Greater Manchester Joint Formulary

Greater Manchester Joint FormularyChapter 5: InfectionsThe infections chapter of the GMMMG Formulary is NOT an antibiotic prescribingguide and is not intended to guide treatment choice.Links to local antimicrobial guidelines should be followed – see page 2.Please refer to local guidelines for appropriate and cost-effective options for treating commonlyencountered infections in your local health economy.For prescribing within secondary care, please refer to relevant acute trust guidelines.In view of the increasing problems of antibiotic resistance and the cost of inappropriate prescribing, CCGand acute trust guidelines are reviewed regularly and should be referred to when making treatmentchoices.The infections chapter only contains drugs and formulations included in the ‘Infection’ chapter of the BNF.It does not include topical preparations which can be found in the ‘Skin’ chapter.Contents5.15.25.35.45.5Antibacterial drugsAntifungal drugsAntiviral drugsAntiprotozoal drugsAntihelminthicsFor cost information please go to the most recent cost comparison chartsKeyRed drug see GMMMG RAG listClick on the symbols to access this listAmber drug see GMMMG RAG listClick on the symbols to access this listGreen drug see GMMMG RAG listClick on the symbols to access this listIf a medicine is unlicensed this should be highlighted in the template asfollowsDrug nameNot RecommendedOTCOver the CounterIn line with NHS England guidance, GM do not routinely supportprescribing for conditions which are self-limiting or amenable to self-care.For further details see GM commissioning statement.Order of Drug ChoiceWhere there is no preferred 1st line agent provided, the drug choiceappears in alphabetical order.Return to contents pageV 6.0Chapter 5 – page 1 of 11

Greater Manchester Joint FormularyBNF chapter5 InfectionsSection5.1 Antibacterial drugsPlease follow the GMMMG Greater Manchester Antimicrobial GuidelinesThe aims of this guidance are to to provide a simple, empirical approach to the treatment of common infections to promote the safe and effective use of antibiotics to minimise the emergence of bacterial resistance in the communityAdditional information:NICE NG50: Cirrhosis in over 16s: assessment and managementNICE NG51: Sepsis: recognition, diagnosis and early managementNICE NG95: Lyme diseaseNICE NG79: Sinusitis (acute): antimicrobial prescribingNICE NG91: Otitis media (acute): antimicrobial prescribingAntimicrobial resistancePublic Health England has published an online bulletin providing information on antimicrobial resistance(AMR). It sets out effective methods to avoid unnecessary prescribing of antibiotics and provides advicefor healthcare ations/health-matters-antimicrobial-resistanceNICE has issued guidance that covers the effective use of antimicrobials (including antibiotics) in children,young people and adults. It aims to change prescribing practice to help slow the emergence ofantimicrobial resistance and ensure that antimicrobials remain an effective treatment for infection.NICE (Aug 2015) Antimicrobial stewardship: systems and processes for effective antimicrobial medicineuse NG15BNF chapter5 InfectionsSection5.1 Antibacterial drugsSubsection5.1.4 AminoglycosidesTobramycinNICE TA276: Cystic fibrosis (pseudomonas lung infection)MHRA DSU: Aminoglycosides (gentamicin, amikacin, tobramycin, and neomycin):increased risk of deafness in patients with mitochondrial mutations, Jan 2021NebulisedTobi nebuliser solution 300mg/5ml ampoulesBramitob nebuliser solution 300mg/4mlampoulesfor new patientspresenting to the service onlyFor existing patients onlyawaiting repatriationReturn to contents pageV 6.0Chapter 5 – page 2 of 11

