▶ Adult: 1 g, to be administered 2 hours before surgery,
then 1 g every 8 hours if required for up to 3 doses (in
▶ Adult: 500 mg, to be administered up to 30 minutes
before the procedure (if rectal administration
inappropriate), then 500 mg every 8 hours if required
for up to 3 further doses (in high-risk procedures)
Invasive intestinal amoebiasis | Extra-intestinal
amoebiasis (including liver abscess)
▶ Child 1–2 years: 200 mg 3 times a day for 5 days in
intestinal infection (for 5–10 days in extra-intestinal
▶ Child 3–6 years: 200 mg 4 times a day for 5 days in
intestinal infection (for 5–10 days in extra-intestinal
▶ Child 7–9 years: 400 mg 3 times a day for 5 days in
intestinal infection (for 5–10 days in extra-intestinal
▶ Child 10–17 years: 800 mg 3 times a day for 5 days in
intestinal infection (for 5–10 days in extra-intestinal
▶ Adult: 800 mg 3 times a day for 5 days in intestinal
infection (for 5–10 days in extra-intestinal infection)
▶ Child 1–2 years: 50 mg 3 times a day for 7 days
▶ Child 3–6 years: 100 mg twice daily for 7 days
▶ Child 7–9 years: 100 mg 3 times a day for 7 days
▶ Child 10–17 years: 200 mg 3 times a day for 7 days,
alternatively 400–500 mg twice daily for 5–7 days,
▶ Adult: 200 mg 3 times a day for 7 days, alternatively
400–500 mg twice daily for 5–7 days, alternatively 2 g
▶ Child 1–2 years: 500 mg once daily for 3 days
▶ Child 3–6 years: 600–800 mg once daily for 3 days
▶ Child 7–9 years: 1 g once daily for 3 days
▶ Child 10–17 years: 2 g once daily for 3 days, alternatively
400 mg 3 times a day for 5 days, alternatively 500 mg
▶ Adult: 2 g once daily for 3 days, alternatively 400 mg
3 times a day for 5 days, alternatively 500 mg twice
▶ Adult: (consult product literature)
▶ With systemic use in adults Metronidazole doses in the BNF
may differ from those in product literature.
l INTERACTIONS → Appendix 1: metronidazole
▶ With systemic use Dry mouth . myalgia . nausea . oral
disorders .taste altered . vomiting
▶ With vaginal use Pelvic discomfort. vulvovaginal candidiasis . vulvovaginal disorders
▶ With systemic use Asthenia . headache . leucopenia (with
long term or intensive therapy)
▶ With vaginal use Menstrual cycle irregularities . vaginal
▶ With systemic use Agranulocytosis . angioedema . appetite
intensive therapy). flushing . hallucination . hepatic
reactions (SCARs). skin reactions .thrombocytopenia . urine dark . vision disorders
▶ With systemic use Depressed mood . gastrointestinal
disorder. hearing impairment.tinnitus
▶ With systemic use Significant amount in milk; manufacturer
advises avoid large single doses though otherwise
compatible; may give milk a bitter taste.
▶ With systemic use Use with caution in hepatic
Dose adjustments ▶ With systemic use In severe liver disease
reduce total daily dose to one-third, and give once daily.
▶ With systemic use Clinical and laboratory monitoring
advised if treatment exceeds 10 days.
l DIRECTIONS FOR ADMINISTRATION
▶ With intravenous use For intravenous infusion, give over
l PRESCRIBING AND DISPENSING INFORMATION
▶ With systemic use Metronidazole is well absorbed orally and
the intravenous route is normally reserved for severe
infections. Metronidazole by the rectal route is an effective
alternative to the intravenous route when oral
administration is not possible.
Medicines for Children leaflet: Metronidazole for bacterial
infections www.medicinesforchildren.org.uk/metronidazolebacterial-infections
l PROFESSION SPECIFIC INFORMATION
Dental practitioners’ formulary
▶ With oral use Metronidazole Tablets may be prescribed.
