Broad-spectrum penicillins tive as phenoxymethylpenicillin (section 5.1.1.1) but they are better absorbed; however, they may encourage Infections

5.1.1.3 Broad-spectrum penicillins tive as phenoxymethylpenicillin (section 5.1.1.1) but they are better absorbed; however, they may encourage Infections

Ampicillin is active against certain Gram-positive and emergence of resistant organisms. Like phenoxymethyl- Gram-negative organisms but is inactivated by peni-

penicillin, amoxicillin and ampicillin are ineffective cillinases including those produced by Staphylococcus

against bacteria that produce beta-lactamases. Amox- aureus and by common Gram-negative bacilli such as

icillin may be useful for short-course oral regimens. Co- Escherichia coli . Almost all staphylococci, approx. 60%

amoxiclav is active against beta-lactamase-producing of E. coli strains and approx. 20% of Haemophilus influ-

bacteria that are resistant to amoxicillin. Co-amoxiclav enzae strains are now resistant. The likelihood of resis-

may be used for severe dental infection with spreading tance should therefore be considered before using ampi-

cellulitis or dental infection not responding to first-line cillin for the ‘blind’ treatment of infections; in particular,

antibacterial treatment. it should not be used for hospital patients without

checking sensitivity.

AMOXICILLIN

Ampicillin is well excreted in the bile and urine. It is

(Amoxycillin)

principally indicated for the treatment of exacerbations Indications see under Ampicillin; oral infections (see of chronic bronchitis and middle ear infections, both of

notes above); also endocarditis treatment (Table 1, which may be due to Streptococcus pneumoniae and H.

section 5.1); anthrax (section 5.1.12); adjunct in influenzae , and for urinary-tract infections (section

listerial meningitis (Table 1, section 5.1); Helicobacter 5.1.13).

pylori eradication (section 1.3) Ampicillin can be given by mouth but less than half the

Cautions see under Ampicillin; maintain adequate dose is absorbed, and absorption is further decreased by

hydration with high doses (particularly during par- the presence of food in the gut.

enteral therapy)

Maculopapular rashes commonly occur with ampicillin Contra-indications see under Ampicillin (and amoxicillin) but are not usually related to true

Side-effects see under Ampicillin penicillin allergy. They almost always occur in patients

Dose

with glandular fever; broad-spectrum penicillins should . By mouth , 250 mg every 8 hours, doubled in severe not therefore be used for ‘blind’ treatment of a sore

infections; CHILD up to 10 years, 125 mg every 8 throat. Rashes are also common in patients with acute

hours, doubled in severe infections or chronic lymphocytic leukaemia or in cytomegalo-

40 mg/kg daily virus infection.

Otitis media, 1 g every 8 hours; CHILD

in 3 divided doses (max. 3 g daily) Amoxicillin (amoxycillin) is a derivative of ampicillin

Pneumonia, 0.5–1 g every 8 hours and has a similar antibacterial spectrum. It is better

Anthrax (treatment and post-exposure prophylaxis— absorbed than ampicillin when given by mouth, produ-

see also section 5.1.12), 500 mg every 8 hours; CHILD cing higher plasma and tissue concentrations; unlike

body-weight under 20 kg, 80 mg/kg daily in 3 divided ampicillin, absorption is not affected by the presence

doses, body-weight over 20 kg, adult dose

5.1.1 Penicillins BNF 57 . Short-course oral therapy

Cautions history of allergy; renal impairment Dental abscess, 3 g repeated after 8 hours

(Appendix 3); erythematous rashes common in Urinary-tract infections, 3 g repeated after 10–12

glandular fever, cytomegalovirus infection, and acute hours

or chronic lymphocytic leukaemia (see notes above); . By intramuscular injection , 500 mg every 8 hours;

interactions: Appendix 1 (penicillins) CHILD , 50–100 mg/kg daily in divided doses

Contra-indications penicillin hypersensitivity . By intravenous injection or infusion , 500 mg every 8

Side-effects nausea, vomiting, diarrhoea; rashes (dis- hours increased to 1 g every 6 hours in severe

continue treatment); rarely, antibiotic-associated col- infections; CHILD , 50–100 mg/kg daily in divided

itis; see also under Benzylpenicillin (section 5.1.1.1) doses

Dose

. Listerial meningitis (in combination with another

antibiotic, see Table 1, section 5.1), , 0.25–1 g every 6 hours, at least 30

. By mouth

minutes before food; CHILD under 10 years, half adult infusion , 2 g every 4 hours for 10–14 days

by intravenous

dose

. Endocarditis (in combination with another antibiotic if necessary, see Table 1, section 5.1),

