Antibiotic prescribing in primary care – eTG 2025
2025 updates to the Therapeutic Guidelines: Antibiotic (March and September 2025 releases):
🔹 SEPTEMBER 2025 RELEASE
Prevention of Infective Endocarditis
- New high-risk category: patients with ventricular assist devices (VADs).
- Clindamycin removed for dental prophylaxis (↑ risk of severe adverse reactions).
- Alternatives for penicillin hypersensitivity: doxycycline or azithromycin.
- Enterococcal cover advised for institutions with high rates of post-TAVI or CIED-related endocarditis (inguinal approach).
🔹 MARCH 2025 RELEASE – MAJOR REVISIONS
Broad Topic Areas Updated
- Cardiovascular infections
- Cryptococcosis
- Infectious diarrhoea
- Cervical lymphadenitis
- Eye infections
- Genital/STIs
- HIV
- Intra-abdominal infections
- Pneumonia
- Other respiratory infections
- Prehospital meningitis & sepsis
- Sepsis & septic shock
- Skin & soft tissue infections
- UTIs (adults & children)
- MDR gram-negative infections
- Vancomycin use (infants, children, adults)
- Penicillin hypersensitivity
🔹 GUIDELINE-WIDE CHANGES
- Kidney impairment: All relevant antimicrobials now link to renal-dose adjustment advice.
- IV amoxicillin+clavulanate: Updated adult & child dosing for both formulations.
- Cefalexin: New 8-hourly option (higher dose) to improve adherence in children.
- Doxycycline: Now permitted in <8 yrs if <21 days (no evidence of tooth effects).
- Critically ill:
- Higher initial meropenem dose for P. aeruginosa, B. pseudomallei, A. baumannii.
- Prefer 3-hour infusion (or continuous 24 h) for piperacillin+tazobactam / meropenem.
- Penicillin allergy: Severe allergy — IV cephalosporins preferred over non-β-lactams.
- Aminoglycosides:
- Use lean body weight for dosing (not total weight).
- New adult dose calculators (amikacin, gentamicin, tobramycin).
- Max gentamicin dose for surgical prophylaxis introduced.
🔹 KEY TOPIC UPDATES
Antibiotic Selection Principles
- Tobramycin now co-equal with gentamicin (preferred if P. aeruginosa suspected).
- Cefazolin = first-line alternative to flucloxacillin for MSSA.
- Cefepime added as antipseudomonal option (alongside ceftazidime, pip/tazo).
- Amoxicillin+clavulanate 875/125 mg 8-hourly for serious Enterobacterales/H. influenzae infections.
- Ceftriaxone: 2 g daily common; 1 g retained in select cases; prefer over cefotaxime except where S. aureus likely.
- MRSA: Vancomycin preferred IV; oral TMP+SMX preferred over clindamycin.
Cardiovascular Infections
- New guidance on:
- Partial oral therapy in endocarditis.
- Management in people who inject drugs (with printable safer-use sheet).
- CIED bacteraemia without proven infection.
- IV catheter-associated infections (new topic).
Cryptococcosis
- Pulmonary + CNS forms merged into one topic.
Infectious Diarrhoea
- Updated faecal testing tables.
- Supportive care emphasised; less empirical antibiotic use.
- Travellers’ diarrhoea: antibiotics only for severe or high-risk cases.
- C. difficile:
- Vancomycin now first-line (superior to metronidazole).
- Management algorithms by age/severity/recurrence.
Cervical Lymphadenitis
- Now includes adults and subacute forms.
Eye Infections
- Added images (dacryocystitis, dendritic ulcer).
- New printable eyelid hygiene handouts.
- Expanded neonatal/child conjunctivitis guidance.
- New diagnostic tables for keratitis and periorbital vs orbital cellulitis.
Genital/STIs
- Doxycycline post-exposure prophylaxis for STIs – new topic.
- Syphilis: major expansion — neurosyphilis, ocular/otosyphilis, delayed doses, antenatal screening.
- Genital herpes: timing of antivirals now episode-specific.
HIV
- Added indicator condition list to prompt routine HIV testing in relevant cases.
Intra-Abdominal Infections
- Shorter therapy durations if adequate source control.
- New appendicitis algorithm (operative vs non-operative approach).
Pneumonia
- Major restructure for usability.
- Severity assessment: use red flags, not numeric scoring.
- Tropical CAP pathogens integrated into standard approach.
- Hydrocortisone for severe CAP within 24 h if high-flow O₂/mechanical ventilation needed.
- HAP: now includes recent discharges (≤7 days).
- VAP: empiric regimens stratified by P. aeruginosa risk; de-escalation principles refined.
- Added directed therapy for A. baumannii and S. maltophilia pneumonia.
- Aspiration pneumonia: new algorithms; reduced emphasis on broad anaerobic cover.
Other Respiratory Infections
- Bronchiectasis: stronger focus on eradication & specialist input.
- COPD exacerbation: antibiotics not routine; new decision algorithm.
- Influenza:
- New antivirals: baloxavir (non-severe) and peramivir (severe, unable to take oseltamivir).
- Thoracic empyema: new management advice (post-trauma, catheter-related, surgical).
Prehospital Sepsis/Meningitis
- Added reconstitution tables for ceftriaxone & benzylpenicillin.
Sepsis and Septic Shock
- Tiered timing of antimicrobials (based on shock, vulnerability, diagnostic certainty).
- Five empirical regimen sets for different patient groups (adults, neonates, etc.).
- Reduced frequency of flucloxacillin/cefazolin in mild sepsis; higher frequency in shock/ICU.
Skin and Soft Tissue Infections
- Simplified IV therapy indications for cellulitis/erysipelas.
- Chickenpox: antivirals within 24 h of rash onset.
- Diabetic foot ulcers: new algorithm + duration tables.
- Impetigo: risk of rheumatic fever now considered; added diagnostic images.
- Staphylococcal scalded skin syndrome: new advice.
Urinary Tract Infections – Adults
- Nitrofurantoin now first-line for cystitis.
- Fosfomycin second-line (better resistance profile; cost/availability limits use).
- Trimethoprim remains alternative if others unsuitable.
- Oral therapy acceptable for non-septic pyelonephritis.
- Ampicillin/amoxicillin dropped from nonpregnant pyelonephritis regimens (kept in pregnancy).
- Emphasis on nonantibiotic & self-initiated strategies for recurrent UTI.
UTI – Children
- New <3 months topic.
- Narrow-spectrum oral options encouraged for those able to swallow tablets.
- Ampicillin/amoxicillin removed from pyelonephritis regimens.
- Sepsis/shock management stratified by age and resistance risk.
Multidrug-Resistant Gram-Negative Infections
- New topic for junior clinicians:
- Identifies MDR risk factors and active/inactive agents.
Vancomycin
- Children:
- Loading doses no longer routine; KidsCalc for dosing.
- Adults:
- Added dialysis dosing topic.
- Updated trough ranges and AUC24 monitoring priorities.
Penicillin Hypersensitivity
- Added validated assessment tools (figures).
- Clearer guidance for skin-prick/oral challenge testing.
- New algorithm considers:
- Type of allergy (severe vs non-severe).
- Clinical setting (community vs hospital).
- Empirical vs directed therapy.
- Infection severity.
🔹 INTERIM TOPIC UPDATES
- Vancomycin dose cap: 2 g for surgical/endocarditis prophylaxis.
- Gentamicin: max dose specified; avoid if CrCl < 20 mL/min.
- New gentamicin safety figure added to surgical prophylaxis principles.