l DIRECTIONS FOR ADMINISTRATION
▶ With intramuscular use or intravenous use Single doses over
750 mg should be administered by the intravenous route
▶ With intravenous use in children Displacement value may be
significant when reconstituting injection, consult local
guidelines. For intermittent intravenous infusion, dilute
reconstituted solution further in glucose 5% or sodium
chloride 0.9%; give over 30 minutes.
▶ With intravenous use in adults For intravenous infusion
(Zinacef ®), give intermittently or via drip tubing in Glucose
5% or Sodium chloride 0.9%. Dissolve initially in water for
injections (at least 2 mL for each 250 mg,15 mL for 1.5 g);
suggested volume 50–100 mL given over 30 minutes.
526 Bacterial infection BNF 78
l PRESCRIBING AND DISPENSING INFORMATION
▶ With oral use See Lyme disease p. 577 for information on
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: solution for
CAUTIONARY AND ADVISORY LABELS 9, 21, 25
▶ Cefuroxime (Non-proprietary)
Cefuroxime (as Cefuroxime axetil) 250 mg Cefuroxime 250mg
tablets | 14 tablet P £17.72 DT = £17.72
▶ Zinnat (GlaxoSmithKline UK Ltd)
Cefuroxime (as Cefuroxime axetil) 125 mg Zinnat 125mg tablets | 14 tablet P £4.56 DT = £4.56
Cefuroxime (as Cefuroxime axetil) 250 mg Zinnat 250mg tablets | 14 tablet P £9.11 DT = £17.72
ELECTROLYTES: May contain Sodium
▶ Cefuroxime (Non-proprietary)
Cefuroxime (as Cefuroxime sodium) 250 mg Cefuroxime 250mg
powder for injection vials | 10 vial P £9.25 (Hospital only)
Cefuroxime (as Cefuroxime sodium) 750 mg Cefuroxime 750mg
powder for injection vials | 1 vial P £2.52 | 10 vial P £25.20
| 10 vial P £24.90 (Hospital only)
Cefuroxime (as Cefuroxime sodium) 1.5 gram Cefuroxime 1.5g
powder for injection vials | 1 vial P £5.05 | 10 vial P £50.50
| 10 vial P £50.50 (Hospital only)
▶ Zinacef (GlaxoSmithKline UK Ltd)
Cefuroxime (as Cefuroxime sodium) 250 mg Zinacef 250mg
powder for injection vials | 5 vial P £4.70
Cefuroxime (as Cefuroxime sodium) 750 mg Zinacef 750mg
powder for injection vials | 5 vial P £11.72 (Hospital only)
Cefuroxime (as Cefuroxime sodium) 1.5 gram Zinacef 1.5g powder
for injection vials | 1 vial P £4.70
CAUTIONARY AND ADVISORY LABELS 9, 21
EXCIPIENTS: May contain Aspartame, sucrose
▶ Zinnat (GlaxoSmithKline UK Ltd)
Cefuroxime (as Cefuroxime axetil) 25 mg per 1 ml Zinnat
125mg/5ml oral suspension | 70 ml P £5.20 DT = £5.20
ANTIBACTERIALS › CEPHALOSPORINS,
Acute infections due to sensitive Gram-positive and Gramnegative bacteria
▶ Child 6–11 months: 75 mg daily
▶ Child 1–4 years: 100 mg daily
▶ Child 5–9 years: 200 mg daily
▶ Child 10–17 years: 200–400 mg daily, alternatively
▶ Adult: 200–400 mg daily in 1–2 divided doses
l UNLICENSED USE Use of cefixime for uncomplicated
gonorrhoea is an unlicensed indication.
l INTERACTIONS → Appendix 1: cephalosporins
pruritus . hypereosinophilia . jaundice . serum sicknesslike reaction .thrombocytosis
l PREGNANCY Not known to be harmful.
l BREAST FEEDING Manufacturer advises avoid unless
essential—no information available.
Dose adjustments ▶ In adults Reduce dose if eGFR less than
20 mL/minute/1.73 m2 (max. 200 mg once daily).
▶ In children Reduce dose if estimated glomerular filtration
rate less than 20 mL/minute/1.73 m2
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
CAUTIONARY AND ADVISORY LABELS 9
Cefixime 200 mg Suprax 200mg tablets | 7 tablet P £13.23 DT =
▶ BY INTRAMUSCULAR INJECTION, OR BY INTRAVENOUS
INJECTION, OR BY INTRAVENOUS INFUSION
Severe susceptible infections due to sensitive Grampositive and Gram-negative bacteria | Meningitis
▶ BY INTRAMUSCULAR INJECTION, OR BY INTRAVENOUS
INJECTION, OR BY INTRAVENOUS INFUSION
▶ Adult: 8 g daily in 4 divided doses, increased if
necessary to 12 g daily in 3–4 divided doses,
intramuscular doses over 1 g should be divided
Emergency treatment of suspected bacterial meningitis or
meningococcal disease, before urgent transfer to
hospital, in patients who cannot be given
benzylpenicillin (e.g. because of an allergy)
▶ BY INTRAVENOUS INJECTION, OR BY INTRAMUSCULAR
▶ Child 1 month–11 years: 50 mg/kg for 1 dose
▶ Child 12–17 years: 1 g for 1 dose
l INTERACTIONS → Appendix 1: cephalosporins
▶ Uncommon Drug fever.Jarisch-Herxheimer reaction . renal impairment. seizure
▶ Frequency not known Arrhythmia (following rapid
injection). bronchospasm . encephalopathy . hepatic
l PREGNANCY Not known to be harmful.
l BREAST FEEDING Present in milk in low concentration, but
Dose adjustments ▶ In adults If eGFR less than
, initial dose of 1 g then use half
▶ In children Usual initial dose, then use half normal dose if
estimated glomerular filtration rate less than
l DIRECTIONS FOR ADMINISTRATION
▶ With intravenous use in children Displacement value may be
significant, consult local guidelines. For intermittent
intravenous infusion dilute in glucose 5% or sodium
chloride 0.9%; administer over 20–60 minutes;
incompatible with alkaline solutions.