Urinary-tract infections, 500 mg every 8 hours; by intravenous CHILD infusion under 10 years, half adult dose , 2 g every 6 hours, increased to 2 g every 4

hours e.g. in enterococcal endocarditis or if amox- . By intramuscular injection or intravenous injection icillin used alone

or infusion , 500 mg every 4–6 hours; CHILD under 10 Note Amoxicillin doses in BNF may differ from those in

years, half adult dose product literature

. Endocarditis (in combination with another antibiotic if necessary), by intravenous infusion , 2 g every 6 Amoxicillin (Non-proprietary) A hours, increased to 2 g every 4 hours e.g. in enter-

Capsules , amoxicillin (as trihydrate) 250 mg, net price ococcal endocarditis or if ampicillin used alone

21 = £1.14; 500 mg, 21 = £1.56. Label: 9 Brands include Amix , Amoram , Amoxident , Galenamox ,

. Listerial meningitis (in combination with another Rimoxallin

antibiotic), by intravenous infusion , 2 g every 4 NEONATE Oral suspension , amoxicillin (as trihydrate) for

hours for 10–14 days;

50 mg/kg every 6

ns INFANT

1–3 months, 50–100 mg/kg every 6 hours; 100 mL = £1.37; 250 mg/5 mL, 100 mL = £1.54. CHILD

hours;

reconstitution with water, 125 mg/5 mL, net price

3 months–12 years, 100 mg/kg every 6 Label: 9

hours (max. 12 g daily) Note

Note Ampicillin doses in BNF may differ from those in product

Infectio

Sugar-free versions are available and can be ordered by specifying ‘sugar-free’ on the prescription

literature

5 Brands include Amoram , Galenamox , Rimoxallin

Ampicillin (Non-proprietary) A Sachets , sugar-free, amoxicillin (as trihydrate) 3 g/

Capsules , ampicillin 250 mg, net price 28 = £3.88; sachet, net price 2-sachet pack = £5.56, 14-sachet

500 mg, 28 = £19.68. Label: 9, 23 pack = £31.94. Label: 9, 13

Brands include Rimacillin Injection , powder for reconstitution, amoxicillin (as

Oral suspension , ampicillin 125 mg/5 mL when sodium salt), net price 250-mg vial = 32p; 500-mg vial

reconstituted with water, net price 100 mL = £3.38; = 66p; 1-g vial = £1.16

250 mg/5 mL, 100 mL = £6.61. Label: 9, 23 Dental prescribing on NHS Amoxicillin Capsules and Oral

Brands include Rimacillin Suspension may be prescribed. Amoxicillin Sachets may be

Injection , powder for reconstitution, ampicillin (as prescribed as Amoxicillin Oral Powder

sodium salt), net price 500-mg vial = £7.83 Amoxil Dental prescribing on NHS c (GSK)

A Ampicillin Capsules and Oral Suspension may be prescribed Capsules , both maroon/gold, amoxicillin (as trihy-

drate), 250 mg, net price 21-cap pack = £3.59; 500 mg, Penbritin c (Chemidex) A 21-cap pack = £7.19. Label: 9

Capsules , grey/red, ampicillin (as trihydrate) 250 mg, Paediatric suspension , amoxicillin 125 mg (as trihy-

net price 28-cap pack = £2.10; 500 mg, 28-cap pack = drate)/1.25 mL when reconstituted with water, net

£5.28. Label: 9, 23 price 20 mL (peach- strawberry- and lemon-fla-

Syrup , apricot- caramel- and peppermint-flavoured, voured) = £3.38. Label: 9, counselling , use of pipette

ampicillin (as trihydrate) for reconstitution with water,

Excipients include sucrose 600 mg/1.25 mL

125 mg/5 mL, net price 100 mL = £3.78; 250 mg/ Sachets SF , powder, sugar-free, amoxicillin (as trihy-

5 mL, 100 mL = £7.39. Label: 9, 23 drate) 3 g/sachet, 2-sachet pack (peach- strawberry-

Excipients include sucrose 3.6 g/5 mL

and lemon-flavoured) = £2.99. Label: 9, 13 Injection , powder for reconstitution, amoxicillin (as

With flucloxacillin sodium salt), net price 500-mg vial = 58p; 1-g vial =

See Co-fluampicil £1.16

Electrolytes Na 3.3 mmol/g

CO-AMOXICLAV

A mixture of amoxicillin (as the trihydrate or as the

AMPICILLIN sodium salt) and clavulanic acid (as potassium cla-

vulanate); the proportions are expressed in the form Indications urinary-tract infections, otitis media,

x /y where x and y are the strengths in milligrams of sinusitis, oral infections (see notes above), bronchitis,

amoxicillin and clavulanic acid respectively uncomplicated community-acquired pneumonia

