[Music] Welcome to the Australian Prescriber Podcast. An
\n independent, no-nonsense podcast for busy health professionals.<\/p>\n
Hi, and welcome to this second podcast in the Australian
\n Prescriber series on updates to Therapeutic Guidelines: Antibiotic. Part 1 was
\n aimed primarily at the hospital level, whereas this podcast focuses on
\n infections in the 99% of the world outside the hospital walls. I’m Dr Justin
\n Coleman, a GP who peddles drugs on a street corner in Brisbane, but always in
\n an evidence-informed way.<\/p>\n
The Antibiotic Guideline was a first ever TG publication way back
\n when I was a med student. And yes, that was post-penicillin, and I reckon it’s
\n still the greatest. It’s the OG. Today we’re going to take a guided tour
\n through the human body. We will start at the kidney, head to the bowels, lungs,
\n skin, and pay a special visit at the end to the genitalia. With me is your tour
\n guide, Dr Kate McKenzie. And Kate is a fellow GP and she’s on the primary care
\n group behind the publication of this guideline. Kate, our tour is going to take
\n us to all the dark places where pathogens like to hide. That’s the thing about
\n bacteria. They get around, Kate.<\/p>\n
They certainly do, Justin. I’m looking forward to going on this
\n tour with everybody.<\/p>\n
Lovely. Well like an uninvited house guest, bacteria turn up to
\n the party, make a mess of the bathroom. But happily we hired security so we
\n never travel without some antibiotic backup. First stop, Kate McKenzie, the
\n bladder. You get UTI symptoms, you think they have a UTI and you treat and of
\n course you treat according to the antibiotic guidelines, which you can look up
\n as has always been the case. The big change is that trimethoprim is now the
\n third-line option for acute cystitis in nonpregnant adult females due to
\n increased resistance. I think it’s up to 20% resistance in many places. So
\n let’s talk Kate, for non-pregnant females under the age of 65, I think we’ve
\n got 2 approaches. One is to consider watchful waiting [nonantibiotic therapy] and
\n the next is for the antibiotics. Is that right?<\/p>\n
Yeah, that’s right, Justin. So there was a bigger emphasis on this
\n update on the option of non-antibiotic treatment, which I think is becoming a
\n lot more popular with some patients. And in that group, so for those patients
\n who are under\u00a065 years with mild cystitis symptoms, they can choose, with
\n you, to use the non-antibiotic management. And so by non-antibiotic management,
\n we’re really talking about giving pain relief, so an anti-inflammatory [drug] and
\n monitoring [of] their symptoms.<\/p>\n
And the reasoning behind that is that many get better within a
\n week with or without antibiotics. I think the number needed to treat to make
\n one extra person symptom-free on day 3 is somewhere between 3 and 6. So on
\n average you’re certainly making the symptoms shorter, but you have to realise
\n it’s only one\u00a0in 3 to one\u00a0in 6 that it’s actually going to make a
\n change and improvement.<\/p>\n
That’s right. So most will be better after 7 days with or without
\n antibiotics. And then I suppose the other thing that people can be concerned
\n about with that is the risk of progression to pyelonephritis, but that is
\n actually fairly low. So there’s a small risk of progression to pyelonephritis,
\n which is slightly reduced if you do give an antibiotic, but it’s probably less
\n than 5% that would progress to that.<\/p>\n
Thank you. So Kate, if trimethoprim is now a third-line option,
\n what is preferred?<\/p>\n
Yeah, so nitrofurantoin I think was in the old guideline, but
\n that’s been promoted to number one. So I think there’s been some concern about
\n using that [nitrofurantoin] in the past. But in short durations it’s actually a
\n very safe antibiotic, as long as your eGFR [estimated Glomerular Filtration
\n Rate] is over 30.<\/p>\n
Okay. And we’re talking about nitrofurantoin for adults and older
\n children who are 29\u00a0kgs or more.<\/p>\n
And who can take tablets. So for lots of kids it’s not an option,
\n but for older kids it may be an option.<\/p>\n
Another antibiotic I’ve never used has crept its way in called
\n fosfomycin, F-O-S-F-O-M, fosfomycin. Tell us about that.<\/p>\n
That’s right. So I don’t think many of us have used it. So it’s an
\n antibiotic, you can use a one-off dose of it, and it’s highly effective in
\n treating UTIs. There’s very little resistance [among E. coli isolates] in
\n Australia. There’s obviously very little resistance because nobody uses it, but
\n even internationally where it has been used, there’s very little resistance to
\n it. So it sounds great. The downside of fosfomycin is it’s not on the PBS
\n [Pharmaceutical Benefits Scheme], so your patients would be out of pocket for
\n that, so that’s not going to be appropriate for everybody. But if your
\n patient’s willing to pay for a one-off dose of antibiotic, then it is an
\n option.<\/p>\n
Okay, thank you. So nitrofurantoin is first line. Looking at
\n continuous antibiotic prophylaxis, I have a handful of patients who are taking
\n it long-term to prevent recurrent UTIs, as is often the case with antibiotics
\n over the years with increasing resistance. There’s a bit of a trend away from
\n that.<\/p>\n
That’s right, it’s certainly de-emphasised in this guideline. So
\n we have recommended trying non-antibiotic prophylaxis first and they have
\n actually included a recommendation for methenamine hippurate in this guideline.
