BNF for Children 2011-2012

BNFC 2011–2012 5.1.1 Penicillins 259Child 6–12 years 250 mg 4 times daily; increasedup to 12.5 mg/kg 4 times daily in severe infectionChild 12–18 years 500 mg 4 times daily;increased in severe infection up to 1 g 4 times dailyPrevention of pneumococcal infection inasplenia or sickle cell disease, see Table 2, section5.1Prevention of recurrence of rheumatic fever, seeTable 2, section 5.1Prevention of group A streptococcal infection,see Table 2, section 5.1Phenoxymethylpenicillin (Non-proprietary) ATablets, phenoxymethylpenicillin (as potassium salt)250 mg, net price 28-tab pack = £1.27. Label: 9, 23Dental prescribing on NHS PhenoxymethylpenicillinTablets may be prescribedOral solution, phenoxymethylpenicillin (as potassiumsalt) for reconstitution with water, net price 125 mg/5 mL, 100 mL = £1.90; 250 mg/5 mL, 100 mL = £2.59.Label: 9, 23Note Sugar-free versions are available and can be ordered byspecifying ‘sugar-free’ on the prescriptionDental prescribing on NHS Phenoxymethylpenicillin OralSolution may be prescribed5.1.1.2 Penicillinase-resistantpenicillinsMost staphylococci are now resistant to benzylpenicillinbecause they produce penicillinases. Flucloxacillin,however, is not inactivated by these enzymes and isthus effective in infections caused by penicillin-resistantstaphylococci, which is the main indication for its use.Flucloxacillin is acid-stable and can, therefore, be givenby mouth as well as by injection.Flucloxacillin is well absorbed from the gut. For awarning on hepatic disorders see under Flucloxacillin.MRSA Infection from Staphylococcus aureus strainsresistant to meticillin [now discontinued] (meticillinresistantStaph. aureus, MRSA) and to flucloxacillincan be difficult to manage. Treatment is guided by thesensitivity of the infecting strain.Rifampicin (section 5.1.9) or sodium fusidate (section5.1.7) should not be used alone because resistance maydevelop rapidly. Clindamycin alone or a combination ofrifampicin and sodium fusidate can be used for skin andsoft-tissue infections caused by MRSA; a tetracycline isan alternative in children over 12 years of age. A glycopeptide(e.g. vancomycin, section 5.1.7) can be used forsevere skin and soft-tissue infections associated withMRSA. A combination of a glycopeptide and sodiumfusidate or a glycopeptide and rifampicin can be consideredfor skin and soft-tissue infections that havefailed to respond to a single antibacterial. Linezolid(section 5.1.7) should be reserved for skin and softtissueinfections that have not responded to other antibacterialsor for children who cannot tolerate otherantibacterials.A glycopeptide can be used for pneumonia associatedwith MRSA. Linezolid should be reserved for hospitalacquiredpneumonia that has not responded to otherantibacterials or for children who cannot tolerate otherantibacterials.Trimethoprim or nitrofurantoin can be used forurinary-tract infections caused by MRSA; a tetracyclineis an alternative in children over 12 years of age. Aglycopeptide can be used for urinary-tract infectionsthat are severe or resistant to other antibacterials.A glycopeptide can be used for septicaemia associatedwith MRSA.For the management of endocarditis, osteomyelitis, orseptic arthritis associated with MRSA, see Table 1,section 5.1.Prophylaxis with vancomycin or teicoplanin (alone or incombination with another antibacterial active againstother pathogens) is appropriate for patients undergoingsurgery if:. there is a history of MRSA colonisation or infectionwithout documented eradication;. there is a risk that the patient’s MRSA carriage hasrecurred;. the patient comes from an area with a high prevalenceof MRSA.It is important that hospitals have infection controlguidelines to minimise MRSA transmission, includingpolicies on isolation and treatment of MRSA carriersand on hand hygiene. For eradication of nasal carriageof MRSA, see section 12.2.3.FLUCLOXACILLINCautions see under Benzylpenicillin (section 5.1.1.1);risk of kernicterus in jaundiced neonates when highdoses given parenterally; interactions: Appendix 1(penicillins)Hepatic disordersCholestatic jaundice and hepatitis may occur veryrarely, up to two months after treatment with flucloxacillinhas been stopped. Administration for more than2 weeks and increasing age are risk factors. Healthcareprofessionals are reminded that:. flucloxacillin should not be used in patients with a historyof hepatic dysfunction associated with flucloxacillin;. flucloxacillin should be used with caution in patients withhepatic impairment;. careful enquiry should be made about hypersensitivityreactions to beta-lactam antibacterials.Contra-indications see under Benzylpenicillin (section5.1.1.1)Hepatic impairment see Cautions and Hepatic DisordersaboveRenal impairment use normal dose every 8 hours ifestimated glomerular filtration rate less than 10 mL/minute/1.73 m 2Pregnancy not known to be harmfulBreast-feeding trace amounts in milk—not known tobe harmful but be alert for hypersensitivity in infantSide-effects see under Benzylpenicillin (section5.1.1.1); also gastro-intestinal disturbances; veryrarely hepatitis and cholestatic jaundice reported (seealso Hepatic Disorders above)5 Infections