Indications infections due to beta-lactamase-produ- (Table 1, section 5.1), Haemophilus influenzae infec-

cing strains (where amoxicillin alone not appropriate) tions, invasive salmonellosis; listerial meningitis

including respiratory-tract infections, genito-urinary (Table 1, section 5.1)

and abdominal infections, cellulitis, animal bites,

BNF 57

5.1.1 Penicillins 295

severe dental infection with spreading cellulitis or potassium salt)/5 mL when reconstituted with water, dental infection not responding to first-line anti-

net price 100 mL = £3.87. Label: 9 bacterial Cautions

Injection 500/100 , powder for reconstitution, co- see under Ampicillin and notes above; also

amoxiclav 500/100 (amoxicillin 500 mg as sodium caution in hepatic impairment (monitor hepatic

salt, clavulanic acid 100 mg as potassium salt), net function), pregnancy; maintain adequate hydration

price per vial = £1.21 with high doses (particularly during parenteral ther- apy)

Injection 1000/200 , powder for reconstitution, co- Cholestatic jaundice CSM has advised that cholestatic

amoxiclav 1000/200 (amoxicillin 1 g as sodium salt, jaundice can occur either during or shortly after the use of

clavulanic acid 200 mg as potassium salt), net price co-amoxiclav. An epidemiological study has shown that the

per vial = £2.42

risk of acute liver toxicity was about 6 times greater with co- amoxiclav than with amoxicillin. Cholestatic jaundice is

Augmentin c (GSK) A more common in patients above the age of 65 years and in

Tablets 375 mg , f/c, co-amoxiclav 250/125 (amox- men; these reactions have only rarely been reported in children. Jaundice is usually self-limiting and very rarely

icillin 250 mg as trihydrate, clavulanic acid 125 mg as fatal. The duration of treatment should be appropriate to the

potassium salt), net price 21-tab pack = £4.45. Label: 9 indication and should not usually exceed 14 days

Tablets 625 mg , f/c, co-amoxiclav 500/125 (amox- Contra-indications penicillin hypersensitivity, history

icillin 500 mg as trihydrate, clavulanic acid 125 mg as of co-amoxiclav-associated or penicillin-associated

potassium salt). Net price 21-tab pack = £8.49. jaundice or hepatic dysfunction

Label: 9

Side-effects see under Ampicillin; hepatitis, chole- Dispersible tablets , sugar-free, co-amoxiclav 250/ static jaundice (see above); Stevens-Johnson

125 (amoxicillin 250 mg as trihydrate, clavulanic acid syndrome, toxic epidermal necrolysis, exfoliative

125 mg as potassium salt). Net price 21-tab pack = dermatitis, vasculitis reported; rarely prolongation of

£10.22. Label: 9, 13

bleeding time, dizziness, headache, convulsions (par- Suspension ‘125/31 SF’ , sugar-free, co-amoxiclav ticularly with high doses or in renal impairment);

125/31 (amoxicillin 125 mg as trihydrate, clavulanic superficial staining of teeth with suspension, phlebitis

acid 31 mg as potassium salt)/5 mL when reconsti- at injection site

tuted with water. Net price 100 mL (raspberry-and Dose

orange-flavoured) = £4.25. Label: 9 . By mouth , expressed as amoxicillin, 250 mg every 8

Excipients include aspartame 12.5 mg/5 mL (section 9.4.1)

Dose CHILD 1–6 years (10–18 kg) 5 mL every 8 hours or hours, dose doubled in severe infections; INFANT CHILD see and CHILD up to 6 years 0.8 mL/kg daily in 3 divided doses; in under preparations below (under 6 years

severe infections dose increased to 1.6 mL/kg daily in 3 divided Augmentin c ‘125/31 SF’ suspension; 6–12 years

doses

Augmentin c ‘250/62 SF’ suspension or for short- Suspension ‘250/62 SF’ , sugar-free, co-amoxiclav

Infections

term treatment with twice daily dosage in c CHILD 2 250/62 (amoxicillin 250 mg as trihydrate, clavulanic months–12 years Augmentin-Duo 400/57 suspen-

acid 62 mg as potassium salt)/5 mL when reconsti- sion)

tuted with water. Net price 100 mL (raspberry-and Severe dental infections (but not generally first-line,

orange-flavoured) = £5.97. Label: 9 see notes above), expressed as amoxicillin, 250 mg

Excipients include aspartame 12.5 mg/5 mL (section 9.4.1)

every 8 hours for 5 days Dose CHILD 6–12 years (18–40 kg) 5 mL every 8 hours or .