Metronidazole Oral Suspension may be prescribed.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: oral suspension, oral
CAUTIONARY AND ADVISORY LABELS 4, 9, 21, 25, 27
▶ Metronidazole (Non-proprietary)
Metronidazole 200 mg Metronidazole 200mg tablets | 21 tablet P £4.99 DT = £1.83
Metronidazole 400 mg Metronidazole 400mg tablets | 21 tablet P £13.03 DT = £5.47
Metronidazole 500 mg Metronidazole 500mg tablets |
21 tablet P £39.27 DT = £39.27
Metronidazole 200 mg Flagyl 200mg tablets | 21 tablet P £4.49 DT = £1.83
Metronidazole 400 mg Flagyl 400mg tablets | 14 tablet P £6.34
CAUTIONARY AND ADVISORY LABELS 4, 9
Metronidazole 500 mg Flagyl 500mg suppositories | 10 suppository P £15.18 DT = £15.18
Metronidazole 1 gram Flagyl 1g suppositories | 10 suppository P £23.06
BNF 78 Bacterial infection 543
CAUTIONARY AND ADVISORY LABELS 4, 9
▶ Metronidazole (Non-proprietary)
Metronidazole (as Metronidazole benzoate) 40 mg per
1 ml Metronidazole 200mg/5ml oral suspension | 100 ml P £37.50 DT = £35.22
EXCIPIENTS: May contain Disodium edetate, hydroxybenzoates
▶ Zidoval (Meda Pharmaceuticals Ltd)
Metronidazole 7.5 mg per 1 gram Zidoval 0.75% vaginal gel | 40 gram P £4.31 DT = £4.31
ELECTROLYTES: May contain Sodium
▶ Metronidazole (Non-proprietary)
Metronidazole 5 mg per 1 ml Metronidazole 500mg/100ml infusion
100ml bags | 20 bag P £63.86 DT = £63.86
l DRUG ACTION Tinidazole is an antimicrobial drug with
high activity against anaerobic bacteria and protozoa; it
has a longer duration of action than metronidazole.
▶ Adult: Initially 2 g, followed by 1 g daily usually for
5–6 days, alternatively 500 mg twice daily usually for
Bacterial vaginosis | Acute ulcerative gingivitis
▶ Adult: 2 g for 1 single dose
▶ Adult: 2 g for 1 single dose, to be administered
approximately 12 hours before surgery
▶ Child 1 month–11 years: 50–60 mg/kg once daily (max.
▶ Child 12–17 years: 2 g once daily for 2–3 days
▶ Adult: 2 g once daily for 2–3 days
▶ Child 1 month–11 years: 50–60 mg/kg once daily (max.
▶ Child 12–17 years: 1.5–2 g once daily for 3–6 days
▶ Adult: 1.5–2 g once daily for 3–6 days
Urogenital trichomoniasis | Giardiasis
▶ Child 1 month–11 years: 50–75 mg/kg (max. per dose 2 g)
for 1 single dose, dose may be repeated once if
▶ Child 12–17 years: 2 g for 1 single dose, dose may be
▶ Adult: 2 g for 1 single dose
Helicobacter pylori eradication
▶ Adult: (consult local protocol)
l INTERACTIONS → Appendix 1: tinidazole
▶ Common or very common Abdominal pain . appetite
decreased . diarrhoea . headache . nausea . skin reactions . vertigo . vomiting
l PREGNANCY Manufacturer advises avoid in first trimester.
l BREAST FEEDING Present in milk—manufacturer advises
avoid breast-feeding during and for 3 days after stopping
l MONITORING REQUIREMENTS Clinical and laboratory
monitoring advised if treatment exceeds 10 days.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
CAUTIONARY AND ADVISORY LABELS 4, 9, 21, 25
Tinidazole 500 mg Fasigyn 500mg tablets | 16 tablet P £11.04
Benzylpenicillin and phenoxymethylpenicillin
Benzylpenicillin sodium p. 547 (Penicillin G) remains an
important and useful antibiotic but is inactivated by
bacterial beta-lactamases. It is effective for many
streptococcal (including pneumococcal), gonococcal, and
meningococcal infections and also for anthrax, diphtheria,
gas-gangrene, and leptospirosis. Pneumococci,
meningococci, and gonococci which have decreased
sensitivity to penicillin have been isolated; benzylpenicillin
sodium is no longer the drug of first choice for pneumococcal
meningitis. Although benzylpenicillin sodium is effective in
the treatment of tetanus, metronidazole p. 542 is preferred.
Benzylpenicillin is inactivated by gastric acid and absorption
from the gastro-intestinal tract is low; therefore it must be
Benzathine benzylpenicillin is used for the treatment of
early syphilis and late latent syphilis; it is given by
Phenoxymethylpenicillin p. 548 (Penicillin V) has a similar
antibacterial spectrum to benzylpenicillin sodium, but is less
active. It is gastric acid-stable, so is suitable for oral
administration. It should not be used for serious infections
because absorption can be unpredictable and plasma
concentrations variable. It is indicated principally for
respiratory-tract infections in children, for streptococcal
tonsillitis, and for continuing treatment after one or more
injections of benzylpenicillin sodium when clinical response
has begun. It should not be used for meningococcal or
gonococcal infections. Phenoxymethylpenicillin is used for
prophylaxis against streptococcal infections following
rheumatic fever and against pneumococcal infections
following splenectomy or in sickle-cell disease.
Penicillinase-resistant penicillins
Most staphylococci are now resistant to benzylpenicillin
because they produce penicillinases. Flucloxacillin p. 554,
however, is not inactivated by these enzymes and is thus
effective in infections caused by penicillin-resistant
staphylococci, which is the sole indication for its use.