Greater Manchester Joint FormularyInhaledTobi Podhaler dry powder inhalation capsules28mgfor cystic fibrosis patientsAdditional notesTobramycin dry powder for inhalation (DPI) is an option for treating chronic pulmonary infectioncaused by Pseudomonas aeruginosa in people with cystic fibrosis only if colistimethate sodium iscontraindicated, is not tolerated, or has not produced an adequate clinical response and themanufacturer provides tobramycin DPI with the discount agreed as part of the patient access schemeto primary, secondary and tertiary care in the NHS.Subsection5.1.7 Some other antibacterialsVancomycinCapsules 125mgFor treating severe orrecurrent Clostridium difficileonlyLinezolidDo NotPrescribePolymixins (colistimethate)NICE TA276: Cystic fibrosis(pseudomonas lung infection)BezlotoxumabCriterion 2 (see RAG list)For prevention of recurrence of Clostridium difficileinfection in adults at high risk of recurrence.HCD commissioning statementNot recommended for routine commissioning. IFRrequired.NebulisedColistimethate injection for nebulisationPromixin powder for nebuliser solutionfor new cystic fibrosispatients presenting to theservice onlyfor existing cystic fibrosispatients only awaitingrepatriationwhen nebulised for noncystic fibrosis patientsInhaledColistimethate sodiumColobreathe 125mg dry powder inhalationcapsuleswhen inhaled for cysticfibrosis patientsAdditional notesColistimethate sodium dry powder inhalation is an option for treating chronic pulmonary infectioncaused by P. aeruginosa in people with cystic fibrosis only if they do not tolerate it in its nebulisedform and the manufacturer provides colistimethate sodium DPI with the discount agreed as part of thepatient access scheme to primary, secondary and tertiary care in the NHS.RifaximinTablets 550mgFollowing specialistinitiationNICE TA337: Rifaximin forpreventing episodes of overthepatic encephalopathy,Return to contents pageV 6.0Chapter 5 – page 3 of 11

Greater Manchester Joint FormularyMarch 2015Return to contents pageV 6.0Chapter 5 – page 4 of 11

Greater Manchester Joint FormularySubsection5.1.9 Antituberculosis drugsFollowing specialistinitiationAdditional notesAll TB treatment must be prescribed by a specialist in treating TB infection. All treatment is thereforeprovided by the specialist centre until patient is stable then RAG status is green.Treatment of drug resistant TB is commissioned by NHSE.Subsection5.1.10 Antileprotic drugsFirst choiceDapsoneTablets 50mg, 100mgFollowing specialistinitiation for leprosy anddermatitis herpetiformisReturn to contents pageV 6.0Chapter 5 – page 5 of 11

Greater Manchester Joint FormularyChapter5 InfectionsSection5.2 Antifungal drugsSubsection5.2.1. Triazole antifungalsFirst choiceFluconazoleCapsules 50mg, 150mg, 200mgAlternativesItraconazoleCapsules 100mgAdditional notesFollowing reports of heart failure, caution is advised when prescribing itraconazole to patients at highrisk of heart failure.PosaconazoleMHRA DSU: Posaconazole(Noxafil): tablets and oralsuspension are not directlyinterchangeableVoriconazoleMHRA DSU: Voriconazole reminder of risk of livertoxicity, phototoxicity andsquamous cell carcinoma, May2014Do NotPrescribeKetoconazoleSubsection5.2.2 Imidazole antifungalsSubsection5.2.3 Polyene antifungalsSubsection5.2.4 Echinocandin antifungalsCriterion 1 (see RAG list)For oral administrationCaspofunginIV infusionMicafunginIV infusionSubsection5.2.5 Other antifungalsTerbinafineTablets 250mgReturn to contents pageV 6.0Chapter 5 – page 6 of 11