\n It’s one of those things that comes in and out depending on which study’s been
\n published most recently but, there’s enough evidence at the moment to put it in
\n there as an option. For some patients it might help.<\/p>\n
And there’s also a recommendation that before you start continuous
\n prophylaxis you give a chance to a couple of other methods?<\/p>\n
That’s right. So trying either patient-initiated treatment or
\n post-coital prophylaxis are recommended before continuous prophylaxis. And so
\n depending on the patient and on the frequency and cause of their UTIs, those
\n are both options to try prior to trying a continuous prophylaxis.<\/p>\n
Wonderful. We probably don’t have time to go into much more
\n detail, but I noticed there’s also new content on UTI management in children
\n younger than 3 months, which of course is always both tricky and does require
\n some pretty serious follow-up in case there’s underlying abnormalities. I’ll
\n let listeners look that up themselves in the new version of Antibiotic
\n guidelines. We’ll move beyond the bladder, Kate, and take ourselves to the gut.<\/p>\n
Looking at infectious diarrhoea, there’s been a lot of work done
\n on the section talking about faecal testing and a reminder to us all that, like
\n most tests, we only should test if the result is likely to make a difference.
\n And the guideline panellists have decided that it’s most likely to make a
\n difference in more severe or prolonged symptoms or bloody diarrhoea or where
\n the patient is immunocompromised, I guess with exceptions where there’s public
\n health implications in a nursing home or something like that. But in general,
\n we should be less enthusiastic about getting those faecal samples for routine
\n infectious diarrhoea.<\/p>\n
That’s right. There’s a nice little table about when you should
\n consider testing, but I think you covered most of the times when that would be
\n appropriate. So very severe diarrhoea, bloody diarrhoea. Patients with
\n immunocompromise or prolonged diarrhoea that was going for more than 5 days, or
\n then there are a few patient groups with moderate diarrhoea, so people over [older
\n than] 70 [years], younger than 3 months or in the third trimester of pregnancy,
\n or people with very significant comorbidities you might consider testing those
\n as well. But that’s right, only if you think that you would give an antibiotic
\n if you get a specific result back is when you test.<\/p>\n
And in terms of getting that result, GPs now have the choice
\n between faecal culture, the good old-fashioned way and some of their PCR
\n [Polymerase Chain Reaction] testing. PCR is certainly quite tempting. It’s a
\n quicker result and we tend to think it nails the result. But one of the issues
\n I think is that it does multiply a tiny amount of that bacteria in the stool,
\n meaning that we do tend to get more of those false positives and perhaps more
\n than one positive because you are really just measuring a small amount of
\n bacteria in the stool, which you get to some extent even on someone’s stool if
\n they don’t have diarrhoea.<\/p>\n
Which is full of bacteria.<\/p>\n
That’s the problem about poo.<\/p>\n
That’s it. Yeah. So a positive PCR result has to be interpreted
\n with caution and if your patient is getting better regardless or if you don’t
\n think that’s the most likely cause of their symptoms, then you wouldn’t treat
\n based on that.<\/p>\n
Any word on travellers\u2019 diarrhoea? I notice perhaps the days of
\n travelling South East Asia with your little box of antibiotics ready to pop at
\n the first sign of diarrhoea perhaps isn’t quite so effective or useful as we
\n thought.<\/p>\n
Yes, that’s right. So there’s only a few people where it may be
\n appropriate. People [with moderate or severe travellers\u2019 diarrhoea] who are at
\n very high risk of having complications if they were to get travellers\u2019
\n diarrhoea and who are travelling to an area where there’s not going to be [adequate]
\n access to healthcare. The problem, I suppose, with sending people off with
\n those antibiotics is one, that they don’t necessarily self-diagnose and treat
\n appropriately or at the right time, and, there’s evidence that it doesn’t
\n reduce the visits to local healthcare facilities for diarrhoea.<\/p>\n
Well, speaking of travelling, it’s time we travelled to yet
\n another area of the body. Let’s go to the lungs. With bronchiectasis, there’s
\n been an update in both adults and children with bronchiectasis. Children, of
\n course, you really should have paediatric involvement because we really need to
\n look at caring for their lungs in the long term, but with adults. Talk to me
\n about the content on directed therapy versus empirical therapy for
\n bronchiectasis.<\/p>\n
Yeah, so this was interesting. So there’s actually pretty good
\n evidence that if you can direct the therapy in bronchiectasis, you’ll get a
\n better outcome. So what the recommendation is, is that obviously you take a
\n sputum culture or a swab at the time of diagnosis before you start an
\n antibiotic, but also if you have a result from the last 12 months, suggesting
\n the colonising agents, then you can direct your therapy to those colonising
\n agents. And there are recommendations for different agents in the Antibiotic
\n guideline. So for Haemophilus [influenzae], Moraxella [catarrhalis],
\n Streptococcus pneumoniae, and Pseudomonas aeruginosa, you can
\n have a look and treat accordingly.
