Antimicrobial restrictions

Lady Cilento Children’s Hospital Antimicrobial formulary

The Lady Cilento Children’s Hospital (LCCH) antimicrobial restriction procedure is a core component of the Antimicrobial stewardship program.

It is the responsibility of prescribing medical officer to obtain appropriate approval for antimicrobials.

The following list of antimicrobials should be followed in conjunction with current List of Approved Medicines (LAM).

All other antimicrobials not listed on this document or used for off label/ off license indications, require approval before use unless specific arrangements have been made with your department.

LCCH Antimicrobial Traffic Light System

The antimicrobial formulary is divided into the following three categories:

Unrestricted (green)

Unrestricted (green)Antimicrobials can be prescribed for clinically appropriate indication by all prescribers as per LAM criteria.

Restricted (amber)

Restricted (amber)Antimicrobials can be prescribed for listed indications for specific time frame. However, approval is required for use outside these indications (and time frames).

Where approval is required, the Prescriber will contact the Infectious Diseases consultant who will consider the antimicrobial’s use.

Please document:

  • The indication
  • Name of the authorising clinician and unique ID approval number must be annotated on the medication chart (or prescription).

For SAS medications, you must also complete the following forms to submit to pharmacy and infectious diseases consultant on service:

Restricted (red)

Restricted (red)Antimicrobials may only be prescribed for following authorisation by Infectious Diseases or Clinical Microbiology and include:

Please document:

  • The indication
  • Name of the authorising clinician and unique ID approval number must be annotated on the medication chart (or prescription).

For SAS medications, you must also complete the following two forms and submit the to pharmacy and Infectious diseases consultant on service:

Search antimicrobial formulary (generic name)

AntibioticColour code

Amoxycillin (IV and PO)

Green

Amoxycillin / Clavulanic acid (PO)

Green

Amphotericin B lozenges (PO)

Green

Ampicillin (IV)

Green

Benzathine penicillin (IM)

Green

Benzylpenicillin (IV)

Green

Cefaclor (PO)

Green

Cephalexin (PO)

Green

Cephazolin (IV)

Green

Chloramphenicol (eye drops)

Green

Clotrimazole (topical)

Green

Dicloxacillin (PO)

Green

Flucloxacillin (IV and PO)

Green

Metronidazole (PO and IV)

Green

Miconazole (topical cream)

Green

Nitrofurantoin (PO)

Green

Nystatin (PO and topical)

Green

Permethrin (topical)

Green

Phenoxymethylpenicillin (PO)

Green

Pyrantel (PO)

Green

Roxithromycin (PO)

Green

Tinidazole (PO)

Green

Trimethoprim (PO)

Green

Trimethoprim / Sulfamethoxazole (PO)

Green

Aciclovir (PO and IV)


Oral



  • Department of ophthalmology for treatment of severe herpes zoster ophthalmicus

  • For up to 48 hours on the advice of Consultant Specialist Staff for (IMPS review and approval required after 48 hours):

  • a) Treatment of herpes simplex virus infections in immunocompromised paediatric patients (up to 18 years of age)


or

  • b) Treatment of herpes zoster in immunocompromised patients;

  • Microbiological confirmation of diagnosis (viral culture, antigen detection or nucleic acid amplification by PCR) is required but need not delay commencing treatment of the initial episode. Once microbiological diagnosis confirmed, subsequent recurrences may be treated on clinical grounds.

  • All other indications including prophylaxis require IMPS approval


Amber

Aciclovir cold sore ointment



  • Haematology/Oncology

  • all other indications require IMPS approval


Amber

Aciclovir Eye Ointment



  • Department of Ophthalmology

  • All other indications require IMPS approval


Amber

Albendazole (PO)



  • Treatment of adults and children with Ancylostoma caninum (Eosinophilic enterocolitis), Ancylostoma duodenale/Necator americanus (Hookworm), Ascaris lumbricoides (Roundworm), Trichuris trichiuria (Whipworm) or Enterobius vermicularis (Pinworm).

  • IMPS approval is required for all other indications including for treatment of Echinococcus granulosus (Hydatids), alternative treatment for children with Strongyloides stercoralis or Snail ingestion.


