Restricted antimicrobials
The following agents are restricted and may be used only for use in certain conditions or by certain clinical specialties, or after approval by a Consultant
Microbiologist. See table below for details.
Partially restricted agents (amber agents) can be used for specific indications. Other uses require approval by a Consultant Microbiologist .
Restricted agents (red agents) require approval by a Consultant Microbiologist for all use.
Approval should be sought by discussing with a Consultant Microbiologist during working hours. Out of hours and at weekends, these agents may be
commenced but approval must be sought the first subsequent working day.
Restricted agents are subject to enhanced surveillance by pharmacy to ensure that prescriptions are appropriate.
*Non formulary agents require authorisation from Chief Pharmacist in addition to requirements below.
CLASS
AGENT
Aminoglycosides
Carbapenems
RESTRICTION
CATEGORY
Partial (amber)
APPROVED INDICATIONS
NOTES
Amikacin
FORMULARY
AGENT?
Y
Infections due to gentamicinresistant bacteria
Streptomycin
Y
Partial (amber)
Tobramycin
Y
Partial (amber)
-TB
-Bacterial endocarditis
Cystic fibrosis
Paediatrics
Ertapenem
Y
Partial (amber)
Amikacin assays are referred
externally for testing and results
will have a longer turnaround time
as compared to gentamcin
-On advice of chest physician
-On advice of Microbiologist
Tobramycin assays are referred
externally for testing and results
will have a longer turnaround time
as compared to gentamcin
Outpatient IV (OPAT) antibiotic
Outpatient IV therapy where a
1
carbapenem is required
Cephalosporins
Imipenem
Meropenem
Y
Y
Partial (amber)
Partial (amber)
Cefotaxime
Y
Partial (amber)
Ceftriaxone
Y
Partial (amber)
Cefixime
Y
Partial (amber)
Ceftazidime
Y
Partial (amber)
See meropenem
-Treatment of infections due to
multiresistant gram negative
bacteria
-Severe hospital-acquired
pneumonia (HAP) or ventilator
associated pneumonia (VAP) if
allergic to penicillin (not
anaphylactic)
-Severe sepsis if penicillin
allergy or ESBL
-Complex UTI – if recent ESBL
-Haematology / Neutropenic
sepsis
-ICU
-Bacterial meningitis
-Typhoid fever
-Epiglottitis
-Paediatrics
-Bacterial meningitis
-PID
-Gonorrhoea
-Typhoid fever
-Outpatient IV (OPAT)
-Typhoid fever
-Oral therapy of resistant
organisms
-Paediatrics
-Pseudomonas infections
(penicillin allergy or no
choice should be discussed with
Consultant Microbiologist prior to
discharge
Use in other conditions requires
approval from Consultant
Microbiologist
-Use of 3rd generation
cephalsosporins must be kept to a
minimum in inpatients due to very
high risks of C.difficile
-Where ceftriaxone is planned to be
used as outpatient parenteral
antibiotic therapy (OPAT) in current
inpatients, it should be started just
prior to discharge. Inpatients
should not receive ceftriaxone if
discharge is not imminent due to
high risk of C.difficile – use
appropriate inpatient regimen
2
Cyclic polypeptide
Daptomycin
Y
Restricted (red)
Echinocandins
Caspofungin
N*
Partial (amber)
Fosfomycins
Fosfomycin
Partial (amber)
Glycopeptides
Teicoplanin
Vancomcyin IV
N*
(unlicensed)
Y
Y
Vancomycin PO
Y
Partial (amber)
Tigecycline
Y
Restricted (red)
Glycylcyclines
Partial (amber)
Partial (amber)
alternative agents)
Nil
-Haematology
-ICU
-altenative to amphotericin for
febrile neutropenia
-alternative for invasive
aspergillosis
-candidaemia caused by nonalbicans or mfluconazoleresistant candida
-Oral treatment of UTI due to
ESBL producing coliforms
-Treatment of infections
caused by resistant gram
positive organisms e.g. MRSA
-Prophylaxis and treatment of
infection in MRSA colonised
patients
-Prophylaxis and treatment of
infection in penicillin-allergic
patients and where other
antibiotics are contraindicated
Severe C.difficile associated
disease
Nil
Reserved for serious gram positive
infections where no suitable
alternative agent is available
Has no activity against
Cryptococcus
See relevant section of policy with
regards to dosing and monitoring.
Serum level monitoring may be
required.
This is the only indication for oral
vancomycin
See C.difficile care pathway for full
details of C.difficile investigation
and treatment
Reserved for complicated skin and
soft tissue infections and
complicated intra-abdominal
3
infections, and other infections
where no suitable alternative
agent.
NB This agent has no antipseudomonal activity
Macrolides
Azithromycin
Y
Partial (amber)
-Chlamydial infections / GUM
-Paediatrics
-Typhoid fever
Nil
Oxazolidinones
Linezolid (PO or IV)
Y
Restricted (red)
Penicillins
Co-amoxiclav IV / PO
Y
Partial (amber)
-Pyelonephritis
-Orbital/pre-septal cellulitis
-Rhinosinusitis (persistent)
-Diabetic foot infection
-Animal/human bite
-Severe community acquired
pneumonia (CAP)
-COPD exacerbation (severe, or
no response to 1st line)
-Hospital acquired pneumonia
-Intra-abdominal sepsis
Piperacillin-tazobactam
Y
Partial (amber)
-ICU
-Haematology / neutropenic
sepsis
-Cholangitis / liver abscess /
spontaneous bacterial
peritonitis/ other severe intraabdominal sepsis
Used for serious gram positive
infections caused by resistant
organisms (e.g. MRSA, VRE) where
no suitable alternative exists.