By intravenous injection 0.4 mL/kg daily in 3 divided doses; in severe infections dose over 3–4 minutes or by intravenous infusion increased to 0.8 mL/kg daily in 3 divided doses , expressed as amoxicillin, 1 g

every 8 hours increased to 1 g every 6 hours in more Injection 600 mg , powder for reconstitution, co- serious infections; INFANTS up to 3 months 25 mg/kg

amoxiclav 500/100 (amoxicillin 500 mg as sodium every 8 hours (every 12 hours in the perinatal

salt, clavulanic acid 100 mg as potassium salt). Net period and in premature infants); CHILD

price per vial = £1.38 Electrolytes years, 25 mg/kg every 8 hours increased to 25 mg/ Na 1.35 mmol, K 0.5 mmol/600-mg vial

3 months–12

kg every 6 hours in more serious infections Injection 1.2 g , powder for reconstitution, co-amoxi- Surgical prophylaxis, expressed as amoxicillin, 1 g at

clav 1000/200 (amoxicillin 1 g as sodium salt, clavu- induction; for high risk procedures (e.g. colorectal

lanic acid 200 mg as potassium salt). Net price per vial = £2.76

surgery) up to 2–3 further doses of 1 g may be given

Electrolytes Na 2.7 mmol, K 1 mmol/1.2-g vial

every 8 hours Augmentin-Duo c (GSK) A Suspension Co-amoxiclav ‘400/57’, sugar-free, strawberry-fla- (Non-proprietary)

A voured, co-amoxiclav 400/57 (amoxicillin 400 mg as Tablets , co-amoxiclav 250/125 (amoxicillin 250 mg

trihydrate, clavulanic acid 57 mg as potassium salt)/ as trihydrate, clavulanic acid 125 mg as potassium salt), net price 21-tab pack = £3.04. Label: 9

5 mL when reconstituted with water. Net price 35 mL Dental prescribing on NHS Co-amoxiclav 250/125 Tablets may

= £4.38, 70 mL = £6.15. Label: 9 be prescribed

Excipients include aspartame 12.5 mg/5 mL (section 9.4.1) Dose CHILD

2 months–2 years 0.15 mL/kg twice daily, 2–6 years Tablets , co-amoxiclav 500/125 (amoxicillin 500 mg

(13–21 kg) 2.5 mL twice daily, 7–12 years (22–40 kg) 5 mL twice as trihydrate, clavulanic acid 125 mg as potassium

daily, doubled in severe infections salt), net price 21-tab pack = £6.32. Label: 9 Oral suspension , co-amoxiclav 125/31 (amoxicillin

125 mg as trihydrate, clavulanic acid 31.25 mg as

CO-FLUAMPICIL

potassium salt)/5 mL when reconstituted with water,

A mixture of equal parts by mass of flucloxacillin and net price 100 mL = £3.07. Label: 9

ampicillin

Oral suspension , co-amoxiclav 250/62 (amoxicillin Indications mixed infections involving beta-lacta- 250 mg as trihydrate, clavulanic acid 62.5 mg as

mase-producing staphylococci

5.1.1 Penicillins BNF 57 Cautions see under Ampicillin and Flucloxacillin

Contra-indications see under Benzylpenicillin (sec- Contra-indications see under Ampicillin and

tion 5.1.1.1)

Flucloxacillin Side-effects see under Benzylpenicillin (section Side-effects see under Ampicillin and Flucloxacillin

5.1.1.1); also nausea, vomiting, diarrhoea; less com- Dose

monly stomatitis, dyspepsia, constipation, jaundice, . By mouth , co-fluampicil, 250/250 every 6 hours,

hypotension, headache, insomnia, and injection-site dose doubled in severe infections; CHILD under 10

reactions; rarely abdominal pain, hepatitis, oedema, years half adult dose, dose doubled in severe

fatigue, and eosinophilia; very rarely hypoglycaemia, infections

hypokalaemia, pancytopenia, Stevens-Johnson . By intramuscular or slow intravenous injection or by

syndrome, and toxic epidermal necrolysis intravenous infusion , co-fluampicil 250/250 every

Dose

6 hours, dose doubled in severe infections; CHILD . See preparations under 2 years quarter adult dose, 2–10 years half

adult dose, dose doubled in severe infections With tazobactam Tazocin c (Lederle)

Co-fluampicil (Non-proprietary) AA , co-fluampicil 250/250 (flucloxacillin

Injection 2.25 g , powder for reconstitution, pipera- Capsules

cillin 2 g (as sodium salt), tazobactam 250 mg (as 250 mg as sodium salt, ampicillin 250 mg as trihy-

sodium salt). Net price per vial = £7.96 drate), net price 28-cap pack = £14.43. Label: 9, 22

Electrolytes Na 5.58 mmol/2.25-g vial Brands include Flu-Amp

Injection 4.5 g , powder for reconstitution, piperacillin Magnapen c (CP) A 4 g (as sodium salt), tazobactam 500 mg (as sodium Capsules , black/turquoise, co-fluampicil 250/250

salt). Net price per vial = £15.79 (flucloxacillin 250 mg as sodium salt, ampicillin

