Aztreonam is a monocyclic beta-lactam (‘monobac- vulsions, confusion and mental disturbances reported; slight increases in liver enzymes and bilirubin

5 Aztreonam is a monocyclic beta-lactam (‘monobac- vulsions, confusion and mental disturbances reported; slight increases in liver enzymes and bilirubin

tam’) antibiotic with an antibacterial spectrum limited reported, rarely hepatitis; increases in serum creat-

to Gram-negative aerobic bacteria including Pseudo- inine and blood urea; red coloration of urine in chil-

monas aeruginosa , Neisseria meningitidis, and Haemo- dren reported; local reactions: erythema, pain and

philus influenzae ; it should not be used alone for ‘blind’ induration, and thrombophlebitis

treatment since it is not active against Gram-positive Dose

organisms. Aztreonam is also effective against Neisseria . By intravenous infusion , in terms of imipenem, 1–

gonorrhoeae (but not against concurrent chlamydial

2 g daily (in 3–4 divided doses); less sensitive infection). Side-effects are similar to those of the other organisms, up to 50 mg/kg daily (max. 4 g daily) in

beta-lactams although aztreonam may be less likely to 3–4 divided doses; CHILD

3 months and older, cause hypersensitivity in penicillin-sensitive patients.

60 mg/kg (up to max. of 2 g) daily in 4 divided doses; over 40 kg, adult dose

AZTREONAM

Surgical prophylaxis, 1 g at induction repeated after 3 hours, supplemented in high risk (e.g. colorectal) Indications Gram-negative infections including surgery by doses of 500 mg 8 and 16 hours after

Pseudomonas aeruginosa , Haemophilus influenzae, and induction

Neisseria meningitidis Cautions hypersensitivity to beta-lactam antibiotics; Primaxin c (MSD) A hepatic impairment; renal impairment (Appendix 3); Intravenous infusion , powder for reconstitution,

breast-feeding (Appendix 5); interactions: Appendix imipenem (as monohydrate) 500 mg with cilastatin (as

1 (aztreonam)

sodium salt) 500 mg, net price per vial = £12.00 Contra-indications

Electrolytes Na 1.72 mmol/vial

aztreonam hypersensitivity; pregnancy (Appendix 4) Side-effects nausea, vomiting, diarrhoea, abdominal

MEROPENEM

cramps; mouth ulcers, altered taste; jaundice and hepatitis; flushing; hypersensitivity reactions; blood

Indications aerobic and anaerobic Gram-positive and disorders (including thrombocytopenia and neutro- Gram-negative infections

penia); rashes, injection-site reactions; rarely hypo- Cautions sensitivity to beta-lactam antibacterials

tension, seizures, asthenia, confusion, dizziness, (avoid if history of immediate hypersensitivity reac-

headache, halitosis, and breast tenderness; very rarely tion, see also p. 290); hepatic impairment (monitor

antibiotic-associated colitis, gastro-intestinal bleed- liver function; Appendix 2); renal impairment

ing, and toxic epidermal necrolysis (Appendix 3); pregnancy (Appendix 4); breast-feeding

Dose

(Appendix 5); interactions: Appendix 1 (meropenem) . By deep intramuscular injection or by intravenous Side-effects nausea, vomiting, diarrhoea (antibiotic-

injection over 3–5 minutes or by intravenous infu- associated colitis reported), abdominal pain, distur-

sion , 1 g every 8 hours or 2 g every 12 hours; 2 g bances in liver function tests; headache; thrombo-

every 6–8 hours for severe infections (including cythaemia, positive Coombs’ test; rash, pruritus,

systemic Pseudomonas aeruginosa and lung infec-

BNF 57

5.1.3 Tetracyclines 303

tions in cystic fibrosis); single doses over 1 g intra- receiving potentially hepatotoxic drugs. Tetracyclines venous route only

may increase muscle weakness in patients with myas- Urinary-tract infections, 0.5–1 g every 8–12 hours

thenia gravis, and exacerbate systemic lupus erythe- . CHILD over 1 week, by intravenous injection or infu-

matosus. Antacids, and aluminium, calcium, iron, sion , 30 mg/kg every 6–8 hours increased in severe

magnesium and zinc salts decrease the absorption of infections for child of 2 years or older to 50 mg/kg

tetracyclines; milk also reduces the absorption of every 6–8 hours; max. 8 g daily

demeclocycline, oxytetracycline, and tetracycline. . Gonorrhoea, cystitis, by intramuscular injection ,1g