Flucloxacillin is acid-stable and can, therefore, be given by
mouth as well as by injection. Flucloxacillin is well absorbed
Temocillin p. 555 is active against Gram-negative bacteria
and is stable against a wide range of beta-lactamases. It
should be reserved for the treatment of infections caused by
beta-lactamase-producing strains of Gram-negative
bacteria, including those resistant to third-generation
cephalosporins. Temocillin is not active against
Pseudomonas aeruginosa or Acinetobacter spp.
Ampicillin p. 550 is active against certain Gram-positive and
Gram-negative organisms but is inactivated by penicillinases
including those produced by Staphylococcus aureus and by
544 Bacterial infection BNF 78
common Gram-negative bacilli such as Escherichia coli.
Almost all staphylococci, approx. 60% of E. coli strains and
approx. 20% of Haemophilus influenzae strains are now
resistant. The likelihood of resistance should therefore be
considered before using ampicillin for the ‘blind’ treatment
of infections; in particular, it should not be used for hospital
patients without checking sensitivity.
Ampicillin is well excreted in the bile and urine. It is
principally indicated for the treatment of exacerbations of
chronic bronchitis and middle ear infections, both of which
may be due to Streptococcus pneumoniae and H. influenzae,
and for urinary-tract infections.
Ampicillin can be given by mouth but less than half the
dose is absorbed, and absorption is further decreased by the
Maculopapular rashes commonly occur with ampicillin
(and amoxicillin p. 548) but are not usually related to true
penicillin allergy. They almost always occur in patients with
glandular fever; broad-spectrum penicillins should not
therefore be used for ‘blind’ treatment of a sore throat. The
risk of rash is also increased in patients with acute or chronic
lymphocytic leukaemia or in cytomegalovirus infection.
Amoxicillin is a derivative of ampicillin and has a similar
antibacterial spectrum. It is better absorbed than ampicillin
when given by mouth, producing higher plasma and tissue
concentrations; unlike ampicillin, absorption is not affected
by the presence of food in the stomach. Amoxicillin is also
used for the treatment of Lyme disease.
Co-amoxiclav p. 551 consists of amoxicillin with the
betalactamase inhibitor clavulanic acid. Clavulanic acid itself
has no significant antibacterial activity but, by inactivating
beta-lactamases, it makes the combination active against
beta-lactamase-producing bacteria that are resistant to
amoxicillin. These include resistant strains of Staph. aureus,
E. coli, and H. influenzae, as well as many Bacteroides and
Klebsiella spp. Co-amoxiclav should be reserved for
infections likely, or known, to be caused by amoxicillinresistant beta-lactamase-producing strains.
either streptococci or staphylococci (e.g. cellulitis).
Piperacillin, a ureidopenicillin, is only available in
combination with the beta-lactamase inhibitor tazobactam.
Ticarcillin, a carboxypenicillin, is only available in
combination with the beta-lactamase inhibitor clavulanic
acid. Both preparations have a broad spectrum of activity
against a range of Gram-positive and Gram-negative
bacteria, and anaerobes. Piperacillin with tazobactam below
has activity against a wider range of Gram-negative
organisms than ticarcillin with clavulanic acid p. 546 and it is
more active against Pseudomonas aeruginosa. These
antibacterials are not active against MRSA. They are used in
the treatment of septicaemia, hospital-acquired pneumonia,
and complicated infections involving the urinary tract, skin
and soft tissues, or intra-abdomen. For severe pseudomonas
infections these antipseudomonal penicillins can be given
with an aminoglycoside (e.g. gentamicin p. 519) since they
Pivmecillinam hydrochloride p. 554 has significant activity
against many Gram-negative bacteria including Escherichia
coli, klebsiella, enterobacter, and salmonellae. It is not active
against Pseudomonas aeruginosa or enterococci.
Pivmecillinam hydrochloride is hydrolysed to mecillinam,
l DRUG ACTION The penicillins are bactericidal and act by
interfering with bacterial cell wall synthesis. They diffuse
well into body tissues and fluids, but penetration into the
cerebrospinal fluid is poor except when the meninges are
inflamed. They are excreted in the urine in therapeutic
▶ Uncommon Antibiotic associated colitis . leucopenia
tubulointerstitial . neutropenia . seizure . severe cutaneous
SIDE-EFFECTS, FURTHER INFORMATION Diarrhoea
frequently occurs during oral penicillin therapy. It is most
common with broad-spectrum penicillins, which can cause
antibiotic-associated colitis.
l ALLERGY AND CROSS-SENSITIVITY The most important
side-effect of the penicillins is hypersensitivity which
causes rashes and anaphylaxis and can be fatal. Allergic
reactions to penicillins occur in 1–10% of exposed
individuals; anaphylactic reactions occur in fewer than
0.05% of treated patients. Patients with a history of atopic
allergy (e.g. asthma, eczema, hay fever) are at a higher risk
of anaphylactic reactions to penicillins. Individuals with a
history of anaphylaxis, urticaria, or rash immediately after
penicillin administration are at risk of immediate
hypersensitivity to a penicillin; these individuals should
not receive a penicillin. Individuals with a history of a
minor rash (i.e. non-confluent, non-pruritic rash restricted
to a small area of the body) or a rash that occurs more than
72 hours after penicillin administration are probably not
allergic to penicillin and in these individuals a penicillin
should not be withheld unnecessarily for serious
infections; the possibility of an allergic reaction should,
however, be borne in mind. Other beta-lactam antibiotics
(including cephalosporins) can be used in these patients.
