l BREAST FEEDING Present in milk—amount too small to be
Dose adjustments Increase interval between doses if
creatinine clearance less than 50 mL/minute.
Monitoring Monitor blood-cycloserine concentration if
creatinine clearance less than 50 mL/minute.
▶ Blood concentration monitoring required especially in
renal impairment or if dose exceeds 500 mg daily or if signs
of toxicity; blood concentration should not exceed
▶ Monitor haematological, renal, and hepatic function.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
CAUTIONARY AND ADVISORY LABELS 2, 8
▶ Cycloserine (Non-proprietary)
Cycloserine 250 mg Cycloserine 250mg capsules | 100 capsule P £442.89 DT = £442.89
Multiple-drug resistant pulmonary tuberculosis, in
▶ Adult: 100 mg twice daily for 24 weeks, continue
appropriate combination therapy after delamanid
l CONTRA-INDICATIONS QTc interval more than
500 milliseconds (derived using Fridericia’s formula). serum albumin less than 28 g/litre
l CAUTIONS Risk factors for QT interval prolongation (e.g.
electrolyte disturbances, acute myocardial infarction,
heart failure with reduced left ventricular ejection fraction,
severe hypertension, left ventricular hypertrophy,
bradycardia, congenital long QT syndrome, history of
l INTERACTIONS → Appendix 1: delamanid
neuropathy . photophobia . psychotic disorder. QT interval
prolongation .reticulocytosis . sensation abnormal . skin
reactions . sleep disorders .throat irritation .tinnitus . tremor. vomiting
▶ Uncommon Aggression . atrioventricular block . balance
impaired . dehydration . delusional disorder, persecutory
paraesthesia . psychiatric disorders .thrombocytopenia . urinary disorders
l CONCEPTION AND CONTRACEPTION Effective
contraception required during treatment.
l PREGNANCY Manufacturer advises avoid—toxicity in
l BREAST FEEDING Manufacturer advises avoid—present in
l HEPATIC IMPAIRMENT Manufacturer advises avoid in
moderate to severe impairment.
l RENAL IMPAIRMENT Manufacturer advises avoid in severe
impairment—no information available.
▶ Monitor serum albumin and electrolytes before starting
treatment and then during treatment—discontinue
treatment if serum albumin less than 28 g/litre.
▶ Obtain ECG before starting treatment and then monthly
during treatment (more frequently if serum albumin
28–34 g/litre, or if concomitant use of potent CYP3A4
inhibitors, or if risk factors for QT interval prolongation, or
if QTc interval 450–500 milliseconds in men or
470–500 milliseconds in women)—discontinue treatment
if QTc interval more than 500 milliseconds (derived using
l HANDLING AND STORAGE Dispense in original container
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
CAUTIONARY AND ADVISORY LABELS 8, 21
▶ Deltyba (Otsuka Novel Products GmbH) A
Delamanid 50 mg Deltyba 50mg tablets | 48 tablet P £1,250.00
Ethambutol hydrochloride 19-Mar-2018
Tuberculosis, in combination with other drugs (standard
unsupervised 6-month treatment)
▶ Child: 20 mg/kg once daily for 2 months (initial phase)
▶ Adult: 15 mg/kg once daily for 2 months (initial phase)
Tuberculosis, in combination with other drugs
(intermittent supervised 6-month treatment) (under
▶ Child: 30 mg/kg 3 times a week for 2 months (initial
▶ Adult: 30 mg/kg 3 times a week for 2 months (initial
l CONTRA-INDICATIONS Optic neuritis . poor vision
l CAUTIONS Elderly . young children
▶ Understanding warnings Patients who cannot understand
warnings about visual side-effects should, if possible, be
given an alternative drug. In particular, ethambutol should
be used with caution in children until they are at least
5 years old and capable of reporting symptomatic visual
l INTERACTIONS → Appendix 1: ethambutol
▶ Common or very common Hyperuricaemia . nerve disorders . visual impairment
▶ Rare or very rare Nephritis tubulointerstitial
▶ Frequency not known Alveolitis allergic . appetite
eruption . sensation abnormal . severe cutaneous adverse
reactions (SCARs). skin reactions .taste metallic . thrombocytopenia .tremor. vomiting
SIDE-EFFECTS, FURTHER INFORMATION Ocular toxicity is
more common where excessive dosage is used or if the
patient’s renal function is impaired. Early discontinuation
of the drug is almost always followed by recovery of
l PREGNANCY Not known to be harmful.
l BREAST FEEDING Amount too small to be harmful.
l RENAL IMPAIRMENT Risk of optic nerve damage. Should
preferably be avoided in patients with renal impairment.
