5.1. Antibacterial drugs
5.1.1. Penicillins
5.1.1.1. Benzylpenicillin and phenoxymethylpenicillin
Prescribing Notes:
Generally given by slow IV injection and use in primary care will be limited.
Prescribing Notes:
The alternative name is penicillin V. Used widely in bacterial tonsillitis, otitis media and cellulitis.
5.1.1.2. Penicillinase-resistant penicillins
Prescribing Notes:
Penicillinase-resistant penicillin used widely in cellulitis, otitis externa and impetigo.
Restrictions:
Restricted to specialist use only on the advice of a microbiologist or an infectious disease physician.
Prescribing Notes:
Please note: this is a PROTECTED ANTIBIOTIC (see policy here) and relevant paperwork should be completed.
5.1.1.3. Broad-spectrum penicillins
Prescribing Notes:
Broad spectrum penicillin with a wide range of indications including chest infections, otitis media, urinary tract infections and prophylaxis of endocarditis.
Restrictions:
Excludes Augmentin Duo®. Inappropriate use of co-amoxiclav is associated with an increased risk of infections such as Clostridium difficile and MRSA. The risk of cholestatic jaundice with co-amoxiclav is six times that seen with amoxicillin and is more common in men and the over 65s. Therefore, co-amoxiclav should be reserved for infections suspected of being due to amoxicillin resistant beta-lactamase producing strains.
Prescribing Notes:
Duration of therapy should not normally exceed 14 days. See Primary Care and Acute infection guidelines for appropriate uses in adults. Co-amoxiclav is a mixture of amoxicillin and clavulanic acid. Care should be taken as to which product should be used in paediatric patients due to the different amounts of clavulanic acid. Consult the BNF for Children for details.
5.1.1.4. Antipseudomonal penicillins
Restrictions:
Restricted to specialist initiation. Recommended for use on the advice of a microbiologist or an infectious disease physician as second line therapy in severely ill patients with multi-resistant organisms.
Prescribing Notes:
Please note: this is a PROTECTED ANTIBIOTIC (see policy here) and relevant paperwork should be completed.
5.1.1.5. Mecillinams
Restrictions:
Restricted to use on advice of microbiology only.
Prescribing Notes:
• Pivmecillinam should not be initiated empirically without prior discussion with microbiology.
• Pivmecillinam, only if first line options trimethoprim and nitrofurantoin are not suitable due to resistant organism or allergy.
• There is no requirement to contact microbiology for approval if pivmecillinam is visible on the most recent lab report or if continuation of therapy (e.g. from secondary care).
• Note pivmecillinam is not appropriate for treatment of upper UTI.
5.1.2. Cephalosporins, carbapenems, and other beta-lactams
5.1.2.1. Cephalosporins
Prescribing Notes:
Approximately 10% of patients with hypersensitivity to penicillins will also be allergic to cephalosporins.
Restrictions:
Restricted to specialist initiation.
Prescribing Notes:
Approximately 10% of patients with hypersensitivity to penicillins will also be allergic to cephalosporins.
Prescribing Notes:
Approximately 10% of patients with hypersensitivity to penicillins will also be allergic to cephalosporins. This can be given by deep IM injection or IV injection/infusion.
Please note: this is a PROTECTED ANTIBIOTIC (see policy here) and relevant paperwork should be completed.
Restrictions:
Restricted to specialist initiation.
Prescribing Notes:
Approximately 10% of patients with hypersensitivity to penicillins will also be allergic to cephalosporins.
For use after cataract surgery please refer to chapter 11.3.1
Restrictions:
Restricted to prescribing by specialists as per Sandyford treatment protocol.
Restrictions:
Restricted to specialist initiation.
Prescribing Notes:
Avoid using oral cephalosporins as a step down following IV use.
Restrictions:
Included on the Formulary only for the treatment of complicated skin and soft tissue infections in adults. It is restricted to specialist use only on the advice of local microbiologists or specialists in infectious disease in accordance with the prescribing notes below.
