Major update to antibiotic guidelines released

After six years, the Therapeutic Guidelines have released an “unprecedented” update to the antibiotic guidelines, covering several infections commonly treated in primary care.

The new guidelines are so large that they’re being updated in three stages. The first was released in March 2025 with two further stages coming out in late 2025 and 2026.

According to Senior Editor of the guidelines, Lisa Waddell, a group of over 100 multidisciplinary clinicians are involved in the update of the guidelines. This first release contained over 200 existing and new clinical topics covering over 1400 drug recommendations.

“It was really lovely having a multidisciplinary group to have a shared understanding that they want to optimise antimicrobial stewardship, but also be aligned on optimising patient outcomes,” she told InSight+.

Some of the key updates

This first release included an update to several infections seen in primary care, including community-acquired pneumonia, infectious diarrhoea and otitis media.

It also included new patient information, images and diagrams and, for the first time, aminoglycoside dosing calculators.

One of the biggest individual changes is the update for cystitis, according to Professor Mark Morgan, Chair of Royal Australian College of General Practitioners (RACGP) Expert Committee – Quality Care.

“The biggest impact as an individual example is the recommendation to use nitrofurantoin as a first choice in uncomplicated urinary tract infections, rather than trimethoprim because of the resistance patterns,” he said.

The expert group discussed the historical concern about the adverse effects of nitrofurantoin, Ms Waddell explained.

“I think the data are fairly clear that adverse effects are associated with long term use. There are also potential systemic adverse effects with trimethoprim (eg, hyperkalaemia), and it affects the whole body, whereas nitrofurantoin is very specific. And so, given the low resistance rates in Escherichia coli, the expert group agreed to make nitrofurantoin number one,” she said.

They have also expanded prioritising non-antibiotic therapy in a select group of patients.

“For non-pregnant females younger than 65 who are not immune-compromised, there is the option to offer non-antibiotic therapy. It’s important for clinicians to be very clear of the potential benefits and complications with this approach, so we’ve expanded information on this,” Ms Waddell said.

For many infections, they had a renewed focus on understanding the benefits of antibiotic therapy.

“That was one of the things we were very mindful of throughout. Rather than talking about the likelihood of bacterial versus viral (unless there was limited evidence to dissuade that approach), to mainly be, what is the benefit of antibiotics for the infection?” she said.  

The future of therapeutic guidelines

The size of this update represented the complicated changing clinical landscape of medicine.

It’s unlikely that doctors will be waiting another 6 years for an antibiotic guideline update. Therapeutic Guidelines are increasingly publishing changes between scheduled updates.

“We’ve got an internal team at the moment reviewing our processes. So, there are lots of different ideas on the table,” Ms Waddell said. 

Professor Morgan would like to see the guidelines be centrally funded rather than through a paid model.

“I think good Australian clinical practice guidelines are a piece of health infrastructure. In the scheme of things, not that expensive to be funded by the taxpayer, for the taxpayer to benefit from.

“I think guidelines should be funded centrally, rather than reliance on subscription fees or specialist college membership fees in order to drive guideline production,” he said.  

How technology can play a part

Regardless of what changes come, the way doctors research clinical information will change. Professor Morgan highlighted that guidelines are becoming too large and updated too frequently to be memorised.

“I think there’s a need for all of us as clinicians to get used to looking things up, rather than relying on fallible memories to know how to treat particular conditions.

“So that begs the question, how do we access the information quickly and efficiently at the point of care?”

Technology should help clinicians access this information.

“I’d very much like to see research conducted on whether the transition to AI scribes for writing progress notes can be leveraged to provide snippets of clinical practice guidelines at the right moment in care, based on the conversation that’s happening in the room,” Professor Morgan suggested.

He’s been involved in a system (called Primary Sense) that provides real-time computer decision support based on algorithms. It produces an alert at the time of prescribing to help doctors make prescribing decisions.

“We know that has quite a profound effect on the decisions that are made by the doctor when there’s a potential of unsafe prescribing about to happen.

“Using a similar approach, not just for unsafe prescribing, but to guide prescribing choices for something that has become quite complicated and might need to be changed on a fairly regular basis as resistance patterns change,” he suggested.

“If the person is coming in with a cough or urine infection symptoms, you would like the system to go to the therapeutic guidelines and pull out the relevant paragraph and present it on-screen to assist with clinicians and their patients, making evidence-based, informed choices of treatments,” he said.

The goal would be to give clinicians more time with the patient so they can make the best decision they can.   

“The system doesn’t encourage us to have the time to do things to the highest standard that we’d like to…

“It all takes time, and time is always at a premium in health care,” Professor Morgan concluded.

You can read What’s New in Antibiotic on the Therapeutic Guidelines website.

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