| Formulary Chapter 5: Infections - Full Chapter
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| Notes: |
FOR THE LATEST INFORMATION REGARDING COVID_19 PLEASE SEE:
COVID-19: guidance for health professionals
https://www.gov.uk/government/collections/wuhan-novel-coronavirus
https://www.england.nhs.uk/coronavirus/primary-care/
Intravenous antibiotics are more expensive than oral equivalents and some are very expensive they also put patients at risk of IV cannula infections. Oral antibiotics are usually fairly cheap. IM injections are rarely if ever indicated.
Course lengths:
Prescriptions for oral antibiotics for in-patients should be reviewed at or before five days. Prescriptions for intravenous antibiotics should be reviewed at or before 48 hours after which the patient should be considered for an oral antibiotic if there is an equivalent available. For uncomplicated urinary tract infections three days treatment is usually sufficient in adult women. Complicated infections require longer treatment.
When initiating therapy with agents marked with  , you must seek Microbiology/Infectious Diseases advice.
The restricted antimicrobials may be prescribed without discussion with microbiology if they are being used for an approved indication as specified. Use outside these indications (and any use for some antimicrobials) requires DOCUMENTED approval from one of the medical microbiologists or Infectious Diseases Physician prior to prescribing.
For further information on prescribing antimicrobials at Royal Papworth Hospital please refer to the Microguide
Prescribing in Primary Care and CPFT should follow the Primary Care Prescribing Guidelines and initiate only those treatments recommended as Green (unless on the advice of a microbiologist).
Use in pregnancy
- It is important to ensure adequate treatment of maternal infection in pregnancy as failure to treat may lead to adverse maternal and fetal outcome as a consequence of uncontrolled infection or fever.
- When considering treatment with antibacterial agents during pregnancy, the following factors should be taken into account: the severity of the maternal infection, the presence of fever, the maternal and fetal risks associated with failing to treat the mother adequately, the pharmacokinetic and pharmacodynamic effects (where known) of pregnancy on drug absorption, distribution, metabolism and excretion, and the potential fetotoxicity of the treatments being considered.
- Where possible, antibiotic choice should be informed by culture and sensitivity tests, however if treatment is required urgently or before test results become available, then penicillins or cephalosporins should be considered where clinically appropriate.
- See UKTIS Antibiotic use in Pregnancy for further information.
- Prescribing in Primary Care and CPFT should follow the Primary Care Prescribing Guidelines which includes specific guidance for pregnancy and initiate only those treatments recommended as Green (unless on the advice of a microbiologist).
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| Chapter Links... |
 C & P Primary Care Antimicrobial Guidelines - long version (Feb 2019) |
| CUHFT Antimicrobial Prescribing App |
| CUHFT: Emergency Medicine Sepsis Guideline |
| NWAFT - Antimicrobial Guidelines |
| Treat your infection: Patient information Leaflet |
| Details... |
| 05.02 |
Antifungal drugs |
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Amphotericin Liposomal (AmBisome®)
(Infusion)
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Restricted
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- Restricted to use in oncology and haematology (Neutropenic sepsis).
- ALL other indications require microbiology approval.
- CUH additional advice: the Consultant Microbiologist authorising the prescription should contact pharmacy (ex 3502). Pharmacy should contact Microbiology to confirm that a Consultant Microbiologist has approved an unexpected prescription.
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Amphotericin (Fungizone®)
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Restricted
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- NWAFT: Non formulary
- CUHFT: For intravitreal use and for eye/ear drop preparation only. Other amphotericin preparations are used for iv administration.
- RPH: Nebulised
- Not restricted for use in Cystic Fibrosis or Transplant patients
- Available via homecare for use by transplant patients
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NPSA alert on injectable amphotericin
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Fluconazole
(Capsule, suspension,)
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Formulary
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- Consider self-care: Capsule (150mg) can be purchased from a Community Pharmacist for treatment of uncomplicated candidal vaginitis. (restrictions on sale may apply based on age and frequency of use)
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UKMI Q&A: Can oral fluconazole be used with breastfeeding?
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Fluconazole IV
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Restricted
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- NWAFT: restricted to use in haematology and oncology patients.
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Flucytosine (Ancotil®)
(Infusion)
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Restricted
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- Consultant Microbiologist approval required.
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Griseofulvin
(Tablet)
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Restricted
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- CUHFT: On recommendation from dermatology only.