586 Bacterial infection BNF 78
Dose adjustments ▶ In adults If creatinine clearance less
than 30 mL/minute, use 15–25 mg/kg (max. 2.5 g) 3 times a
▶ In children If creatinine clearance less than
, use 15–25 mg/kg (max. 2.5 g)
Monitoring If creatinine clearance less than 30 mL/minute,
monitor plasma-ethambutol concentration.
▶ ‘Peak’ concentration (2–2.5 hours after dose) should be
2–6 mg/litre (7–22 micromol/litre); ‘trough’ (pre-dose)
concentration should be less than 1 mg/litre
▶ Renal function should be checked before treatment.
▶ Visual acuity should be tested by Snellen chart before
▶ In children In young children, routine ophthalmological
l PRESCRIBING AND DISPENSING INFORMATION The RCPCH
and NPPG recommend that, when a liquid special of
ethambutol is required, the following strength is used:
Ocular toxicity The earliest features of ocular toxicity are
subjective and patients should be advised to discontinue
therapy immediately if they develop deterioration in vision
and promptly seek further advice.
Medicines for Children leaflet: Ethambutol for the treatment of
tuberculosis www.medicinesforchildren.org.uk/ethambutoltreatment-tuberculosis
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 8
▶ Ethambutol hydrochloride (Non-proprietary)
Ethambutol hydrochloride 100 mg Ethambutol 100mg tablets |
56 tablet P £17.00 DT = £11.51
Ethambutol hydrochloride 400 mg Ethambutol 400mg tablets | 56 tablet P £42.74 DT = £42.74
Combinations available: Rifampicin with ethambutol,
isoniazid and pyrazinamide, p. 583
Tuberculosis, in combination with other drugs (standard
unsupervised 6-month treatment)
▶ BY MOUTH, OR BY INTRAMUSCULAR INJECTION, OR BY
▶ Child: 10 mg/kg once daily (max. per dose 300 mg) for
6 months (initial and continuation phases)
▶ Adult: 300 mg daily for 6 months (initial and
Tuberculosis, in combination with other drugs
(intermittent supervised 6-month treatment) (under
▶ BY MOUTH, OR BY INTRAMUSCULAR INJECTION, OR BY
▶ Child: 15 mg/kg 3 times a week (max. per dose 900 mg)
for 6 months (initial and continuation phases)
▶ Adult: 15 mg/kg 3 times a week (max. per dose 900 mg)
for 6 months (initial and continuation phases)
Prevention of tuberculosis in susceptible close contacts or
those who have become tuberculin positive
▶ INITIALLY BY MOUTH, OR BY INTRAMUSCULAR INJECTION, OR
▶ Child 1 month–11 years: 10 mg/kg daily (max. per dose
300 mg) for 6 months, alternatively (by mouth)
10 mg/kg daily (max. per dose 300 mg) for 3 months, to
be taken in combination with rifampicin
▶ Child 12–17 years: 300 mg daily for 6 months,
alternatively (by mouth) 300 mg daily for 3 months, to
be taken in combination with rifampicin
▶ Adult: 300 mg daily for 6 months, alternatively (by
mouth) 300 mg daily for 3 months, to be taken in
l CONTRA-INDICATIONS Drug-induced liver disease
infection . malnutrition . slow acetylator status (increased
▶ Peripheral neuropathy Peripheral neuropathy is more likely
to occur where there are pre-existing risk factors such as
diabetes, alcohol dependence, chronic renal failure,
pregnancy, malnutrition and HIV infection. In patients at
increased risk of peripheral neuropathy, pyridoxine
hydrochloride p. 1080 should be given prophylactically
l INTERACTIONS → Appendix 1: isoniazid
▶ Rare or very rare Severe cutaneous adverse reactions
SIDE-EFFECTS, FURTHER INFORMATION Hepatitis more
common in those aged over 35 years and those with a daily
l PREGNANCY Not known to be harmful; prophylactic
l BREAST FEEDING Theoretical risk of convulsions and
neuropathy; prophylactic pyridoxine advisable in mother.
