   
Elvitegravir with cobicistat, emtricitabine and tenofovir disoproxilBlack Triangle (Stribild®)
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Formulary
  • Available as tablets
  • Women of child-bearing potential should use effective contraception during treatment (if using a hormonal contraceptive, it must contain norgestimate as the progestogen and at least 30mcg ethinylestradiol).
  • If a dose is more than 18 hours late, the missed dose should not be taken and the next dose should be taken at the normal time.
 
   
Emtricitabine (Emtriva®)
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Formulary
  • Available as capsules
  • If a dose is more than 12 hours late, the missed dose should not be taken and the next dose should be taken at the normal time.
 
   
Emtricitabine with rilpivirine and tenofovir alafenamideBlack Triangle (Odefsey®)
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Formulary
  • Available as tablets
  • Patients and carers should be counselled on the effects on driving and performance of skilled tasks due to the increased risk of dizziness.
  • If vomiting occurs within 4 hours of taking a dose, a replacement dose should be taken.
 
   
Emtricitabine with tenofivir alafenamideBlack Triangle (Descovy®)
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Formulary
  • Available as tablets
  • Patients and carers should be counselled on the effects on driving and performance of skilled tasks due to the increased risk of dizziness.
 
   
Emtricitabine with tenofivir disoproxil (Truvada®)
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Formulary
  • Available as tablets
  • Patients with swallowing difficulties may disperse tablet in half a glass of water, orange juice, or grape juice (but bitter taste).
  • If a dose is more than 12 hours late, the missed dose should not be taken and the next dose should be taken at the normal time.
 
   
Emtricitabine, Rilpivirine and Tenofovir  (Eviplera®)
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Formulary
  • Available as tablets
  • If a dose is more than 12 hours late, the missed dose should not be taken and the next dose should be taken at the normal time.
 
   
Lamivudine oral solution (Epivir®)
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Restricted Drug Restricted
  • Lamivudine oral solution is not stocked in pharmacy but can be ordered in for use in neonates (2nd line agent for PEP in neonates as per BHIVA guidelines)
 
   
Lamivudine tablets (Epivir®)
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Formulary  
   
Tenofovir Disproxil (Viread®)
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Formulary
  • Available as tablets
  • If a dose in more than 12 hours late, the missed dose should not be taken and the next dose should be taken at the normal time.
 
Link  NICE CG165: Hepatitis B (chronic) - incorporates TA173
Link  NICE TA173: Tenofovir disoproxil for the treatment of chronic hepatitis B
   
Tenofovir, Efavirenz and Emtricitabine  (Atripla®)
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Formulary
  • Available as tablets
  • If a dose is more than 12 hours late, the missed dose should not be taken and the next dose should be taken at the normal time.
 
   
Zidovudine oral solution (Retrovir®)
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Restricted Drug Restricted
  • Zidovudine oral solution is not stocked in pharmacy but can be ordered in for use in neonates (1st and 2nd line agent for PEP in neonates as per BHIVA guidelines)
 
   
05.03.01  Protease inhibitors
Atazanavir (Reyataz®)
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Formulary
  • Available as capsules
  • Mild to moderate rash occurs commonly, usually within the first 3 weeks of therapy. Severe rash occurs less frequently and may be accompanied by systemic symptoms. Discontinue if severe rash develops.
 
   
Atazanavir with cobicistatBlack Triangle (Evotaz®)
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Formulary
  • Available as tablets
 
   
Darunavir (Prezista®)
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Formulary
  • Available as tablets
  • Mild to moderate rash occurs commonly, usually within the first 4 weeks of therapy and resolvees without stopping treatment. Severe skin rash (including Stevens-Johnson symtrom and toxic epidermal necrolysis) occurs less frequently and may be accompanied by fever, malaise, arthralgia, myalgia, oral lesions, conjunctivitis, hepatitis or eosinophilia; treatment should be stopped if this develops.
  • If a dose is more than 6 hours late on the twice daily regimen (or more than 12 hours late on the once daily regimen), the missed dose should not be taken and the next dose should be taken at the normal time.
 