Amber

Amoxicillin/ Clavulanic acid (IV)


For empiric treatment of animal bites/wounds and retropharyngeal abscess for up to 24 hours according to CHQ Antibiocard. ID review and approval required after 24 hours


Amber

Amphotericin B Liposomal (IV)



  • Haematology/ Oncology (according to CHQ Febrile neutropenia protocol – febrile neutropenic >96hours – ID consultation required within 24hours from commencing)


or

  • in accordance with CHQ Post liver transplant protocol (Use in high risk patients -with cholestasis OR a 2nd transplant OR if active fungal infection)

  • All other indications including prophylaxis require IMPS approval


Amber

Azithromycin (IV)



Amber

Azithromycin (tablets and suspension) (PO)



Amber

Cefepime (IV)



Amber

Cefotaxime (IV)



or



or



  • ID Approval required after 24 hours therapy for:

  • Empirical therapy for suspected Tracheitis, epiglottitis and retropharyngeal abscess (according to CHQ Antibiocard)


All other indications require IMPS approval


Amber

Cefoxitin (IV)



Amber

Ceftazidime (IV)



  • For use in Cystic fibrosis patients for inpatient and HITH (intermittent dosing) management according to CHQ Respiratory antibiocard

  • For use in accordance with the CHQ Febrile Neutropenia protocol for up to 72hours (ID approval required after 72hours), in patients with delayed type hypersensitivity to piperacillin/tazobactam.

  • For Nosocomial sepsis (PICU) for up to 72 hours (ID approval required after 72hours) according to CHQ PICU Empirical antibiotic guidelines

  • For Nosocomial/ ventilator associated pneumonia for patients who have been in PICU for more than 5 days, for up to 72 hours (ID approval required after 72hours) according to CHQ PICU Empirical antibiotic guidelines

  • All other indications require IMPS approval


Amber

Ceftazidime intravitreal injection



  • Department of Ophthalmology

  • all other indications require IMPS approval.


Amber

Ceftriaxone (IV)



or




  • For Nosocomial/ ventilator associated pneumonia for patients who have been in PICU for less than 5 days, for up to 72 hours (ID approval required after 72hours) according to CHQ PICU Empirical antibiotic guidelines



  •  

  • OR

  • ID Approval required after 24 hours therapy for:

  • Empirical therapy for suspected Tracheitis, epiglottitis and retropharyngeal abscess (according to CHQ Antibiocard)


All other indications require IMPS approval


Amber

Cephalothin eyedrops



  • Department of Ophthalmology

  • all other indications require IMPS approval.




Amber

Chloramphenicol eye ointment



  • For ophthalmic use only

  • All other indications require IMPS approval


Amber

Ciprofloxacin (PO)



or



Amber

Ciprofloxacin ear/eye drops



  • Eye drops: Department of Ophthalmology – for treatment of bacterial keratitis


or


Ear drops: On advice from ENT consultant for the treatment of:



  • Chronic suppurative otitis media in an Aboriginal or a Torres Strait Islander person aged 1 month or older

  • Chronic suppurative otitis media in a patient less than 18 years of age with perforation of the tympanic membrane

  • Chronic suppurative otitis media in a patient less than 18 years of age with a grommet in situ)

  • Otitis externa associated with perforation

  • all other indications require IMPS approval


Amber

Clindamycin (PO)


Approval required after 48 hours therapy for:



  • Empiric therapy for suspected or proven impetigo or cellulitis or cervical lymphadenitis (outpatient management) in patients at risk of nMRSA in accordance with CHQ Antibiocard.

  • All other indications require IMPS Approval


Amber

Colistin (nebulised)



  • For Cystic fibrosis patients as second-line treatment to nebulised tobramycin for treatment of pulmonary infection with Pseudomonas aeruginosa OR in cases with demonstrated resistance by pseudomonas to tobramycin adverse reactions due to tobramycin as per CHQ Respiratory Antibiocard (for 12 weeks duration)

  • all other indications require IMPS approval


Amber

Dapsone (PO)



For use by haematology/oncology as alternative to trimethoprim/sulfamethoxazole as PCP prophylaxis



Amber

Doxycycline (IV - SAS)



  • For use by Physicians trained in interventional radiology and with proper skills in sclerotherapy – for use in schlerotherapy for treatment of lymphatic malformations in paediatric patients.

  • all other indications require IMPS approval


Amber

Doxycycline (PO)



  • For empiric therapy according to CHQ guideline: Management of Water-related Wound Infections in Children, in an established wound infection where wound was sustained during exposure to water (treatment – no organism identified) in children > 8 years of age. IMPS review and approval required within 24hours.