▶ With intravenous use in adults For intravenous infusion, give
intermittently in Glucose 5% or Sodium chloride 0.9%.
Suggested volume 40–100 mL given over 20–60 minutes;
incompatible with alkaline solutions.
BNF 78 Bacterial infection 527
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
Powder for solution for injection
▶ Cefotaxime (Non-proprietary)
Cefotaxime (as Cefotaxime sodium) 500 mg Cefotaxime 500mg
powder for solution for injection vials | 10 vial P £30.00 |
10 vial P £21.00 (Hospital only)
Cefotaxime (as Cefotaxime sodium) 1 gram Cefotaxime 1g powder
for solution for injection vials | 10 vial P £35.00 | 10 vial P £42.00 (Hospital only)
Cefotaxime (as Cefotaxime sodium) 2 gram Cefotaxime 2g powder
for solution for injection vials | 10 vial P £37.50
Prophylaxis for transurethral resection of prostate
▶ BY INTRAVENOUS INJECTION, OR BY INTRAVENOUS INFUSION,
OR BY DEEP INTRAMUSCULAR INJECTION
▶ Adult: 1 g, single dose to be administered up to
30 minutes before procedure and may be repeated if
necessary when catheter removed
Pseudomonal lung infection in cystic fibrosis
▶ BY INTRAVENOUS INFUSION, OR BY INTRAVENOUS INJECTION,
OR BY DEEP INTRAMUSCULAR INJECTION
▶ Adult: 100–150 mg/kg daily in 3 divided doses;
Complicated urinary-tract infection
▶ BY INTRAVENOUS INJECTION, OR BY INTRAVENOUS INFUSION,
OR BY DEEP INTRAMUSCULAR INJECTION
▶ Adult: 1–2 g every 8–12 hours
Septicaemia | Hospital-acquired pneumonia
▶ BY INTRAVENOUS INFUSION, OR BY INTRAVENOUS INJECTION
▶ BY INTRAVENOUS INFUSION, OR BY INTRAVENOUS INJECTION
▶ BY INTRAVENOUS INFUSION, OR BY INTRAVENOUS INJECTION
Susceptible infections due to sensitive Gram-positive and
▶ BY INTRAVENOUS INFUSION, OR BY INTRAVENOUS INJECTION,
OR BY DEEP INTRAMUSCULAR INJECTION
l INTERACTIONS → Appendix 1: cephalosporins
▶ Common or very common Thrombocytosis . thrombophlebitis
▶ Rare or very rare Acute kidney injury
l PREGNANCY Not known to be harmful.
l BREAST FEEDING Present in milk in low concentration, but
l HEPATIC IMPAIRMENT Manufacturer advises close
monitoring in severe impairment—no information
Dose adjustments Manufacturer advises reduce dose if
creatinine clearance 50 mL/minute or less—consult
l DIRECTIONS FOR ADMINISTRATION Intramuscular
administration used when intravenous administration not
possible; single doses over 1 g by intravenous route only.
▶ With intravenous use For intravenous infusion give
intermittently or via drip tubing in Glucose 5% or 10% or
Sodium chloride 0.9%. Dissolve 2 g initially in 10 mL (3 g in
15 mL) infusion fluid. For Fortum® dilute further to a
concentration of 40 mg/mL. For Kefadim® dilute further to
a concentration of 20 mg/mL. Give over up to 30 minutes.
