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BNSSG Adult Joint Formulary

5.2 Bacterial infection

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Last edited: 03-07-2024

First line drugs

Second line drugs

Specialist drugs

Secondary care drugs

Guidelines

BNSSG Primary Care Antimicrobial Guidelines
NBT antibiotic guidelines (N.B. Only available via Trust intranet)
Community IV charts

App available for digital devices (RxGuidelines)

UHB antibiotic guidelines (N.B. Only available via Trust intranet) App available for digital devices (Microguide)
WAHT see local guidance App available for digital devices (RxGuidelines)
BNSSG Guidelines for the management of bronchiectasis

Please note that the colours used in this chapter refer to the formulary Traffic Light Status, please see local Trust Guidance for information on restrictions on use which may also use a Traffic light colour system.

Antimicrobial stewardship

Antimicrobial stewardship is an organisational or healthcare-system-wide approach to promoting and monitoring judicious use of antimicrobial drugs to preserve their future effectiveness.

The approach to prescribing in line with the principles of antimicrobial stewardship recommended for primary care is as follows:

Prescribe an antibiotic only if there is likely to be a clear clinical benefit.
Consider a no, or delayed, antibiotic strategy for acute self-limiting upper respiratory tract infections.
Limit prescribing over the phone to exceptional cases.
Use simple generic antibiotics if possible. Avoid broad-spectrum antibiotics (for example, co-amoxiclav, quinolones and cephalosporins) if narrow-spectrum antibiotics remain effective because the former increase the risk of Clostridium difficile, methicillin-resistant Staphylococcus aureus (MRSA) and antibiotic-resistant urinary tract infections.
Avoid widespread use of topical antibiotics (especially those that are also available as systemic preparations, such as fusidic acid).

For further information see the Royal College of General Practitioners TARGET Antibiotics toolkit

The approach to prescribing in line with the principles of antimicrobial stewardship recommended for secondary care is as follows:

Do not start antibiotics without clinical evidence of bacterial infection.

If there is evidence or suspicion of bacterial infection, use local guidelines to start prompt, effective antibiotic treatment.

Document the following on the medicines chart and in the person's medical notes: clinical indication, duration or review date, route and dose.
Obtain cultures – knowing the susceptibility of an infecting organism can lead to narrowing of broad-spectrum therapy, changing therapy to effectively treat resistant pathogens, and stopping antibiotics when cultures suggest an infection is unlikely.
Prescribe single-dose antibiotics for surgical prophylaxis if antibiotics have been shown to be effective.
Review the clinical diagnosis and the continuing need for antibiotics by 48 hours from the first antibiotic dose and make a clear plan of action – the 'Antimicrobial Prescribing Decision'. The 5 Antimicrobial Prescribing Decision options are: Stop, Switch IV (intravenous) to Oral, Change, Continue, and Outpatient Parenteral Antibiotic Therapy (OPAT). Clearly document the review and subsequent decision in the person's medical notes.

For further information see Public Health Guidance Start smart –then focus

(Taken from Infection prevention and control NICE quality standard 61)

Aminoglycosides

Amikacin (parenteral) (TLS Red)

Secondary Care Restricted, see local guidelines

Amikacin (nebulised) (TLS Red)

NHSE Clinical commissioning policy: Nebulised liposomal amikacin for the treatment of non-tuberculous mycobacterial pulmonary disease caused by mycobacterium avium complex refractory to current treatment options (adults and post pubescent children)

Gentamicin (parenteral) (TLS blue)

Restricted, see local guidelines

Gentamicin (nebulised) (TLS Red)

TLS Red for management of acute infections
Restricted, see local guidelines

Gentamicin (intravesical) (TLS Red)

TLS Red for urology for intravesical administration
Please see Guidance for GPs on Intravesical Gentamicin

Gentamicin (nebulised) (TLS Amber 3 months)

Restricted, see local guidelines
TLS Amber for chronic infections in non-CF bronchiectasis only. Click here for the SCP for nebulised Gentamicin
Generally a trial of eradication or maintenance of Colistimethate sodium would be considered first line in these patients. Progression between antibiotics would be dictated by tolerance or treatment failure (defined by decline in lung function or no change / increase in rate of exacerbations)

Pristinamycin (oral) (unlicensed) (TLS Red)

Tobramycin (parenteral) (TLS Red)

Secondary Care Restricted, see local guidelines

Tobramycin (nebulised) (TLS Red)

