Most antibiotic use in Australia arises from prescriptions in the community.
The risk of antibiotic-related adverse events, including resistance, increases with longer treatment courses.
When antibiotics are indicated for treatment, short courses are as effective as standard ones for most common infections.
Therapeutic Guidelines: Antibiotic is a key reference for antimicrobial prescribing in Australia.
General practitioners play a key role in reducing antibiotic use.
Optimising prescribing of antibiotics in the community is important because it is where most antibiotics are prescribed. In 2015, 30% of all patients attending a general practice received an antibiotic prescription.1 Most are for acute respiratory infections, and in quantities several-fold more than recommended by Australian guidelines.2 Repeat prescriptions have been highlighted as a cause for over-use in this setting.1
Yet antibiotics are not entirely benign. Their use can be associated with adverse events such as toxicity, allergy (including anaphylaxis), candidiasis, Clostridium difficile infection, and antimicrobial resistance – both at community and individual levels.3-6 The more they are used, the greater the likelihood of adverse events, including resistance.4-7
It is important for prescribers to be up to date with best-practice antibiotic prescribing for common infections (Box), particularly the duration of treatment. In Australia, antibiotic prescribing is ideally concordant with the Therapeutic Guidelines: Antibiotic.8 While other resources are commonly used, such as the Australian Medicines Handbook and MIMS, it is Therapeutic Guidelines that offers comprehensive information on the clinical indications for antibiotic prescription and advice on antibiotic choice, dose and duration. It is also the guideline currently endorsed by the Australian Commission on Safety and Quality in Health Care as the preferred reference for prescribing in the absence of local guidelines.
Box - Best-practice antimicrobial prescribing in general practice
- consider microbiological testing to direct therapy (e.g. urinary tract infection, abscess), especially when the causative organism is difficult to predict (e.g. recurrent or unresponsive infection, or overseas travel)
- use the current version of Therapeutic Guidelines: Antibiotic, or available local guidelines
- know why you are prescribing the antibiotic (document indication and duration in the medical record)
- prescribe the shortest duration of therapy (or total number of tablets), even if this means the pharmacist breaking the pack.
- culture every infection, or potential infection (especially urine in residential aged-care facilities)
- prescribe an antimicrobial without an appropriate indication
- routinely provide a repeat prescription.
Antimicrobials are not always needed
Antibiotics are not necessary for most acute respiratory infections including acute rhinosinusitis, acute sore throat and acute otitis media. This is not just because so many of these infections are viral, but because even when the infection is bacterial, the benefits of antibiotic therapy for most patients are modest and outweighed by the harm from adverse effects.9-12 Australian and local guidelines provide recommendations on when antimicrobial therapy should be used for these conditions.8,13
Practice points on optimising antibiotic prescribing
It can be difficult to clinically differentiate a patient with a trivial acute respiratory infection from one at an early stage of serious bacterial infection, particularly in children.14 One option is to ‘watch and wait’ and ask patients to return if there is clinical deterioration. An alternative is to prescribe an antibiotic but advise the patient to not have it dispensed unless specific symptoms occur. In the setting of acute respiratory infection, this has been shown to reduce antibiotic use by 50% with no significant decrease in patient satisfaction, and importantly no increase in complication rates.15
When antibiotics are prescribed, the duration (or number of tablets) should be written on the prescription. This should enable the pharmacist to supply only the number of tablets or capsules required (even if it means breaking the antibiotic pack) which avoids excessive antibiotic use. Repeat scripts are almost never required and we recommend changing the default setting to ‘no repeats’ in electronic prescribing software when technically feasible.
Antibiotic duration for common infections
Historically, the recommendations for duration of antibiotic treatment have been largely arbitrary. The theoretical principles have been to use enough antibiotic to eliminate the infecting organism and prevent the development of resistance. However, empirical evidence does not support this – shorter courses are nearly always as effective as standard ones.16 Also, the longer the antibiotic exposure, the greater the pressure to select for antibiotic resistance in commensal bacteria that may cause serious infection in the future.6,17
Currently recommended antibiotic durations for the most common bacterial infections managed in general practice are shown in the Table. The total tablet quantity for the suggested duration in adults is included.