Other interactions: Appendix 1 (tetracyclines). as a single dose

c Contra-indications Azactam Deposition of tetracyclines in (Squibb) A growing bone and teeth (by binding to calcium) causes Injection , powder for reconstitution, aztreonam. Net

staining and occasionally dental hypoplasia, and they price 500-mg vial = £5.00; 1-g vial = £9.98; 2-g vial =

should not be given to children under 12 years, or to £19.98

pregnant (Appendix 4) or breast-feeding women (Appendix 5). However, doxycycline may be used in children for treatment and post-exposure prophylaxis of anthrax when an alternative antibacterial cannot be given [unlicensed indication]. With the exception of doxycycline and minocycline, the tetracyclines may

5.1.3 Tetracyclines

exacerbate renal failure and should not be given to patients with kidney disease (Appendix 3). Tetracyclines

The tetracyclines are broad-spectrum antibiotics whose should not be given to patients with acute porphyria value has decreased owing to increasing bacterial resis-

(section 9.8.2)

tance. They remain, however, the treatment of choice for infections caused by chlamydia (trachoma, psitta-

Side-effects Side-effects of the tetracyclines include cosis, salpingitis, urethritis, and lymphogranuloma

nausea, vomiting, diarrhoea (antibiotic-associated col- venereum), rickettsia (including Q-fever), brucella (dox-

itis reported occasionally), dysphagia, and oesophageal ycycline with either streptomycin or rifampicin), and the

irritation. Other rare side-effects include hepatotoxicity, spirochaete, Borrelia burgdorferi (Lyme disease—see

pancreatitis, blood disorders, photosensitivity (particu- section 5.1.1.3). They are also used in respiratory and

larly with demeclocycline), and hypersensitivity reac- genital mycoplasma infections, in acne, in destructive

tions (including rash, exfoliative dermatitis, Stevens- (refractory) periodontal disease, in exacerbations of

Johnson syndrome, urticaria, angioedema, anaphylaxis, chronic bronchitis (because of their activity against

pericarditis). Headache and visual disturbances may

Haemophilus influenzae ), and for leptospirosis in peni- indicate benign intracranial hypertension (discontinue

Infections

cillin hypersensitivity (as an alternative to erythro- treatment); bulging fontanelles have been reported in mycin).

infants.

For the role of tetracyclines in the management of meticillin-resistant Staphylococcus aureus (MRSA) infec-

TETRACYCLINE

tion, see p. 292. Indications see notes above; acne vulgaris, rosacea Microbiologically, there is little to choose between the

(section 13.6)

various tetracyclines, the only exception being mino- Cautions see notes above cycline which has a broader spectrum; it is active

against Neisseria meningitidis and has been used for Contra-indications see notes above meningococcal prophylaxis but is no longer recom-

Side-effects see notes above; also acute renal failure, mended because of side-effects including dizziness

skin discoloration

and vertigo (see section 5.1, table 2 for current recom-

Dose

mendations). Compared to other tetracyclines, mino- . 250 mg every 6 hours, increased in severe infections cycline is associated with a greater risk of lupus-erythe-

to 500 mg every 6–8 hours matosus-like syndrome. Minocycline sometimes causes

. Acne, see section 13.6.2 irreversible pigmentation.

. Non-gonococcal urethritis, 500 mg every 6 hours for 7–14 days (21 days if failure or relapse after first Oral infections In adults, tetracyclines can be effec-

course)

tive against oral anaerobes but the development of Counselling Tablets should be swallowed whole with plenty resistance (especially by oral streptococci) has reduced

of fluid while sitting or standing their usefulness for the treatment of acute oral infec-

tions; they may still have a role in the treatment of Tetracycline (Non-proprietary) A

destructive (refractory) forms of periodontal disease. Tablets , coated, tetracycline hydrochloride 250 mg,

Doxycycline has a longer duration of action than tetra- net price 28-tab pack = £8.85. Label: 7, 9, 23, coun- cycline or oxytetracycline and need only be given once

selling, posture

Dental prescribing on NHS daily; it is reported to be more active against anaerobes Tetracycline Tablets may be pre-

scribed

than some other tetracyclines. For the use of doxycycline in the treatment of recurrent