Electrolytes Na 11.16 mmol/4.5-g vial

250 mg as trihydrate), net price 20-cap pack = £4.00. Dose lower respiratory-tract, urinary-tract, intra-abdominal and Label: 9, 22

skin infections, and septicaemia, ADULT and CHILD over 12 years, by intravenous injection over 3–5 minutes or by intravenous

Syrup , co-fluampicil 125/125 (flucloxacillin 125 mg infusion , 2.25–4.5 g every 6–8 hours, usually 4.5 g every 8 hours

ns

as magnesium salt, ampicillin 125 mg as trihydrate)/ Complicated appendicitis, by intravenous injection over 3–5

5 mL when reconstituted with water, net price 100 mL minutes or by intravenous infusion , CHILD 2–12 years, 112.5 mg/ = £4.99. Label: 9, 22

kg every 8 hours (max. 4.5 g every 8 hours) for 5–14 days; CHILD Excipients include sucrose 3.14 g/5 mL

under 2 years, not recommended

Infectio

Infections in neutropenic patients (in combination with an ami- Injection 500 mg , powder for reconstitution, co-flu-

noglycoside), by intravenous injection over 3–5 minutes or 5 by

ampicil 250/250 (flucloxacillin 250 mg as sodium salt, intravenous infusion , ADULT and CHILD over 50 kg, 4.5 g every 6 ampicillin 250 mg as sodium salt), net price per vial =

hours; CHILD less than 50 kg, 90 mg/kg every 6 hours £1.33

Electrolytes Na 1.3 mmol/vial

TICARCILLIN

Indications infections due to Pseudomonas and Proteus

5.1.1.4 Antipseudomonal penicillins

spp, see notes above Cautions see under Benzylpenicillin (section 5.1.1.1)

The carboxypenicillin, ticarcillin, is principally indi- Contra-indications see under Benzylpenicillin (sec- cated for serious infections caused by Pseudomonas

tion 5.1.1.1)

aeruginosa although it also has activity against certain Side-effects see under Benzylpenicillin (section other Gram-negative bacilli including Proteus spp. and

5.1.1.1); also nausea, vomiting, coagulation disorders, Bacteroides fragilis .

haemorrhagic cystitis (more frequent in children), Ticarcillin is now available only in combination with

injection-site reactions, Stevens-Johnson syndrome, clavulanic acid (section 5.1.1.3); the combination (Time-

toxic epidermal necrolysis, hypokalaemia, eosino- ntin c ) is active against beta-lactamase-producing bac-

philia

teria resistant to ticarcillin.

Dose

Tazocin c contains the ureidopenicillin piperacillin with . See under preparation the beta-lactamase inhibitor tazobactam. Piperacillin is

more active than ticarcillin against Ps. aeruginosa. The With clavulanic acid spectrum of activity of Tazocin c is comparable to that of

Note For a CSM warning on cholestatic jaundice possibly associated with clavulanic acid, see under Co-amoxiclav

the carbapenems, imipenem and meropenem (section

p. 295.

5.1.2). Timentin (GSK) A For pseudomonas septicaemias (especially in neutrope-

Injection 3.2 g , powder for reconstitution, ticarcillin nia or endocarditis) these antipseudomonal penicillins

3 g (as sodium salt), clavulanic acid 200 mg (as should be given with an aminoglycoside (e.g. gentamicin

potassium salt). Net price per vial = £5.66 section 5.1.4) since they have a synergistic effect.

Electrolytes Na 16 mmol, K 1 mmol /3.2-g vial

Owing to the sodium content of many of these anti- Dose by intravenous infusion , 3.2 g every 6–8 hours increased to every 4 hours in more severe infections; CHILD

80 mg/kg every 6– biotics, high doses may lead to hypernatraemia.

8 hours (every 12 hours in neonates)

PIPERACILLIN

Mecillinams

Indications

see preparations Cautions see under Benzylpenicillin (section 5.1.1.1);

Pivmecillinam has significant activity against many renal impairment (Appendix 3); pregnancy (Appendix

Gram-negative bacteria including Escherichia coli, kleb- 4); breast-feeding (Appendix 5)

siella, enterobacter, and salmonellae. It is not active

BNF 57

5.1.2 Cephalosporins, carbapenems, and other beta-lactams 297

against Pseudomonas aeruginosa or enterococci. suitable alternative antibacterial is not available, then Pivmecillinam is hydrolysed to mecillinam, which is

cefixime, cefotaxime, ceftazidime, ceftriaxone, or cefur- the active drug.

oxime can be used with caution; cefaclor, cefadroxil, cefalexin, and cefradine should be avoided.

