BNF for Children 2011-2012

BNFC 2011–2012 5.1.12 Quinolones 297Metronidazole (Non-proprietary) ATablets, metronidazole 200 mg, net price 21-tab pack= £1.36; 400 mg, 21-tab pack = £1.35. Label: 4, 9, 21,25, 27Brands include Vaginyl cDental prescribing on NHS Metronidazole Tablets may beprescribedTablets, metronidazole 500 mg, net price 21-tab pack= £29.84. Label: 4, 9, 21, 25, 27Dental prescribing on NHS Metronidazole Tablets may beprescribedSuspension, metronidazole (as benzoate) 200 mg/5 mL. Net price 100 mL = £11.43. Label: 4, 9Brands include Norzol cDental prescribing on NHS Metronidazole Oral Suspensionmay be prescribedIntravenous infusion, metronidazole 5 mg/mL. Netprice 20-mL amp = £1.56, 100-mL container = £3.41Flagyl c (Winthrop) ATablets, both f/c, ivory, metronidazole 200 mg, netprice 21-tab pack = £4.49; 400 mg, 14-tab pack =£6.34. Label: 4, 9, 21, 25, 27Suppositories, metronidazole 500 mg, net price 10 =£15.18; 1 g, 10 = £23.06. Label: 4, 9Flagyl S c (Winthrop) ASuspension, orange- and lemon-flavoured, metronidazole(as benzoate) 200 mg/5 mL. Net price100 mL = £11.18. Label: 4, 9Metrolyl c (Sandoz) AIntravenous infusion, metronidazole 5 mg/mL, netprice 100-mL Steriflex c bag = £1.22Electrolytes Na + 14.53 mmol/100-mL bagSuppositories, metronidazole 500 mg, net price 10 =£12.34; 1 g, 10 = £18.34. Label: 4, 95.1.12 QuinolonesCiprofloxacin is active against both Gram-positive andGram-negative bacteria. It is particularly active againstGram-negative bacteria, including salmonella, shigella,campylobacter, neisseria, and pseudomonas. Ciprofloxacinhas only moderate activity against Gram-positivebacteria such as Streptococcus pneumoniae and Enterococcusfaecalis; it should not be used for pneumococcalpneumonia. It is active against chlamydia andsome mycobacteria. Most anaerobic organisms are notsusceptible. Ciprofloxacin is licensed in children over 1year of age for pseudomonal infections in cystic fibrosis,for complicated urinary-tract infections, and for treatmentand prophylaxis of inhalation anthrax. When thebenefits of treatment outweigh the risks, ciprofloxacin islicensed in children over 1 year of age for severe infectionsof the respiratory tract and of the gastro-intestinalsystem (including typhoid fever). It is also used in thetreatment of septicaemia caused by multi-resistantorganisms (usually hospital acquired) and gonorrhoea(although resistance is increasing). Ciprofloxacin is alsoused in the prophylaxis of meningococcal disease.Nalidixic acid may be used in uncomplicated urinarytractinfections that are resistant to other antibiotics.Many staphylococci are resistant to quinolones andtheir use should be avoided in MRSA infections.Ofloxacin eye drops are used in ophthalmic infections(section 11.3.1).There is much less experience of the other quinolones inchildren; expert advice should be sought.Anthrax Inhalation or gastro-intestinal anthraxshould be treated initially with either ciprofloxacin or,in children over 12 years, doxycycline [unlicensedindication] (section 5.1.3) combined with one or twoother antibacterials (such as amoxicillin, benzylpenicillin,chloramphenicol, clarithromycin, clindamycin,imipenem with cilastatin, rifampicin [unlicensed indication],and vancomycin). When the condition improvesand the sensitivity of the Bacillus anthracis strain isknown, treatment may be switched to a single antibacterial.Treatment should continue for 60 daysbecause germination may be delayed.Cutaneous anthrax should be treated with either ciprofloxacin[unlicensed indication] or doxycycline [unlicensedindication] (section 5.1.3) for 7 days. Treatmentmay be switched to amoxicillin (section 5.1.1.3) if theinfecting strain is susceptible. Treatment may need to beextended to 60 days if exposure is due to aerosol. Acombination of antibacterials for 14 days is recommendedfor cutaneous anthrax with systemic features,extensive oedema, or lesions of the head or neck.Ciprofloxacin or doxycycline may be given for postexposureprophylaxis. If exposure is confirmed, antibacterialprophylaxis should continue for 60 days. Antibacterialprophylaxis may be switched to amoxicillinafter 10–14 days if the strain of B. anthracis is susceptible.Vaccination against anthrax (section 14.4) mayallow the duration of antibacterial prophylaxis to beshortened.Cautions Quinolones should be used with caution inchildren with a history of epilepsy or conditions thatpredispose to seizures, in G6PD deficiency (section9.1.5), myasthenia gravis (risk of exacerbation). Exposureto excessive sunlight should be avoided (discontinueif photosensitivity occurs). The CSM has warnedthat quinolones may induce convulsions in patientswith or without a history of convulsions; taking NSAIDsat the same time may also induce them. Other interactions:Appendix 1 (quinolones).Quinolones cause arthropathy in the weight-bearingjoints of immature animals and are therefore generallynot recommended in children and growing adolescents.However, the significance of this effect in humans isuncertain and in some specific circumstances shorttermuse of a quinolone in children is justified. Nalidixicacid is used for resistant urinary-tract infections inchildren over 3 months of age.Tendon damageTendon damage (including rupture) has beenreported rarely in patients receiving quinolones.Tendon rupture may occur within 48 hours of startingtreatment; cases have also been reported severalmonths after stopping a quinolone. Healthcare professionalsare reminded that:. quinolones are contra-indicated in patients witha history of tendon disorders related to quinoloneuse;. the risk of tendon damage is increased by theconcomitant use of corticosteroids;. if tendinitis is suspected, the quinolone shouldbe discontinued immediately.5 Infections