DEMECLOCYCLINE HYDROCHLORIDE

aphthous ulceration, oral herpes, or as an adjunct to

gingival scaling and root planing for periodontitis, see Indications see notes above; also inappropriate section 12.3.1 and section 12.3.2.

secretion of antidiuretic hormone, section 6.5.2 Cautions see notes above, but photosensitivity more Cautions Tetracyclines should be used with caution in

common (avoid exposure to sunlight or sun lamps) patients with hepatic impairment (Appendix 2) or those

Contra-indications see notes above

5.1.3 Tetracyclines BNF 57 Side-effects see notes above; also reversible nephro-

Side-effects see notes above genic diabetes insipidus, acute renal failure

Dose

Dose . 408 mg every 12 hours, increased to 1.224–1.632 g . 150 mg every 6 hours or 300 mg every 12 hours

daily in severe infections Ledermycin c (Goldshield) A . Acne, 408 mg daily for at least 8 weeks

Capsules , red, demeclocycline hydrochloride 150 mg, net price 28-cap pack = £13.73. Label: 7, 9, 11, 23

Tetralysal 300 c (Galderma) A Capsules , red/yellow, lymecycline 408 mg (= tetra- cycline 300 mg), net price 28-cap pack = £7.16, 56-cap

pack = £14.26. Label: 6, 9 Indications see notes above; chronic prostatitis;

DOXYCYCLINE

sinusitis, syphilis, pelvic inflammatory disease (Table

1, section 5.1); treatment and prophylaxis of anthrax

MINOCYCLINE

[unlicensed indication]; malaria treatment and prophylaxis (section 5.4.1); recurrent aphthous ulcer-

Indications see notes above; meningococcal carrier ation, adjunct to gingival scaling and root planing for

state; acne vulgaris (section 13.6.2) periodontitis (section 12.3.1); oral herpes simplex

Cautions see notes above, but may be used in renal (section 12.3.2); rosacea [unlicensed indication], acne

impairment; if treatment continued for longer than 6 vulgaris (section 13.6)

months, monitor every 3 months for hepatotoxicity, Cautions see notes above, but may be used in renal

pigmentation and for systemic lupus erythematosus— impairment; alcohol dependence; photosensitivity

discontinue if these develop or if pre-existing systemic reported (avoid exposure to sunlight or sun lamps)

lupus erythematosus worsens Contra-indications see notes above

Contra-indications see notes above Side-effects see notes above; also anorexia, flushing,

Side-effects see notes above; also dizziness and and tinnitus

vertigo (more common in women); rarely anorexia, ns Dose

tinnitus, impaired hearing, hyperaesthesia, paraes- . 200 mg on first day, then 100 mg daily; severe infec-

thesia, acute renal failure, pigmentation (sometimes tions (including refractory urinary-tract infections),

irreversible), and alopecia; very rarely systemic lupus

Infectio

200 mg daily erythematosus, discoloration of conjunctiva, tears, . Early syphilis, 100 mg twice daily for 14 days; late

and sweat

5 latent syphilis, 100 mg twice daily for 28 days; neu-

Dose

rosyphilis, 200 mg twice daily for 28 days . 100 mg twice daily . Uncomplicated genital chlamydia, non-gonococcal

. Acne, see section 13.6.2 and under preparations, urethritis, 100 mg twice daily for 7 days (14 days in

below

pelvic inflammatory disease, see also Table 1, section . Prophylaxis of asymptomatic meningococcal carrier 5.1)

state (but no longer recommended, see notes above), . Anthrax (treatment or post-exposure prophylaxis; see

100 mg twice daily for 5 days usually followed by also section 5.1.12), 100 mg twice daily; CHILD (only if

rifampicin

alternative antibacterial cannot be given) [unlicensed Counselling Tablets or capsules should be swallowed whole dose] 5 mg/kg daily in 2 divided doses (max. 200 mg

with plenty of fluid while sitting or standing daily)

Minocycline (Non-proprietary) Counselling Capsules should be swallowed whole with

A plenty of fluid during meals while sitting or standing

Capsules , minocycline (as hydrochloride) 50 mg, net Note Doxycycline doses in BNF may differ from those in

price 56-cap pack = £15.27; 100 mg, 28-cap pack = product literature

£13.09. Label: 6, 9, counselling, posture Brands include Aknemin Doxycycline (Non-proprietary) A Tablets , minocycline (as hydrochloride) 50 mg, net

Capsules , doxycycline (as hyclate) 50 mg, net price price 28-tab pack = £3.96, 100 mg, 28-tab pack = 28-cap pack = £1.78; 100 mg, 8-cap pack = £1.15.