Monitoring In breast-feeding, monitor infant for possible
l HEPATIC IMPAIRMENT Use with caution.
Monitoring In patients with pre-existing liver disease or
hepatic impairment monitor liver function regularly and
particularly frequently in the first 2 months.
l RENAL IMPAIRMENT Risk of ototoxicity and peripheral
neuropathy; prophylactic pyridoxine hydrochloride
▶ Renal function should be checked before treatment.
▶ Hepatic function should be checked before treatment. If
there is no evidence of liver disease (and pre-treatment
liver function is normal), further checks are only necessary
if the patient develops fever, malaise, vomiting, jaundice
or unexplained deterioration during treatment.
▶ In adults Those with alcohol dependence should have
frequent checks of hepatic function, particularly in the
l PRESCRIBING AND DISPENSING INFORMATION
▶ With oral use in children In general, doses should be rounded
up to facilitate administration of suitable volumes of liquid
or an appropriate strength of tablet. The RCPCH and NPPG
recommend that, when a liquid special of isoniazid is
required, the following strength is used: 50 mg/5 mL.
▶ In children Doses may need to be recalculated to allow for
weight gain in younger children.
Hepatic disorders Patients or their carers should be told how
to recognise signs of liver disorder, and advised to
discontinue treatment and seek immediate medical
attention if symptoms such as persistent nausea,
vomiting, malaise or jaundice develop.
Medicines for Children leaflet: Isoniazid for latent tuberculosis
www.medicinesforchildren.org.uk/isoniazid-latent-tuberculosis
Medicines for Children leaflet: Isoniazid for the treatment of
tuberculosis www.medicinesforchildren.org.uk/isoniazidtreatment-tuberculosis
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
Isoniazid 25 mg per 1 ml Isoniazid 50mg/2ml solution for injection
ampoules | 10 ampoule P £361.98
Isoniazid 60 mg per 1 ml Cemidon Intravenoso 300mg/5ml solution
for injection ampoules | 5 ampoule P s
CAUTIONARY AND ADVISORY LABELS 8, 22
Isoniazid 50 mg Isoniazid 50mg tablets | 56 tablet P £19.25 DT
Isoniazid 100 mg Isoniazid 100mg tablets | 28 tablet P £19.24
Isoniazid 300 mg Isoniazid 300mg tablets | 30 tablet P s
Combinations available: Rifampicin with ethambutol,
isoniazid and pyrazinamide, p. 583 . Rifampicin with isoniazid,
p. 584 . Rifampicin with isoniazid and pyrazinamide, p. 584
Tuberculosis, in combination with other drugs (standard
unsupervised 6-month treatment)
▶ Child (body-weight up to 50 kg): 35 mg/kg once daily for
2 months (initial phase); maximum 1.5 g per day
▶ Child (body-weight 50 kg and above): 35 mg/kg once daily
for 2 months (initial phase); maximum 2 g per day
▶ Adult (body-weight up to 50 kg): 1.5 g once daily for
▶ Adult (body-weight 50 kg and above): 2 g once daily for
Tuberculosis, in combination with other drugs
(intermittent supervised 6-month treatment) (under
▶ Child (body-weight up to 50 kg): 50 mg/kg 3 times a week
(max. per dose 2 g 3 times a week) for 2 months (initial
▶ Child (body-weight 50 kg and above): 50 mg/kg 3 times a
week (max. per dose 2.5 g 3 times a week) for 2 months
▶ Adult (body-weight up to 50 kg): 2 g 3 times a week for
▶ Adult (body-weight 50 kg and above): 2.5 g 3 times a week
l CONTRA-INDICATIONS Acute attack of gout (in adults)
l CAUTIONS Diabetes . gout (in adults)
l INTERACTIONS → Appendix 1: pyrazinamide
l PREGNANCY Manufacturer advises use only if potential
l BREAST FEEDING Amount too small to be harmful.
l HEPATIC IMPAIRMENT Manufacturer advises avoid in
severe impairment, acute hepatic disease and for up to
6 months after occurrence of hepatitis (risk of increased
Dose adjustments ▶ In adults 25–30 mg/kg 3 times a week if
eGFR less than 30 mL/minute/1.73 m2
▶ In children If estimated glomerular filtration rate less
Monitoring Monitor for gout in renal impairment.
▶ Renal function should be checked before treatment.