  • CHQ IMPS Approval and discussion required for children <8 years of age and a diagnosis of Ricksettsial disease including Q Fever.

  • All other indications require IMPS Approval


Amber

Erythromycin (PO)


IMPS approval required for all off label/off license indications


Amber

Famciclovir (PO)



  • Haematology/Oncology team for use in the paediatric population (up to 18 years of age) for:

  • Prophylaxis of viral infection for 12 months following allogeneic bone marrow transplant;

  • Prophylaxis of viral infection for 3 months following autologous bone marrow transplant.

  • Treatment of immunocompetent patients with herpes zoster in whom the duration of rash is less than 72 hours.

  • Herpes zoster in immunocompromised patients.

  • Ophthalmic herpes zoster.


All other indications require IMPS Approval


Amber

Fluconazole (PO and IV)



Amber

Gentamicin (IV)


Approval required after 72 hours therapy for:



  • Empiric therapy for suspected sepsis (neonates), peritonitis, necrotising enterocolitis, NEC or uncomplicated and complicated appendicitis, pyelonephritis (or UTI in < 3 month old) and endocarditis according to CHQ Antibiocard

  • For severe abdominal infection (including peritonitis and necrotising enterocolitis), nosocomial sepsis (including central venous line sepsis), surgical wound infection, urinary tract infection for critically ill patients according to CHQ PICU Empirical antibiotic guidelines

  • For Use in accordance with CHQ Paediatric Surgical Antibiotic Prophylaxis guideline

  • all other indications require IMPS approval


Amber

Gentamicin eye drops


On advice from Ophthalmology team


Amber

Griseofulvin (PO)



  • For use in recalcitrant laboratory proven tinea infections.

  • All other indications require CHQ IMPS or Dermatology approval.


Amber

Hydroxychloroquine (PO)



  • For use in rheumatological /interstitial lung disease/ immunological conditions.

  • All other indications require IMPS approval


Amber

Itraconazole (PO)



or



Amber

Lincomycin (IV)



Approval required after 48 hours therapy for:




Amber

Mebendazole (PO)



  • Alternative treatment of Eosinophilic enterocolitis, Hookworm, Roundworm, Whipworm or Pinworm.

  • all other indications require IMPS approval


Amber

Minocycline (PO)



  • For use by Dermatologist in the treatment of severe acne

  • all other indications require IMPS approval


Amber

Mupirocin (intranasal ointment)

Amber

Mupirocin (topical ointment)



Amber

Neomycin (PO)



  • For emergency management of hepatic encephalopathy.

  • all other indications require IMPS approval


Amber

Ofloxacin eye drops



  • On advice from Ophthalmology team

  • All other indications require IMPS approval


Amber

Oseltamivir (PO)

Amber

Piperacillin/ Tazobactam (IV)



  • For use in Cystic fibrosis pulmonary optimization for patients transferring to HITH within 72 hours according to CHQ Respiratory antibiocard (ID approval required after 72 hours) If not transferring to HITH, use IV Ceftazidime.


or



  • For open compound fractures with severe tissue damage or clinical evidence of skin/soft tissue infection (up to 24hours) according to CHQ Antibiocard (ID approval required after 24 hours)

  • For use in accordance with the CHQ Febrile Neutropenia protocol for up to 72 hours (ID approval required after 72 hours)


or



  • Empiric therapy for suspected or proven cholangitis or complicated appendicitis (up to 72hrs) according to CHQ Antibiocard


or



or



Amber

Posaconazole (PO)



Amber

Rifampicin (PO)



Amber

Teicoplanin (IV)



Amber

Terbinafine (PO)



  • For use on advice from Dermatologist

  • All other indications require IMPS approval


Amber

Tobramycin (inhaled – TOBI podhaler)



Amber

Tobramycin (IV and nebulised)



  • For use in Cystic fibrosis patients according to CHQ Respiratory antibiocard (Parenteral use: Approved for inpatient and HITH use according to CHQ@Home manual and Respiratory antibiocard)

  • All other indications require IMPS Approval


Amber

Tobramycin Eye drops and eye ointment



  • For use on advice from Ophthalmology team

  • All other indications require IMPS approval


Amber

Trimethoprim/ Sulfamethoxazole (IV)


Approval required after 48hours for:



  • use as initial treatment of suspected or proven PCP OR for PCP prophylaxis if unable to tolerate oral therapy. IMPS review and approval required within 48hours.