£8.43. Label: 6, 9, counselling, posture Label: 6, 9, 11, 27, counselling, posture Brands include Doxylar

Dental prescribing on NHS Doxycycline Capsules 100 mg may Modified release be prescribed

Acnamino c MR (Dexcel) A Vibramycin c (Pfizer) A Capsules , m/r, buff/brown (enclosing pink and peach Capsules , doxycycline (as hyclate) 50 mg (green/

tablets), minocycline (as hydrochloride) 100 mg, net ivory), net price 28-cap pack = £7.74. Label: 6, 9, 11,

price 56-cap pack = £21.14. Label: 6, 25

27, counselling, posture Dose acne, 1 capsule daily Vibramycin-D c (Pfizer) A Minocin MR c (Meda) A

Dispersible tablets , yellow, scored, doxycycline Capsules , m/r, orange/brown (enclosing yellow and 100 mg, net price 8-tab pack = £4.91. Label: 6, 9, 11,

white pellets), minocycline (as hydrochloride) 100 mg.

13 Net price 56-cap pack = £21.14. Label: 6, 25 Dose acne, 1 capsule daily

Sebomin MR c (Actavis) A Indications see notes above

LYMECYCLINE

Capsules , m/r, orange, minocycline (as hydro- Cautions

chloride) 100 mg, net price 56-cap pack = £21.14. see notes above

Label: 6, 25

Contra-indications see notes above Dose acne, 1 capsule daily

BNF 57

5.1.4 Aminoglycosides 305

mycin is active against Mycobacterium tuberculosis and Indications

OXYTETRACYCLINE

is now almost entirely reserved for tuberculosis (section see notes above; acne vulgaris, rosacea

(section 13.6) Cautions see notes above

The aminoglycosides are not absorbed from the gut Contra-indications

(although there is a risk of absorption in inflammatory see notes above Side-effects

bowel disease and liver failure) and must therefore be see notes above

given by injection for systemic infections. Dose Excretion is principally via the kidney and accumulation . 250–500 mg every 6 hours

occurs in renal impairment. . Acne, see section 13.6.2

Most side-effects of this group of antibiotics are dose- Oxytetracycline (Non-proprietary) A related therefore care must be taken with dosage and

Tablets , coated, oxytetracycline dihydrate 250 mg, whenever possible treatment should not exceed 7 days. net price 28-tab pack = £1.00. Label: 7, 9, 23

The important side-effects are ototoxicity, and nephro- Brands include Oxymycin Dental prescribing on NHS Oxtetracycline Tablets may be pre-

toxicity; they occur most commonly in the elderly and in scribed

patients with renal failure. If there is impairment of renal function (or high pre-dose

serum concentrations) the interval between doses must

Tigecycline

be increased; if the renal impairment is severe the dose itself should be reduced as well. Tigecycline is a glycylcycline antibacterial structurally related to the tetracyclines; side-effects similar to those

Aminoglycosides may impair neuromuscular transmis- of the tetracyclines can potentially occur. Tigecycline is

sion and should not be given to patients with myas- active against Gram-positive and Gram-negative bacter-

thenia gravis; large doses given during surgery have ia, including tetracycline-resistant organisms, and some

been responsible for a transient myasthenic syndrome anaerobes. It is also active against meticillin-resistant

in patients with normal neuromuscular function. Staphylococcus aureus and vancomycin-resistant entero-

Aminoglycosides should preferably not be given with cocci, but Pseudomonas aeruginosa and many strains of

potentially ototoxic diuretics (e.g. furosemide (fruse- Proteus spp are resistant to tigecycline. Tigecycline

mide)); if concurrent use is unavoidable administration should be reserved for the treatment of complicated

of the aminoglycoside and of the diuretic should be skin and soft-tissue infections and complicated abdo-

separated by as long a period as practicable. minal infections caused by multiple-antibacterial resis-

tant organisms. Once daily dosage Once daily administration of

aminoglycosides is more convenient, provides adequate

Infections