Prescribing Notes:
It is Formulary for use in patients with known or suspected meticillin resistant Staphylococcus aureus (MRSA) infection in the following settings:
- For Gram-positive only infections where vancomycin iv is inappropriate/has not been tolerated or treatment modification is required; and daptomycin iv or linezolid iv is normally used.
- For polymicrobial Gram-positive and common Gram-negative pathogens, where vancomycin iv in combination with gentamicin iv is inappropriate/has not been tolerated or treatment modification is required; and daptomycin iv in combination with gentamicin iv, or linezolid iv in combination with gentamicin iv, or tigecycline iv is normally used.
Ceftaroline is also licensed for the treatment of community acquired pneumonia, but this indication has not been reviewed by SMC and is therefore non-Formulary
Restrictions:
Restricted to specialist initiation.
Prescribing Notes:
Please note: this is a PROTECTED ANTIBIOTIC (see policy here) and relevant paperwork should be completed.
Restrictions:
Restricted to use only on the advice of a Microbiologist or Infectious Disease specialist for use in the treatment of Hospital-acquired pneumonia (excluding ventilator-associated pneumonia) when activity is required against suspected methicillin-resistant Staphylococcus aureus (MRSA) and Gram-negative pathogens (including Pseudomona aeruginosa, Escherichia coli and Klebsiella pneumoniae) and when combination treatment that includes vancomycin or teicoplanin is inappropriate or has not been tolerated, or when treatment modification is required, i.e. as an alternative to linezolid-based regimen
Prescribing Notes:
Please note: this is a PROTECTED ANTIBIOTIC (see policy here) and relevant paperwork should be completed.
5.1.2.2. Carbapenems
Restrictions:
Restricted to specialist initiation. Restricted to second or third line treatment of community-acquired intra-abdominal infections resistant to current conventional treatments. Treatment of diabetic foot infections of the skin and soft tissue is restricted to use by specialists managing diabetic foot infection on the advice of a microbiologist. The indication of prophylaxis of surgical site infection following elective colorectal surgery in adults remains non-Formulary. The use for other infections should only be on the advice of a microbiologist or infectious disease physician.
Prescribing Notes:
Please note: this is a PROTECTED ANTIBIOTIC (see policy here) and relevant paperwork should be completed.
Restrictions:
Restricted to specialist initiation. Restricted to use on microbiological and infectious disease physician advice only.
Prescribing Notes:
Please note: this is a PROTECTED ANTIBIOTIC (see policy here) and relevant paperwork should be completed.
Restrictions:
Restricted to specialist initiation. Restricted to use on microbiological and infectious disease physician advice only.
Prescribing Notes:
Please note: this is a PROTECTED ANTIBIOTIC (see policy here) and relevant paperwork should be completed.
Restrictions:
Use in adult patients with confirmed carbapenem-resistant Enterobacteriaceae (CRE), which is involved in the production of Klebsiella pneumoniae carbapenemase (KPC) associated with
- complicated urinary tract infection (cUTI, including acute pyelonephritis [AP])
- complicated intra-abdominal infection (cIAI)
- hospital-acquired pneumonia (HAP), including ventilator associated pneumonia (VAP)
and bacteraemia that occurs in association with, or is suspected to be be associated with any of the infections previously mentioned, is restricted to use on the advice of a consultant microbiologist or infectious disease physician in adults with confirmed CRE.
Prescribing Notes:
Please note: this is a PROTECTED ANTIBIOTIC (see policy here) and relevant paperwork should be completed.
5.1.2.3. Other beta-lactam antibiotics
Restrictions:
Restricted to specialist initiation. Restricted to use on microbiological and infectious disease physician advice only.