   
Darunavir with cobicistatBlack Triangle (Rezolsta®)
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Formulary
  • Available as tablets
 
   
Ritonavir (Norvir®)
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Formulary
  • Available as tablets
 
   
05.03.01  Non-nucleoside reverse transcriptase inhibitors
Efavirenz (Sustiva®)
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Formulary
  • Available as tablets
  • Rash usually in the first 2 weeks, is the most common side-effect; discontinue if sever rash with blistering, desquamation, mucosal involvement or fever; if rash mild or moderate, may continue withoug interruption - usually resolves within 1 month.
  • Administration at bedtime especially in the first 2-4 weeks reduces CNS effeccts.
  • Patients or their carers should be advised to seek immediate medical attention if symptoms such as sever depression, psychosis or suicidal ideation occur.
 
   
Nevirapine oral solution (Viramune®)
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Restricted Drug Restricted
  • Nevirapine oral solution is not stocked in pharmacy but can be ordered in for use in neonates (2nd line agent for PEP in neonates as per BHIVA guidelines)
 
   
Nevirapine tablets (Viramune®)
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Formulary
  • Potentially life-threatening hepatoxicity including fatal fulminant hepatitis reported usually in first 6 weeks; discontinue permanently if abnormalities in LFTs accompanied by hypersensitivity reaction; suspend if severe abnormalities in LFTs but no hypersensitivity reaction - discontinue permanently if significant liver function abnormalities recur; monitor patient closely if mild to moderate abnormalities in LFTS with no hypersensitivity reaction.
  • Rash usually in the first 6 weeks is the most common side effect; incidence reduced if introduced at low dose and dose increased gradually over 14 days. Discontinue permanently if severe rash or if rash is accompanied by blistering, oral lesions, conjunctivitis, facial oedema, general malaise or hypersensitivity reaction. If rash mild or moderate may continue without interruption but dose hould not be increased until rash resolves.
  • Patients or their carers should be told how to recognise hypersensitivity reactions and advised to discontinue treatment and seek immediate medical attention if severe skin reactions or symptoms of hepatitis develop.
  • If a dose is more than 8 hours late with the 'immediate release' preparation or more than 12 hours late with teh 'modified release' preparation, the missed dose hsould not be taken and the next dose should be taken at the usual time.
 
   
Rilpivirine hydrochloride (Edurant®)
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Formulary
  • Available as tablets
  • If a a dose is more than 12 hours late, the missed dose should not be taken and the next dose should be taken at the normal time.
 
   
05.03.01  Other antiretrovirals
DolutegravirBlack Triangle (Tivicay®)
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Formulary

Dolutegravir is a HIV-integrase inhibitor

  • Available as tablets
  • Hypersensitivity reactions (including severe rash, or rash accompanied by fever, malaise, arthralgia, myalgia, blistering, oral lesions, conjunctivitis, angiodema, eosinophilia or raised LFTs) reported uncommonly. Discontinue immediately if any sign or symptoms of hypersensitivity reactions develop.
  • If a dose is more than 20 hours late on the once daily regimen or more than 8 hours late on the twice daily regimen, the missed dose should not be taken and the next dose should be taken at the normal time.
 
Link  MHRA/CHM advice: Dolutegravir (Tivicay, Triumeq, Juluca): signal of increased risk of neural tube defects; do not prescribe to women seeking to become pregnant; exclude pregnancy before initiation and advise use of effective contraception
   
Maraviroc
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Formulary

Maraviroc is an antagonist of the CCR5 chemokine receptor.

  • Available as tablets
 
   
Raltegravir (Isentress ®)
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Formulary

Raltegravir is a HIV-integrase inhibitor

  • Available as tablets
  • Rash occurs commonly, discontinue if severe rash accompanied by fever, malaise, arthralgia, myalgia, blistering, mouth ulceration, conjunctivitis, angiodema, hepatitis or eosinophilia.
 
   
05.03.02  Herpesvirus infections to top
05.03.02.01  Herpes simplex and varicella-zoster infection
 note 

The two most important herpesvirus pathogens are herpes simplex virus and varicella-zoster virus.

Herpes simplex infections

Herpes infection of the mouth and lips and in the eye is generally associated with (HSV-1); other areas of the skin may also be infected, especially in immunodeficiency. Genital infection is most often associated with HSV-2 and also HSV-1. Treatment of herpes simplex infection should start as early as possible and usually within 5 days of the appearance of the infection. In individuals with good immune function, mild infection of the eye (ocular herpes) and of the lips (herpes labialis or cold sores) is treated with a topical antiviral drug. Severe infection, neonatal herpes infection or infection in immunocompromised individuals requires treatment with a systemic antiviral drugs. Primary or recurrent genital herpes simplex infection is treated an antiviral drug given by mouth.