▶ Hepatic function should be checked before treatment. If
there is no evidence of liver disease (and pre-treatment
liver function is normal), further checks are only necessary
if the patient develops fever, malaise, vomiting, jaundice
or unexplained deterioration during treatment.
▶ In adults Those with alcohol dependence should have
frequent checks of hepatic function, particularly in the
l PRESCRIBING AND DISPENSING INFORMATION
▶ In children In general, doses should be rounded up to
facilitate administration of suitable volumes of liquid or an
appropriate strength of tablet. Doses may also need to be
recalculated to allow for weight gain in younger children.
The RCPCH and NPPG recommend that, when a liquid
special of pyrazinamide is required, the following strength
Hepatic disorders Patients or their carers should be told how
to recognise signs of liver disorder, and advised to
discontinue treatment and seek immediate medical
attention if symptoms such as persistent nausea,
vomiting, malaise or jaundice develop.
Medicines for Children leaflet: Pyrazinamide for treatment of
tuberculosis www.medicinesforchildren.org.uk/pyrazinamidetreatment-tuberculosis
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 8
▶ Pyrazinamide (Non-proprietary)
Pyrazinamide 500 mg Pyrazinamide 500mg tablets |
30 tablet P £36.12 DT = £36.12
▶ Zinamide (Genus Pharmaceuticals Ltd)
Pyrazinamide 500 mg Zinamide 500mg tablets | 30 tablet P £31.35 DT = £36.12
Combinations available: Rifampicin with ethambutol,
isoniazid and pyrazinamide, p. 583 . Rifampicin with isoniazid
588 Bacterial infection BNF 78
Urinary-tract infection is more common in women than in
men; when it occurs in men there is frequently an underlying
abnormality of the renal tract. Recurrent episodes of
infection are an indication for radiological investigation
especially in children in whom untreated pyelonephritis may
lead to permanent kidney damage.
Escherichia coli is the most common cause of urinary-tract
infection; Staphylococcus saprophyticus is also common in
sexually active young women. Less common causes include
Proteus and Klebsiella spp. Pseudomonas aeruginosa
infections usually occur in the hospital setting and may be
associated with functional or anatomical abnormalities of
the renal tract. Staphylococcus epidermidis and Enterococcus
faecalis infection may complicate catheterisation or
A specimen of urine should be collected for culture and
sensitivity testing before starting antibacterial therapy;
. in children under 3 years of age;
. in patients with suspected upper urinary-tract infection;
. complicated infection, or recurrent infection;
. if resistant organisms are suspected;
. if urine dipstick testing gives a single positive result for
leucocyte esterase or nitrite;
. if clinical symptoms are not consistent with results of
Treatment should not be delayed while waiting for results.
The antibacterial chosen should reflect current local
bacterial sensitivity to antibacterials.
Antibacterial therapy for lower urinary-tract
Uncomplicated lower urinary-tract infections often respond to
trimethoprim p. 574 or nitrofurantoin p. 590, or alternatively,
amoxicillin p. 548, ampicillin p. 550 or oral cephalosporin.
Suggested duration of treatment is 7 days, but a short course
(e.g. 3 days) is usually adequate for uncomplicated urinarytract infections in women.
Infections caused by fully sensitive bacteria respond to
Widespread bacterial resistance to ampicillin, amoxicillin,
and trimethoprim has been reported. Alternatives for
resistant organisms include co-amoxiclav p. 551 (amoxicillin
with clavulanic acid), an oral cephalosporin, nitrofurantoin,
pivmecillinam hydrochloride p. 554, or a quinolone.
Fosfomycin p. 570 can be used, on the advice of a
microbiologist, for the treatment of acute uncomplicated
lower urinary-tract infections caused by organisms sensitive
Long-term low dose therapy may be required in selected
patients to prevent recurrence of infection; indications
include frequent relapses and significant kidney damage.
Trimethoprim, nitrofurantoin and cefalexin p. 524 have been
recommended for long-term therapy.
Methenamine hippurate below (hexamine hippurate)
should not generally be used because it requires an acidic
urine for its antimicrobial activity and it is ineffective for
upper urinary-tract infections; it may, however, have a role
in the prophylaxis and treatment of chronic or recurrent
uncomplicated lower urinary-tract infections.
Antibacterial therapy for upper urinary-tract
Acute pyelonephritis can lead to septicaemia and is treated
initially by injection of a broad-spectrum antibacterial such
as a cephalosporin (e.g. cefuroxime p. 526) or a quinolone if
the patient is severely ill; gentamicin p. 519 can also be used.