\n <\/p>\n
Thank you, Kate. Let’s journey outwards to the skin.
\n Diabetes-related foot ulcers. There’s a new thing talking about mild infection
\n and even detecting infection and certainly when they updated the Ulcer and
\n Wounds guideline, there was a strong emphasis on the fact that if you keep
\n swabbing these things, regardless of whether there’s a significant infection or
\n not, you often do grow something but that doesn’t help you treat. So the idea
\n is look for signs very indicative of infection before you take a swab.<\/p>\n
Yeah, that’s right, Justin. So I suppose the first thing with your
\n considerations about treating a diabetic foot ulcer is first to decide if
\n there’s actually an infection of the ulcer. So if there are no signs of
\n infection and we all know what those are, so redness, inflammation, heat,
\n significant pain surrounding [the ulcer], purulent discharge, if none of those
\n signs exist, it’s probably not infected. So there’s no need to treat with
\n antibiotics. If those signs do exist, swabbing the ulcer is still not
\n particularly useful because what you grow could still be a colonising agent.
\n It’s not necessarily useful to direct your therapy. However, if you’ve got microscopy
\n from a tissue sample, so a biopsy, then that can be a useful way to direct your
\n therapy. Then if you find out that you do have an infected ulcer, looking at
\n the guideline, there’s some useful algorithms and tables about how you should
\n decide to treat, because as we probably all know, these ulcers are complicated.
\n Treating them is complicated and they often are worse than they might look at
\n first.<\/p>\n
A reminder that if we are going to use oral therapy legitimately, in
\n patients with moderate infection of diabetes-related foot ulcers, we do tend
\n towards higher doses of whatever it is, amoxicillin + clavulanate, or
\n cephalexin in order to penetrate the area and be effective. So if you are going
\n to treat, do go for those higher doses. Just to mention a couple of other
\n updates, which we won\u2019t go into too much, but there’s one on impetigo and one
\n on periorbital cellulitis. Tell us about those.<\/p>\n
So the impetigo chapter’s been updated. There was a lot of
\n discussion about it. In GP land, we obviously see impetigo quite a lot, but
\n just a reminder to consider risk of rheumatic fever when you’re treating
\n impetigo and if there are risk factors for rheumatic fever, then you consider
\n treating even mild impetigo more aggressively. So treating it with an oral
\n antibiotic rather than topical. And I think they added in an option to use
\n trimethoprim + sulfamethoxazole as a second line agent in that one as well. But
\n still dicloxacillin, flucloxacillin, and cephalexin are your first
\n recommendations.<\/p>\n
And the periorbital cellulitis, we won’t go into it in much
\n detail, but I noticed there are some big fancy tables.<\/p>\n
So there was an ophthalmologist on the group and so it’s worth
\n listeners having a look at those tables because they’re quite useful just to
\n consider at times when periorbital cellulitis needs to be monitored more
\n carefully or treated more carefully because of risks for converting to orbital
\n cellulitis, which is an emergency that needs immediate hospital and
\n ophthalmological management.<\/p>\n
We’ll finish now at the genitalia. There’s been some extra work
\n done on post-exposure prophylaxis. What’s that regarding?<\/p>\n
So there’s a section here now mentioning the use of doxy [doxycycline]
\n for post-exposure prophylaxis. I don’t think there’s a specific drug
\n recommendation there, but more like a recommendation to consider it and to look
\n at the Australian sexual health management guideline [Australasian Society for
\n HIV, Viral Hepatitis and Sexual Health Medicine (ASHM) 2023 Consensus statement
\n on doxycycline prophylaxis (Doxy-PEP)] if that is something you want to
\n consider. And it would be in people who are at very high risk, especially of
\n syphilis, but also chlamydia and, to some extent, gonorrhoea, although we have
\n a lot of doxycycline resistance to gonorrhoea in Australia.<\/p>\n
Thank you. And we might finish with syphilis. Always dear to my
\n heart. I’ve lived and worked in remote communities for 7 years of my life so
\n I’m no stranger to treating syphilis, but I guess most GPs in Australia are
\n relative strangers to it, although unfortunately becoming more familiar with it
\n again.<\/p>\n
That’s right. Unfortunately, it’s been cropping up in more and
\n more unexpected areas over the last few years. So there are new recommendations
\n in the guideline, one about diagnosis and also about management of syphilis.<\/p>\n
Well, Kate McKenzie, thank you for your input. It’s been a
\n pleasure having you talking about the new Therapeutic Guidelines: Antibiotics.
\n Thanks for coming along.<\/p>\n
You are very welcome, Justin. And I would encourage people to have
\n a look at the guideline. There’s lots of really good information \u2013 so much work
\n that goes into more than just the drug recommendations. So if you’ve got some
\n time and you want to do some reading, there’s lots of interesting information
\n in the guideline that we haven’t covered today.<\/p>\n
[Music]<\/p>\n
My guests’ views are their own and don’t represent Australian Prescriber,
\n and my views are certainly all mine.<\/p>\n","protected":false},"excerpt":{"rendered":"[Music] Welcome to the Australian Prescriber Podcast. An
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