Cambridgeshire and Peterborough Formulary


	Cambridgeshire and Peterborough Formulary

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Formulary Chapter 5: Infections - Full Chapter

Notes:

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COVID-19: guidance for health professionals

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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).

Chapter Links...

C & P Primary Care Antimicrobial Guidelines - February 2020

CUHFT Antimicrobial Prescribing App

CUHFT: Emergency Medicine Sepsis Guideline

NWAFT - Antimicrobial Guidelines

Treat your infection: Patient information Leaflet

Details...

05.02

Antifungal drugs

Amphotericin Liposomal (AmBisome^®)
(Infusion)

Restricted

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^®)

Restricted

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

NPSA alert on injectable amphotericin

Fluconazole
(Capsule, suspension,)

Formulary

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)

UKMI Q&A: Can oral fluconazole be used with breastfeeding?

Fluconazole IV

Restricted

NWAFT: restricted to use in haematology and oncology patients.

Flucytosine (Ancotil^®)
(Infusion)

Restricted

Consultant Microbiologist approval required.

Griseofulvin
(Tablet)

Restricted

CUHFT: On recommendation from dermatology only.

Non-formulary at all other Trusts

Isavuconazole (Cresemba)

Restricted

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)

Restricted

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^®)

Restricted

RPH: Use is restricted

Non-formulary at all other Trusts

Posaconazole (oral) (Noxafil^®)

Restricted

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)

Restricted

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

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

C&P CCG Antimicrobial Treatment Guidelines - Primary Care

Voriconazole (Vfend^®)
(Tablet, Suspension, Infusion)

Restricted

CUHFT and NWAFT: Consultant Microbiologist approval only.

RPH: No restriction for use in Thoracic Directorate and Transplant

PbR tariff excluded

MHRA: reminder of risk of liver toxicity, phototoxicity, and squamous cell carcinoma

Fungal infections in haematology: Prophylaxis and treatment (NUH)

UKMI Q&A: Can oral fluconazole be used during pregnancy?

Use of antibiotics, antifungal and antiviral drugs in adult patients with renal impairment or who are on renal replacement therapies (RRT)

05.02.01

Triazole antifungals

05.02.02

Imidazole antifungals

05.02.03

Polyene antifungals

05.02.04

Echinocandin antifungals

Anidulafungin

Restricted

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

RPH: Restricted use.

NWAFT: Hospital only as indicated in the antifungal guidelines.

Letters sent to healthcare professionals February 2020: Ecalta 100mg (anidulafungin) - Solution for infusion must no longer be frozen

Caspofungin (Cancidas^®)
(Infusion)

Restricted

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)

Restricted

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

Non-formulary at all other Trusts

05.02.05

Other antifungals

....

Non Formulary Items

Amphotericin (Abelcet^®)

Non Formulary

Infusion

Key

	Notes
	Section Title (top level)
	Section Title (sub level)
	First Choice item
	Non Formulary section
	Restricted Drug
	Unlicensed
	Display tracking information
	Link to adult BNF
	Link to children's BNF
	Link to SPCs
	Scottish Medicines Consortium

	Cytotoxic Drug
	Controlled Drug
	High Cost Medicine
	Cancer Drugs Fund
	NHS England
	Homecare
	CCG

Traffic Light Status Information

Status	Description
	Available Over the Counter. Consider Self Care
	Formulary - Can be prescribed in both secondary and primary care.
	Formulary - Specialist Advice, secondary care advice provided for primary care initiation.
	Formulary - Specialist initiation without shared care guidance.
	Formulary - Specialist initiation with shared care guidance.
	Restricted - Prescribing (and monitoring where applicable) to remain with the hospital or specialist service. Not to be prescribed in Primary Care
	Not recommended for prescribing. Switch to alternative cost-effective option.
	Not recommended for prescribing in primary or secondary care.
	Not recommended as no formal application made for addition to the formulary. Contact relevant pharmacy team for further information.
	Non-Formulary (category under review).