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, solution
Powder for solution for injection
ELECTROLYTES: May contain Sodium
▶ Ceftazidime (Non-proprietary)
Ceftazidime (as Ceftazidime pentahydrate) 500 mg Ceftazidime
500mg powder for solution for injection vials | 1 vial P £4.25–
Ceftazidime (as Ceftazidime pentahydrate) 1 gram Ceftazidime 1g
powder for solution for injection vials | 1 vial P £9.06 (Hospital
only) | 10 vial P £13.90–£79.00 | 10 vial P £79.10 (Hospital
Ceftazidime (as Ceftazidime pentahydrate) 2 gram Ceftazidime 2g
powder for solution for injection vials | 1 vial P £19.09 (Hospital
only) | 5 vial P £79.15 (Hospital only) | 10 vial P £27.70–
Ceftazidime (as Ceftazidime pentahydrate) 3 gram Ceftazidime 3g
powder for solution for injection vials | 10 vial P £257.60
▶ Fortum (GlaxoSmithKline UK Ltd)
Ceftazidime (as Ceftazidime pentahydrate) 500 mg Fortum
500mg powder for solution for injection vials | 1 vial P £4.40
Ceftazidime (as Ceftazidime pentahydrate) 1 gram Fortum 1g
powder for solution for injection vials | 1 vial P £8.79 (Hospital
Ceftazidime (as Ceftazidime pentahydrate) 2 gram Fortum 2g
powder for solution for injection vials | 1 vial P £17.59 (Hospital
Ceftazidime (as Ceftazidime pentahydrate) 3 gram Fortum 3g
powder for solution for injection vials | 1 vial P £25.76 (Hospital
Combinations available: Ceftazidime with avibactam, p. 530
Community-acquired pneumonia |Hospital-acquired
pneumonia | Intra-abdominal infections | Complicated
urinary-tract infections | Acute exacerbations of chronic
▶ BY INTRAVENOUS INFUSION, OR BY INTRAVENOUS INJECTION,
OR BY DEEP INTRAMUSCULAR INJECTION
▶ Adult: 1–2 g once daily, 2 g dose to be used for
hospital-acquired pneumonia and severe cases
Complicated skin and soft tissue infections | Infections of
▶ BY INTRAVENOUS INFUSION, OR BY INTRAVENOUS INJECTION,
OR BY DEEP INTRAMUSCULAR INJECTION
Suspected bacterial infection in neutropenic patients
▶ BY INTRAVENOUS INFUSION, OR BY INTRAVENOUS INJECTION,
OR BY DEEP INTRAMUSCULAR INJECTION
▶ Adult: 2–4 g daily, doses at the higher end of the
recommended range used in severe cases
Bacterial meningitis | Bacterial endocarditis
▶ BY INTRAVENOUS INFUSION, OR BY INTRAVENOUS INJECTION,
OR BY DEEP INTRAMUSCULAR INJECTION
▶ Adult: 2–4 g daily, doses at the higher end of the
recommended range used in severe cases
▶ Child 1 month–11 years (body-weight up to 50 kg):
80–100 mg/kg once daily, 100 mg/kg once daily dose
should be used for bacterial endocarditis; maximum 4 g
528 Bacterial infection BNF 78
▶ Child 9–11 years (body-weight 50 kg and above): 2–4 g
once daily, doses at the higher end of the
recommended range used in severe cases
▶ Child 12–17 years: 2–4 g once daily, doses at the higher
end of the recommended range used in severe cases
▶ Child 9–11 years (body-weight 50 kg and above): 2–4 g
once daily, doses at the higher end of the
recommended range used in severe cases; doses of
50 mg/kg or more should be given by infusion
▶ Child 12–17 years: 2–4 g once daily, doses at the higher
end of the recommended range used in severe cases
▶ BY DEEP INTRAMUSCULAR INJECTION
▶ Child 1 month–11 years (body-weight up to 50 kg):
80–100 mg/kg daily, 100 mg/kg daily dose should be
used for bacterial endocarditis; maximum 4 g per day
▶ Child 9–11 years (body-weight 50 kg and above): 2–4 g
daily, doses at the higher end of the recommended
▶ Child 12–17 years: 2–4 g daily, doses at the higher end of
the recommended range used in severe cases
▶ BY INTRAVENOUS INFUSION, OR BY INTRAVENOUS INJECTION,
OR BY DEEP INTRAMUSCULAR INJECTION
▶ Adult: 2 g for 1 dose, dose to be administered
30–90 minutes before procedure
Uncomplicated gonorrhoea | Pelvic inflammatory disease
▶ BY DEEP INTRAMUSCULAR INJECTION
▶ BY INTRAVENOUS INFUSION, OR BY INTRAVENOUS INJECTION,
OR BY DEEP INTRAMUSCULAR INJECTION
▶ Adult: 0.5–1 g once daily for 10–14 days, dose
increased to 2 g once daily for neurosyphilis
Lyme disease [affecting central nervous system]
▶ BY INTRAVENOUS INFUSION, OR BY INTRAVENOUS INJECTION
▶ Adult: 2 g twice daily for 21 days, alternatively 4 g once
Lyme arthritis | Acrodermatitis chronica atrophicans
▶ BY INTRAVENOUS INFUSION, OR BY INTRAVENOUS INJECTION
▶ Adult: 2 g once daily for 28 days
▶ BY INTRAVENOUS INFUSION, OR BY INTRAVENOUS INJECTION
▶ Adult: 2 g once daily for 21 days
Prevention of secondary case of meningococcal meningitis
Prevention of secondary case of Haemophilus influenzae
▶ BY INTRAMUSCULAR INJECTION, OR BY INTRAVENOUS
INJECTION, OR BY INTRAVENOUS INFUSION
▶ BY DEEP INTRAMUSCULAR INJECTION
▶ Adult: 1–2 g for 1 dose, dose can be given for 3 days if
severely ill or previous therapy failed
l UNLICENSED USE g Not licensed for prophylaxis of
Haemophilus influenzae type b disease. lNot licensed for
prophylaxis of meningococcal meningitis.
▶ In adults g Dose not licensed for treatment of pelvic
inflammatory disease in adults over 18 years. Ceftriaxone
is used for Lyme disease affecting the central nervous
system, hbut the dose is not licensed for this indication.