Table - Recommended antibiotic prescribing for common bacterial infections*
|Diagnosis||Indications for antibiotic therapy||First-line antimicrobial
|Acute tonsillopharyngitis||2–25 years, high risk of acute rheumatic fever, or rheumatic heart disease, or scarlet fever||Phenoxymethylpenicillin 12-hourly||10 days†||20 x 500 mg|
|Acute rhinosinusitis||Symptoms >7 days, or high fever >3 days, or biphasic illness||Amoxicillin 8-hourly||5 days†||15 x 500 mg|
|Acute otitis media||<6 months old, or systemic symptoms, or indigenous community||Non-indigenous: amoxicillin 12-hourly||5 days†||20 x 500 mg|
|Indigenous: amoxicillin 12-hourly||7 days†||28 x 500 mg|
|Community-acquired pneumonia (mild, can review progress in 48 hours)||
Adults: amoxicillin 8-hourly, or doxycycline 12-hourly
||30 x 500 mg / 10 x 100 mg|
|Uncomplicated urinary tract infection||Non-pregnant women: trimethoprim daily
||3 days||3 x 300 mg|
|Pregnant women: cefalexin or nitrofurantoin 12-hourly||5 days||10 x 500 mg / 10 x 100 mg|
|Men: trimethoprim daily||7 days||7 x 300 mg|
|Children ≥1 month: trimethoprim/sulfamethoxazole 12-hourly||3–5 days¶||–|
|Cellulitis (mild, low risk for methicillin-resistant Staphylococcus aureus)||Dicloxacillin or flucloxacillin 6-hourly, OR||5 days††||20 x 500 mg|
|phenoxymethylpenicillin 6-hourly**||5 days†,††||20 x 500 mg|
||3–10 days‡‡||40 x 500 mg|
||5 days||10 x 160/800 mg|
|Abscess (low risk for methicillin-resistant
|Spreading cellulitis, or systemic symptoms, or large lesion/critical area||Dicloxacillin or flucloxacillin 6-hourly, as an adjunct to incision and drainage||5 days||20 x 500 mg|
* As recommended by Therapeutic Guidelines: Antibiotic. Refer to the complete guideline for further information on indications for antibiotic dosing, second-line antibiotics, and when broader spectrum therapy and specialist involvement may be appropriate. Refer also to local guidelines. Use oral regimen unless indicated otherwise.
† Repeat script required only if using liquid formulation for a large child.
‡ Chlamydia trachomatis may be the cause in this age group if afebrile and only mildly unwell.
§ Atypical cover with doxycycline, azithromycin or clarithromycin is recommended if Mycoplasma pneumoniae or another atypical pathogen is suspected. Doxycycline should not be used in children younger than 8 years of age.
# Repeat prescription required only if using amoxicillin.
¶ 5 days for children <1 year, 3 days for children ≥1 year.
** If Streptococcus pyogenes clinically suspected or isolated from culture.
†† Up to 10 days if cellulitis more severe.
‡‡ Stop therapy earlier than 10 days if infection has resolved.
Evidence for short-course antimicrobial therapy
There is evidence to support recommendations for shorter antibiotic courses.
A systematic review of 12 studies found no significant difference in clinical cure rate, microbiological efficacy and relapse when 3–7 days versus 6–10 days of antibiotics were given for acute bacterial sinusitis.16
Short-course antibiotic treatment (5–7 days vs standard 10 days) is associated with equivalent rates of clinical cure in acute tonsillopharyngitis.18 There is inferior bacteriological eradication, but this is of unknown clinical significance. It also is not known whether short-course therapy reduces the risk of non-suppurative complications (acute rheumatic fever and glomerulonephritis). A full 10-day course is still currently recommended to prevent these complications, especially in high-risk populations (previous history, remote indigenous populations).
Acute otitis media
A systematic review of short-course (<7 days) versus longer duration therapy in children with acute otitis media found that short-course therapy is non-inferior for clinical cure measured at one month and is associated with a significant reduction in gastrointestinal adverse events.19
Mild community-acquired pneumonia
Australian studies show that a penicillin and doxycycline (or a macrolide) is effective and safe for most patients with community-acquired pneumonia.20 Monotherapy is recommended for mild infections providing the patient’s progress can be reviewed after 48 hours.8 A duration of 5–7 days of antibiotics is recommended in adults. This is supported by a systematic review showing no significant difference in outcomes between 3–7 days of antibiotics compared to 7 days or longer.16 For children with non severe pneumonia there is no difference between 3 versus 5 days of antibiotics.21 Therapeutic Guidelines: Antibiotic currently recommends 5 days of oral antibiotics.8 However, 3 days is endorsed by other Australian expert groups such as the Australian and New Zealand Paediatric Infectious Diseases group.22
Acute uncomplicated urinary tract infection
The evidence for antibiotic duration in urinary tract infections is sparser than for acute respiratory infections. For uncomplicated urinary tract infections in women there is no significant difference in clinical cure rates, and fewer adverse events in those given 3 days of antibiotics versus 5 days or longer.23 However, the risk of bacteriological failure is higher in women given a shorter course. Bacterial elimination from the urine is likely to be relevant for women who are pregnant, experience recurrent and painful urinary tract infections or who have urinary tract prosthetic material in situ (e.g. stent or catheter).