Also PVL-producing S.aureus
infections
Use in other conditions requires
approval by Consultant
Microbiologist
Use in other conditions requires
approval by Consultant
Microbiologist
4
Polyenes
Polymyxins
Pyrimidines
Quinolones
Pivmecillinam
N*
Partial (amber)
Lipid associated
Amphotericin B (e.g.
Ambisome)
Colistin (Colomycin)
IV and by nebulisation
Y
Partial (amber)
Y
Partial (amber)
Flucytosine
Ciprofloxacin (IV)
Y
Y
Partial (amber)
Partial (amber)
Ciprofloxacin (PO)
Y
Partial (amber)
-Pseudomonas infections or
other bacterial infections
where narrower spectrum
antibiotics are not active
-Severe hospital acquired
pneumonia (HAP) or ventilator
associated pneumonia (VAP)
-Severe sepsis
-Necrotising fasciitis /
Fournier’s gangrene
-Oral treatment of UTI due to
ESBL producing coliforms
-Serious suspected or
confirmed fungal infections
-Haematology
-severe gram negative
infections resistant to other
antimicrobial agents and
where no other alternatives
-chronic respiratory infection
(Pseudomonas) – nebulised
colistin
-Cryptococcal meningitis
-Haematology / neutropenic
sepsis
-ICU
-Initial treatment for PO
indications below if unable to
take PO medication (switch to
oral as soon as possible)
-UTI where resistance to other
May be combined with coamoxiclav 375mg tds po to enhance
activity against ESBL producing
coliforms. Used mainly in UTIs.
IV Colistin has significant toxicity –
it should only be used where no
alternatives and where
recommended by Consultant
Microbiologist
High risk for C.difficile – use
alternative agents where possible
High risk for C.difficile – use
5
Ofloxacin
Y
Partial (amber)
Moxifloxacin (PO)
Levofloxacin (PO,IV)
Norfloxacin (PO)
Y
Y
Y
Partial (amber)
Partial (amber)
Partial (amber)
Streptogramins
Quinupristin/Dalfopristin Y
Restricted (red)
Triazoles
Voriconazole
Partial (amber)
N*
antibiotics
-Prostatitis
-ERCP prophylaxis
-Malignant otitis externa
-Typhoid and paratyphoid
fever
-Oral treatment of
P.aeruginosa infections
-Liver abscess (penicillin
allergy)
-Diabetic foot ulcer
-Severe sepsis (penicillin
allergy)
-ICU
-Haematology / neutropenic
sepsis
-Salmonella enteritis (Micro
recommended)
-Bacillary dysentery
-Typhoid fever (only if fully
sensitive)
-Complex UTI in urology
patients
-Pelvic inflammatory disease
(PID)
-Respiratory medicine
-Pneumonia (penicillin allergy)
-Prophylaxis of spontaneous
bacterial peritonitis
-Haematology
alternative agents where possible
For serious infections where no
suitable alternative agent is
available
Cautions – drug interactions
6
Others
Other agents used in
specialist groups
-Systemic Aspergillus infection
or other invasive mycosis
-Systemic Candida infection
due to non-albicans candida
Hydatid disease, strongloides
Albendazole
N*
Restricted (red)
Chloramphenicol
N*
Partial (amber)
Clindamycin
Y
Partial (amber)
Co-trimozaxole
Y
Partial (amber)
Foscarnet
Y
Partial (amber)
-Meningitis if severe
cephalosporin allergy
-Serious infections due to
resistant bacteria
-Staphylococcal infections of
soft tissue and bone
-Human and animal bites
-Group B streptococcal
prophylaxis (maternity)
-Adjunctive treatment of
severe soft tissue infection /
streptococcal toxic shock / PVL
staphylococcal infection
-Pneumocystis pneumonia /
infection
-S.maltophilia infection
-CMV infection
Gancyclovir IV
Y
Partial (amber)
-CMV infection
Rifampicin
Y
Partial (amber)
Anti-tuberculous agents
e.g. capreomycin,
cycloserine, ethambutol,
Y
Partial (amber)
-Staphylococcal infection (in
combination only)
-Prosthetic joint infection (in
combination only)
-TB
common
Used on advice of Consultant
Microbiologist
Used on advice of Consultant
Microbiologist
On advice of Haematologist or
Microbiologist
On advice of Haematologist or
Microbiologist
On advice of Consultant
Microbiologist
On advice of chest physician
7
isoniazid, pyrazinamide,
rifabutin, rifampicin,
rifanah, rimactazid
Antivirals (antiretrovirals) – see
formulary for full list
available
Antivirals (hepatitis) see formulary for full list
available
Y
Partial (amber)
-HIV
On advice of GUM physician
Y
Partial (amber)
-Viral hepatitis B & C
On advice of Gastroenterologist
8