Restrictions:
Restricted to specialist initiation for use as suppressive therapy of chronic pulmonary infections due to Pseudomonas aeriginosa in patients with cystic fibrosis (age 6 and above) when inhaled colistemethate sodium and inhaled tobramycin are not tolerated or not providing satisfactory therapeutic benefit (measured as a 2% decline in forced expiratory volume in 1 second (FEV1)
Prescribing Notes:
Aztreonam nebules for the suppressive therapy of Pseudomonas aeruginosa infections in adults with cystic fibrosis is not recommended for use by the SMC and is non-Formulary.
5.1.3. Tetracyclines
Prescribing Notes:
Doxycycline is no more effective than oxytetracycline and is several times more expensive. Uses include sinusitis and pelvic inflammatory disease.
Restrictions:
Restricted to specialist initiation. Restricted to second or third line use under the advice of local microbiologists or specialists in infectious diseases.
Prescribing Notes:
Please note: this is a PROTECTED ANTIBIOTIC (see policy here) and relevant paperwork should be completed.
5.1.4. Aminoglycosides
Prescribing Notes:
Restricted to specialist initiation. Gentamicin should be prescribed in line with local guidelines and is subject to dose adjustment in line with therapeutic drug monitoring.
Restrictions:
Restricted to specialist initiation. Restricted to use on microbiological and infectious disease physician advice only.
Restrictions:
Treatment of non-tuberculous mycobacterial (NTM) lung infections caused by Mycobacterium avium Complex (MAC) in adults with limited treatment options who do not have cystic fibrosis is restricted to specialist use only in line with national guidance.
Prescribing Notes:
All requests for liposomal amikacin nebuliser solution must be approved by an antimicrobial pharmacist.
Restrictions:
Restricted to use on the advice of local microbiologists and infectious disease specialists only in the following situations:
- in accordance with OPAT service clinical management pathway for second-line use or when meticillin-resistant Staphylococcus aureus (MRSA) infection is suspected AND when the patient is initially hospitalised due to ABSSSI, requires intravenous antibiotics, but is eligible for early discharge as soon as their medical condition does not require further inpatient treatment.
Prescribing Notes:
Please note: this is a PROTECTED ANTIBIOTIC (see policy here) and relevant paper work should be completed.
Restrictions:
Restricted to specialist initiation.
Prescribing Notes:
No licensed product available. Unlicensed product used for pre-op surgical prophylaxis for colonic surgery.
Restrictions:
Restricted to use on the advice of local microbiologists and infectious disease specialists only in the following situation:
- in accordance with OPAT service clinical management pathway for second-line use or when meticillin-resistant Staphylococcus aureus (MRSA) infection is suspected AND when the patient is initially hospitalised due to ABSSSI, requires intravenous antibiotics, but is eligible for early discharge as soon as their medical condition does not require further inpatient treatment.
Prescribing Notes:
Please note: this is a PROTECTED ANTIBIOTIC (see policy here) and relevant paper work should be completed.
Restrictions:
Restricted to specialist initiation as second-line use after colistimethate (colistin).
Restrictions:
Restricted to specialist initiation as second-line use after colistimethate (colistin).
Prescribing Notes:
All available brand of nebulised tobramycin are included in the Formulary. Prescribers are asked to use the preparation with the lowest acquisition cost taking into account of patient tolerability.
5.1.5. Macrolides
Prescribing Notes:
Erythromycin has a spectrum of activity similar to penicillin, which makes it a useful alternative for penicillin allergic patients for many infections.
Restrictions:
Oral formulations are only Formulary for indications which require its powerful anti-chlamydial effect. Azithromycin IV infusion is restricted to use for the treatment of community acquired pneumonia (CAP) and pelvic inflammatory disease (PID) only on the advice of a microbiologist or infectious disease physician when the oral route of administration is compromised.
Please note: the intravenous formulation is a PROTECTED ANTIBIOTIC (see policy here) and relevant paper work should be completed.
5.1.6. Clindamycin
5.1.7. Some other antibacterials
Restrictions:
Restricted to specialist initiation where nebulised colistimethate is not tolerated and tobramycin is being considered.
