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5.1 Antibacterial: Tetracyclines, aminoglycosides, macrolides, clindamycin

5.1.3 Tetracyclines

ORAL
Demeclocycline capsules
Doxycycline capsules
Minocycline tablets, Modified Release, see note.
Oxytetracycline tablets (for acne)
Lymecycline tablets
Tetracycline tablets (as part of Helicobacter pylori eradication regimen only)
PARENTERAL
Doxycycline Injection for pleurodesis only
Tigecycline - Consultant Microbiolgist use only: please see notes below.

Notes:

1. Lymecycline is used 2nd Line for moderate to severe acne (see 13.6.2)

2. Demeclocycline - this tetracycline is included to enable it to be used in the treatment of syndrome of inappropriate ADH secretion (SIADH). Recommended dosage for this indication is 900-1200mg daily in divided doses, reducing to 600-900mg daily in divided doses for maintenance therapy.

3. Doxycycline has been shown not to accumulate in patients with renal impairment and is therefore the tetracycline of choice in this situation.

4. Tigecycline is only approved for treatment of complicated skin & soft tissue infections and complicated intra-abdominal infections. It will be restricted to use in:

  • patients who have a history of anaphylaxis or facial swelling with penicillin AND an extended spectrum beta-lactamase (ESBL) or an AMPC- producing coliform causing a systemic infection.
  • Patients with multi-resistant OXA23-producing Acinetobacter

5. Tigecycline (Tygacil): increased mortality in clinical trials - use only when other antibiotics are unsuitable.

From Drug Safety Update 2011:

    • Numerically higher mortality rates have been reported in patients treated with tigecycline in clinical studies in approved and unapproved indications, comparwith patients treated with other antibacterial agents.

    • Patients who develop superinfections particularly nosocomial pneumonia seem to be at particular risk of having a poor outcome. Patients should be closely monitored for the development of superinfections. If medically indicated, they should be switched to alternative antibiotic treatment which has been shown t obe efficacious in the treatment of the specific infection present.

 

6. Minocycline is restricted for specialist use in autoimmune bullous disorders and pyoderma gangrenosum

 

5.1.4  Aminoglycosides

NEBULISERS/INHALERS
Tobramycin nebuliser solution. Second line agent in the management of cystic fibrosis patients with chronic Pseudomonas aeruginosa infection (first-line is colistimethate). A dry powder inhaler is available if nebulisers are poorly tolerated or otherwise deemed unsuitable (e.g. poor adherence). See NICE TA 276.

ORAL
Neomycin tablets, mixture

PARENTERAL
Gentamicin IM/IV (see note 2)
Amikacin IM/IV - restricted antibiotic

 

TOPICAL
Gentamicin (Collatamp) dressing - for use after permanent pacemaker implantation - see Guidelines

Notes:

1. Neomycin is not absorbed when given orally and is therefore only included for treatment of hepatic encephalopathy.

2. Gentamicin dosage - see the once daily gentamicin policy.

 

5.1.5 Macrolides

ORAL
Azithromycin tablets, suspension (1. Second-line use in Pelvic Inflammatory Disease; 2. Prophylaxis in moderate-severe bronchiectasis with ≥ 3 exacerbations per year requiring antibiotics [500mg three times/week])                  
Erythromycin tablets, sachets, suspension
Clarithromycin tablets, oral suspension
PARENTERAL  
Clarithromycin IV infusion
Erythromycin IV infusion     

Notes:

1. Clarithromycin is now listed in the antibiotic guidelines in place of erythromycin (more convenient dosing, improved gastrointestinal tolerability, improved bioavailability).

2. Erythromycin will continue to be used as a pro-kinetic and also in GU medicine and is the preferred macrolide in pregnancy and breast feeding.

3. Erythromycin is involved in several significant drug interactions. Check the BNF section for details before prescribing. 

 

5.1.6 Clindamycin                 

ORAL
Clindamycin capsules, suspension - Under specific guidelines or only on the advice of a Consultant Microbiologist.  
PARENTERAL
Clindamycin IM/IV Infusion -Under specific guidelines or only on the advice of a Consultant Microbiologist.  

Note:

Clindamycin has been associated with pseudomembranous colitis, though its reputation is probably exaggerated. If a severe diarrhoea does develop, stop the clindamycin and follow the C. difficile treatment guidelines. It is restricted to use in cellulitis and dental abscess in people with penicillin allergy.

 

For link to BNF section: 5.1 Antibacterial drugs