Currently 5 days of therapy is recommended for pregnant women and for second-line drugs in non-pregnant women.8 The first-line 3-day recommendation of trimethoprim in non-pregnant women has been extrapolated from data for trimethoprim/sulfamethoxazole, a drug that is considered equivalent to trimethoprim for this condition.24
Short-course therapy has not been adequately evaluated in men and so it is not recommended at present. A Cochrane review of childhood lower urinary tract infection found no difference in persistent bacteriuria or recurrence when comparing 2–4 days with 7–14 days of oral antibiotics.25
Oral fosfomycin has recently been registered for use in Australia as a single-dose treatment for uncomplicated urinary tract infections in females over the age of 12 years. However, this antibiotic should generally be reserved for resistant organisms.
Skin and soft tissue infections
There is a lack of systematic review data to guide short-course therapy for skin and soft tissue infection.
Incision and drainage is the primary therapeutic modality for soft tissue abscesses. A recently published systematic review found that for uncomplicated abscesses, adjunctive antibiotic therapy provides a modest benefit in terms of treatment success and prevention of recurrence,26 but this needs to be balanced against an increased risk of adverse events. Antibiotic courses ranged from 3–14 days and no recommendation on duration was made.26
A randomised controlled trial conducted in the remote Australian setting showed that short-course oral trimethoprim/sulfamethoxazole for 3–5 days is effective for impetigo, and equivalent to intramuscular benzathine penicillin.27
Stopping antibiotics earlier than the intended standard duration
Since many common infections are spontaneously remitting, the use of antibiotics is often discretionary. Numerous opinions have been published in support of stopping antibiotics earlier.28-30
A practical approach in the community setting is to educate patients and advise them that it is safe to cease the antibiotics early if microbiological results exclude a bacterial cause for their symptoms (e.g. negative urine culture or viral acute respiratory infection), or the patient feels better for conditions where the benefit of antibiotics is small and the infection is not severe (e.g. acute respiratory infections).
Patients should be advised to return any remaining antibiotics to the pharmacy for safe disposal, rather than storing them (which risks future inappropriate use) or disposing of them in general household waste (which risks environmental contamination).
There is good evidence that shorter durations of antimicrobials can reduce adverse effects associated with their use. Furthermore, systematic reviews have found that clinical outcomes are similar between short and long courses for many common infections. Given Australia’s relatively high rates of prescribing, we can all play a significant role in reducing the burden of inappropriate antimicrobial use by prescribing short-course therapy when appropriate and limiting prescriptions when they are not indicated.
Christopher Del Mar has been awarded grants by the National Health and Medical Research Council for research into antibiotic resistance in primary care, and for the Cochrane Acute Respiratory Infections Group.
Australian Prescriber welcomes Feedback
- Australian Commission on Safety and Quality in Health Care (ACSQHC). AURA 2017: second Australian report on antimicrobial use and resistance in human health. Sydney: ACSQHC; 2017. [cited 2019 Jan 3]
- McCullough AR, Pollack AJ, Plejdrup Hansen M, Glasziou PP, Looke DF, Britt HC, et al. Antibiotics for acute respiratory infections in general practice: comparison of prescribing rates with guideline recommendations. Med J Aust 2017;207:65-9.
- Gillies M, Ranakusuma A, Hoffmann T, Thorning S, McGuire T, Glasziou P, et al. Common harms from amoxicillin: a systematic review and meta-analysis of randomized placebo-controlled trials for any indication. CMAJ 2015;187:E21-31.
- Ironmonger D, Edeghere O, Verlander NQ, Gossain S, Hopkins S, Hilton B, et al. Effect of general practice characteristics and antibiotic prescribing on Escherichia coli antibiotic non-suceptiblity in the West Midlands region of England: a 4 year ecological study. J Antimicrob Chemother 2018;73:787-94.
- Stevens V, Dumyati G, Fine LS, Fisher SG, van Wijngaarden E. Cumulative antibiotic exposures over time and the risk of Clostridium difficile infection. Clin Infect Dis 2011;53:42-8.
- Costelloe C, Metcalfe C, Lovering A, Mant D, Hay AD. Effect of antibiotic prescribing in primary care on antimicrobial resistance in individual patients: systematic review and meta-analysis. BMJ 2010;340:c2096.
- Katchman EA, Milo G, Paul M, Christiaens T, Baerheim A, Leibovici L. Three-day vs longer duration of antibiotic treatment for cystitis in women: systematic review and meta-analysis. Am J Med 2005;118:1196-207.
- eTG complete (Internet). Melbourne: Therapeutic Guidelines Limited: 2018. [cited 2019 Jan 3]
- Lemiengre MB, van Driel ML, Merenstein D, Young J, De Sutter AI. Antibiotics for clinically diagnosed acute rhinosinusitis in adults. Cochrane Database Syst Rev 2012;10:CD006089.
- Smith MJ. Evidence for the diagnosis and treatment of acute uncomplicated sinusitis in children: a systematic review. Pediatrics 2013;132:e284-96.