Patients who are allergic to one penicillin will be allergic
to all because the hypersensitivity is related to the basic
penicillin structure. Patients with a history of immediate
hypersensitivity to penicillins may also react to the
cephalosporins and other beta-lactam antibiotics, they
should not receive these antibiotics. If a penicillin (or
another beta-lactam antibiotic) is essential in an
individual with immediate hypersensitivity to penicillin
then specialist advice should be sought on hypersensitivity
testing or using a beta-lactam antibiotic with a different
structure to the penicillin that caused the hypersensitivity.
ANTIPSEUDOMONAL WITH BETALACTAMASE INHIBITOR
Piperacillin with tazobactam 01-May-2019
Hospital-acquired pneumonia | Septicaemia | Complicated
infections involving the urinary-tract| Complicated
infections involving the skin | Complicated infections
involving the soft-tissues | Acute exacerbation of chronic
obstructive pulmonary disease | Acute exacerbation of
▶ Adult: 4.5 g every 8 hours; increased if necessary to
4.5 g every 6 hours, increased frequency may be used
for severe infections continued→
BNF 78 Bacterial infection 545
Infections in neutropenic patients
l UNLICENSED USE g Piperacillin with tazobactam is
used for the treatment of acute exacerbation of chronic
obstructive pulmonary disease, hbut is not licensed for
this indication. See Respiratory system infections,
antibacterial therapy p. 515 for further information.
g Piperacillin with tazobactam is used for the
treatment of acute exacerbation of bronchiectasis, hbut
is not licensed for this indication. See Respiratory system
infections, antibacterial therapy p. 515 for further
l CAUTIONS High doses may lead to hypernatraemia (owing
to sodium content of preparations)
l INTERACTIONS → Appendix 1: penicillins
▶ Uncommon Arthralgia . flushing . hypokalaemia . hypotension . myalgia .thrombophlebitis
▶ Rare or very rare Epistaxis . stomatitis
l PREGNANCY Manufacturers advise use only if potential
l BREAST FEEDING Trace amount in milk, but appropriate to
Dose adjustments Max. 4.5 g every 8 hours if eGFR
Max. 4.5 g every 12 hours if eGFR less than
l EFFECT ON LABORATORY TESTS False-positive urinary
glucose (if tested for reducing substances).
l DIRECTIONS FOR ADMINISTRATION For intravenous
infusion, give intermittently in Glucose 5% or Sodium
chloride 0.9%. Reconstitute initially (2.25 g in 10 mL, 4.5 g
in 20 mL) with water for injections, or glucose 5%
(Tazocin ® brand only), or sodium chloride 0.9%, then
dilute to 50–150 mL with infusion fluid; give over
l PRESCRIBING AND DISPENSING INFORMATION Dose
expressed as a combination of piperacillin and tazobactam
(both as sodium salts) in a ratio of 8:1.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: infusion
Powder for solution for infusion
ELECTROLYTES: May contain Sodium
▶ Piperacillin with tazobactam (Non-proprietary)
Tazobactam (as Tazobactam sodium) 500 mg, Piperacillin (as
Piperacillin sodium) 4 gram Piperacillin 4g / Tazobactam 500mg
powder for solution for infusion vials | 1 vial P £15.75–£19.97
(Hospital only) | 1 vial P £12.90 | 10 vial P £48.00–£153.00
| 10 vial P £163.30 (Hospital only)
Tazobactam (as Tazobactam sodium) 500 mg, Piperacillin (as
Piperacillin sodium) 4 gram Tazocin 4g/0.5g powder for solution
for infusion vials | 1 vial P £15.17 (Hospital only)
Powder for solution for injection
ELECTROLYTES: May contain Sodium
▶ Piperacillin with tazobactam (Non-proprietary)
Tazobactam (as Tazobactam sodium) 250 mg, Piperacillin (as
Piperacillin sodium) 2 gram Piperacillin 2g / Tazobactam 250mg
powder for solution for infusion vials | 1 vial P £9.55 DT = £7.65
(Hospital only) | 10 vial P £82.30 (Hospital only)
Tazobactam (as Tazobactam sodium) 250 mg, Piperacillin (as
Piperacillin sodium) 2 gram Tazocin 2g/0.25g powder for solution
for infusion vials | 1 vial P £7.65 DT = £7.65
Ticarcillin with clavulanic acid
Infections due to Pseudomonas and Proteus spp.