Restrictions:
For restrictions please see prescribing notes below
Prescribing Notes:
- Restricted to specialist initiation. Restricted to use on microbiological and infectious disease physician advice only.
Restrictions:
Restricted to specialist initiation by a microbiologist or specialist in infectious diseases. Restricted to use in patients not responding to or intolerant of a glycopeptide, or those with microbiological cultures which indicate glycopeptide resistance.
Prescribing Notes:
Please note, this is a PROTECTED ANTIBIOTIC (see policy here) and relevant paper work should be completed.
For daptomycin dosing in adults click here
Restrictions:
Fidaxomicin is restricted to use for the treatment of adults with microbiologically proven recurrence of Clostridium difficile infection (CDI) only on the advice of Consultant microbiologists or Consultants in Infectious Diseases.
Please note: this is a PROTECTED ANTIBIOTIC (see policy here) and relevant paper work should be completed.
It is non-formulary for use in adults with first episode of CDI or as empirical treatment in CDI.
Restrictions:
Restricted to use on the advice of microbiologists or infectious disease physicians when laboratory results indicate sensitivity and according to local treatment protocols where applicable.
- The NHSGGC acute care and primary care protocols click here
Prescribing Notes:
Formulary indications:
- Treatment of extended-spectrum beta-lactamases (ESBL) lower urinary tract infection (LUTI) in non-septic men as an oral alternative to current intravenous treatments.
- Treatment of extended-spectrum beta-lactamases (ESBL) lower urinary tract infection (LUTI) in non-pregnant women as an oral alternative to current intravenous treatments.
- Treatment of acute lower uncomplicated urinary tract infections, caused by pathogens sensitive to fosfomycin in adult and adolescent females.
- Prophylactic treatment in diagnostic and surgical transurethral procedures.
Restrictions:
Restricted to use only on the advice of a microbiologist or infectious disease physician for multi-resistant organisms.
Prescribing Notes:
Please note: the IV FORM of fosfomycin is a PROTECTED ANTIBIOTIC (see policy here) and relevant paperwork should be completed.
Restrictions:
Restricted to specialist use only. Restricted to hospital-based use on the advice of a microbiologist or infectious disease physician. Prolonged use (>2 weeks) must be avoided.
Prescribing Notes:
Access Linezolid treatment protocol and discharge & outpatient checklist by clicking the hyperlinks.
Please note: this is a PROTECTED ANTIBIOTIC (see policy here) and relevant paperwork should be completed.
Restrictions:
Not to be used in patients with structural urological abnormalities or indwelling catheters.
Prescribing Notes:
Can be as an antibiotic-sparing treatment option in pre-and post-menopausal women with recurrent UTIs alongside measures recommended by NHS.
Restrictions:
Use 550mg tablets for the reduction in recurrence of episodes of overt hepatic encephalopathy (HE) in patients ≥18 years of age is restricted to initiation by a consultant gastroenterologist.
Prescribing Notes:
Rifaximin is considered to be most useful in a highly selective group of patients with hepatic encephalopathy who are resistant to other standard therapies such as lactulose and dietary measures.
Restrictions:
Restricted to use only on the advice of microbiologists and specialists in infectious diseases for use in patients with ABSSSI caused by Gram-positive Staphylococcus aureus (specifically methicillin-resistant Staphylococcus aureus [MRSA] isolates) as an alternative oxazolidinone antibacterial.
Please note: this is a PROTECTED ANTIBIOTIC (see policy here) and relevant paper work should be completed.
Restrictions:
Restricted to specialist initiation. Restricted to use on microbiological and infectious disease physician advice only. Vancomycin is the first line glycopeptide.
Restrictions:
Restricted to specialist initiation. Restricted to use on microbiological and infectious disease physician advice only. Vancomycin is the first line glycopeptide.
