14 November 2017
New entries for the antibiotic choices guide
To mark antibiotics awareness week (13th – 19th November), we are releasing a new chapter,
three new conditions and some revisions in our guide - Antibiotics: choices for common infections.
Due to popular request, we have created a new chapter in the Guide for dental infections. This includes topics on
managing dental abscess and prophylactic antibiotic treatment prior to undergoing dental procedures for patients at high risk of developing infective endocarditis.
Ideally patients would attend a dental clinic for treatment of a tooth abscess, however in practice this is often
not possible due to barriers such as location, access and cost, and patients will instead present
to their general practice. Abscess can often be treated with incision and drainage, followed by salty
mouthwashes. Antibiotic treatment may be required if the infection
is severe, i.e. the patient has cellulitis, diffuse tense swelling around the affected tooth or systemic
symptoms. Ultimately, dental treatment will be required as it is likely that the abscess will reoccur
if the underlying cause is not managed.
We have added a new topic in the gastrointestinal chapter of the Guide on the management of diverticulitis. It is thought that in many cases,
uncomplicated diverticulitis is caused by inflammatory processes, rather than infection. Therefore antibiotic treatment is not routinely required,
but it may be considered if the patient’s symptoms persist or worsen despite dietary management and analgesia. There is a lack of consistent guidance
as to what antibiotic should be used; some guidelines recommend amoxicillin clavulanate or ciprofloxacin, but in order to preserve and limit use of
these antibiotics, we have suggested, based on expert advice, combination treatment with trimethoprim + sulfamethoxazole (co-trimoxazole) and metronidazole.
Previously this topic in the Guide was referred to as “pharyngitis”, however this generated enquiries from
prescribers as to whether the same advice applied to treating tonsillitis. In addition, there is
some uncertainty around guidance for prescribing antibiotics for patients with sore throat, outside
of the context of rheumatic fever prevention.
We have revised the section and renamed it as “Sore throat”, which includes both pharyngitis and tonsillitis. The guidance for rheumatic fever
prevention remains the same, and the same antibiotic choices apply. Antibiotic treatment is unnecessary in almost all other cases of sore throat as
it is often viral in origin and usually self-limiting, however, we have added advice in the management section about when it is reasonable to consider
antibiotic treatment, i.e. if the patient has severe symptoms or is at risk of complications.
The New Zealand Sexual Health Society has recently released an update of its management guidelines for sexually transmitted
infections (September, 2017). We have revised our STI topics in the genito-urinary chapter in the
Guide to reflect this. The most significant change is in the recommended first-line and alternative treatments for urethritis: seven days treatment
with doxycycline is now first-line, rather than azithromycin, with stat azithromycin an alternative
if adherence to doxycycline is a concern or it is contraindicated.
Other changes include clarification that for most STIs, sexual contacts within the last three months should be notified
and advised to seek assessment; empiric treatment is recommended while awaiting laboratory results for some infections.
In the Chlamydia section we have specified that azithromycin is recommended for patients with asymptomatic
urogenital infection (e.g. positive test result but no obvious symptoms), and doxycycline is recommended
for patients with symptomatic urethritis, rectal or oral infection, or if an alternative to azithromycin
is required. We have also noted that a longer treatment duration is required for patients with anorectal
symptoms, and suggest that you discuss this with a sexual health physician.
To read the updated NZSHS guidelines, see: www.nzshs.org/guidelines
Antibiotic use in New Zealand is higher per head of population than in many similar developed countries. Increased antibiotic use leads to the development of resistance by
eliminating antibiotic-susceptible bacteria and leaving antibiotic-resistant bacteria to multiply. Antimicrobial stewardship aims to limit the use of antibiotics to
situations where they deliver the greatest clinical benefit. Along with infection control, this is the key strategy to counter the emerging threat of antimicrobial resistance.
Information on national antimicrobial resistance patterns is available from the Institute of
Environmental Science and Research Ltd (ESR), Public Health Surveillance:
Regional resistance patterns may vary; check with your local laboratory.