- Non-formulary at all other Trusts
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Isavuconazole (Cresemba)
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Restricted
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- CUHFT: JDTC has approved the use of isavuconazole for treatment of invasive aspergillosis and mucormucosis under the following conditions:
- microbiology recommendation only
- GPs should not be asked to prescribe (HOSPITAL ONLY)
- voriconazole to be used first line for invasive aspergillosis; isavuconazole to be reserved as a secondline treatment option only if voriconazole can not be used; isavuconazole is licensed for the treatment of mucormycosis in patient for whom amphotericin is inappropriate.
- If IV is indicated, Ambisome may be more cost-effective if fewer than 5 vials are required to deliver the daily dose.
- Non-formulary at all other Trusts
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Itraconazole
(Capsule, Liquid, IV)
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Restricted
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- CUHFT- IV on micro approval only. Oral formulations are Formulary.
- Oral treatment : use suspension as the bioavailability of capsules is poor. A trough level after 7-14 days of therapy should be taken.
- NWAFT: Restricted to Hameatology and Oncology patients
- RPH: No restricted when used by Thoracic Directorate or in transplant. Capsules are used in preferance to the suspension.
- Intavenous administration is hospital only
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Posaconazole (IV) (Noxafil®)
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Restricted
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- RPH: Use is restricted
- Non-formulary at all other Trusts
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Posaconazole (oral) (Noxafil®)
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Restricted
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- RPH: Restricted use. Available via homecare for use in transplant.
- Non-formulary at all other Trusts
N.B.Doses differ according to formulation used and thus tablets and suspension are not interchangeable. When prescribing, the formulation must be specified.
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Terbinafine
(Tablet)
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Restricted
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- Primary care: GP can prescribe in line with primary care guidelines on antimicrobial therapy.
- CUH only : On recommendation from microbiologist and/or dermatologist only.
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C&P CCG Antimicrobial Treatment Guidelines - Primary Care
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Voriconazole (Vfend®)
(Tablet, Suspension, Infusion)
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Restricted
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- CUHFT and NWAFT: Consultant Microbiologist approval only.
- RPH: No restriction for use in Thoracic Directorate and Transplant
- PbR tariff excluded
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MHRA: reminder of risk of liver toxicity, phototoxicity, and squamous cell carcinoma
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| 05.02.01 |
Triazole antifungals |
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| 05.02.02 |
Imidazole antifungals |
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| 05.02.03 |
Polyene antifungals |
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| 05.02.04 |
Echinocandin antifungals |
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Anidulafungin
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Restricted
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- CUHFT: Hospital only via inpatient pharmacy for invasive candidiasis in adult patients.
- RPH: Restricted use.
- Non-formulary at all other Trusts.
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 Letters sent to healthcare professionals February 2020: Ecalta 100mg (anidulafungin) - Solution for infusion must no longer be frozen
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Caspofungin (Cancidas®)
(Infusion)
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Restricted
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- CUHFT: Microbiology approval only when Ambisome not effective.
- NWAFT: Recommended as per Trust guidelines or on microbiology advice
- RPH: No restriction when used by Thoracic, Transplant or Critical Care Directorates.
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Micafungin (Mycamine®)
(Infusion)
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Restricted
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- CUHFT: Restricted in line with Trust guidelines or on microbiology approval
- Non-formulary at all other Trusts
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| 05.02.05 |
Other antifungals |
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| .... |
| Non Formulary Items |
Amphotericin (Abelcet®)
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Non Formulary
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Infusion
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Key |
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Cytotoxic Drug
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Controlled Drug
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High Cost Medicine
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Cancer Drugs Fund
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NHS England |
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Homecare |
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CCG |
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Traffic Light Status Information
| Status |
Description |
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Available Over the Counter. Consider Self Care |
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Formulary - Can be prescribed in both secondary and primary care. |
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Formulary - Specialist Advice, secondary care advice provided for primary care initiation. |
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Formulary - Specialist initiation without shared care guidance. |
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Formulary - Specialist initiation with shared care guidance. |
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Restricted - Hospital only, not to be prescribed in primary care. |
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Not recommended for prescribing. Switch to alternative cost-effective option. |
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Not recommended for prescribing in primary or secondary care. |
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Not recommended as no formal application made for addition to the formulary. Contact relevant pharmacy team for further information.
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Non-Formulary (category under review). |
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