Restricted, see local guidelines
TLS Red for the management of acute infections
TLS Red for the management of chronic CF infections in accordance with the NHS England Clinical Commissioning Policy: Inhaled Therapy for Adults and Children with Cystic Fibrosis (A01/P/b)

Tobramycin (nebulised) (TLS Amber 3 months)

Restricted, see local guidelines
TLS Amber for chronic infections in non-CF bronchiectasis only. Click here for the SCP for nebulised Tobramycin
Generally a trial of eradication or maintenance of Colistimethate sodium would be considered first line in these patients. Progression between antibiotics would be dictated by tolerance or treatment failure (defined by decline in lung function or no change / increase in rate of exacerbations)

Tobramycin (inhaled) (TLS Red)

Secondary Care Restricted, see local guidelines
Tobi^® Podhaler
In accordance with NICE guidance TA276 Colistimethate sodium and tobramycin dry powders for inhalation for treating pseudomonas lung infection in cystic fibrosis and the NHS England Clinical Commissioning Policy: Inhaled Therapy for Adults and Children with Cystic Fibrosis (A01/P/b)

Bacterial Transpeptidation Inhibitors

Chloramphenicol (oral & parenteral) (TLS Red)

Secondary care restricted, see local guidelines

Carbapenems

Ertapenem (parenteral) (TLS amber Specialist Recommended)

Restricted, see local guidelines
GPs may prescribe, but only on the recommendation of a medical microbiologist
Ertapenem can be obtained by a community pharmacy by supplying AAH with a copy of a redacted prescription

Meropenem (parenteral) (TLS Red)

Restricted, see local guidelines

Cephalosporins

Cefalexin (oral) (TLS blue)

Restricted, see local guidelines

Cefixime (oral) (TLS Blue)

Restricted, see local guidelines

Ceftriaxone (parenteral) (TLS Blue)

Restricted, see local guidelines

Cefiderocol (parenteral) (TLS Red)

Restricted - microbiology only - see local guidelines
For treatment of multidrug resistant aerobic gram-negative infections where there are no other treatment options available

Cefuroxime (parenteral) (TLS Red)

Secondary Care Restricted, see local guidelines

Ceftazidime (parenteral) (TLS Red)

Secondary Care Restricted, see local guidelines

Cefoxitin (parenteral) (unlicensed) (TLS Red)

Secondary Care Restricted, see local guidelines

Ceftolozane & Tazobactam (parenteral) (TLS Red)

Secondary Care Restricted, see local guidelines

Cefazolin (parenteral) (TLS Red)

Restricted - microbiology only - see local guidelines
For treatment of susceptible MSSA infections where flucloxacillin is not suitable due to intolerance or adverse effects

Cephalosporins, with Beta-lactamase Inhibitor

Ceftazidime / Avibactam (parenteral) (TLS Red)

Secondary Care Restricted, on the advice of microbiology for proven multi-drug resistant gram-negative pathogens most likely carbapenem resistant enterobacteriaceae due to KPC or OXA-48 B.lactamases

Diaminopyrimidines

Recommended:

Trimethoprim (oral) (TLS Green)

Alternatives:

Co-trimoxazole (oral) (TLS Blue)

Co-trimoxazole (parenteral) (TLS Red)

Secondary care restricted, see local guidelines

Fusidates

Sodium fusidate (oral) (TLS Blue)

Restricted, see local guidelines

Glycopeptide Antibacterials

Teicoplanin (parenteral) (TLS Red)

Secondary care restricted, see local guidelines

Vancomycin (oral) (TLS Green)

For C Diff infection only, see local guidelines

Vancomycin (parenteral) (TLS Red)

Secondary care restricted, see local guidelines

Oritavancin (parenteral) (TLS Red)

Restricted to use on advice of a Consultant Microbiologist only – see local guidelines.