Antibiotic-associated colitis may occur with the use of Indications

PIVMECILLINAM HYDROCHLORIDE

broad-spectrum cephalosporins. see under Dose below Cautions see under Benzylpenicillin (section 5.1.1.1);

Cefradine (cephradine) has generally been replaced by also liver and renal function tests required in long-

the newer cephalosporins. term use; avoid in acute porphyria (section 9.8.2);

Cefuroxime is a ‘second generation’ cephalosporin that pregnancy; interactions: Appendix 1 (penicillins)

is less susceptible than the earlier cephalosporins to Contra-indications see under Benzylpenicillin (sec-

inactivation by beta-lactamases. It is, therefore, active tion 5.1.1.1); also carnitine deficiency, oesophageal

against certain bacteria which are resistant to the other strictures, gastro-intestinal obstruction, infants under

drugs and has greater activity against Haemophilus influ-

3 months enzae and Neisseria gonorrhoeae. Side-effects see under Benzylpenicillin (section

Cefotaxime, ceftazidime and ceftriaxone are ‘third 5.1.1.1); nausea, vomiting, dyspepsia; also reduced

generation’ cephalosporins with greater activity than serum and total body carnitine (especially with long-

the ‘second generation’ cephalosporins against certain term or repeated use)

Gram-negative bacteria. However, they are less active Dose

than cefuroxime against Gram-positive bacteria, most . Acute uncomplicated cystitis, ADULT and CHILD over

notably Staphylococcus aureus. Their broad antibacterial

40 kg, initially 400 mg then 200 mg every 8 hours for 3 spectrum may encourage superinfection with resistant days

bacteria or fungi.

. Chronic or recurrent bacteriuria, ADULT and CHILD over Ceftazidime has good activity against pseudomonas. It

40 kg, 400 mg every 6–8 hours is also active against other Gram-negative bacteria. . Urinary-tract infections, CHILD under 40 kg, 20–

40 mg/kg daily in 3–4 divided doses Ceftriaxone has a longer half-life and therefore needs to

be given only once daily. Indications include serious . Salmonellosis, not recommended therefore no dose

infections such as septicaemia, pneumonia, and stated

meningitis. The calcium salt of ceftriaxone forms a Counselling Tablets should be swallowed whole with plenty of fluid during meals while sitting or standing

precipitate in the gall bladder which may rarely cause symptoms but these usually resolve when the antibiotic

A Tablets , f/c, pivmecillinam hydrochloride 200 mg, net

Selexid c (LEO)

is stopped.

Infections

price 10-tab pack = £4.50. Label 9, 21, 27, counselling, Orally active cephalosporins The orally active ‘first posture (see Dose above)

generation’ cephalosporins, cefalexin (cephalexin), cefradine, and cefadroxil and the ‘second generation’ cephalosporin, cefaclor, have a similar antimicrobial spectrum. They are useful for urinary-tract infections

5.1.2 Cephalosporins,

which do not respond to other drugs or which occur in

carbapenems, and other pregnancy, respiratory-tract infections, otitis media,

sinusitis, and skin and soft-tissue infections. Cefaclor

beta-lactams

has good activity against H. influenzae, but it is asso- ciated with protracted skin reactions especially in chil-

Antibiotics in this section include the cephalosporins, dren. Cefadroxil has a long duration of action and can be such as cefotaxime, ceftazidime, cefuroxime, cefalexin

given twice daily; it has poor activity against H. influ- and cefradine, the monobactam, aztreonam, and the

enzae . Cefuroxime axetil, an ester of the ‘second gen- carbapenems, imipenem (a thienamycin derivative),

eration’ cephalosporin cefuroxime, has the same anti- meropenem, doripenem, and ertapenem.

bacterial spectrum as the parent compound; it is poorly absorbed.

Cefixime has a longer duration of action than the other

5.1.2.1 Cephalosporins

cephalosporins that are active by mouth. It is only licensed for acute infections.

The cephalosporins are broad-spectrum antibiotics Cefpodoxime proxetil is more active than the other which are used for the treatment of septicaemia, pneu-

oral cephalosporins against respiratory bacterial patho- monia, meningitis, biliary-tract infections, peritonitis,

gens and it is licensed for upper and lower respiratory- and urinary-tract infections. The pharmacology of the

tract infections.

cephalosporins is similar to that of the penicillins, excre- tion being principally renal. Cephalosporins penetrate

For treatment of Lyme disease, see section 5.1.1.3. the cerebrospinal fluid poorly unless the meninges are

inflamed; cefotaxime is a suitable cephalosporin for Oral infections The cephalosporins offer little advan- infections of the CNS (e.g meningitis).

tage over the penicillins in dental infections, often being less active against anaerobes. Infections due to oral

The principal side-effect of the cephalosporins is hyper- streptococci (often termed viridans streptococci) sensitivity and about 0.5–6.5% of penicillin-sensitive

which become resistant to penicillin are usually also patients will also be allergic to the cephalosporins.

resistant to cephalosporins. This is of importance in the Patients with a history of immediate hypersensitivity

case of patients who have had rheumatic fever and are to penicillin should not receive a cephalosporin. If a

on long-term penicillin therapy. Cefalexin and cefradine cephalosporin is essential in these patients because a

have been used in the treatment of oral infections.

