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 Formulary Chapter 5: Infections - Full Chapter
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 Restricted, 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).
Chapter Links...
 Details...
05.02  Expand sub section  Antifungal drugs
Amphotericin Liposomal  (AmBisome)
(Infusion)
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Restricted Drug Restricted
Red Hospital
High Cost Medicine

 




    • 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.



 

 
   
Amphotericin (Fungizone)
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Restricted Drug Restricted
Red Hospital

  • 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







 

 
Link  NPSA alert on injectable amphotericin
   
Fluconazole
(Capsule, suspension,)
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Formulary
OTC

  • 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)

 
Link  UKMI Q&A: Can oral fluconazole be used with breastfeeding?
   
Fluconazole IV
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Restricted Drug Restricted
Red Hospital

  • NWAFT: restricted to use in haematology and oncology patients.

 
   
Flucytosine (Ancotil)
(Infusion)
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Restricted Drug Restricted
Red Hospital

  • Consultant Microbiologist approval required.

 
   
Griseofulvin
(Tablet)
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Restricted Drug Restricted
Red Hospital

  • CUHFT: On recommendation from dermatology only.

  • Non-formulary at all other Trusts


 

 
   
Isavuconazole (Cresemba)
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Restricted Drug Restricted
Red Hospital
High Cost Medicine

  • 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


 

 
   
Itraconazole
(Capsule, Liquid, IV)
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Restricted Drug Restricted
Advice

  • 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


 


 

 
   
Posaconazole (IV) (Noxafil)
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Restricted Drug Restricted
Red Hospital
High Cost Medicine

  • RPH: Use is restricted

  • Non-formulary at all other Trusts

 
   
Posaconazole (oral) (Noxafil)
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Restricted Drug Restricted
Red Hospital
High Cost Medicine

  • 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.

 
   
Terbinafine
(Tablet)
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Restricted Drug Restricted
Green

  • Primary care: GP can prescribe in line with primary care guidelines on antimicrobial therapy. 

  • CUH only : On recommendation from microbiologist and/or dermatologist only.

 
Link  C&P CCG Antimicrobial Treatment Guidelines - Primary Care
   
Voriconazole (Vfend)
(Tablet, Suspension, Infusion)
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Restricted Drug Restricted
Red Hospital
High Cost Medicine

  • CUHFT and NWAFT: Consultant Microbiologist approval only.

  • RPH: No restriction for use in Thoracic Directorate and Transplant

  • PbR tariff excluded


 

 
Link  MHRA: reminder of risk of liver toxicity, phototoxicity, and squamous cell carcinoma
   
05.02.01  Expand sub section  Triazole antifungals
05.02.02  Expand sub section  Imidazole antifungals
05.02.03  Expand sub section  Polyene antifungals
05.02.04  Expand sub section  Echinocandin antifungals to top
Anidulafungin
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Restricted Drug Restricted
Red Hospital
High Cost Medicine

  • CUHFT: Hospital only via inpatient pharmacy for invasive candidiasis in adult patients.

  • RPH: Restricted use.

  • Non-formulary at all other Trusts.

 
Link  Letters sent to healthcare professionals February 2020: Ecalta 100mg (anidulafungin) - Solution for infusion must no longer be frozen
   
Caspofungin (Cancidas)
(Infusion)
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Restricted Drug Restricted
Red Hospital
High Cost Medicine

  • 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.


 

 
   
Micafungin (Mycamine)
(Infusion)
View adult BNF View SPC online View childrens BNF  Track Changes
Restricted Drug Restricted
Red Hospital
High Cost Medicine

  • CUHFT: Restricted in line with Trust guidelines or on microbiology approval

  • Non-formulary at all other Trusts

 
   
05.02.05  Expand sub section  Other antifungals
 ....
 Non Formulary Items
Amphotericin  (Abelcet)

View adult BNF View SPC online View childrens BNF Track Changes
Non Formulary
Non Formulary
High Cost Medicine
Infusion
 
  
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

OTC

Available Over the Counter. Consider Self Care   

Green

Formulary - Can be prescribed in both secondary and primary care.   

Advice

Formulary - Specialist Advice, secondary care advice provided for primary care initiation.  

Amber No SCG

Formulary - Specialist initiation without shared care guidance.  

Amber SCG

Formulary - Specialist initiation with shared care guidance.  

Red Hospital

Restricted - Hospital only, not to be prescribed in primary care.  

Switch

Not recommended for prescribing. Switch to alternative cost-effective option.   

Black

Not recommended for prescribing in primary or secondary care.  

Grey

Not recommended as no formal application made for addition to the formulary. Contact relevant pharmacy team for further information.   

Non Formulary

Non-Formulary (category under review).  

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