Glycylcycline Antibacterials

Tigecycline (parenteral) (TLS Red)

Secondary Care Restricted, see local guidelines

Lincosamide Antibacterials

Clindamycin (oral) (TLS blue)

Restricted, see local guidelines

Clindamycin (parenteral) (TLS Red)

Secondary care restricted, see local guidelines

Lipopeptide Antibacterials

Daptomycin (parenteral) (TLS Red)

Secondary care restricted, see local guidelines

Macrocyclic Antibacterials

Fidaxomicin (oral) (TLS Amber Specialist Recommended)

Macrolides and Related Drugs

Recommended:

Clarithromycin (oral) (TLS Green)

Erythromycin (oral) (TLS Green)

For use in gut motility

Alternatives:

Erythromycin (oral) (TLS Blue)

Restricted, see local guidelines

Azithromycin (oral) (TLS Blue)

Restricted, see local guidelines

Clarithromycin (parenteral) (TLS Red)

Erythromycin (parenteral) (TLS red)

Secondary care restricted, see local guidelines. Not restricted for use in gut motility

Monocyclic Beta-lactam Antibacterials

Aztreonam (nebulised) (TLS Red)

Non- formulary
See NHS England Clinical Commissioning Policy 16001/P Use via NHSE IFR process

5-Nitroimidazole Derivatives

Recommended:

Metronidazole (oral & rectal) (TLS Green)

Alternative:

Metronidazole (parenteral) (TLS Red)

Secondary care restricted, see local guidelines

Oxazolidinone Antibacterials

Linezolid (oral & parenteral) (TLS Red)

Secondary care restricted, see local guidelines

Penicillins (Antipseudomonal)

Piperacillin / Tazobactam (parenteral) (TLS Red)

Secondary Care Restricted, see local guidelines

Penicillins (Beta-lactamase Sensitive)

Recommended:

Phenoxymethylpenicillin (oral) (TLS Green)

Alternatives:

Benzylpenicillin sodium (parenteral) (TLS Blue)

Benzathine benzylpenicillin (parenteral) (unlicensed) (TLS Red)

Secondary care Restricted – refer to local guidance

Procaine benzylpenicillin (parenteral) (unlicensed) (TLS Red)

Secondary care Restricted – refer to local guidance
Probenecid (TLS Red) – given in conjuction with procaine benzylpenicillin to treat neurosyphilis

Penicillins (Broad-spectrum)

Recommended:

Amoxicillin (oral) (TLS Green)

Alternatives:

Amoxicillin (parenteral) (TLS blue)

Co-amoxiclav (oral) (TLS blue)

Co-amoxiclav (parenteral) (TLS Red)

Secondary Care Restricted, see local guidelines

Penicillins (Mecillinam-type)

Pivmecillinam hydrochloride (oral) (TLS Blue)

Restricted, see local guidelines

Penicillins (Penicillinase-resistant)

Recommended:

Flucloxacillin (oral) (TLS Green)

Alternative:

Flucloxacillin (parenteral) (TLS Blue)

Temocillin (parenteral) (TLS Red)

Secondary Care Restricted, see local guidelines

Phosphonic Acid Antibacterials

Fosfomycin (oral & parenteral) (TLS Green)

For patients at high risk of resistance, with type 1 penicillin allergy
Restricted, see local guidelines

Fosfomycin (oral & parenteral) (TLS Amber Specialist Recommended)

Restricted, see local guidelines

Polymyxin Antibacterials

Vancomycin (oral) (TLS Green)

For C Diff infection only, see local guidelines

Vancomycin (parenteral) (TLS Red)

Secondary care restricted, see local guidelines

Dalbavancin (parenteral) (TLS Red)

Secondary care restricted, see local guidelines

Colistimethate sodium (injection to be used via nebuliser) (TLS Red)

TLS Red for management of acute infections
TLS Red for the management of chronic CF infections in accordance with the NHS England Clinical Commissioning Policy: Inhaled Therapy for Adults and Children with Cystic Fibrosis (A01/P/b)

Colistimethate sodium (injection to be used via nebuliser) (TLS Amber 3 months)

TLS Amber for chronic infections in non-CF bronchiectasis only. Click here for the SCP for nebulised Colistimethate sodium
Generally a trial of eradication or maintenance of Colistimethate sodium would be considered first line in these patients. Progression between antibiotics would be dictated by tolerance or treatment failure (defined by decline in lung function or no change / increase in rate of exacerbations)
Colomycin^®injection can be used for nebulisation
Nebulisation of colistimethate should take place in a well ventilated room. The output from the nebuliser may be vented to the open air or a filter may be fitted. Usually jet or ultrasonic nebulisers are preferred for colistimethate inhalation to ensure the particles are of a suitable diameter

Colistimethate sodium (parenteral) (TLS Red)

Restricted in secondary care

Colistimethate sodium Dry Powder Inhaler (inhaled) (TLS Red)

