Six antibiotic gems

16 November 2021

Bruce Arroll, Professor of General Practice and Primary Health Care, the University of Auckland 

To highlight World Antimicrobial Awareness Week (18-24 November) Dr Arroll shares some tips to think about when deciding whether or not to prescribe these medications.

Acute sinusitis is usually viral and does not need antibiotics

There is agreement that most acute sinusitis is caused by viral infections causing pressure in the facial sinuses.The so-called second sickening (the bacterial component) is not well established in terms of research on this issue. There are very rare occasions when patients can be very sick and need hospitalisation, but these patients look very sick. There are some older descriptions that include unilateral coloured nasal discharge, maxillary facial and dental pain, and failure of decongestants to relieve symptoms. Duration of more than five days or symptoms getting worse may warrant antibiotics. The safest ones for initial treatment are the narrow spectrum ones such as Amoxil or Doxycycline. 

Augmentin only has two first line indications
There are only two indications for this medication and these are diabetic foot ulcers and human or animal bites. Thus the 700,000 prescriptions annually in New Zealand are unlikely to be for these conditions. In Greenstone clinic in Manurewa they run an Augmentin free clinic. When a clinician wishes to prescribe this medication s/he needs to ask another clinician for their blessing to give Augmetin. This system puts a block on prescribing this medication for a just in case scenario. There are usually better alternatives such as flucloxacillin for skin infections. Augmentin has been used for taste in children but there are safer alternatives such as cephalexin which is very consumable. 

UTI nitrofurantoin (Macrobid) twice daily now the first line antibiotic for cystitis
There is now a new first line option for cystitis (due to increasing resistance to Trimethoprim). It is a micronized form of Nitrofurantoin and has fewer GI side effects that the older 3 to 5 times per day. However, to prescribe it you need to put the trade name Macrobid into the prescribing line on your computer to get the correct product otherwise you may under dose the patient. 100 mg BD for five days is probably long enough but the duration has not been well studied. There is very little resistance to it but a MSU will confirm the correct antibiotic or confirm there is no infection. 

Stop using topical antibiotics

This is to preserve them for eradicating nasal carriage. Due to the widespread use of topical Bactroban and Foban the prevalence of resistance has increased markedly. If a topical medicine is needed hydrogen peroxide or povidone-iodine can be tried first. If that fails, then an oral antibiotic is preferred to a topical one. 

Pimafucort is overkill
There are 180,000 prescriptions for this medication annually. The problem is that it contains a corticosteroid, an antibiotic and an antifungal and if the lesion gets better you don’t know what worked. And if the condition returns you may feel the need to repeat the Pimafucort. Fungal infections are rarer than eczema in primary care and can be confirmed with a skin scraping. So a more precise prescribing is to try one thing and if that does not work try another. 

Colds and secondary bacterial infection are a myth
Secondary bacterial infection is a myth and the production of coloured sputum later in the course of an illness is usually oxygenated mucous and not an infection. A true bacterial infection would be pneumonia and that is clinically fairly obvious and certainly needs antibiotics.