The latest updates to the Therapeutic Guidelines: Antibiotics have been released, focusing on infections that occur outside hospital settings. This development is crucial as it addresses the 99% of infections that occur in the broader community, offering new insights and recommendations for general practitioners. The updates were discussed in a recent episode of the Australian Prescriber Podcast by Dr. Justin Coleman and Dr. Kate McKenzie, both experienced general practitioners.
Dr. Coleman, who practices in Brisbane, emphasized the importance of evidence-informed antibiotic use. The guidelines, originally published when he was a medical student, have evolved significantly since the post-penicillin era. Dr. McKenzie, part of the primary care group behind the guidelines, guided listeners through the updates, starting with urinary tract infections (UTIs).
Revised Recommendations for Urinary Tract Infections
The guidelines now recommend nitrofurantoin as the first-line treatment for acute cystitis in non-pregnant adult females, moving trimethoprim to a third-line option due to increased resistance rates, which are up to 20% in many areas. Dr. McKenzie highlighted the growing emphasis on non-antibiotic treatments, such as pain relief and symptom monitoring, for mild cystitis symptoms in women under 65.
“Most will be better after 7 days with or without antibiotics,” noted Dr. McKenzie, underscoring the rationale behind this shift.
Fosfomycin, a lesser-known antibiotic, has also been introduced as an effective one-off treatment for UTIs, though it is not covered by the Pharmaceutical Benefits Scheme, making it a more expensive option for patients.
Guidance on Infectious Diarrhoea and Testing
For infectious diarrhoea, the guidelines caution against routine faecal testing unless the results are likely to influence treatment decisions. Testing is recommended primarily for severe or prolonged symptoms, bloody diarrhoea, or in immunocompromised patients. Dr. Coleman pointed out the potential for false positives with PCR testing, which amplifies small amounts of bacteria present in the stool.
“A positive PCR result has to be interpreted with caution,” he advised, especially if the patient is improving without treatment.
Regarding travellers’ diarrhoea, the guidelines suggest antibiotics only for high-risk individuals traveling to areas with limited healthcare access, reflecting a shift away from the previous practice of carrying antibiotics as a precaution.
Bronchiectasis and Skin Infections: New Insights
In the section on bronchiectasis, the guidelines advocate for directed therapy based on sputum culture results to improve outcomes. This approach is supported by evidence showing better results when treatment targets specific colonising agents.
For skin infections, particularly diabetes-related foot ulcers, the guidelines emphasize identifying signs of infection before swabbing, as colonising agents may not require treatment. The guidelines recommend higher doses of antibiotics for moderate infections to ensure efficacy.
Updates also include recommendations for impetigo and periorbital cellulitis, with a focus on considering rheumatic fever risk factors when treating impetigo and detailed tables for managing periorbital cellulitis.
Genital Infections and Post-Exposure Prophylaxis
The guidelines introduce considerations for using doxycycline as post-exposure prophylaxis for high-risk individuals, particularly for syphilis, chlamydia, and gonorrhoea, despite existing doxycycline resistance to gonorrhoea in Australia.
Dr. Coleman, with extensive experience in remote communities, noted the resurgence of syphilis in unexpected areas, highlighting the importance of updated diagnostic and management recommendations in the guidelines.
Dr. McKenzie encouraged practitioners to explore the guidelines further, noting the wealth of information beyond drug recommendations. The updated guidelines reflect a comprehensive effort to address community infections with a nuanced approach, balancing antibiotic use with non-antibiotic strategies to combat resistance and improve patient outcomes.
