Guess posting from Dr Catherine Berry, Antimicrobial Stewardship Physician, Hunter New England Health, Staff Specialist, Infectious Diseases, John Hunter Hospital, Conjoint Lecturer,  School of Medicine & Public Health,  University of Newcastle .

This update has been a big one – the first substantial update since 2019. There is a lot to take in and a comprehensive summary is here. I’ve been using these in my day to day recently and these are my top take homes:

1. Save the kidneys!

Our first priority in treating people with life-threatening infections is to provide highly effective antibiotic treatments. The second is to do so without harm.  Emerging data from SNAP and CAMERA-2 has been picked up in the latest eTG and we see cefazolin given equal emphasis for treating serious Staphylococcus aureus infections. Once SNAP is published, we expect to see these recommendations strengthen. Why? – because it appears that cefazolin works just as well as flucloxacillin BUT high dose intravenous flucloxacillin looks to cause acute kidney injury.

Similarly, we see emphasis on optimised monitoring of vancomycin using AUC-guided (area under the curve) dosing rather than trough levels. This is associated with lower rates of kidney injury  but it’s a bit more involved. We’re hoping to get this up and running in Hunter New England soon but this is a work in progress. Curious? – here is a good explainer.

2.  Men are not so complicated after all (when it comes to cystitis)

In line with recent IDSA guidance, we no longer consider cystitis in men as automatically “complicated”. Previously we were giving much longer courses – around 14 days for men (or presumed male at birth). 7 days is now adequate therapy (once prostatitis is ruled out).

From – IDSA complicated urinary tract infections Complicated Urinary Tract Infections (cUTI): Clinical Guidelines for Treatment and Management

3. Trimethoprim is dead for empirical treatment of UTI 

Speaking of cystitis, an old stalwart – trimethoprim – has been deprioritised for the empirical treatment of cystitis. A well tolerated, once daily treatment. Why? – susceptibility amongst E coli has dropped below 80%. Instead, nitrofurantoin has stepped up – unfortunately needing four times per day administration. It is relatively safe in pregnancy. We do expect to see some of the rare but unpleasant side effects pop up again like acute pulmonary toxicity and will be something to watch for.  Mind you, trimethoprim (and co-trimoxazole) does not have a benign safety record – an unpredictable proportion of patients develop serious hyperkalaemia. A reliable study of older patients on ACE inhibitors documented an adverse impact equivalent to 3 excess sudden deaths within 14 days per 1000 co-trimoxazole prescriptions.

4. Diabetic foot infections made easy

Ok – anyone who provides support for people suffering from diabetic foot infections (DFI) might have rolled their eyes because these are hard! The new eTG does however provide an excellent decision aid for antibiotic choice and framework for duration. One great innovation is helping decide when narrow spectrum options like oral flucloxacillin are still a good idea as initial therapy. It would be great to see improvements in the quality of care delivered to people with DFI – but this is a great place to start.

5. Putting the “CAP” on IV therapy

There is increasing evidence that oral antibiotics work fine in many infections. These are associated with shorter length of stay, less need for cannulas and work just as well. In line with British guidelines, the recommendation to use upfront oral antibiotics in moderate community acquired pneumonia has been strengthened.   So amoxicillin plus doxycycline may be your new go to for moderate CAP (but we still love benzylpenicillin). A great summary here.

These are just a few of my key practice changes. What are yours?  Please send them to me or comment below!