  • All other indications require IMPS approval


Amber

Valaciclovir (PO)


Oral



  • Department of Ophthalmology for treatment of severe herpes zoster ophthalmicus


On the advice of Consultant Specialist Staff for:



  • a) Treatment of herpes simplex virus infections in immunocompromised paediatric patients (up to 18 years of age);

  • or

  • b) Treatment of herpes zoster in immunocompromised patients;

  • or

  • c) Use in the paediatric population (up to 18 years of age) for:

  • Prophylaxis of viral infection for 12 months following allogeneic bone marrow transplant;

  • Prophylaxis of viral infection for 3 months following autologous bone marrow transplant.

  • All other indications require IMPS approval

  • Microbiological confirmation of diagnosis (viral culture, antigen detection or nucleic acid amplification by PCR) is required but need Not delay commencing treatment of the initial episode. Once microbiological diagnosis confirmed, subsequent recurrences may be treated on clinical grounds.


Amber

ValGANciclovir (PO)



Amber

Vancomycin (IV)


For use in accordance with the:



Approval required after 72 hours therapy for:



Amber

Vancomycin intravitreal injection



  • Department of Ophthalmology

  • All other indications require IMPS approval


Amber

Voriconazole (PO)



Amber

Abacavir

Red

Adefovir (PO)

Red

Amikacin (IV and nebulised)

Red

Amorolfine (nail lacquer 5%)

Red

Amphotericin B lipid complex (Abelcet ) (IV)

Red

Amphotericin (Fungizone ) (SAS) IV

Red

Anidulafungin (IV)

Red

Artemether+Lumefantrine (Riamet) (PO)

Red

Artesunate (SAS) IV

Red

Atazanavir

Red

Atovaquone (PO)

Red

Atovaquone/ Proguanil (Malarone ) (PO)

Red

Aztreonam (IV and nebulised)

Red

Brincidofovir (Compassionate use/SAS) (PO)

Red

Capreomycin (SAS) (IV)

Red

Caspofungin (IV)

Red

Ceftolazone/Tazobactam (IV)

Red

Ceftazidime/Avibactam (IV)

Red

Ceftaroline (IV)

Red

Cefuroxime (PO)

Red

Chloramphenicol (SAS) (IV)

Red

Chloroquine (SAS)

Red

Cidofovir (IV)

Red

Ciprofloxacin (IV)

Red

Colistin (IV)

Red

Ciprofloxacin/hydrocortisone (ear drops)

Red

Clarithromycin (PO)

Red

Clindamycin (IV)

Red

Cycloserine (SAS) (PO)

Red

Daclatasvir

Red

Daptomycin (IV)

Red

Darunavir (PO)

Red

Dicloxacillin (IV)

Red

Dolutegravir

Red

Doripenem (IV)

Red

Efavirenz

Red

Emtricitabine

Red

Enfuviritide

Red

Entecavir (PO)

Red

Ethambutol (PO) and (SAS – IV)

Red

Ertapenem (IV)

Red

Erythromycin (IV)

Red

Fluconazole (IV)

Red

Flucytosine (SAS) (IV and PO)

Red

Fosfomycin (SAS) (IV and PO)

Red

Foscarnet (IV)

Red

Fusidic acid (sodium fusidate) (PO)

Red

Ganciclovir (IV)

Red

HITH (Hospital in the home IV antimicrobials)



  • All patients require IMPS approval, unless patient with Cystic fibrosis (receiving Tobramycin +/- Piperacillin/Tazobactam or Ceftazidime) or Non CF bronchiectasis (receiving Ceftriaxone)


Red

Imipenem/cilastatin (IV)

Red

Isoniazid (PO) (SAS – IV)

Red

Ivermectin (PO)

Red

Ketoconazole (PO)

Red

Lamivudine

Red

Ledipasvir with Sofosbuvir

Red

Linezolid (PO and IV)

Red

Lopinavir/Ritonavir

Red

Maraviroc (PO)

Red

Mefloquine (PO)

Red

Miltefosine (SAS)

Red

Moxifloxacin (PO and IV)

Red

Meropenem (IV)

Red

Micafungin (IV)

Red

Nalidixic acid (PO) (SAS)