5.1.8. Sulfonamides and trimethoprim
Restrictions:
Restricted to specialist initiation. The CSM has recommended that co-trimoxazole be restricted to use in Pneumocystis carinii pneumonia, toxoplasmosis and nocardiasis. It should only be used in urinary or respiratory tract infections where there is bacterial evidence of sensitivity and good reason to prefer the combination to a single antibiotic.
5.1.9. Antituberculosis drugs
Restrictions:
Restricted to specialist initiation. Restricted to patients with mycobacterial infections resistant to conventional anti-tuberculosis drugs.
Prescribing Notes:
Recommended for the prevention of secondary cases of meningococcal meningitis and Haemophilus influenza type B infection.
5.1.10. Antileprotic drugs
Restrictions:
Restricted to specialist initiation.
Prescribing Notes:
For indications in dermatology please refer to section 13.10.1.2
5.1.11. Metronidazole and tinidazole
Prescribing Notes:
A useful antibiotic for anaerobic infections. Patients should be counselled to avoid alcohol whilst taking this medicine because of the potential disulfiram-like reaction.
5.1.12. Quinolones
Prescribing Notes:
- Due to the risk of severe, disabling and potentially permanent adverse events, new restrictions apply to the prescribing of fluoroquinolones. Please see new MHRA advice (January 2024) and NHSGGC statement (April 2024) for more details.
- Ciprofloxacin should be prescribed by mouth in preference to IV where possible, as oral dosing gives similar concentrations to IV administration. The exception is when the oral route is compromised (e.g. nil by mouth, reduced absorption, unconsciousness, vomiting or mechanical swallowing disorder).
- The NHSGGC Infection Management guidelines can provide advice on when use is appropriate.
- Please note: the IV FORM of ciprofloxacin is a PROTECTED ANTIBIOTIC (see policy here) and relevant paperwork should be completed.
Restrictions:
Restricted to use on the advice of a consultant microbiologist or consultant infectious disease physician for patients with acute bacterial skin and skin structure infections (ABSSSI) who have suspected or confirmed polymicrobial infection following treatment failure or when standard antibacterial therapies are not suitable.
Please note: this is a PROTECTED ANTIBIOTIC (see policy here) and relevant paper work should be completed.
Prescribing Notes:
Due to the risk of severe, disabling and potentially permanent adverse events, new restrictions apply to the prescribing of fluoroquinolones.
Please see new MHRA advice (January 2024) and NHSGGC statement (March 2024) for more details.
Restrictions:
Restricted to specialist initiation.
- oral tablets and infusion: restricted to second line use by hospital specialists for penicillin allergic patients with community or hospital acquired pneumonia or for cystic fibrosis patients intolerant of ciprofloxacin where a quinolone is required.
- nebules (Quinsair®): restricted to specialist initiation and use as third-line treatment option after colistimethate sodium (first line) and tobramycin (second line).
Prescribing Notes:
Due to the risk of severe, disabling and potentially permanent adverse events, new restrictions apply to the prescribing of fluoroquinolones.
Please see new MHRA advice (January 2024) and NHSGGC statement (March 2024) for more details.
Restrictions:
Restricted to specialist initiation. Treatment of community acquired pneumonia (CAP) is restricted to use on the advice of microbiologists or specialists in infectious diseases. Restricted to second line use by hospital specialists for cystic fibrosis patients intolerant of ciprofloxacin where a quinolone is required.
Prescribing Notes:
Due to the risk of severe, disabling and potentially permanent adverse events, new restrictions apply to the prescribing of fluoroquinolones.
Please see new MHRA advice (January 2024) and NHSGGC statement (March 2024) for more details.
Please note: Oral and IV forms are a PROTECTED ANTIBIOTIC (see policy here) and relevant paperwork should be completed.
Restrictions:
Restricted to use in the treatment of pelvic inflammatory disease and epididymitis.
Prescribing Notes:
Due to the risk of severe, disabling and potentially permanent adverse events, new restrictions apply to the prescribing of fluoroquinolones.
Please see new MHRA advice (January 2024) and NHSGGC statement (March 2024) for more details.