GENERAL CAUTIONS History of hypercalciuria . history of
▶ With intravenous use concomitant treatment with
intravenous calcium (including total parenteral nutrition
containing calcium) (in adults)
l INTERACTIONS → Appendix 1: cephalosporins
▶ Uncommon Anaemia . coagulation disorder
▶ Rare or very rare Bronchospasm . glycosuria . haematuria . oedema
SIDE-EFFECTS, FURTHER INFORMATION Precipitates of
calcium ceftriaxone can occur in the gall bladder and urine
(particularly in very young, dehydrated or those who are
immobilised)—consider discontinuation if symptomatic.
l PREGNANCY Manufacturer advises use only if benefit
outweighs risk—limited data available but not known to be
harmful in animal studies.g Specialist sources indicate
suitable for use in pregnancy. k
l BREAST FEEDING g Specialist sources advise
ceftriaxone is compatible with breastfeeding—present in
milk in low concentration but limited effects to breast-fed
Dose adjustments Manufacturer advises reduce dose and
monitor efficacy in patients with severe renal impairment
in combination with hepatic impairment—no information
▶ In adults Manufacturer advises reduce dose if eGFR less
than 10 mL/minute/1.73 m2 (max. 2 g daily).
▶ In children Manufacturer advises reduce dose if estimated
glomeruler filtration rate less than 10 mL/minute/1.73 m2
max. 50 mg/kg daily or max. 2 g daily).
l MONITORING REQUIREMENTS Manufacturer advises to
monitor full blood count regularly during prolonged
l DIRECTIONS FOR ADMINISTRATION
▶ With intramuscular use or intravenous use Twice daily dosing
may be considered for doses greater than 2 g daily.
▶ With intravenous use in children For intravenous infusion
(preferred route), dilute reconstituted solution with
Glucose 5% (or 10% in neonates) or Sodium Chloride 0.9%;
give over at least 30 minutes (60 minutes in neonates—
may displace bilirubin from serum albumin). Not to be
given simultaneously with parenteral nutrition or infusion
fluids containing calcium, even by different infusion lines;
in children, may be infused sequentially with infusion
fluids containing calcium if infusion lines at different sites
are used, or if the infusion lines are replaced or thoroughly
flushed between infusions with Sodium Chloride 0.9% to
avoid precipitation—consult product literature.
Displacement value may be significant, consult local
guidelines. For intravenous injection, give over 5 minutes.
▶ With intramuscular use in children For intramuscular injection,
may be mixed with 1% Lidocaine Hydrochloride Injection
to reduce pain at intramuscular injection site.
Intramuscular injection should only be considered when
the intravenous route is not possible or less appropriate. If
administered by intramuscular injection, the lower end of
the dose range should be used for the shortest time
possible; volume depends on the age and size of the child,
but doses over 1 g must be divided between more than one
site. Displacement value may be significant, consult local
guidelines. The maximum single intramuscular dose is 2 g,
doses greater than 2 g must be given in divided doses or by
intravenous administration (see above).
▶ With intravenous use in adults For intravenous infusion
(preferred route) (Rocephin ®; Ceftriaxone Injection, Genus),
give intermittently or via drip tubing in Glucose 5% or 10%
or Sodium Chloride 0.9%. Reconstitute 2-g vial with 40 mL
BNF 78 Bacterial infection 529
infusion fluid. Give by intermittent infusion over at least
30 minutes. Not to be given simultaneously with total
parenteral nutrition or infusion fluids containing calcium,
even by different infusion lines. May be infused
sequentially with infusion fluids containing calcium if
infusion lines at different sites are used, or if the infusion
lines are replaced or thoroughly flushed between infusions
with Sodium Chloride 0.9% to avoid precipitation—consult
product literature. For intravenous injection, give over
▶ With intramuscular use in adults For intramuscular injection,
doses over 1 g must be divided between more than one
site. Displacement value may be significant, consult local
guidelines. The maximum single intramuscular dose is 2 g,
doses greater than 2 g must be given in divided doses or by
l PRESCRIBING AND DISPENSING INFORMATION See Lyme
disease p. 577 for place in therapy and further information
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
▶ Ceftriaxone (Non-proprietary)
Ceftriaxone (as Ceftriaxone sodium) 250 mg Ceftriaxone 250mg
powder for solution for injection vials | 1 vial P £2.30 DT = £2.40
Ceftriaxone (as Ceftriaxone sodium) 1 gram Ceftriaxone 1g powder
Ceftriaxone (as Ceftriaxone sodium) 2 gram Ceftriaxone 2g
powder for solution for injection vials | 1 vial P £18.30 DT =
£19.18 (Hospital only) | 1 vial P s DT = £19.18 | 10 vial P £191.80
▶ Rocephin (Roche Products Ltd)
Ceftriaxone (as Ceftriaxone sodium) 250 mg Rocephin 250mg
powder for solution for injection vials | 1 vial P £2.40 DT = £2.40
Ceftriaxone (as Ceftriaxone sodium) 1 gram Rocephin 1g powder
for solution for injection vials | 1 vial P £9.58 DT = £9.58
Ceftriaxone (as Ceftriaxone sodium) 2 gram Rocephin 2g powder
for solution for injection vials | 1 vial P £19.18 DT = £19.18
ANTIBACTERIALS › CEPHALOSPORINS,
THIRD-GENERATION WITH BETALACTAMASE INHIBITOR
Ceftazidime with avibactam 27-Jul-2017
The properties listed below are those particular to the
combination only. For the properties of the components
please consider, ceftazidime p. 528.