5.1.2 Cephalosporins, carbapenems, and other beta-lactams

BNF 57

CEFACLOR

Dose

Indications . Patients over 40 kg, 0.5–1 g twice daily; skin, soft infections due to sensitive Gram-positive

tissue, and simple urinary-tract infections, 1 g daily; and Gram-negative bacteria, but see notes above Cautions

CHILD under 1 year, 25 mg/kg daily in divided doses; sensitivity to beta-lactam antibacterials

1–6 years, 250 mg twice daily; over 6 years, 500 mg (avoid if history of immediate hypersensitivity reac-

twice daily

tion, see also notes above and p. 290); renal impair- ment (Appendix 3); pregnancy and breast-feeding (but

Cefadroxil (Non-proprietary) A appropriate to use); false positive urinary glucose (if

Capsules , cefadroxil (as monohydrate) 500 mg, net tested for reducing substances) and false positive

price 20-cap pack = £5.25. Label: 9 Coombs’ test; interactions: Appendix 1 (cephalo- sporins)

Baxan c (Bristol-Myers Squibb) A Contra-indications cephalosporin hypersensitivity

Capsules , cefadroxil (as monohydrate) 500 mg, net Side-effects diarrhoea and rarely antibiotic-asso-

price 20-cap pack = £5.64. Label: 9 ciated colitis (CSM has warned both more likely with

Suspension , cefadroxil (as monohydrate) for recon- higher doses), nausea and vomiting, abdominal dis-

stitution with water, 125 mg/5 mL, net price 60 mL = comfort, headache; allergic reactions including

£1.63; 250 mg/5 mL, 60 mL = £3.24; 500 mg/5 mL, rashes, pruritus, urticaria, serum sickness-like reac-

60 mL = £4.85. Label: 9 tions with rashes, fever and arthralgia, and anaphy-

laxis; Stevens-Johnson syndrome, toxic epidermal necrolysis reported; disturbances in liver enzymes, transient hepatitis and cholestatic jaundice; other

CEFALEXIN

side-effects reported include eosinophilia and blood (Cephalexin) disorders (including thrombocytopenia, leucopenia,

Indications see under Cefaclor agranulocytosis, aplastic anaemia and haemolytic

Cautions see under Cefaclor anaemia); reversible interstitial nephritis, hyperactiv-

Contra-indications see under Cefaclor

ns

confusion, hypertonia, and dizziness see under Cefaclor Dose

ity, nervousness, sleep disturbances, hallucinations,

Side-effects

Dose

Infectio . 250 mg every 8 hours, doubled for severe infections;

. 250 mg every 6 hours or 500 mg every 8–12 hours max. 4 g daily; CHILD over 1 month, 20 mg/kg daily in

increased to 1–1.5 g every 6–8 hours for severe

5 3 divided doses, doubled for severe infections, max.

infections; CHILD

25 mg/kg daily in divided doses,

1 g daily; or 1 month–1 year, 62.5 mg every 8 hours; 1– doubled for severe infections, max. 100 mg/kg daily;

5 years, 125 mg; over 5 years, 250 mg; doses doubled or under 1 year 125 mg every 12 hours, 1–5 years for severe infections

125 mg every 8 hours, 5–12 years 250 mg every 8 hours

Cefaclor (Non-proprietary) A . Prophylaxis of recurrent urinary-tract infection, ADULT Capsules , cefaclor (as monohydrate) 250 mg, net

125 mg at night

Cefalexin (Non-proprietary) A Brands include Keftid

price 21-cap pack = £4.52; 500 mg, 50-cap pack = £23.88. Label: 9

Capsules , cefalexin 250 mg, net price 28-cap pack = Suspension , cefaclor (as monohydrate) for reconsti-

£2.07; 500 mg, 21-cap pack = £2.61. Label: 9 tution with water, 125 mg/5 mL, net price 100 mL =

Tablets , cefalexin 250 mg, net price 28-tab pack = £8.33; 250 mg/5 mL, 100 mL = £9.33. Label: 9

£2.27; 500 mg, 21-tab pack = £2.84. Label: 9 Note Sugar-free versions are available and can be ordered by specifying ‘sugar-free’ on the prescription

Oral suspension , cefalexin for reconstitution with Brands include Keftid

water, 125 mg/5 mL, net price 100 mL = £1.83; 250 mg/5 mL, 100 mL = £2.27. Label: 9

Distaclor c (Flynn) A Dental prescribing on NHS Cefalexin Capsules, Tablets, and Capsules , cefaclor (as monohydrate) 500 mg (violet/

Oral Suspension may be prescribed grey), net price 20 = £17.33. Label: 9

Ceporex c (Galen) A Suspension , both pink, cefaclor (as monohydrate) for

Capsules , both caramel/grey, cefalexin 250 mg, net reconstitution with water, 125 mg/5 mL, net price

price 28-cap pack = £4.02; 500 mg, 28-cap pack = 100 mL = £4.13; 250 mg/5 mL, 100 mL = £8.26.