Varicella-zoster infections

Regardless of immune function and the use of any immunoglobulins, neonates with chickenpox should be treated with a parenteral antiviral to reduce the risk of severe disease. Oral therapy in children is not recommended as absorption is variable. Chickenpox in otherwise healthy children between 1 month and 12 years is usually mild and antiviral treatment is not usually required. Chickenpox is more severe in adolescents  and adults than in children; antiviral treatment started within 24 hours of the onset of rash may reduce the duration and severity of symptoms in otherwise healthy adults and adolescents. Antiviral treatment is generally recommended in immunocompromised patients and those at special risk (e.g. because of severe CV or respiratory disease or chronic skin disorder); in such cases, an antiviral is given for 10 days with at least 7 days of parenteral treatment.

In herpes zoster (shingles) systemic antiviral treatment can reduce the severity and duration of pain, reduce complications, and reduce viral shedding. Treatment with the antiviral should be started within 72 hours of the onset of rash and is usually continued for 7-10 days. Immunocompromised patients at high risk of disseminated or severe infection should be treated with a parenteral antiviral drug.

Aciclovir
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Formulary
  • Available as:
    • Tablets
    • Dispersible tablets
    • Oral solution
    • Injection
 
   
Valaciclovir (Valtrex®)
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Formulary
  • Available as tablets
 
   
05.03.03  Viral hepatitis
 note 

Treatment for viral hepatitis should be initiated by a specialist. The management of uncomplicated acute viral hepatitis is largely symptomatic.

05.03.03.01  Chronic hepatitis B
Peginterferon alfa (Pegasys®)
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Formulary
  • Available as injection
 
   
05.03.03.02  Chronic hepatitis C
DaclatasvirBlack Triangle (Daklinza®)
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Formulary
Red SO
  • Available as tablets
  • If a dose is more than 20 hours late, the missed dose shold not be taken an the next dose should be taken at normal time.
  • May affect performance of skilled tasks (e.g. driving).
 
Link  MHRA/CHM advice: Direct-acting antiviral interferon-free regimens to treat chronic hepatitis C: risk of hepatitis B reactivation
Link  MHRA/CHM advice: Direct-acting antivirals for chronic hepatitis C: risk of hypoglycaemia in patients with diabetes
Link  MHRA/CHM advice: Direct-acting antivirals to treat chronic hepatitis C: risk of interaction with vitamin K antagonists and changes in INR
Link  NICE TA364: Daclatasvir for treating chronic hepatitis C
   
DasabuvirBlack Triangle (Exviera®)
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Formulary
Red SO
  • Available as tablets
 
Link  Ombitasvir–paritaprevir–ritonavir with or without dasabuvir for treating chronic hepatitis C
   
Elbasvir with grazoprevirBlack Triangle (Zepatier®)
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Formulary
Red SO
  • Available as tablets
  • Patients and their carers should consult a healthcare professional if signs and symptoms of hepatic dysfunction occur (including fatigue, weakness, lack of appetite, nausea and vomiting, jaundice or discoloured faeces).
  • If vomiting occurs within 4 hours of a dose, an additional dose should be taken.
  • If a dose is more than 16 hours late, the missed dose should not be taken and the next dose should be taken at the normal time.
 
Link  MHRA/CHM advice: Direct-acting antiviral interferon-free regimens to treat chronic hepatitis C: risk of hepatitis B reactivation
Link  MHRA/CHM advice: Direct-acting antivirals for chronic hepatitis C: risk of hypoglycaemia in patients with diabetes
Link  MHRA/CHM advice: Direct-acting antivirals to treat chronic hepatitis C: risk of interaction with vitamin K antagonists and changes in INR
Link  NICE TA413: Elbasvir–grazoprevir for treating chronic hepatitis C
   
Ombitasvir with paritaprevir and ritonavirBlack Triangle (Viekirax®)
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Formulary
Red SO
  • Available as tablets
  • If a dose is more than 12 hours late, the missed dose should not be taken and the next dose should be taken at the normal time.
 