Complicated intra-abdominal infection
▶ Adult: 2/0.5 g every 8 hours for 5–14 days
Complicated urinary tract infection, including
▶ Adult: 2/0.5 g every 8 hours for 5–10 days
Hospital-acquired pneumonia, including ventilatorassociated pneumonia
▶ Adult: 2/0.5 g every 8 hours for 7–14 days
Infections due to Gram-negative bacteria with limited
▶ Adult: 2/0.5 g every 8 hours, duration of treatment
guided by infection severity, pathogen, and response
DOSE EQUIVALENCE AND CONVERSION
▶ Dose expressed as x/y g ceftazidime/avibactam
l INTERACTIONS → Appendix 1: cephalosporins
▶ Common or very common Thrombocytosis
▶ Uncommon Acute kidney injury . lymphocytosis . paraesthesia .taste altered
l PREGNANCY Manufacturer advises avoid unless potential
benefit outweighs risk—toxicity in animal studies.
l BREAST FEEDING Manufacturer advises avoid—presence of
l DIRECTIONS FOR ADMINISTRATION Manufacturer advises
for intravenous infusion (Zavicefta ®) give in Glucose 5%, or
Sodium Chloride 0.9%, or Sodium Chloride 0.45% with
Glucose 2.5% combination or Lactated Ringer’s solution.
Reconstitute each 2 g/0.5 g vial with 10 mL water for
injections; dilute requisite dose in an appropriate infusion
bag and give over 120 minutes.
Driving and skilled tasks Manufacturer advises patients and
carers should be counselled on the effects on driving and
performance of skilled tasks—risk of dizziness.
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 Sodium
Avibactam (as Avibactam sodium) 500 mg, Ceftazidime (as
Ceftazidime pentahydrate) 2 gram Zavicefta 2g/0.5g powder for
concentrate for solution for infusion vials | 10 vial P £857.00
Ceftolozane with tazobactam 09-Mar-2017
Complicated intra-abdominal infection (in combination
with metronidazole when anaerobic pathogens
▶ Adult: 1/0.5 g every 8 hours for 4–14 days
Complicated urinary tract infection | Acute pyelonephritis
▶ Adult: 1/0.5 g every 8 hours for 7 days
DOSE EQUIVALENCE AND CONVERSION
▶ Dose expressed as x/y g where x and y are ceftolozane
l INTERACTIONS → Appendix 1: cephalosporins
disorders . hyperglycaemia . ischaemic stroke .renal
l PREGNANCY Manufacturer advises to use only if potential
benefit outweighs risk—toxicity in animal studies with
l BREAST FEEDING Manufacturer advises avoid—no
l RENAL IMPAIRMENT Manufacturer advises monitor for
Dose adjustments Manufacturer advises reduce dose to
500/250 mg every 8 hours if eGFR
530 Bacterial infection BNF 78
30–50 mL/minute/1.73 m2 and 250/125 mg every 8 hours if
l DIRECTIONS FOR ADMINISTRATION For intravenous infusion
(Zerbaxa ®), give intermittently in Glucose 5% or Sodium
chloride 0.9%; reconstitute initially each vial with 10 mL
Water for Injections or Sodium chloride 0.9% to give a final
volume of 11.4 mL; dilute requisite dose in 100 mL of
Glucose 5% or Sodium chloride 0.9%; give over 1 hour.
l HANDLING AND STORAGE Manufacturer advises store in a
Driving and skilled tasks Manufacturer advises ceftolozane
with tazobactam may influence driving and performance
of skilled tasks—increased risk of dizziness.
l NATIONAL FUNDING/ACCESS DECISIONS
Scottish Medicines Consortium (SMC) decisions
The Scottish Medicines Consortium has advised (May 2016)
that ceftolozane with tazobactam (Zerbaxa ®) is not
recommended for use within NHS Scotland for the
treatment of complicated intra-abdominal infections,
complicated urinary tract infections, and acute
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 Sodium
▶ Zerbaxa (Merck Sharp & Dohme Ltd) A
Tazobactam (as Tazobactam sodium) 500 mg, Ceftolozane (as
Ceftolozane sulfate) 1 gram Zerbaxa 1g/0.5g powder for
concentrate for solution for infusion vials | 10 vial P £670.30
ANTIBACTERIALS › CEPHALOSPORINS,
▶ Adult: 600 mg every 12 hours for 5–7 days
Complicated skin infections | Complicated soft-tissue
▶ Adult: 600 mg every 12 hours for 5–14 days
l INTERACTIONS → Appendix 1: cephalosporins
▶ Uncommon Anaemia . hypersensitivity
l PREGNANCY Manufacturer advises avoid unless
essential—no information available.
l BREAST FEEDING Manufacturer advises avoid—no
l RENAL IMPAIRMENT Manufacturer advises avoid if eGFR
less than 30 mL/minute/1.73 m2
Dose adjustments 400 mg every 12 hours if eGFR
l DIRECTIONS FOR ADMINISTRATION For intravenous
infusion, give intermittently in Glucose 5% or Sodium
chloride 0.9%. Reconstitute 600 mg with 20 mL water for
injections, then dilute with 250 mL infusion fluid (in fluid
restriction, may be diluted with 50–100 mL infusion fluid);
l NATIONAL FUNDING/ACCESS DECISIONS
Scottish Medicines Consortium (SMC) decisions
The Scottish Medicines Consortium, has advised (Dec 2012)
that ceftaroline fosamil (Zinforo ®) is accepted for
restricted use within NHS Scotland when
meticillin–resistant S. aureus is suspected in complicated
skin and soft-tissue infection and vancomycin cannot be
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
Powder for solution for infusion
Ceftaroline fosamil (as Ceftaroline fosamil acetic acid solvate
monohydrate) 600 mg Zinforo 600mg powder for concentrate for
solution for infusion vials | 10 vial P £375.00 (Hospital only)
Hospital-acquired pneumonia (excluding ventilatorassociated pneumonia)| Community-acquired
l CAUTIONS Pre-existing seizure disorder—increased risk of
seizures . supra-normal creatinine clearance
▶ Supra-normal creatinine clearance Manufacturer advises to
measure baseline renal function and increase duration of
infusion if creatinine clearance greater than
l INTERACTIONS → Appendix 1: cephalosporins
failure . sleep disorders .thrombocytosis
l PREGNANCY Manufacturer advises avoid unless
essential—no information available.