- Spinks A, Glasziou PP, Del Mar CB. Antibiotics for sore throat. Cochrane Database Syst Rev 2013;11:CD000023.
- Venekamp RP, Sanders SL, Glasziou PP, Del Mar CB, Rovers MM. Antibiotics for acute otitis media in children. Cochrane Database Syst Rev 2015;6:CD000219.
- Remote Primary Health Care Manuals. CARPA standard treatment manual: a clinical manual for primary health care practitioners in remote and indigenous health services in central and northern Australia. 7th ed. Alice Springs: Centre for Remote Health; 2017. [cited 2019 Jan 3]
- Craig JC, Williams GJ, Jones M, Codarini M, Macaskill P, Hayen A, et al. The accuracy of clinical symptoms and signs for the diagnosis of serious bacterial infection in young febrile children: prospective cohort study of 15 781 febrile illnesses. BMJ 2010;340:c1594.
- Spurling GK, Del Mar CB, Dooley L, Foxlee R, Farley R. Delayed antibiotic prescriptions for respiratory infections. Cochrane Database Syst Rev 2017;9:CD004417.
- Dawson-Hahn EE, Mickan S, Onakpoya I, Roberts N, Kronman M, Butler CC, et al. Short-course versus long-course oral antibiotic treatment for infections treated in outpatient settings: a review of systematic reviews. Fam Pract 2017;34:511-9.
- Chastre J, Wolff M, Fagon JY, Chevret S, Thomas F, Wermert D, et al.; PneumA Trial Group. Comparison of 8 vs 15 days of antibiotic therapy for ventilator-associated pneumonia in adults: a randomized trial. JAMA 2003;290:2588-98.
- Falagas ME, Vouloumanou EK, Matthaiou DK, Kapaskelis AM, Karageorgopoulos DE. Effectiveness and safety of short-course vs long-course antibiotic therapy for group A β‑hemolytic streptococcal tonsillopharyngitis: a meta-analysis of randomized trials. Mayo Clin Proc 2008;83:880-9.
- Kozyrskyj A, Klassen TP, Moffatt M, Harvey K. Short-course antibiotics for acute otitis media. Cochrane Database Syst Rev 2010;9:CD001095.
- Charles PG, Whitby M, Fuller AJ, Stirling R, Wright AA, Korman TM, et al.; Australian CAP Study Collaboration. The etiology of community-acquired pneumonia in Australia: why penicillin plus doxycycline or a macrolide is the most appropriate therapy. Clin Infect Dis 2008;46:1513-21.
- Haider BA, Saeed MA, Bhutta ZA. Short-course versus long-course antibiotic therapy for non-severe community-acquired pneumonia in children aged 2 months to 59 months. Cochrane Database Syst Rev 2008;2:CD005976.
- McMullan BJ, Andresen D, Blyth CC, Avent ML, Bowen AC, Britton PN, et al.; ANZPID-ASAP group. Antibiotic duration and timing of the switch from intravenous to oral route for bacterial infections in children: systematic review and guidelines. Lancet Infect Dis 2016;16:e139-52.
- Milo G, Katchman EA, Paul M, Christiaens T, Baerheim A, Leibovici L. Duration of antibacterial treatment for uncomplicated urinary tract infection in women. Cochrane Database Syst Rev 2005;2:CD004682.
- Gupta K, Hooton TM, Naber KG, Wullt B, Colgan R, Miller LG, et al.; Infectious Diseases Society of America; European Society for Microbiology and Infectious Diseases. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: a 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis 2011;52:e103-20.
- Michael M, Hodson EM, Craig JC, Martin S, Moyer VA. Short versus standard duration oral antibiotic therapy for acute urinary tract infection in children. Cochrane Database Syst Rev 2003;1:CD003966.
- Wang W, Chen W, Liu Y, Siemieniuk RA, Li L, Martínez JP, et al. Antibiotics for uncomplicated skin abscesses: systematic review and network meta-analysis. BMJ Open 2018;8:e020991.
- Bowen AC, Tong SY, Andrews RM, O’Meara IM, McDonald MI, Chatfield MD, et al. Short-course oral co-trimoxazole versus intramuscular benzathine benzylpenicillin for impetigo in a highly endemic region: an open-label, randomised, controlled, non-inferiority trial. Lancet 2014;384:2132-40.
- Spellberg B. The new antibiotic mantra – ‘shorter is better’. JAMA Intern Med 2016;176:1254-5.
- Llewelyn MJ, Fitzpatrick JM, Darwin E, Tonkin-Crine S, Gorton C, Paul J, et al. The antibiotic course has had its day. BMJ 2017;358:j3418.
- Del Mar C, Looke DF. Should we abandon “finishing the course” of antimicrobials? BMJ 2017;358:j4170.