£7.85. Label: 9

Label: 9 Tablets , all pink, f/c, cefalexin 250 mg, net price 28- Distaclor MR c (Flynn) A tab pack = £4.02; 500 mg, 28-tab pack = £7.85.

Tablets , m/r, both blue, cefaclor (as monohydrate)

Label: 9

375 mg. Net price 14-tab pack = £6.93. Label: 9, 21, 25 Syrup , all orange, cefalexin for reconstitution with Dose 375 mg every 12 hours with food, dose doubled for pneu-

water, 125 mg/5 mL, net price 100 mL = £1.43; monia

250 mg/5 mL, 100 mL = £2.87; 500 mg/5 mL, 100 mL Lower urinary-tract infections, 375 mg every 12 hours with food

= £5.57. Label: 9 Keflex c (Flynn) A

Capsules , cefalexin 250 mg (green/white), net price Indications

CEFADROXIL

28-cap pack = £1.76; 500 mg (pale green/dark green), see under Cefaclor; see also notes above

21-cap pack = £2.66. Label: 9 Cautions see under Cefaclor Tablets Contra-indications , both peach, cefalexin 250 mg, net price 28-

see under Cefaclor tab pack = £2.09; 500 mg (scored), 21-tab pack = Side-effects see under Cefaclor

£2.47. Label: 9

BNF 57

5.1.2 Cephalosporins, carbapenems, and other beta-lactams 299

Suspension , cefalexin for reconstitution with water, Side-effects see under Cefaclor 125 mg/5 mL, net price 100 mL = 88p; 250 mg/5 mL,

Dose

100 mL = £1.51. Label: 9 . Upper respiratory-tract infections (but in pharyngitis and tonsillitis reserved for infections which are

recurrent, chronic, or resistant to other antibacterials), Indications

CEFIXIME

100 mg twice daily (200 mg twice daily in sinusitis); see under Cefaclor (acute infections only);

15 days–6 months 4 mg/kg every 12 hours, 6 gonorrhoea [unlicensed indication] (Table 1, section

CHILD

months–2 years 40 mg every 12 hours, 3–8 years 5.1)

80 mg every 12 hours, over 9 years 100 mg every 12 Cautions see under Cefaclor

hours

Contra-indications see under Cefaclor . Lower respiratory-tract infections (including bronch- Side-effects see under Cefaclor

itis and pneumonia), 100–200 mg twice daily; CHILD 15 Dose

days–6 months 4 mg/kg every 12 hours, 6 months–2 . ADULT and CHILD over 10 years, 200–400 mg daily in 1–

years 40 mg every 12 hours, 3–8 years 80 mg every 12

2 divided doses; CHILD over 6 months 8 mg/kg daily in hours, over 9 years 100 mg every 12 hours 1–2 divided doses or 6 months–1 year 75 mg daily; 1–

. Skin and soft-tissue infections, 200 mg twice daily;

15 days–6 months 4 mg/kg every 12 hours, 6 . Gonorrhoea [unlicensed indication], 400 mg as a sin-

4 years 100 mg daily; 5–10 years 200 mg daily

CHILD

months–2 years 40 mg every 12 hours, 3–8 years gle dose

80 mg every 12 hours, over 9 years 100 mg every 12

c Suprax hours (Rhoˆne-Poulenc Rorer) A Tablets , f/c, scored, cefixime 200 mg. Net price 7-tab

. Uncomplicated urinary-tract infections, 100 mg twice pack = £13.23. Label: 9

daily (200 mg twice daily in uncomplicated upper urinary-tract infections); CHILD

15 days–6 months Paediatric oral suspension , cefixime 100 mg/5 mL

4 mg/kg every 12 hours, 6 months–2 years 40 mg when reconstituted with water, net price 50 mL (with

every 12 hours, 3–8 years 80 mg every 12 hours, over double-ended spoon for measuring 3.75 mL or 5 mL

9 years 100 mg every 12 hours since dilution not recommended) = £10.53, 100 mL =

. Uncomplicated gonorrhoea, 200 mg as a single dose £18.91. Label: 9 Orelox c (Hoechst Marion Roussel) A