Local Formulary
BNF Chapter 5 Infections
Staff Group covered by this document
All prescribers working within the Stockport Health Economy
Key Objective of the document
In view of the increasing problems of antibiotic resistance and the cost of inappropriate prescribing, local
and Acute Trust guidelines are reviewed regularly and should be referred to when making treatment
choices.
The Infections chapter only contains drugs and formulations listed in chapter 5 in the BNF and therefore
does not include topical preparations which can be found in the alternative relevant chapter e.g. skin.
Please refer to local guidelines for appropriate and cost-effective options for the treatment of
commonly encountered infections in Stockport.
Verification
This guideline has been reviewed and approved by the following;
NHS Stockport STAMP committee
NHS Stockport Prescribing Advisers
CCG Prescribing Lead
Head of Service Sign Off …………………………………
Date
Signed off by ………………………………………….
Date
(Director)
Version Control
Version 1.1 Approved at STAMP May 13
Version 1.1.1 Approved at STAMP Mar 14
Key
Amber drug (shared care)
These drugs may be prescribed in General Practice provided an Approved Shared
Care Protocol has been Provided and that the GP is happy to accept the clinical
responsibilities and monitoring responsibilities detailed in said protocol.
See NHS Stockport CCG website for details of approved Protocols and Local RAG
list or See GMMMG RAG list
Red Drug ( Red in GM or red locally due to the lack of an approved shared care
protocol )
These drugs are funded by Stockport CCG for NHS patients but should be prescribed
by the patients specialist and not in primary care unless GMMMG rate as amber and
a shared care protocol is provided.
OTC
Over the Counter
These items can be purchased without prescription. Prescribers may suggest
patients buy such medication at their own discretion
If a medicine is unlicensed this should be highlighted in the template as follows
For cost information please go to Drug Tariff or your Clinical System
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Review date May 2015
Chapter 5 – page 1 of 7
Local Formulary
BNF Chapter 5 Infections
Subsections are intentionally omitted where there is no formulary drug choice
Section 5.1 Antibacterial drugs
5.1.1
Penicillins
5.1.1.1 Penicillins
& Benzylpenicillin
First choice
Phenoxymethylpenicillin 250mg
tablets
Benzylpenicillin
IM Injection 600mg, 1.2g vial
5.1.1.2 Penicillins First choice
Penicillinase
Flucloxacillin 250mg, 500mg capsules
resistant
Additional notes
CSM warning: Cholestatic jaundice may occur up to several weeks after treatment with
flucloxacillin has been stopped. Administration for more than 2 weeks and increasing age are risk
factors.
5.1.1.3
First choice
Broad spectrum
penicillins
Amoxicillin 250mg, 500mg capsules
3G sachets not cost effective
however may be useful in some
dental circumstances
Alternatives
Co-amoxiclav tablets (Amoxicillin/
clavulanic acid) 250/125, 500/125mg
Additional notes
Following the CSM warning Co-amoxiclav is only recommended as first line treatment in specific
indications. The risk of liver toxicity is 6 times greater with co-amoxiclav than with amoxicillin.
Cholestatic jaundice is more common in patients over the age of 65 and in males. The duration of
treatment should not usually exceed 14 days
5.1.2
First choice
Cephalosporins,
Cefalexin 250mg, 500mg capsules
carbapenems and
other beta-lactams
Complicated UTI in pregnant
women only.
Additional notes
Cefalexin should not be prescribed unless urine culture and sensitivity results in non pregnant
women demonstrated due to risk of Clostridium difficile.
5.1.3
First choice
Tetracyclines
Oxytetracycline 250mg tablets
For different indications
Doxycyline 50mg & 100mg capsules
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Alternatives
2nd line for acne only
Lymecyline 408mg capsules
Additional notes
Treatment of moderate to severe acne requires the use of both systemic and topical agents.
5.1.4
First choice
Aminoglycosides
Tobramycin
Amber drug
Tobi® nebuliser solution
5.1.5
First choice
Macrolides
Erythromycin 250mg tablets
NICE TA276 Cystic fibrosis
(pseudomonas lung infection) colistimethate sodium and
tobramycin
Clarithromycin 250mg, 500mg tablets
Alternatives
Azithromycin 250mg, 500mg tablets
Alternative first line if penicillin
allergy. Do not prescribe the
capsule formulation of
erythromycin (not cost effective)
Only for treatment of Chlamydia
unless initiated in secondary care
Additional notes
Clarithromycin is an acceptable alternative in those who are unable to tolerate erythromycin
because of side effects. An alternative to erythromycin in the treatment of community acquired
pneumonia and in the treatment of many skin and soft tissue infections is doxycycline.
The HPA recommends clarithromycin as it has less side-effects than erythromycin, greater
compliance as twice rather than four times daily & generic tablets are similar cost.
5.1.6 Clindamycin
nd
First choice
Clindamycin 150mg capsules
Only to be considered 2 line if
penicillin allergy for severe cellulitis
infections.
Additional notes
Clindamycin is associated with Clostridium difficile diarrhoea, which limits its use. Patients should
discontinue treatment immediately if diarrhoea develops.
5.1.8
First choice
Sulphonamides &
Trimethoprim
Trimethoprim 100mg, 200mg
tablets
Secondary care
initiated
Co-trimoxazole
tablets
5.1.9
Specialist centres only
480mg,
3 days treatment only in
uncomplicated UTIs
960mg For cholecystitis/ascending
cholangitis and diverticulitis
Drugs for
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tuberculosis
Additional notes
All TB treatment must be prescribed by a specialist in treating TB infection. All treatment is
therefore provided by the specialist centre until patient stable then RAG status is green.