Suggested duration of treatment is 10–14 days (longer
treatment may be necessary in complicated pyelonephritis).
Prostatitis can be difficult to cure and requires treatment
for several weeks with an antibacterial which penetrates
prostatic tissue such as some of the quinolones
(ciprofloxacin p. 558 or ofloxacin p. 561), or alternatively,
Suggested duration of treatment is 28 days.
Where infection is localised and associated with an
indwelling catheter, a bladder instillation is often effective.
Urinary-tract infection in pregnancy may be asymptomatic
and requires prompt treatment to prevent progression to
acute pyelonephritis. Penicillins and cephalosporins are
suitable for treating urinary-tract infection during
pregnancy. Nitrofurantoin may also be used but it should be
avoided at term. Sulfonamides and quinolones should be
avoided during pregnancy; trimethoprim should also
preferably be avoided particularly in the first trimester.
In renal failure antibacterials normally excreted by the
kidney accumulate with resultant toxicity unless the dose is
reduced. This applies especially to the aminoglycosides
which should be used with great caution; tetracyclines,
methenamine hippurate, and nitrofurantoin should be
Methenamine hippurate 06-Aug-2018
Prophylaxis and long-term treatment of chronic or
recurrent uncomplicated lower urinary-tract infections
Prophylaxis and long-term treatment of chronic or
recurrent uncomplicated lower urinary-tract infections
l CONTRA-INDICATIONS Gout. metabolic acidosis . severe
l INTERACTIONS → Appendix 1: methenamine
▶ Uncommon Epigastric discomfort. skin reactions
l PREGNANCY There is inadequate evidence of safety, but it
has been in wide use for many years without apparent ill
consequence, however, manufacturer advises it is
l BREAST FEEDING Amount too small to be harmful.
l HEPATIC IMPAIRMENT Manufacturer advises avoid.
l RENAL IMPAIRMENT Avoid if eGFR less than
—risk of hippurate crystalluria.
l EFFECT ON LABORATORY TESTS False results for urinary
steroids, catecholamines and 5-hydroxyindole acetic acid
l LESS SUITABLE FOR PRESCRIBING Methenamine
(hexamine) hippurate should not generally be used
BNF 78 Urinary tract infections 589
because it requires an acidic urine for its antimicrobial
activity and it is ineffective for upper urinary-tract
infections; it may, however, have a role in the prophylaxis
and treatment of chronic or recurrent uncomplicated
lower urinary-tract infections. It is considered less suitable
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
CAUTIONARY AND ADVISORY LABELS 9
▶ Hiprex (Meda Pharmaceuticals Ltd)
Methenamine hippurate 1 gram Hiprex 1g tablets | 60 tablet p
Acute uncomplicated urinary-tract infections
▶ BY MOUTH USING IMMEDIATE-RELEASE MEDICINES
▶ Child 3 months–11 years: 750 micrograms/kg 4 times a
▶ Child 12–17 years: 50 mg 4 times a day for 3–7 days
▶ Adult: 50 mg 4 times a day for 3–7 days, dose to be
▶ BY MOUTH USING MODIFIED-RELEASE MEDICINES
▶ Child 12–17 years: 100 mg twice daily, dose to be taken
▶ Adult: 100 mg twice daily, dose to be taken with food
Severe chronic recurrent urinary-tract infections
▶ BY MOUTH USING IMMEDIATE-RELEASE MEDICINES
▶ Child 12–17 years: 100 mg 4 times a day for 3–7 days
▶ Adult: 100 mg 4 times a day for 7 days, dose to be taken
with food, reduce dose or discontinue treatment if
Prophylaxis of urinary-tract infection (considered for
recurrent infection, significant urinary-tract anomalies,
▶ BY MOUTH USING IMMEDIATE-RELEASE MEDICINES
▶ Child 3 months–11 years: 1 mg/kg once daily, dose to be
▶ Child 12–17 years: 50–100 mg once daily, dose to be
▶ Adult: 50–100 mg once daily, dose to be taken at night
Genito-urinary surgical prophylaxis
▶ BY MOUTH USING MODIFIED-RELEASE MEDICINES
▶ Adult: 100 mg twice daily on day of procedure and for
l CONTRA-INDICATIONS Acute porphyrias p. 1058 .G6PD
deficiency . infants less than 3 months old
l CAUTIONS Anaemia . diabetes mellitus . electrolyte
coloured yellow or brown . vitamin B deficiency
l INTERACTIONS → Appendix 1: nitrofurantoin
anaemia . headache . hepatic disorders . idiopathic
hypersensitivity . pulmonary reaction (possible association
with lupus erythematosus-like syndrome).respiratory
l PREGNANCY Avoid at term—may produce neonatal
l BREAST FEEDING Avoid; only small amounts in milk but
enough to produce haemolysis in G6PD-deficient infants.