Greater Manchester Joint FormularyDo NotPrescribeFungal nail infectionsNail lacquers, paints and softening productsSee commissioning statement for exceptionsChapter5 InfectionsSection5.3 Antiviral drugsSubsection5.3.1 HIV infectionIn line with NHS England guidance,GM do not routinely supportprescribing for conditions which areself-limiting or amenable to selfcare. For further details see GMcommissioning statement.Only prescribed by a specialist experienced in the management of HIV infectionSubsection5.3.2 Herpes virus infections5.3.2.1 Herpes simplex and varicella-zoster infectionFirst choiceAciclovirTablets 200mg, 400mg, 800mgCream 5% 2g – see Skin chapterEye ointment 3% 4.5g – see Eye chapterAlternativesValaciclovirTablets 250mg, 500mgDo NotPrescribeInfrequent cold sores of the lipAciclovir cream, Zovirax cold sore creamSee commissioning statement for exceptionsIn line with NHS England guidance,GM do not routinely supportprescribing for conditions which areself-limiting or amenable to selfcare. For further details see GMcommissioning statement.5.3.2.2 CytomegalovirusLetermovirTablets 240mg (Prevymis )SubsectionNICE TA591: Letermovir forpreventing cytomegalovirusdisease after a stem cell transplant5.3.3 Viral hepatitis5.3.3.1 Chronic hepatitis BAdefovir dipivoxilTablets 10mgNICE TA96: Adefovir dipivoxil andpeginterferon alfa-2a for thetreatment of chronic hepatitis BReturn to contents pageV 6.0Chapter 5 – page 7 of 11

Greater Manchester Joint Formulary5.3.3.2 Chronic hepatitis CNICE TA75: Interferon alfa (pegylated and non-pegylated) and ribavirin for the treatment of chronichepatitis C,NICE TA106: Peginterferon alfa and ribavirin for the treatment of mild chronic hepatitis C,NICE TA200: hepatitis C - peginterferon alfa and ribavirinMHRA: Direct-acting antiviral interferon-free regimens to treat chronic hepatitis C: risk of hepatitis BreactivationMHRA: Direct-acting antivirals to treat chronic hepatitis C: risk of interaction with vitamin Kantagonists and changes in INRMHRA DSU: Direct-acting antivirals for chronic hepatitis C: risk of hypoglycaemia in patients withdiabetes (December 2018)Boceprevir Capsules 200mgNICE TA253: Hepatitis C (genotype1) boceprevirElbasvir–grazoprevir 50mg/100mg film-coated tabletsNICE TA413: Elbasvir–grazoprevirfor treating chronic hepatitis CGlecaprevir-pibrentasvir 100mg/40mg film-coated tabletsNICE TA499: Glecaprevir–pibrentasvir for treating chronichepatitis CSofosbuvir Tablets 400mgNICE TA330: Sofosbuvir fortreating chronic hepatitis CMHRA DSU: Sofosbuvir withdaclatasvir; sofosbuvir withledipasvir: risks of severebradycardia and heart block whentaken with amiodarone, May 2015Sofosbuvir-velpatasvir Tablets 400mg/100mgTA430: Sofosbuvir–velpatasvir fortreating chronic hepatitis CSofosbuvir-velpatasvir-voxilaprevir 400mg/100mg/100mg film-coated tabletsNICE TA507: Sofosbuvir–velpatasvir–voxilaprevir fortreating chronic hepatitis CTelaprevir Tablets 375mgNICE TA252: hepatitis C (genotype1) telaprevirReturn to contents pageV 6.0Chapter 5 – page 8 of 11

Greater Manchester Joint FormularySubsection5.3.4 InfluenzaFirst choiceOseltamivirCapsules 30mg, 45mg, 75mgSuspension 6mg/1mlAlternativesSuspension only for children under1 year of ageZanamivirDry powder for inhalation 5mg blisterSolution for infusion 10mg/mlAdditional Notes:Influenza vaccination remains the first line preventative treatment for influenza. Vaccinationprogrammes should be promoted to all at risk patients, and programmes should be initiated inresidential settings as a priority. For more information see Public Health England.NICE TA158: Oseltamivir, amantadine (review) and zanamivir for the prophylaxis of influenza, Sep2008NICE TA168: amantadine, oseltamivir and zanamivir for the treatment of influenza, Feb 2009NICE guidance for the use of antivirals for seasonal influenza does not apply in an influenzapandemic; other guidelines will be issued.Subsection5.3.5 Respiratory syncytial virusRibavirinTablets 200mgReturn to contents pageV 6.0Chapter 5 – page 9 of 11