Chloramphenicol

Chloramphenicol

• Capsules 250mg
• Powder for solution for injection 1g

Fusidic acid

Sodium fusidate

• Tablets 250mg (£6.02 = 10 tablets)
• Fusidic acid oral suspension 250mg/5ml (5ml is approximately equivalent to 175mg sodium fusidate) (£12.11 = 90ml)

Indications

• Infections caused by staphylococci, especially in osteomyelitis

Notes

1. MHRA Drug Safety Update (September 2011): Systemic fusidic acid and interaction with statins
   1. Systemic fusidic acid should not be given with statins because of a risk of (potentially fatal) rhabdomyolysis
   2. In patients for whom the use of systemic fusidic acid is essential, statin treatment should be temporarily discontinued throughout the duration of fusidic acid treatment. To ensure clearance of systemic fusidic acid, statin therapy may be reintroduced 7 days after the last dose of systemic fusidic acid

Glycopeptide antibacterials

Vancomycin

• Capsules 125mg, 250mg (£132.49 = 28 x 125mg capsules)
• Powder for solution for infusion vial 500mg, 1g
• Intrathecal injection 10mg/2ml (unlicensed preparation)

Indications

• C. difficile infection

Notes

1. The intravenous route should not be used for C. difficile infections. Alternative oral formulations may be available, seek specialist advice
2. Therapeutic drug monitoring (serum-vancomycin measurement) is required for intravenous use

Dalbavancin

• Powder for solution for infusion vial 500mg

Teicoplanin

• Injection 200mg, 400mg

Fidaxomicin

Fidaxomicin

• Tablets 200mg (£1,350.00 = 20 tablets)
• Oral suspension sugar free 40mg/ml (£1,350.00 = 110ml bottle)

Indications and dose

• C. difficile infection
  • Tablets: Adults and children with body-weight ≥ 12.5kg: 200mg orally twice a day for 10 days
  • Oral suspension: Adults and children from birth to < 18 years of age (doses given twice a day for 10 days)
    • Body-weight under 4kg: 40mg (1ml reconstituted oral suspension)
    • Body-weight 4kg - < 7kg: 80mg (2ml reconstituted oral suspension)
    • Body-weight 7kg - < 9kg: 120mg (3ml reconstituted oral suspension)
    • Body-weight 9kg - < 12.5kg: 160mg (4ml reconstituted oral suspension)
    • Body-weight ≥ 12.5kg: 200mg (5ml reconstituted oral suspension)

Notes

1. The routine commissioning of fidaxomicin is accepted in Devon for the treatment of Clostridioides difficile infection (see Commissioning Policy for more details)
2. Reconstituted oral suspension may be administered via enteral feeding tube; for further information, including recommended tube size and flush volume of water are available refer to the SmPC.