▶ Adult: 3.2 g every 6–8 hours; increased if necessary to
3.2 g every 4 hours, increased frequency used for more
l CAUTIONS High doses may lead to hypernatraemia (owing
to sodium content of preparations)
▶ Cholestatic jaundice Cholestatic jaundice is possibly
associated with clavulanic acid. An epidemiological study
has shown that the risk of acute liver toxicity was about
6 times greater with co-amoxiclav (amoxicillin, clavulanic
acid) than with amoxicillin. Cholestatic jaundice is more
common in patients above the age of 65 years and in men;
these reactions have only rarely been reported in children.
Jaundice is usually self-limiting and very rarely fatal. The
duration of treatment should be appropriate to the
indication and should not usually exceed 14 days.
l INTERACTIONS → Appendix 1: clavulanic acid . penicillins
l SIDE-EFFECTS Eosinophilia . haemorrhage . hypokalaemia .thrombophlebitis
l PREGNANCY Not known to be harmful.
l BREAST FEEDING Trace amounts in milk, but appropriate
l HEPATIC IMPAIRMENT Manufacturer advises caution in
l RENAL IMPAIRMENT Accumulation of electrolytes
contained in preparation can occur in patients with renal
Dose adjustments Reduce dose to 3.2 g every eight hours if
if eGFR less than 10 mL/minute/1.73 m2
l EFFECT ON LABORATORY TESTS False-positive urinary
glucose (if tested for reducing substances).
l DIRECTIONS FOR ADMINISTRATION For intravenous infusion
(Timentin ®), give intermittently in Glucose 5%. Suggested
volume (depending on dose) 100–150 mL; give over
l PRESCRIBING AND DISPENSING INFORMATION Dose is
expressed as a combination of ticarcillin (as sodium salt)
and clavulanic acid (as potassium salt) in a ratio of 15:1.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
Powder for solution for infusion
ELECTROLYTES: May contain Potassium, sodium
▶ Timentin (GlaxoSmithKline UK Ltd)
Clavulanic acid (as Potassium clavulanate) 200 mg, Ticarcillin (as
Ticarcillin sodium) 3 gram Timentin 3.2g powder for solution for
infusion vials | 4 vial P £21.32
546 Bacterial infection BNF 78
ANTIBACTERIALS › PENICILLINS, BETALACTAMASE SENSITIVE
Mild to moderate susceptible infections | Throat infections
| Otitis media | Cellulitis | Pneumonia
▶ BY INTRAMUSCULAR INJECTION, OR BY SLOW INTRAVENOUS
INJECTION, OR BY INTRAVENOUS INFUSION
▶ Adult: 0.6–1.2 g every 6 hours, dose may be increased if
necessary in more serious infections (consult product
literature), single doses over 1.2 g to be given by
Endocarditis (in combination with other antibacterial if
▶ BY SLOW INTRAVENOUS INJECTION, OR BY INTRAVENOUS
▶ Adult: 1.2 g every 4 hours, increased if necessary to
2.4 g every 4 hours, dose may be increased in infections
such as enterococcal endocarditis
Anthrax (in combination with other antibacterials)
▶ BY SLOW INTRAVENOUS INJECTION, OR BY INTRAVENOUS
Intrapartum prophylaxis against group B streptococcal
▶ BY SLOW INTRAVENOUS INJECTION, OR BY INTRAVENOUS
▶ Adult: Initially 3 g for 1 dose, then 1.5 g every 4 hours
Meningitis | Meningococcal disease
▶ BY SLOW INTRAVENOUS INJECTION, OR BY INTRAVENOUS
▶ Neonate up to 7 days: 50 mg/kg every 12 hours.
▶ Neonate 7 days to 28 days: 50 mg/kg every 8 hours.
▶ Child: 50 mg/kg every 4–6 hours (max. per dose 2.4 g
▶ BY INTRAVENOUS INJECTION, OR BY INTRAMUSCULAR
▶ Child 1–11 months: 300 mg, administer as single dose
prior to urgent transfer to hospital so long as does not
▶ Child 1–9 years: 600 mg, administer as single dose prior
to urgent transfer to hospital so long as does not delay
▶ Child 10–17 years: 1.2 g, administer as single dose prior
to urgent transfer to hospital so long as does not delay
▶ Adult: 1.2 g, administer as single dose prior to urgent
transfer to hospital so long as does not delay transfer
Suspected bacterial meningitis without non-blanching
rash where patient cannot be transferred to hospital
▶ BY INTRAVENOUS INJECTION, OR BY INTRAMUSCULAR
▶ Child 1–11 months: 300 mg, administer as single dose
▶ Child 1–9 years: 600 mg, administer as single dose prior
▶ Child 10–17 years: 1.2 g, administer as single dose prior
▶ Adult: 1.2 g, administer as single dose prior to transfer
▶ In adults Benzylpenicillin doses in the BNF may differ from
Intrathecal injection of benzylpenicillin is not
l CAUTIONS Accumulation of sodium from injection can
l INTERACTIONS → Appendix 1: penicillins
▶ Common or very common Fever. Jarisch-Herxheimer
▶ Rare or very rare Neurotoxicity
l PREGNANCY Not known to be harmful.