Link  MHRA/CHM advice: Direct-acting antiviral interferon-free regimens to treat chronic hepatitis C: risk of hepatitis B reactivation
Link  MHRA/CHM advice: Direct-acting antivirals for chronic hepatitis C: risk of hypoglycaemia in patients with diabetes
Link  MHRA/CHM advice: Direct-acting antivirals to treat chronic hepatitis C: risk of interaction with vitamin K antagonists and changes in INR
Link  NICE TA365: Ombitasvir–paritaprevir–ritonavir with or without dasabuvir for treating chronic hepatitis C
   
Ribavirin
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Formulary
  • Available as tablets
  • Exclude pregnancy before treatment in females of childbearing age. Effective contraception is essential during treatment and for 4 months after treatment in females and for 7 months after treatment in males of childbearing age. Routine monthly pregnancy tests recommended. Condoms must be used if partner of male patient is pregnant (ribavirin excreted in semen). 
 
Link  NICE TA75: Hepatitis C - pegylated interferons, ribavirin and alfa interferon
Link  NICE TA106: Hepatitis C - peginterferon alfa and ribavirin
Link  NICE TA200: Hepatitis C - peginterferon alfa and ribavirin
Link  NICE TA300: Hepatitis C (children and young people) - peginterferon alfa and ribavirin
   
Sofosbuvir with ledipasvirBlack Triangle (Harvoni®)
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Formulary
Red SO
  • Available as tablets
  • If vomiting occurs within 5 hours of administration, an additional dose should be taken.
  • If a dose is more than 18 hours late, the missed dose should not be taken and the next dose should be taken at the normal time.
  • Manufacturer advises reduce dose of concurrent H2 receptor antagonist if above a dose comparable famotidine 40mg daily.
  • Manufacturer advises reduce dose of concurrent PPI if above a dose comparable to omeprazole 20mg; take at the same time as sofosbuvir with ledipasvir.
 
Link  NICE TA363: Ledipasvir–sofosbuvir for treating chronic hepatitis C
   
Sofosbuvir with velpatasvirBlack Triangle (Epclusa®)
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Formulary
Red SO
  • Available as tablets
  • If vomiting occurs within 3 hours of administration, an additional dose should be taken.
  • Manufacturer advises reduce dose of concurrent H2-receptor antagonist if above a dose comparable to famotidine 40mg twice daily.
  • Manufacturer advises reduce dose of concurrent PPI if above a dose comparable to omeprazole 20mg; take 4 hours after sofosbuvir with velpatasvir.
 
Link  NICE TA430: Sofosbuvir–velpatasvir for treating chronic hepatitis C
   
05.03.04  Influenza to top
Oseltamivir (Tamiflu®)
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Formulary
  • Available as:
    • Capsules (can be opened and dispersed in water)
    • Oral solution
 
Link  NICE TA158: Oseltamivir, amantadine (review) and zanamivir for the prophylaxis of influenza
Link  NICE TA168: Amantadine, oseltamivir and zanamivir for the treatment of influenza
Link  UKMI Q&A: Can mothers breastfeed after taking oseltamivir and zanamivir
Link  UKMI Q&A: Can oseltamivir be taken by patients taking methotrexate?
   
Zanamivir inhalation (Relenza®)
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Formulary  
Link  NICE TA158: Oseltamivir, amantadine (review) and zanamivir for the prophylaxis of influenza
Link  NICE TA168: Amantadine, oseltamivir and zanamivir for the treatment of influenza
   
05.03.05  Respiratory syncytial virus
Palivizumab (Synagis®)
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Restricted Drug Restricted
  • Available as injection
  • Restricted for Respiratory Syncytial Virus (RSV) in paediatrics
 
   
05.04  Antiprotozoal drugs
05.04.01  Antimalarials
 ....
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

Red SO

SPECIALIST ONLY - These drugs are deemed to be not appropriate for prescribing by GPs. Specialists should not ask GPs to prescribe these drugs.   

Green SI

SPECIALIST INITIATED - These drugs must be initiated, i.e. the first dose prescribed, by the specialist and then may be continued when appropriate by the patients GP following communication from the specialist.   

Green SA

SPECIALIST ADVISED – Specialists may simply advise a patients GP to initiate these drugs themselves after they have made an initial assessment.   

Amber SC

SHARED CARE - Responsibility for prescribing may be transferred from secondary to primary care with the agreement of an individual GP and when agreed shared care arrangements have been established. The specialist MUST stabilize the patient before asking for care to be transferred. Only specialists should initiate these drugs. Prescribing should be transferred to GPs according to an Shared Care Agreement [SCA]   

netFormulary