l BREAST FEEDING Manufacturer advises avoid—present in
l RENAL IMPAIRMENT Manufacturer advises use with
caution in severe impairment—limited information
Dose adjustments Reduce dose to 500 mg every 12 hours in
moderate impairment and 250 mg every 12 hours in severe
l DIRECTIONS FOR ADMINISTRATION Manufacturer advises
for intravenous infusion (Zevtera ®), give intermittently in
Glucose 5%, or Sodium Chloride 0.9%, or Lactated Ringer’s
solution; reconstitute each 500 mg with 10 mL Water for
injections or Glucose 5%; dilute in 250 mL infusion fluid
and give over 2 hours (increased to 4 hours if creatinine
clearance greater than 150 mL/minute). Do not mix with
calcium-containing solutions (except Lactated Ringer’s
solution) in the same intravenous line—precipitation may
l HANDLING AND STORAGE Manufacturer advises store in a
refrigerator (2–8°C)—consult product literature for storage
after reconstitution and dilution.
Driving and skilled tasks Manufacturer advises patients and
carers should be counselled on the effects on driving and
performance of skilled tasks—increased risk of dizziness.
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 Sodium
Ceftobiprole (as Ceftobiprole medocaril sodium) 500 mg Zevtera
500mg powder for concentrate for solution for infusion vials | 10 vial P £396.30 (Hospital only)
BNF 78 Bacterial infection 531
l DRUG ACTION Dalbavancin is a glycopeptide antibacterial;
it has bactericidal activity against Gram-positive bacteria
including various staphylococci. However, there are
reports of Staphylococcus aureus with reduced
susceptibility to glycopeptides and increasing reports of
glycopeptide-resistant enterococci.
Acute bacterial skin and skin structure infections
▶ Adult: 1500 mg for 1 dose, alternatively 1000 mg, then
▶ Common or very common Diarrhoea . headache . nausea
altered .thrombocytosis . vomiting . vulvovaginal pruritus
▶ Rare or very rare Bronchospasm
▶ Frequency not known Ototoxicity
l ALLERGY AND CROSS-SENSITIVITY Manufacturer advises
use with caution in patients with other glycopeptide
Dose adjustments Manufacturer advises avoid unless
essential—toxicity in animal studies.
Dose adjustments Manufacturer advises avoid—present in
l HEPATIC IMPAIRMENT Manufacturer advises caution in
moderate to severe impairment (no information available).
Dose adjustments Manufacturer advises reduce dose to
1000 mg as a single infusion or reduce dose to 750 mg
followed one week later by 375 mg if creatinine clearance
l DIRECTIONS FOR ADMINISTRATION Manufacturer advises
for intravenous infusion (Xydalba ®), reconstitute each
500 mg vial to produce a 20 mg/mL solution with 25 mL
water for injections. Dilute reconstituted solution to a
concentration of 1–5 mg/mL with Glucose 5%; give
intermittently over 30 minutes (avoid rapid infusion—risk
l NATIONAL FUNDING/ACCESS DECISIONS
Scottish Medicines Consortium (SMC) decisions
The Scottish Medicines Consortium has advised (January
2017) that dalbavancin (Xydalba ®) is accepted for
restricted use within NHS Scotland for the treatment of
acute bacterial skin and skin structure infections (ABSSSI),
. used as second-line treatment, or
. meticillin-resistant Staphylococcus aureus infection is
. under local microbiologist or infectious diseases
. the patient is initially hospitalised due to ABSSSI
requiring intravenous antibiotics but is eligible for early
discharge as soon as their medical condition does not
require further inpatient treatment.
All Wales Medicines Strategy Group (AWMSG) decisions
The All Wales Medicines Strategy Group has advised (July
2018) that dalbavancin (Xydalba ®) is recommended as an
option for restricted use within NHS Wales for the
treatment of acute bacterial skin and skin structure
infections (ABSSSI) in adults:
. as a second-line treatment of ABSSSI, or
. when meticillin-resistant Staphylococcus aureus (MRSA)
. on the advice of local microbiologists or infectious
. the patient is at first hospitalised due to ABSSSI and
needs intravenous antibiotics but is allowed early
discharge as they don’t need further inpatient
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
Powder for solution for infusion
Dalbavancin (as Dalbavancin hydrochloride) 500 mg Xydalba
500mg powder for concentrate for solution for infusion vials |
1 vial P £558.70 (Hospital only)
l DRUG ACTION The glycopeptide antibiotic teicoplanin has
However, there are reports of Staphylococcus aureus with
reduced susceptibility to glycopeptides and increasing
reports of glycopeptide-resistant enterococci. Teicoplanin
is similar to vancomycin, but has a significantly longer
duration of action, allowing once daily administration
Clostridium difficile infection
▶ Adult: 100–200 mg twice daily for 7–14 days
Serious infections caused by Gram-positive bacteria (e.g.