Red

Natamycin eye drops (SAS)

Red

Netilmicin (SAS)

Red

Nevirapine

Red

Niclosamide (PO) (SAS)

Red

Nitazoxanide (SAS) (PO)

Red

Norfloxacin (PO)

Red

Palivizumab (IM)

Red

Paromomycin (SAS) (PO and topical)

Red

Para-Aminosalicylic acid (SAS)

Red

Pentamidine (IV and nebulised)

Red

Posaconazole (IV) (compassionate use)

Red

Praziquantel (PO)

Red

Primaquine (PO)

Red

Pyrazinamide (PO) (SAS)

Red

Pyrimethamine (PO)

Red

Quinine (IV and PO)

Red

Quinupristin/Dalfopristin (IV)

Red

Raltegravir (PO)

Red

Ribavirin (PO)

Red

Ribavirin (IV) (SAS)

Red

Rifabutin (PO)

Red

Rifampicin (IV)

Red

Rifaximin (SAS – suspension) (PO)

Red

Rilpirivine (with tenofovir and emtricitabine) (PO)

Red

Sofosbuvir

Red

Streptomycin (SAS) (IM)

Red

Sulfadiazine (PO)

Red

Taurolidine/citrate antiseptic lock (Taurolock)

Red

Tenofovir

Red

Ticarcillin/Clavulanate (IV)

Red

Tigecycline (IV)

Red

Vancomycin (PO)



Red

Voriconazole (IV)

Red

Voriconazole (eye drops)

Red

Zanamavir (inhaled) (IV- compassionate use only)

Red

Zidovudine

Red

Clinical scenarios involving antimicrobials that require ID approval

  • All patients requiring Hospital in the Home (HITH) Parenteral Antibiotics (excluding CF patients receiving Tobramycin and Piperacillin/Tazobactam for HITH OR non-CF bronchiectasis patients receiving Ceftriaxone- see LCCH Antimicrobial formulary)
  • Antimicrobials which may require special aseptic compounding
  • Antimicrobial eye drops e.g. Ceftazidime, Cephazolin, Vancomycin, Voriconazole, Natamycin
  • Antimicrobials for Intravitreal injections e.g. Amphotericin, Voriconazole, Ceftazidime and Vancomycin;
  • Antimicrobials for Intrathecal or Intraventricular administration e.g. Vancomycin, Gentamicin.

Authorising infectious diseases physicians and clinical microbiologists at LCCH

Use of a restricted antimicrobial at LCCH can be authorised by the clinicians listed below:

  • Dr Julia Clark
  • Dr Clare Nourse
  • Dr Meryta May
  • Dr Vikram Vaska
  • Dr Sophie Wen
  • ID Fellow/Registrar
  • Clinical Microbiologist: Dr Claire Heney

CHQ medication approval process

Antimicrobial supply for inpatients

Pharmacy may provide 24 hours initial supply of antibiotics to avoid unnecessary delay in treatment. Exceptions may apply.

Antimicrobial supply for outpatients

ID consultation and approval is required before antimicrobial supply will be dispensed.

Further supply will be dependent on receipt of ID approval. If no approval is forthcoming, this will be escalated to the primary treating Consultant, IMPS Consultant on call and the AMS Team. It is the responsibility of the prescriber to notify the pharmacy if ID approval is granted.

If approval is required, the Prescriber will contact the Infectious Diseases consultant who will consider the antimicrobial’s use.

This consultation must be documented in the patient’s medical notes and any approvals also documented, before further stock will be supplied from the pharmacy.

A unique approval number will be given to the prescriber and be annotated as described below.

Document the antimicrobial plan on the medication chart as per this example:

The National Inpatient Medication Chart should be annotated with the following information:

  • The Indication for Antimicrobial Therapy
  • The Intended Duration or Review Date for Antimicrobial Therapy
  • The words “ID approved” and the unique ID Approval number provided by the Approving ID Physician or Microbiologist.

The chart should be Numbered with the Days of Therapy to assist with review.

National Inpatient Medication Chart

Outpatient prescription

The Outpatient prescription should be annotated with the following information:

  • The Indication for Antimicrobial Therapy
  • The Intended Duration or Review Date for Antimicrobial Therapy
  • The PBS restriction/ authority number (If required)
  • The unique ID Approval number provided by the Approving ID Physician or Microbiologist.

Hospital outpatient prescription