l BREAST FEEDING Trace amounts in milk, but appropriate
l RENAL IMPAIRMENT Accumulation of sodium from
injection can occur in renal failure. High doses may cause
neurotoxicity, including cerebral irritation, convulsions, or
Dose adjustments ▶ In adults Reduce dose—consult
▶ In children Estimated glomerular filtration rate
8–12 hours. Estimated glomerular filtration rate less than
10 mL/minute/1.73 m2 use normal dose every 12 hours.
l EFFECT ON LABORATORY TESTS False-positive urinary
glucose (if tested for reducing substances).
l DIRECTIONS FOR ADMINISTRATION
▶ With intravenous use in children Intravenous route
recommended in neonates and infants. For intravenous
infusion, dilute with Glucose 5% or Sodium Chloride 0.9%;
give over 15–30 minutes. Longer administration time is
particularly important when using doses of 50 mg/kg (or
greater) to avoid CNS toxicity.
▶ With intravenous use in adults For intravenous infusion
(Crystapen ®), give intermittently in Glucose 5% or Sodium
chloride 0.9%; suggested volume 100 mL given over
30–60 minutes. Continuous infusion not usually
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: infusion
Powder for solution for injection
ELECTROLYTES: May contain Sodium
▶ Benzylpenicillin sodium (Non-proprietary)
Benzylpenicillin sodium 600 mg Benzylpenicillin 600mg powder for
solution for injection vials | 2 vial P £6.01–£6.08 DT = £6.08 | 25 vial P £75.12–£76.00
Benzylpenicillin sodium 1.2 gram Benzylpenicillin 1.2g powder for
solution for injection vials | 25 vial P £109.49–£113.92 DT =
BNF 78 Bacterial infection 547
Oral infections | Tonsillitis | Otitis media | Erysipelas |
▶ Child 1–11 months: 62.5 mg 4 times a day; increased if
necessary up to 12.5 mg/kg 4 times a day
▶ Child 1–5 years: 125 mg 4 times a day; increased if
necessary up to 12.5 mg/kg 4 times a day
▶ Child 6–11 years: 250 mg 4 times a day; increased if
necessary up to 12.5 mg/kg 4 times a day
▶ Child 12–17 years: 500 mg 4 times a day; increased if
necessary up to 1 g 4 times a day
▶ Adult: 500 mg every 6 hours, increased if necessary up
Prevention of recurrence of rheumatic fever
▶ Child 1 month–5 years: 125 mg twice daily
▶ Child 6–17 years: 250 mg twice daily
Prevention of secondary case of invasive group A
▶ Child 1–11 months: 62.5 mg every 6 hours for 10 days
▶ Child 1–5 years: 125 mg every 6 hours for 10 days
▶ Child 6–11 years: 250 mg every 6 hours for 10 days
▶ Child 12–17 years: 250–500 mg every 6 hours for 10 days
▶ Adult: 250–500 mg every 6 hours for 10 days
Prevention of pneumococcal infection in asplenia or in
patients with sickle-cell disease
▶ Child 1–11 months: 62.5 mg twice daily
▶ Child 1–4 years: 125 mg twice daily
▶ Child 5–17 years: 250 mg twice daily
▶ Child 1–11 months: 62.5 mg 4 times a day for 5 days
▶ Child 1–5 years: 125 mg 4 times a day for 5 days
▶ Child 6–11 years: 250 mg 4 times a day for 5 days
▶ Child 12–17 years: 500 mg 4 times a day for 5 days
▶ Adult: 500 mg 4 times a day for 5 days
l UNLICENSED USE g Duration of treatment for acute
sinusitis adheres to national guidelines. hSee Sinusitis
(acute) p. 1203 for further information.
▶ In adults Phenoxymethylpenicillin doses in the BNF may
differ from product literature.
l INTERACTIONS → Appendix 1: penicillins
l PREGNANCY Not known to be harmful.
l BREAST FEEDING Trace amounts in milk, but appropriate
l EFFECT ON LABORATORY TESTS False-positive urinary
glucose (if tested for reducing substances).
Medicines for Children leaflet: Penicillin V for bacterial infections
www.medicinesforchildren.org.uk/penicillin-v-bacterialinfections
Medicines for Children leaflet: Penicillin V for prevention of
pneumococcal infection www.medicinesforchildren.org.uk/
penicillin-v-prevention-pneumococcal-infection
l PROFESSION SPECIFIC INFORMATION
Dental practitioners’ formulary
Phenoxymethylpenicillin Tablets may be prescribed.