complicated skin and soft-tissue infections, pneumonia,
complicated urinary tract infections)
▶ BY INTRAVENOUS INJECTION, OR BY INTRAVENOUS INFUSION,
▶ Adult: Initially 6 mg/kg every 12 hours for 3 doses, then
Streptococcal or enterococcal endocarditis (in
combination with another antibacterial)| Bone and joint
▶ INITIALLY BY INTRAVENOUS INJECTION, OR BY INTRAVENOUS
▶ Adult: 12 mg/kg every 12 hours for 3–5 doses, then (by
intravenous injection or by intravenous infusion or by
intramuscular injection) 12 mg/kg once daily
▶ Adult: 400 mg, to be administered up to 30 minutes
Surgical prophylaxis in open fractures
▶ Adult: 800 mg, to be administered up to 30 minutes
before skeletal stabilisation and definitive soft-tissue
Peritonitis associated with peritoneal dialysis (added to
▶ Adult: (consult local protocol)
▶ Teicoplanin should not be given by mouth for systemic
infections because it is not absorbed significantly.
l UNLICENSED USE Not licensed for surgical prophylaxis.
532 Bacterial infection BNF 78
l INTERACTIONS → Appendix 1: teicoplanin
▶ Common or very common Fever. pain . skin reactions
▶ Rare or very rare Abscess .red man syndrome
reactions (SCARs).thrombophlebitis
SIDE-EFFECTS, FURTHER INFORMATION Teicoplanin is
associated with a lower incidence of nephrotoxicity than
l ALLERGY AND CROSS-SENSITIVITY Caution if history of
l PREGNANCY Manufacturer advises use only if potential
l BREAST FEEDING No information available.
Dose adjustments Use normal dose regimen on days 1–4,
then use normal maintenance dose every 48 hours if eGFR
30–80 mL/minute/1.73 m2 and use normal maintenance
dose every 72 hours if eGFR less than
Monitoring Monitor renal and auditory function during
prolonged treatment in renal impairment.
▶ With intramuscular use or intravenous use Manufacturer
advises monitor serum-teicoplanin trough concentration
at steady state after completion of loading dose and during
maintenance treatment—consult product literature.
▶ Blood counts and liver and kidney function tests required.
▶ Manufacturer advises monitoring for adverse reactions
when doses of 12 mg/kg twice daily are administered.
l DIRECTIONS FOR ADMINISTRATION
▶ With intravenous use For intravenous infusion (Targocid ®),
give intermittently in Glucose 5% or Sodium chloride 0.9%;
reconstitute initially with water for injections provided;
infuse over 30 minutes. Continuous infusion not usually
▶ With oral use Injection can be used to prepare solution for
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: solution for
Powder and solvent for solution for injection
ELECTROLYTES: May contain Sodium
▶ Teicoplanin (non-proprietary) A
Teicoplanin 200 mg Teicoplanin 200mg powder and solvent for
solution for injection vials | 1 vial P £4.45 DT = £3.93
Teicoplanin 400 mg Teicoplanin 400mg powder and solvent for
solution for injection vials | 1 vial P £7.57 DT = £7.32
Teicoplanin 200 mg Targocid 200mg powder and solvent for solution
for injection vials | 1 vial P £3.93 DT = £3.93
Teicoplanin 400 mg Targocid 400mg powder and solvent for
solution for injection vials | 1 vial P £7.32 DT = £7.32
l DRUG ACTION Telavancin is a glycopeptide antibacterial; it
has bactericidal activity against aerobic and anaerobic
Gram-positive bacteria including multi-resistant
staphylococci. However, there are reports of
Staphylococcus aureus with reduced susceptibility to
glycopeptides. There are increasing reports of
glycopeptide-resistant enterococci.
Hospital-acquired pneumonia, known or suspected to be
caused by meticillin-resistant Staphylococcus aureus
when other antibacterials cannot be used
▶ Adult: 10 mg/kg once daily for 7–21 days
electrolyte disturbances, congenital long QT syndrome,
uncompensated heart failure, severe left ventricular
l INTERACTIONS → Appendix 1: telavancin
infection . insomnia . nausea .renal impairment. skin
reactions .taste altered . urine abnormalities . vomiting
▶ Uncommon Altered smell sensation . anaemia . angina
hypoaesthesia . pain . palpitations . paraesthesia . QT
l ALLERGY AND CROSS-SENSITIVITY Use with caution in
patients with vancomycin or teicoplanin sensitivity.
l CONCEPTION AND CONTRACEPTION Effective
contraception required during treatment.
l PREGNANCY Avoid (teratogenic in animal studies).
l BREAST FEEDING Manufacturer advises avoid unless
potential benefit outweighs risk—no information
l HEPATIC IMPAIRMENT Manufacturer advises caution in
severe impairment (no information available).
l RENAL IMPAIRMENT Avoid in acute renal failure—risk of
mortality increased. In chronic renal failure, avoid if eGFR
less than 30 mL/minute/1.73 m2
Dose adjustments In chronic renal failure, use 7.5 mg/kg
once daily if eGFR 30–50 mL/minute/1.73 m2
l MONITORING REQUIREMENTS Monitor renal function daily
for at least the first 3–5 days, then every 2–3 days
l DIRECTIONS FOR ADMINISTRATION For intravenous infusion
(Vibativ ®). Avoid rapid infusion (can cause ’red man’
syndrome). Give intermittently in Glucose 5% or Sodium
chloride 0.9%; reconstitute each 750 mg with 45 mL
glucose 5%, sodium chloride 0.9%, or water for injections
to produce a 15 mg/mL solution; for doses of 150–800 mg,
dilute requisite dose in 100 to 250 mL infusion fluid; for
doses outside this range, dilute to a final concentration of
0.6–8 mg/mL; give over at least 60 minutes.