l HEPATIC IMPAIRMENT Manufacturer advises caution.
l RENAL IMPAIRMENT Risk of peripheral neuropathy;
antibacterial efficacy depends on renal secretion of the
▶ In adults Avoid if eGFR less than 45 mL/minute/1.73 m2
may be used with caution if eGFR
30–44 mL/minute/1.73 m2 as a short-course only (3 to
7 days), to treat uncomplicated lower urinary-tract
infection caused by suspected or proven multidrug
resistant bacteria and only if potential benefit outweighs
▶ In children Avoid if estimated glomerular filtration rate less
estimated glomerular filtration rate
30–44 mL/minute/1.73 m2 as a short-course only (3 to
7 days), to treat uncomplicated lower urinary-tract
infection caused by suspected or proven multidrug
resistant bacteria and only if potential benefit outweighs
l MONITORING REQUIREMENTS On long-term therapy,
monitor liver function and monitor for pulmonary
symptoms, especially in the elderly (discontinue if
deterioration in lung function).
l EFFECT ON LABORATORY TESTS False positive urinary
glucose (if tested for reducing substances).
Medicines for Children leaflet: Nitrofurantoin for urinary tract
infections www.medicinesforchildren.org.uk/nitrofurantoinurinary-tract-infections
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 9, 14, 21
▶ Nitrofurantoin (Non-proprietary)
▶ Genfura (Genesis Pharmaceuticals Ltd)
Nitrofurantoin 50 mg Genfura 50mg tablets | 28 tablet P £8.00
DT = £8.34 | 100 tablet P £28.57
Nitrofurantoin 100 mg Genfura 100mg tablets | 100 tablet P £30.36
CAUTIONARY AND ADVISORY LABELS 9, 14, 21
▶ Nitrofurantoin (Non-proprietary)
Nitrofurantoin 5 mg per 1 ml Nitrofurantoin 25mg/5ml oral
suspension sugar free sugar-free | 300 ml P £446.95 DT =
CAUTIONARY AND ADVISORY LABELS 9, 14, 21, 25
Nitrofurantoin 100 mg Macrobid 100mg modified-release capsules
| 14 capsule P £9.50 DT = £9.50
CAUTIONARY AND ADVISORY LABELS 9, 14, 21
▶ Nitrofurantoin (Non-proprietary)
Nitrofurantoin 50 mg Nitrofurantoin 50mg capsules | 30 capsule P £15.42 DT = £15.42
Nitrofurantoin 100 mg Nitrofurantoin 100mg capsules |
30 capsule P £10.42 DT = £10.42
590 Bacterial infection BNF 78
The systemic treatment of common fungal infections is
outlined below; specialist treatment is required in most
forms of systemic or disseminated fungal infections. Local
treatment is suitable for a number of fungal infections
(genital, bladder, eye, ear, oropharynx, and skin).
Aspergillosis most commonly affects the respiratory tract
but in severely immunocompromised patients, invasive
forms can affect the heart, brain, and skin. Voriconazole
p. 599 is the treatment of choice for aspergillosis; liposomal
amphotericin p. 593 is an alternative first-line treatment
when voriconazole cannot be used. Caspofungin p. 592, or
itraconazole p. 597, can be used in patients who are
refractory to, or intolerant of voriconazole and liposomal
amphotericin. Itraconazole is also used for the treatment of
chronic pulmonary aspergillosis or as an adjunct in the
treatment of allergic bronchopulmonary aspergillosis
[unlicensed indication]. Posaconazole p. 598 is licensed for
use in patients with invasive aspergillosis who are refractory
to, or intolerant of itraconazole or amphotericin.
Many superficial candidal infections including infections of
the skin are treated locally; widespread or intractable
infection requires systemic antifungal treatment. Vaginal
candidiasis may be treated with locally acting antifungals or
with fluconazole p. 595 given by mouth; for resistant
organisms in adults, itraconazole can be given by mouth.
