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5.1 Antibacterial: Some other antibiotics, trimethoprim, antituberculous drugs

5.1.7 Some other antibiotics

ORAL
Sodium fusidate tablets - see note       
Fusidic acid suspension                                                      
Vancomycin capsules - see note                                   
Linezolid tablets - see note
Rifaximin tablets is available for:

(i). The treatment and prophylaxis of recurrent hepatic encephalopathy unresponsive to standard therapy. Specialist initiated use only [usual dose 550mg twice daily]. See NICE TA 337

(ii). Clostridium difficile associated diarrhoea which has failed to respond to vancomycin or metronidazole, only after discussion with a consultant microbiologist or gastroenterologist. GPs should not usually be asked to prescribe (RED drug). Usual dose 200-400mg three times daily for 10-14 days. See Clostridium difficile infection treatment guidelines.

Fosfomycin granules - for lower UTI due to multi-resistant E.coli (e.g. ESBL producing). Microbiologist recommendation only. See table below for dose.
Fosfomycin injection - for multi-drug resistant organisms in patients with severe penicillin allergy (consultant microbiologist recommendation only)
Fidaxomicin tablets - on microbiologist recommendation only in the treatment of Clostridium difficile infection in patients
 
 
 Dose

eGFR

>≥ 60ml/min

eGFR

20-60ml/min

eGFR

<20ml/min

Uncomplicated cystitis

3g oral x 1 dose

3g oral x 1 dose

Inadequate concentrations may be reached in the urine

Complicated cystitisa

3G oral every 2 days for 3 doses

3G oral every 3 days for 2 doses

Inadequate concentrations may be reached in the urine

a definition of complicated = anything which increases the risk of treatment failure e.g. male patient, diabetes, urinary catheter, immunocompromised, functional or anatomical abnormality of the urinary tract

 

PARENTERAL
Chloramphenicol IM/IV         
*Colistimethate (for administration by nebulisation only). Pseudomas aeruginosa lung infection in adults with bronchiectasis. Click here for shared care guidelines.
*Vancomycin IV Infusion - see note                               
*Teicoplanin IV - see note                           
*Linezolid IV Infusion - see note 
Daptomycin IV - complicated skin/soft tissue infection/right sided endocarditis due to S.aureus (to be started on microbiologist recommendation only, who will recommend an appropriate dose for the indication; doses higher than the SPC have been used in endocarditis) - see note
Inhalers
Colistimethate dry powder inhaler is available for use in children with cystic fibrosis (aged 6 years and over) if nebulisers are poorly tolerated or otherwise deemed unsuitable e.g. poor adherence. See NICE TA 276.
Risk of capsule breakage – new instructions for use: see Drug Safety Update Nov 2014.

Notes:

1. Sodium fusidate is a narrow spectrum antibiotic to which resistance easliy emerges. It should be used in conjunction with a second anti-staphylococcal agent.  Liver function tests should be performed as sodium fusidate occasionally causes reversible change in liver function.  It should not be given to patients on statins (increased risk of rhabdomyolysis - see drug safety update Sept 2011). Statin therapy could be temporarily discontinued if sodium fusidate is needed and restarted 7 days after the last dose. 

2. Vancomycin capsules are included for the treatment of antibiotic induced diarrhoea (see guidelines on Clostridium difficile toxin induced diarrhoea). Vancomycin infusion requires monitoring of blood levels.  Do pre-vancomycin levels prior to the second dose.  If these levels are satisfactory, then repeat pre-vancomycin dose level twice a week.  Guidelines can be found here and from a clinical pharmacist.

3. Teicoplanin is indicated for treatment of serious gram positive infections only on consultant microbiologist advice.

4. Linezolid is for:

a). Microbiologist use only in patients with documented MRSA infections who are Vancomycin Resistant, E faecalis infections that are vancomycin resistant, and in MRSA where there is intolerance to Rifamipicin.

b).It is also available in the Intensive Care Unit for patients with confirmed or highly suspicious MRSA pneumonia.

Click here for Linezolid Prescribing Guidelines.

5. Daptomycin has rarely been linked with the development of eosinophilic pneumonia. The drug should be stopped immediately if this is suspected (cough, fever, dyspnoea). See the MHRA Drug Safety Update for Feb 2011.

6. Visual function should be routinely monitored in those patients on prolonged (greater than 28 days) linezolid therapy and evaluated in all patients with new visual symptoms

 

5.1.8 Trimethoprim

ORAL
Trimethoprim tablets, suspension
PARENTERAL
Trimethoprim IV

Note:

Co-trimoxazole is excluded from the Formulary in deference to single agent therapy with Trimethoprim.  However, stocks will be kept in pharmacies for the treatment and prophylaxis of pneumocystis carinii pneumonia (PCP).

 


5.1.9 Antituberculous Drugs

ORAL
Ethambutol tablets    
Isoniazid tablets
Isoniazid syrup                                                 
Pyrazinamide tablets
Rifampicin capsules,syrup 
Rifampicin + Isoniazid 150/100; 300/150 tablets
Rifampicin + Isoniazid + Pyrazinamide ("Rifater")                       
*Rifabutin capsules (see note). Under specific guidelines or only on the advice of a consultant microbiologist.
PARENTERAL
Isoniazid IM
Rifampicin IV Infusion                                      
Streptomycin IM                                                                     

Notes:

1. Advice on antituberculous therapy may be obtained from the chest physicians.

2. Ethambutol and pyrazinamide syrups can be prepared in the Pharmacy.

3. Isoniazid interferes with pyridoxine metabolism and causes a pyridoxine-responsive peripheral neuropathy. particularly with high dose (>300mg daily) therapy and in patients having a slow acetylator status.  Pyridoxine may be given prophylactically in a dose of 10mg daily. or 50-100mg daily for high dose therapy and slow acetylators.  The higher dose is also recommended for correction of existing Isoniazid-induced neuropathy.

4. In cases of resistaance to two or more of the primary anti-tuberculous drugs, preparations such as cycloserine or capreomycin will be obtained if necessary.

5. Rifabutin is indicated for prophylaxis against Mycobacterium avium complex infections.

 

 

 

For link to BNF section: 5.1 Antibacterial Drugs