Phenoxymethylpenicillin Oral Solution may be
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
CAUTIONARY AND ADVISORY LABELS 9, 23
▶ Phenoxymethylpenicillin (Non-proprietary)
Phenoxymethylpenicillin (as Phenoxymethylpenicillin potassium)
25 mg per 1 ml Phenoxymethylpenicillin 125mg/5ml oral solution |
Phenoxymethylpenicillin 125mg/5ml oral solution sugar free sugarfree | 100 ml P £25.00 DT = £7.10
Phenoxymethylpenicillin (as Phenoxymethylpenicillin potassium)
50 mg per 1 ml Phenoxymethylpenicillin 250mg/5ml oral solution | 100 ml P £35.00 DT = £5.23
Phenoxymethylpenicillin 250mg/5ml oral solution sugar free sugarfree | 100 ml P £35.00 DT = £7.72
CAUTIONARY AND ADVISORY LABELS 9, 23
▶ Phenoxymethylpenicillin (Non-proprietary)
Phenoxymethylpenicillin (as Phenoxymethylpenicillin potassium)
250 mg Phenoxymethylpenicillin 250mg tablets | 28 tablet P £5.00 DT = £0.93
Susceptible infections (including urinary-tract infections,
sinusitis, uncomplicated community acquired
pneumonia, salmonellosis, oral infections)
▶ Child 1–11 months: 125 mg 3 times a day; increased if
necessary up to 30 mg/kg 3 times a day
▶ Child 1–4 years: 250 mg 3 times a day; increased if
necessary up to 30 mg/kg 3 times a day
▶ Child 5–11 years: 500 mg 3 times a day; increased if
necessary up to 30 mg/kg 3 times a day (max. per dose
▶ Child 12–17 years: 500 mg 3 times a day; increased if
necessary up to 1 g 3 times a day, use increased dose in
▶ Adult: 500 mg every 8 hours, increased if necessary to
1 g every 8 hours, increased dose used in severe
▶ BY INTRAVENOUS INJECTION, OR BY INTRAVENOUS INFUSION
▶ Adult: 500 mg every 8 hours, increased to 1 g every
6 hours, use increased dose in severe infections
Acute exacerbation of bronchiectasis
▶ Child 1–11 months: 125 mg 3 times a day for 7–14 days
▶ Child 1–4 years: 250 mg 3 times a day for 7–14 days
▶ Child 5–17 years: 500 mg 3 times a day for 7–14 days
▶ Adult: 500 mg 3 times a day for 7–14 days
Acute exacerbation of chronic obstructive pulmonary
▶ Adult: 500 mg 3 times a day for 5 days, increased if
necessary to 1 g 3 times a day, increased dose used in
▶ BY INTRAVENOUS INJECTION, OR BY INTRAVENOUS INFUSION
▶ Adult: 500 mg every 8 hours, increased to 1 g every
6 hours, increased dose used in severe infections
548 Bacterial infection BNF 78
Acute cough [if systemically very unwell or at higher risk
▶ Child 1–11 months: 125 mg 3 times a day for 5 days
▶ Child 1–4 years: 250 mg 3 times a day for 5 days
▶ Child 5–17 years: 500 mg 3 times a day for 5 days
▶ Adult: 500 mg 3 times a day for 5 days
▶ Child 1–11 months: 125 mg 3 times a day for 5–7 days
▶ Child 1–4 years: 250 mg 3 times a day for 5–7 days
▶ Child 5–17 years: 500 mg 3 times a day for 5–7 days
Lyme disease [erythema migrans and/or non-focal
symptoms]| Lyme disease [affecting cranial nerves or
▶ Adult: 1 g 3 times a day for 21 days
Lyme arthritis | Acrodermatitis chronica atrophicans
▶ Adult: 1 g 3 times a day for 28 days
Anthrax (treatment and post-exposure prophylaxis)
▶ Adult: 3 g, then 3 g after 8 hours
Urinary-tract infections (short course)
▶ Adult: 3 g, then 3 g after 10–12 hours
Listerial meningitis (in combination with another
Endocarditis (in combination with another antibiotic if
Helicobacter pylori eradication in combination with
Helicobacter pylori eradication in combination with
clarithromycin and esomeprazole; or in combination
with clarithromycin and lansoprazole; or in combination
with metronidazole and lansoprazole; or in combination
with clarithromycin and omeprazole; or in combination
with clarithromycin and pantoprazole; or in combination
with clarithromycin and rabeprazole
l UNLICENSED USE Amoxicillin doses in BNF Publications
may differ from those in product literature.
g Duration of treatment for acute otitis media differs
from product literature and adheres to national
guidelines. hSee Ear infections, antibacterial therapy
p. 511 for further information.
g Amoxicillin is used for the treatment of acute
exacerbation of bronchiectasis, hbut is not licensed for
this indication. See Respiratory system infections,
antibacterial therapy p. 515 for further information.
GENERAL CAUTIONS Acute lymphocytic leukaemia
(increased risk of erythematous rashes). chronic
lymphocytic leukaemia (increased risk of erythematous
rashes). cytomegalovirus infection (increased risk of
erythematous rashes). glandular fever (erythematous
rashes common). maintain adequate hydration with high
doses (particularly during parenteral therapy)
▶ With intravenous use accumulation of sodium can occur with
l INTERACTIONS → Appendix 1: penicillins
▶ Frequency not known Jarisch-Herxheimer reaction
▶ With oral use Black hairy tongue
l PREGNANCY Not known to be harmful.
l BREAST FEEDING Trace amount in milk, but appropriate to
l RENAL IMPAIRMENT Risk of crystalluria with high doses
(particularly during parenteral therapy).