Oropharyngeal candidiasis generally responds to topical
therapy; fluconazole is given by mouth for unresponsive
infections; it is effective and is reliably absorbed.
Itraconazole may be used for infections that do not respond
to fluconazole. Topical therapy may not be adequate in
immunocompromised patients and an oral triazole
For invasive or disseminated candidiasis, an echinocandin
can be used. Fluconazole is an alternative for Candida
albicans infection in clinically stable patients who have not
received an azole antifungal recently. Amphotericin is an
alternative when an echinocandin or fluconazole cannot be
used, however, amphotericin should be considered for the
initial treatment of CNS candidiasis. Voriconazole can be
used for infections caused by fluconazole-resistant Candida
spp. when oral therapy is required, or in patients intolerant
of amphotericin or an echinocandin. In refractory cases,
flucytosine p. 601 can be used with intravenous
Cryptococcosis is uncommon but infection in the
immunocompromised, especially in HIV-positive patients,
can be life-threatening; cryptococcal meningitis is the most
common form of fungal meningitis. The treatment of choice
in cryptococcal meningitis is amphotericin by intravenous
infusion and flucytosine by intravenous infusion for 2 weeks,
followed by fluconazole by mouth for 8 weeks or until
cultures are negative. In cryptococcosis, fluconazole is
sometimes given alone as an alternative in HIV-positive
patients with mild, localised infections or in those who
cannot tolerate amphotericin. Following successful
treatment, fluconazole can be used for prophylaxis against
relapse until immunity recovers.
Itraconazole can be used for the treatment of
immunocompetent patients with indolent non-meningeal
infection, including chronic pulmonary histoplasmosis.
Amphotericin by intravenous infusion is used for the initial
treatment of fulminant or severe infections, followed by a
course of itraconazole by mouth. Following successful
treatment, itraconazole can be used for prophylaxis against
relapse until immunity recovers.
Mild localised fungal infections of the skin (including tinea
corporis, tinea cruris, and tinea pedis) respond to topical
therapy. Systemic therapy is appropriate if topical therapy
fails, if many areas are affected, or if the site of infection is
difficult to treat such as in infections of the nails
(onychomycosis) and of the scalp (tinea capitis). Oral
imidazole or triazole antifungals (particularly itraconazole)
and terbinafine p. 1234 are used more frequently than
griseofulvin p. 601 because they have a broader spectrum of
activity and require a shorter duration of treatment.
Tinea capitis is treated systemically; additional topical
application of an antifungal may reduce transmission.
Griseofulvin is used for tinea capitis in adults and children; it
is effective against infections caused by Trichophyton
tonsurans and Microsporum spp. Terbinafine is used for tinea
capitis caused by T. tonsurans [unlicensed indication]. The
role of terbinafine in the management of Microsporum
Pityriasis versicolor may be treated with itraconazole by
mouth if topical therapy is ineffective; fluconazole by mouth
is an alternative. Oral terbinafine is not effective for
Antifungal treatment may not be necessary in
asymptomatic patients with tinea infection of the nails. If
treatment is necessary, a systemic antifungal is more
effective than topical therapy. Terbinafine and itraconazole
have largely replaced griseofulvin for the systemic treatment
of onychomycosis, particularly of the toenail; terbinafine is
considered to be the drug of choice. Itraconazole can be
administered as intermittent ‘pulse’ therapy. Topical
antifungals also have a role in the treatment of
Immunocompromised patients are at particular risk of fungal
infections and may receive antifungal drugs
prophylactically; oral triazole antifungals are the drugs of
choice for prophylaxis. Fluconazole is more reliably absorbed
than itraconazole, but fluconazole is not effective against
Aspergillus spp. Itraconazole is preferred in patients at risk of
invasive aspergillosis. Posaconazole can be used for
prophylaxis in patients who are undergoing haematopoietic
stem cell transplantation or receiving chemotherapy for
acute myeloid leukaemia or myelodysplastic syndrome.
Micafungin p. 593 can be used for prophylaxis of candidiasis
in patients undergoing haematopoietic stem cell
transplantation when fluconazole, itraconazole or
Amphotericin by intravenous infusion or caspofungin is
used for the empirical treatment of serious fungal infections;
caspofungin is not effective against fungal infections of the
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