BNF 78 Bacterial infection 533
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
Powder for solution for infusion
▶ Vibativ (Clinigen Healthcare Ltd)
Telavancin (as Telavancin hydrochloride) 750 mg Vibativ 750mg
powder for solution for infusion vials | 1 vial P £645.00 (Hospital
l DRUG ACTION The glycopeptide antibiotic vancomycin has
However, there are reports of Staphylococcus aureus with
reduced susceptibility to glycopeptides. There are
increasing reports of glycopeptide-resistant enterococci.
Penetration into cerebrospinal fluid is poor.
Clostridium difficile infection [first episode]
▶ Adult: 125 mg every 6 hours for 10 days; increased if
necessary to 500 mg every 6 hours for 10 days,
increased dose if severe or complicated infection
Clostridium difficile infection [multiple recurrences]
▶ Adult: 125 mg every 6 hours for 10 days, followed by,
either tapering the dose (gradually reducing until
125 mg daily) or a pulse regimen (125–500 mg every
2–3 days for at least 3 weeks)
Complicated skin and soft tissue infections | Bone
infections | Joint infections | Community-acquired
pneumonia | Hospital-acquired pneumonia [including
ventilator-associated pneumonia]| Infective
endocarditis | Acute bacterial meningitis | Bacteraemia
[occurring in association with or suspected to be
associated with the licensed indications]
▶ Adult: 15–20 mg/kg every 8–12 hours (max. per dose
2 g) adjusted according to plasma-concentration
monitoring, duration should be tailored to type and
severity of infection and the individual clinical
response—consult product literature for further
information, in seriously ill patients, a loading dose of
25–30 mg/kg (usual max. 2 g) can be used to facilitate
rapid attainment of the target trough serumvancomycin concentration
Perioperative prophylaxis of bacterial endocarditis [in
patients at high risk of developing bacterial endocarditis
when undergoing major surgical procedures]
▶ Adult: 15 mg/kg, to be given prior to induction of
anaesthesia, a second dose may be required depending
Surgical prophylaxis (when high risk of MRSA)
Peritonitis associated with peritoneal dialysis
▶ BY INTRAPERITONEAL ADMINISTRATION
▶ Adult: (consult local protocol)
▶ Vancomycin should not be given by mouth for systemic
infections because it is not absorbed significantly.
l UNLICENSED USE Vancomycin doses in BNF publications
may differ from those in product literature. Use of
vancomycin (added to dialysis fluid) for the treatment of
peritonitis associated with peritoneal dialysis is an
▶ With intravenous use Previous hearing loss
▶ With oral use systemic absorption may be enhanced in
patients with inflammatory disorders of the intestinal
mucosa or with Clostridium difficile-induced
pseudomembranous colitis (increased risk of adverse
l INTERACTIONS → Appendix 1: vancomycin
GENERAL SIDE-EFFECTS Agranulocytosis . dizziness . drug
fever. eosinophilia . hypersensitivity . nausea . nephritis
tubulointerstitial . neutropenia (more common after
1 week or cumulative dose of 25g).renal failure . severe
▶ With intravenous use Back pain . bradycardia . cardiac arrest
(on rapid intravenous injection). cardiogenic shock (on
SIDE-EFFECTS, FURTHER INFORMATION Vancomycin is
associated with a higher incidence of nephrotoxicity than
l ALLERGY AND CROSS-SENSITIVITY Caution if teicoplanin
l PREGNANCY Manufacturer advises use only if potential
Monitoring Plasma-vancomycin concentration monitoring
essential to reduce risk of fetal toxicity.
l BREAST FEEDING Present in milk—significant absorption
following oral administration unlikely.
l RENAL IMPAIRMENT Manufacturer advises serial
▶ With intravenous use Manufacturer advises use with
caution—increased risk of toxic effects with prolonged
Dose adjustments ▶ With oral use Manufacturer advises
dose adjustment is unlikely to be required unless
substantial oral absorption occurs in inflammatory
disorders of the intestinal mucosa or with Clostridium
difficile-induced pseudomembranous colitis, see
▶ With intravenous use Manufacturer advises initial dose
must not be reduced—consult product literature.
▶ With intravenous use Manufacturer advises initial doses
should be based on body-weight; subsequent dose
adjustments should be based on serum-vancomycin
concentrations to achieve targeted therapeutic
concentrations. All patients require serum-vancomycin
measurement (on the second day of treatment,
immediately before the next dose if renal function normal,
earlier if renal impairment—consult product literature).
Frequency of monitoring depends on the clinical situation
and response to treatment; regular monitoring indicated
in high-dose therapy and longer-term use, particularly in
patients with impaired renal function, impaired hearing,
or concurrent use of nephrotoxic or ototoxic drugs.
Manufacturer advises pre-dose (‘trough’) concentration
should normally be 10–20 mg/litre depending on the site
of infection and the susceptibility of the pathogen; trough
concentration of 15–20 mg/litre is usually recommended
to cover susceptible pathogens with MIC greater than or
equal to 1 mg/litre—consult product literature.
▶ Manufacturer advises periodic testing of auditory function.
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