5.2 Bacterial infection

5.2 Bacterial infection

Guidelines

• BNSSG Primary Care Antimicrobial Guidelines
• NBT antibiotic guidelines click here 
• UHB antibiotic guidelines click here (NB 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

Aminoglycosides

Amikacin (parenteral) (TLS Red)

• Secondary Care Restricted, see local guidelines

Gentamicin (parenteral) (TLS Red)

• Secondary Care Restricted, see local guidelines

Gentamicin (nebulised) (TLS Red)

• Secondary Care Restricted, see local guidelines

Tobramycin (parenteral) (TLS Red)

• Secondary Care Restricted, see local guidelines

Tobramycin (nebulised) (TLS Red)

• Restricted, see local guidelines
• 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 (inhaled) (TLS Red)

• Secondary Care Restricted, see local guidelines
• Tobi^® Podhaler
• NICE 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, on Microbiology advice only

Carbapenems

Ertapenem (parenteral) (TLS Red)

• Restricted, see local guidelines

Meropenem (parenteral) (TLS Red)

• Restricted, see local guidelines

Imipenem / cilastatin (parenteral) (TLS Red)

• Restricted, see local guidelines

Cephalosporins

Cefalexin (oral) (TLS blue)

• Restricted, see local guidelines

Cefadroxil (oral) (TLS Red)

• Restricted, see local guidelines

Cefixime (oral) (TLS Red)

• Restricted, see local guidelines

Cefaclor (oral) (TLS Red)

• Restricted, see local guidelines

Cefotaxime (oral) (TLS Red)

• Restricted, see local guidelines

Cefradine (oral) (TLS Red)

• Restricted, see local guidelines

Ceftriaxone (parenteral) (TLS Red)

• Restricted, see local guidelines

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

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

Diaminopyrimidines

Trimethoprim (oral) (TLS Green)

Co-trimoxazole (oral & parenteral) (TLS Red)

Glycopeptide Antibacterials

Teicoplanin (parenteral) (TLS Red)

• Secondary care restricted, see local guidelines

Vancomycin (oral) (TLS Blue)

• For C Diff infection only, see local guidelines

Vancomycin (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

Macrocyclic Antibacterials

Macrolides and Related drugs

Clarithromycin (oral) (TLS Green)

Erythromycin (oral) (TLS Blue)

• For use in gut motility

Alternatives:

Erythromycin (oral) (TLS Blue)

• Restricted, see local guidelines

Azithromycin (oral) (TLS Blue)

• Restricted, see local guidelines

Erythromycin (parenteral) (TLS red)

• Secondary care restricted, see local guidelines

Clarithromycin (parenteral) (TLS Red)

• Secondary care restricted, see local guidelines

Monocyclic Beta-lactam Antibacterials

Aztreonam (nebulised) (TLS Red)

• Secondary Care Restricted, see local guidelines
• In accordance with the NHS England Clinical Commissioning Policy: Inhaled Therapy for Adults and Children with Cystic Fibrosis. A01/P/b

5-Nitroimidazole Derivatives

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)

Phenoxymethylpenicillin (oral) (TLS Green)

Benzylpenicillin sodium (parenteral) (TLS Red)

• Secondary care Restricted – refer to local guidance

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

• Secondary care Restricted – refer to local guidance

Penicillins (Broad-spectrum)

Amoxicillin (oral) (TLS Green)

Amoxicillin (parenteral) (TLS Red)

Co-amoxiclav (oral) (TLS Blue)

Co-amoxiclav (parenteral) (TLS Red)

• Secondary Care Restricted, see local guidelines

Penicillins (Penicillinase-resistant)

Flucloxacillin (oral) (TLS Green)

Flucloxacillin (parenteral) (TLS Red)

• Secondary Care Restricted, see local guidelines

Temocillin (parenteral) (TLS Red)

• Secondary Care Restricted, see local guidelines

Phosphonic Acid Antibacterials

Fosfomycin (oral & parenteral) (TLS Red)

• Restricted, see local guidelines

Polymixin Antibacterials

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 (parenteral) (TLS Red)

• Restricted in secondary care

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

• NICE 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)

Quinolones

Ciprofloxacin (oral) (TLS Blue)

• Restricted, see local guidelines

Ciprofloxacin (parenteral) (TLS Red)

• Secondary care restricted, see local guidelines

Tetracyclines and Related Drugs

Doxycycline (oral) (TLS Green)

Lymecycline (oral) (TLS Green)

Demeclocycline hydrochloride (oral) (TLS Blue)

Tetracycline (oral) (TLS Blue)

5.2.4 Tuberculosis

Antimycobacterials

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

Ethambutol hydrochloride (oral) (TLS Red)

• Secondary care restricted, see local guidelines

Pyrazinamide (oral) (unlicensed) (TLS Red)

• Secondary care restricted, see local guidelines

Streptomycin (parenteral) (unlicensed) (TLS Red)

• Secondary care restricted, see local guidelines

Rifabutin (oral) (TLS Red)

Isoniazid (oral) (TLS Red)

5.2.6 Urinary tract infections

Nitrofurantoin (oral) (TLS Green)