▶ With intravenous use Accumulation of sodium from injection
can occur in patients with renal failure.
Dose adjustments Reduce dose in severe impairment;
l DIRECTIONS FOR ADMINISTRATION
▶ With intravenous use in adults For intravenous infusion
(Amoxil ®), give intermittently in Glucose 5% or Sodium
chloride 0.9%. Reconstituted solutions diluted and given
without delay; suggested volume 100 mL given over
30–60 minutes or give via drip tubing in Glucose 5% or
Sodium chloride 0.9%; continuous infusion not usually
l PRESCRIBING AND DISPENSING INFORMATION See Lyme
disease p. 577 for place in therapy and further information
Flavours of oral liquid formulations and sachets may
include peach, strawberry, or lemon.
l PATIENT AND CARER ADVICE Patient counselling is advised
for Amoxicillin (Amoxil ®) paediatric suspension (use of
Medicines for Children leaflet: Amoxicillin for bacterial infections
www.medicinesforchildren.org.uk/amoxicillin-bacterialinfections-0
l PROFESSION SPECIFIC INFORMATION
Dental practitioners’ formulary
Amoxicillin capsules may be prescribed.
Amoxicillin sachets may be prescribed as Amoxicillin
Amoxicillin Oral Suspension may be prescribed.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
Powder for solution for injection
ELECTROLYTES: May contain Sodium
▶ Amoxicillin (Non-proprietary)
Amoxicillin (as Amoxicillin sodium) 250 mg Amoxicillin 250mg
powder for solution for injection vials | 10 vial P £4.80 | 10 vial P £4.50 (Hospital only)
Amoxicillin (as Amoxicillin sodium) 500 mg Amoxicillin 500mg
powder for solution for injection vials | 10 vial P £9.60 DT = £5.48
| 10 vial P £12.00 DT = £5.48 (Hospital only)
Amoxicillin (as Amoxicillin sodium) 1 gram Amoxicillin 1g powder
for solution for injection vials | 1 vial P £1.92 | 10 vial P £16.50 DT = £10.96 (Hospital only)
▶ Amoxil (GlaxoSmithKline UK Ltd)
Amoxicillin (as Amoxicillin sodium) 500 mg Amoxil 500mg powder
for solution for injection vials | 10 vial P £5.48 DT = £5.48
Amoxicillin (as Amoxicillin sodium) 1 gram Amoxil 1g powder for
solution for injection vials | 10 vial P £10.96 DT = £10.96
BNF 78 Bacterial infection 549
CAUTIONARY AND ADVISORY LABELS 9
EXCIPIENTS: May contain Sucrose
▶ Amoxicillin (Non-proprietary)
Amoxicillin (as Amoxicillin trihydrate) 25 mg per 1 ml Amoxicillin
125mg/5ml oral suspension sugar free sugar-free | 100 ml P £25.00 DT = £1.13
Amoxicillin 125mg/5ml oral suspension | 100 ml P £25.00 DT =
Amoxicillin (as Amoxicillin trihydrate) 50 mg per 1 ml Amoxicillin
250mg/5ml oral suspension sugar free sugar-free | 100 ml P £35.00 DT = £1.26
Amoxicillin 250mg/5ml oral suspension | 100 ml P £35.00 DT =
▶ Amoxil (GlaxoSmithKline UK Ltd)
Amoxicillin (as Amoxicillin trihydrate) 100 mg per 1 ml Amoxil
125mg/1.25ml paediatric oral suspension | 20 ml P £3.18 DT =
CAUTIONARY AND ADVISORY LABELS 9, 13
▶ Amoxicillin (Non-proprietary)
Amoxicillin (as Amoxicillin trihydrate) 3 gram Amoxicillin 3g oral
powder sachets sugar free sugar-free | 2 sachet P £15.00 DT =
CAUTIONARY AND ADVISORY LABELS 9
▶ Amoxicillin (Non-proprietary)
Amoxicillin (as Amoxicillin trihydrate) 250 mg Amoxicillin 250mg
Amoxicillin (as Amoxicillin trihydrate) 500 mg Amoxicillin 500mg
Combinations available: Co-amoxiclav, p. 551
Susceptible infections (including bronchitis, urinary-tract
infections, otitis media, sinusitis, uncomplicated
community-acquired pneumonia, salmonellosis)
▶ Child 1–11 months: 125 mg 4 times a day; increased if
necessary up to 30 mg/kg 4 times a day
▶ Child 1–4 years: 250 mg 4 times a day; increased if
necessary up to 30 mg/kg 4 times a day
▶ Child 5–11 years: 500 mg 4 times a day; increased if
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