Treatment of multi drug resistant (MDR) TB may include other antibiotic classes but therapy must
be prescribed by a specialist in TB medicine.
5.1.10
First choice
Antileprotic drugs
Dapsone 50mg, 100mg tablets
For dermatology use only
Additional notes
Dapsone also used in secondary care for treating pneumocystis pneumonia (5.4.8)
5.1.11
First choice
Metronidazole and
tinidazole
Metronidazole 200mg, 400mg
tablets
5.1.12
First choice
Quinolones
Ciprofloxacin 250mg, 500mg
tablets
Acute prostatitis or pyelonephritis
only
Alternative
2 line for acute prostatitis and
pelvic inflammatory disease only
Ofloxacin 200mg. 400mg tablets
nd
Additional notes
Quinolones are a recognised cause of Clostridium difficile infections and their use should be
restricted. They should be used in caution in patients with a history of epilepsy or conditions that
predispose to seizures.
CSM Advice: Tendon damage (including rupture) has been reported in patients receiving
quinolones. Tendon rupture may occur within 48 hours of starting treatment; cases have also
been reported several months after stopping a quinolone.
5.1.13
First choice
Urinary tract
infections
For Trimethoprim see section 5.1.8
Nitrofurantoin 50mg, 100mg tablets
Additional notes
Nitrofurantoin should not be used in patients with renal dysfunction because of the risk of
peripheral neuropathy.
Section 5.2 Antifungal drugs
5.2.1
First choice
Triazole anti-
Fluconazole 50mg, 150mg, 200mg
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fungals
capsules
Alternative
Itraconazole 100mg capsules
Additional notes
Itraconazole is associated with liver damage and should not be given to patients with a history of
liver disease.
CSM advice: Following reports of heart failure, caution is advised when prescribing itraconazole
to patients at high risk of heart failure.
5.2.5
Terbinafine 250mg tablets
Dermatology only
Other anti-fungals
Section 5.3 Antiviral drugs
5.3.2
First choice
Herpes virus
infections
Aciclovir 200mg, 400mg & 800mg
tablets
5.3.2.1
Aciclovir 5% cream 2G ( see Skin
Chapter)
Herpes simplex
and varicellazoster infection
Avoid prescribing dispersible
Aciclovir tablets as not costeffective
Aciclovir 3% eye ointment 4.5G (see
Eye Chapter)
Alternative
Cost prohibitive
Valaciclovir
Tablets 250mg, 500mg
Subsection
5.3.3 Viral hepatitis
5.3.3.1 Chronic hepatitis B
NICE Technology appraisals
NICE TA96 Hepatitis B (chronic) - adefovir dipivoxil and pegylated interferon alfa-2a
NICE TA153 Hepatitis B - entecavir
NICE TA154 Hepatitis B - telbivudine
NICE TA173 Hepatitis B - tenofovir disoproxil fumarate
5.3.3.2 Chronic hepatitis C
NICE Technology appraisals
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NICE TA75 Hepatitis C - pegylated interferons, ribavirin and alfa interferon
NICE TA106 Hepatitis C - peginterferon alfa and ribavirin
NICE TA200 Hepatitis C - peginterferon alfa and ribavirin
NICE TA252 Hepatitis C (genotype 1) - telaprevir
NICE TA253 Hepatitis C (genotype 1) - boceprevir
NICE TA300 Hepatitis C (children and young people) - peginterferon alfa and ribavirin
5.3.4
First choice
Influenza
Oseltamivir
Capsules 30mg, 45mg, 75mg
Suspension 6mg/1ml
In October 2012, the strength of
Oseltamivir oral suspension
changed from 60mg/5ml to
6mg/1ml. Prescriptions for oral
suspension should state the dose
in ml
Alternative
Zanamivir dry powder for inhalation
5mg blister
First choice in pregnancy or
patients with long term kidney
disease
Additional notes
Influenza vaccination remains the first line preventative treatment for influenza. Vaccination
programmes should be promoted to all at risk patients, and programmes should be initiated in
residential settings as a priority. For more information see www.hpa.org.uk. NICE guidance:
NICE TA158 Influenza (prophylaxis) - amantadine, oseltamivir and zanamivir
NICE TA168 Influenza - zanamivir, amantadine and oseltamivir (review)
NICE Guidance for the use of antivirals for seasonal influenza does not apply in an influenza
pandemic, other guidelines will be issued.
Section 5.4 Antiprotozoal drugs
5.4.1
Malaria prophylaxis
Antimalarials
Drugs for malaria prophylaxis are
not prescribable on the NHS.
Additional notes
Chloroquine and proguanil are available ‘over the counter’ (OTC) whereas mefloquine and
®
Malarone require a private prescription.
Refer to BNF or MIMS for telephone numbers for up to date advice on recommended products.
5.4.2
First choice
Amoebicides
Metronidazole 200mg, 400mg tablets
Alternative
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Tinidazole 500mg tablets
5.4.3
Trichomonacides
Metronidazole 400mg tablets
5.4.4
Antigiardial drugs
Metronidazole 400mg tablets
Section 5.5 Anthelmintecs
5.5.1
First choice
Drugs for
threadworms
Mebenadazole 100mg (chewable)
tablets
5.5.2
Ascaricides
5.5.4
Drugs for
hookworms
Alternative
OTC 2 years and over
OTC 3 months and over
Piperazine (Pripsen) 4G sachets
Mebenadazole 100mg (chewable)
tablets
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