Daptomycin

Daptomycin

• Powder for solution for intravenous infusion vial 350mg, 500mg

Linezolid

Linezolid

• Tablets 600mg
• Oral suspension 100mg/5ml
• Intravenous infusion 600mg/300ml

Notes

• Monitor full blood count (including platelet count) weekly.
• Linezolid should only be initiated in a hospital environment and after consultation with a relevant specialist such as a microbiologist. In exceptional circumstances it may be considered appropriate for a GP to commence treatment in a primary care setting (off-license use), only under the recommendation and supervision of a microbiologist. This should be discussed on an individual patient basis.
• Linezolid should only be used for life-threatening or deep seated infections due to MRSA where alternate therapy, e.g. vancomycin, is unsuitable. Linezolid is not active against infections caused by Gram negative pathogens. Specific therapy against Gram negative organisms must be initiated concomitantly if a Gram negative pathogen is documented or suspected.
• The maximum treatment duration is 28 days. The safety and effectiveness of linezolid when administered for periods longer than 28 days have not been established.
• BNF CHM advice
  Optic neuropathy:
  Severe optic neuropathy may occur rarely, particularly if linezolid is used for longer than 28 days. The CHM recommends that:
  1. patients should be warned to report symptoms of visual impairment (including blurred vision, visual field defect, changes in visual acuity and colour vision) immediately;
  2. patients experiencing new visual symptoms (regardless of treatment duration) should be evaluated promptly, and referred to an ophthalmologist if necessary;
  3. visual function should be monitored regularly if treatment is required for longer than 28 days.
  Blood disorders:
  Haematopoietic disorders (including thrombocytopenia, anaemia, leucopenia, and pancytopenia) have been reported in patients receiving linezolid. It is recommended that full blood counts are monitored weekly. Close monitoring is recommended in patients who:
  1. receive treatment for more than 10–14 days;
  2. have pre-existing myelosuppression;
  3. are receiving drugs that may have adverse effects on haemoglobin, blood counts, or platelet function;
  4. have severe renal impairment.
  If significant myelosuppression occurs, treatment should be stopped unless it is considered essential, in which case intensive monitoring of blood counts and appropriate management should be implemented.
• Spontaneous reports of serotonin syndrome associated with the co-administration of linezolid and serotonergic agents, including antidepressants such as selective serotonin reuptake inhibitors (SSRIs) have been reported. Co-administration of linezolid and serotonergic agents is therefore contraindicated except where administration of linezolid and concomitant serotonergic agents is essential. In those cases patients should be closely observed for signs and symptoms of serotonin syndrome.

For additional interaction and monitoring requirements associated with treatment, please refer to the manufacturer's summary of product characteristics for up-to-date information.

Polymixins

Colistimethate sodium

• Powder for solution for injection vial 1million unit, 2million unit (£18.00 = 10 x 1million unit vials; £32.40 = 10 x 2million unit vials)
• Colobreathe 1,662,500 unit dry powder for inhalation (Cystic Fibrosis (CF) treatment only)
• Promixin 1million unit powder for nebuliser solution (CF treatment only)
  

Notes

1. For patients with CysticFibrosis (CF): treatment should only be prescribed by secondary care
2. Non-CF bronchiectasis patients: Colistimethate sodium powder for solution for injection is included for nebulised use in this patient group (unlicensed)
3. National commissioning criteria for inhaled treatments for CF can be found in the NHS England commissioning policy, available here
4. NICE TA276: Colistimethate sodium and tobramycin dry powders for inhalation for treating pseudomonas lung infection in cystic fibrosis (March 2013):
   1. Colistimethate sodium DPI (Colobreathe) is recommended as an option for treating chronic pulmonary infection caused by Pseudomonas aeruginosa in people with CF only if the criteria within the NICE TA are met

Rifaximin

Rifaximin

• Tablets 550mg (£259.23 = 56 tablets)

Indications

• Hepatic encephalopathy

Dose

• 550mg twice a day
• The clinical benefit of rifaximin was established from a controlled study in which subjects were treated for 6 months. Treatment beyond 6 months should take into consideration the individual balance between benefits and risks, including those associated with the progression of hepatic dysfunction.
• Rifaximin should be co-prescribed alongside lactulose (or alternative laxative) sufficient to open bowels twice per day.

Notes

1. Treatment with rifaximin should be initiated by a Gastroenterology Consultant. Once the patient is stabilised on treatment repeat prescriptions may be issued by primary care, however the ongoing management of the patient's liver disease will continue to be the responsibility of secondary care.
2. Rifaximin is a non-absorbed antibacterial agent and there are no specific monitoring requirements associated with treatment.
3. Secondary care will monitor the ongoing need for continuation of rifaximin in individual patients
4. NICE TA337 Rifaximin is recommended, within its marketing authorisation, as an option for reducing the recurrence of episodes of overt hepatic encephalopathy in people aged 18 years or older (March 2015).

Tedizolid

Tedizolid

• Tablets 200mg
• Powder for concentrate for solution for infusion 200 mg