In accordance with NICE guidance TA276 Colistimethate sodium and tobramycin dry powders for inhalation for treating pseudomonas lung infection in cystic fibrosis and the NHS England Clinical Commissioning Policy Statement: Inhaled Therapy for Adults and Children with Cystic Fibrosis (A01/PS/a)
And also for use in patients with non-Cystic Fibrosis bronchiectasis when colistimethate sodium is indicated, but the patient does not tolerate it in its nebulised form, or are unable to comply with the process of reconstitution and nebulisation of colistimethate despite appropriate training and support

Quinolones

Recommended:

Ciprofloxacin (oral) (TLS Green)

Restricted, see local guidelines

Alternatives:

Ciprofloxacin (parenteral) (TLS Red)

Secondary care restricted, see local guidelines

Moxifloxacin (oral) (TLS Blue)

Restricted, see local guidelines

Ofloxacin (oral) (TLS Blue)

Restricted, see local guidelines

Ofloxacin (parenteral) (TLS Red)

Secondary care restricted, see local guidelines

Levofloxacin (oral) (TLS Blue)

Restricted, see local guidelines

Levofloxacin (parenteral) (TLS Red)

Secondary care restricted, see local guidelines

Levofloxacin (nebulised) (TLS Red)

As per NHS Commissioning Policy: Levofloxacin nebuliser solution for chronic Pseudomonas lung infection in cystic fibrosis

Rifaximin (oral) (TLS Amber Specialist initiated)

Hepatic encephalopathy – treatment and prophylaxis
NICE TA337 Rifaximin for preventing episodes of overt hepatic encephalopathy

Rifaximin (oral) (TLS Red)

Secondary care restricted - use according to local procedures or microbiology advice

Tetracyclines and Related Drugs

Recommended:

Doxycycline (oral) (TLS Green)

Lymecycline (oral) (TLS Green)

Oxytetracycline (oral) (TLS Green)

Alternative:

Minocycline (oral) (TLS Amber Specialist Recommended)

Restricted, see local guidelines
Non-formulary for the treatment of acne

Specific Indications:

Demeclocycline hydrochloride (oral) (TLS Blue)

Used in the treatment of hyponatraemia resulting from SIADH

Tigecycline (parenteral) (TLS Red)

Secondary Care Restricted, see local guidelines

Other

Faecal Microbiota Transplant (TLS Red)

For treatment of recurrent C. difficile infection

5.2.5 Tuberculosis

Antimycobacterials

Dapsone (oral) (TLS Red)

Secondary care restricted, see local guidelines
For treatment of dermatoses and oral ulceration see 13.3 and 12.3 oropharynx for the shared care protocol for these indications

Bedaquiline (oral) TLS Red

Delamanid (oral) TLS Red

See NHS England Policy F04/P/a Bedaquiline and Delamanid for defined patients with MDR-TB and XDR-TB

Rifampicin (oral) (TLS Amber Specialist Recommended)

For joint infections

Rifampicin (oral) (TLS Red)

For the treatment of Tuberculosis

Rifampicin (parenteral) (TLS Red)

Secondary care restricted, see local guidelines

Rifampicin / Isoniazid / Pyrazinamide / Ethambutol (oral) (Voractiv^®) (TLS Red)

Rifampicin / Isoniazid / Pyrazinamide (oral) (Rifater^®) (TLS Red)

Rifampicin / Isoniazid (oral) (Rifinah^®) (TLS Red)

Ethambutol hydrochloride (oral) (TLS Red)

Isoniazid (oral) (TLS Red)

Pyrazinamide (oral) (unlicensed) (TLS Red)

Rifabutin (oral) (TLS Red)

Streptomycin (parenteral) (unlicensed) (TLS Red)

Secondary care restricted, see local guidelines

Clofazimine (oral) (unlicensed) (TLS Red)

Cycloserine (oral) (TLS Red)

Terizidone (oral) (unlicensed) (TLS Red)

Prothionamide (oral) (unlicensed) (TLS Red)

N.B. In some circumstances, other antibiotics listed on this page may also be used for treatment of multi-resistant TB guided by microbiology advice.

5.2.6 Urinary tract infections

See Infections Guideline page for UTI guidelines

Recommended:

Nitrofurantoin (oral) (TLS Green)

Methenamine (oral) (TLS Blue)

For prophylaxis of urinary tract infections see Recurrent UTIs in Adults Guidelines. Suitable for patients with mild to moderate renal impairment (10-45mL/min)

Uromune Sublingual Spray Vaccine (TLS Red)

For prevention of recurrent UTIs, on advice of the recurrent UTI MDT

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