Guidelines Updates 2019-20

Updated Guidelines

• Toxicology and Toxinology View Updates

As well as including a comprehensive revision of the Toxicology and Toxinology guidelines, the August 2020 release of eTG complete also includes the following practice-changing updates to other guidelines. With each release, we are also continuing to implement drug name changes in line with the Therapeutic Goods Administration.

Antibiotic guidelines

• Tinidazole was discontinued in Australia in February 2020. A footnote about this has been added to tinidazole drug recommendations; metronidazole is recommended as an alternative when an oral nitroimidazole is required.
• Amphotericin B lipid complex is no longer registered for use in Australia, but is available via the Special Access Scheme. A footnote about this change in availability has been added to amphotericin B lipid complex drug recommendations.
• The empirical recommendations for sepsis and septic shock from a biliary or gastrointestinal tract source have been updated to ensure patients with acalculous cholecystitis who have penicillin hypersensitivity receive antibiotic therapy with activity against Pseudomonas aeruginosa.
• New data are available on the safety of erythromycin use in early pregnancy. The erythromycin entry in ‘Drug use in pregnancy and breastfeeding’ has been updated to include links to the relevant publications.
• Combination therapy with flucloxacillin and vancomycin was observed in a recent randomised controlled trial to be associated with nephrotoxicity. Despite this, combination therapy continues to be recommended for initial therapy for Staphylococcus aureus bacteraemia to ensure adequate treatment of both methicillin-susceptible and methicillin-resistant strains. New advice is included to limit the duration of combination therapy to 48 hours.
• Vancomycin dosage adjustments should be made in a linear manner. Updated guidance on the practical application of linear dosage adjustments is included.
• A recent randomised controlled trial showed that a single dose of amoxicillin+clavulanate reduced the incidence of maternal infection after assisted (vacuum or forceps) vaginal delivery. Advice on which women should receive prophylaxis and what drug should be used has been added.

Cardiovascular guidelines

• A comment has been added to ‘Venous thromboembolism: prophylaxis’ topic to clarify that optimal prophylaxis in obese patients has not been fully determined. Expert advice is recommended for drug choice and dosing.

Dermatology guidelines

• The ‘Vulvovaginitis in girls’ topic has been updated to reflect that candidal vulvovaginitis occurs very rarely in prepubertal girls, rather than not occurring in this patient group.

Diabetes guidelines

• Dapagliflozin has now been approved by the Australian Therapeutic Goods Administration (TGA) for use in patients with a creatinine clearance of 45 mL/min or more (previously 60 mL/min or more), as for all other sodium-glucose co-transporter 2 (SGLT2) inhibitors available in Australia. The drug recommendation for dapagliflozin for patients with type 2 diabetes has been updated.
• The Lantus brand of insulin glargine 100 units/mL has been discontinued in Australia and replaced by the Optisulin brand, which is made by the same drug company and is therapeutically identical. Optisulin has been added to the list of available insulin formulations in Table 18.4.

March 2020

Practice-changing updates:

The March 2020 release of eTG complete includes a new topic on coronavirus disease (COVID-19), with links to useful resources, and the following practice-changing updates to specific guidelines. With each release, we are also continuing to implement drug name changes in line with the Therapeutic Goods Administration.

Antibiotic guidelines

• To help users navigate the sepsis topics, the categories applied in these guidelines to antibiotic regimens for sepsis or septic shock have been defined. A new table summarises the empirical regimens for sepsis or septic shock when the source of infection is not known. A list summarising the pathogen-specific regimens for bloodstream infections has also been added.
• In the topic on ‘Pneumonia diagnosis and follow-up’, the statement on repeat chest X-ray has been reworded to clarify that a repeat chest X-ray is only recommended 6 to 8 weeks after the episode of pneumonia for patients in whom there is a clinical suspicion of lung malignancy (eg elderly, smokers).
• The intravenous dose of trimethoprim+sulfamethoxazole for add-on empirical therapy for meningitis and encephalitis in patients with risk factors for Listeria infection, and for directed therapy of Listeria meningoencephalitis, has been updated to align with standard references.
• The oral dose of trimethoprim+sulfamethoxazole for extended treatment of Listeria meningoencephalitis has been changed to a 12-hourly dosing schedule to improve patient adherence and avoid tablet splitting.
• All trimethoprim+sulfamethoxazole 5+25 mg/kg doses for adults have been capped at 96 kg to avoid overdosing in obese patients. This equates to a maximum unit dose of 480+2400 mg.
• Isavuconazole is now registered for use in Australia, so the footnote about availability through the Special Access Scheme has been deleted from the Aspergillosis section.

Dermatology guidelines

• The time needed to store clothes, towels and bedding in a sealed plastic bag to prevent transmission of scabies has been increased to 8 days in line with new evidence.

Gastrointestinal guidelines

• Table 6.22 (Oral 5-aminosalicylate preparations and dosages for ulcerative colitis) has been updated to reflect the change in criteria for accessing oral mesalazine on the Pharmaceutical Benefits Scheme (PBS)—for the treatment of ulcerative colitis, oral mesalazine is no longer reserved for patients with a documented history of a hypersensitivity reaction to a sulfonamide, or those intolerant to sulfasalazine.

Psychotropic guidelines

Contact details for the Psychotropic Drug Advisory Service have been updated.

December 2019

Updated Guidelines

• Oral and Dental View updates

Practice-changing updates:

As well as including a comprehensive update to the Oral and Dental guidelines, the December 2019 release of eTG complete also includes the following practice-changing updates to other guidelines.

Antibiotic guidelines

• A PDF guide for assessing patients with reported penicillin allergy has been added.
• The advice on dosage adjustment of vancomycin in neonates and children has been updated to recommend seeking expert advice if a total daily dose of more than 70 mg/kg is required to achieve the target plasma concentration. The maximum unit dose of benzylpenicillin for children with erysipelas or cellulitis with systemic features has been changed from 2 g to 1.2 g to align with the maximum unit dose recommended for adults.
• A footnote has been added to explain the basis for the recommendations for dosage adjustment of oseltamivir for adults with impaired renal function.

Cardiovascular guidelines

• A footnote has been added to acknowledge the recommendation to use the sexless CHA2DS2-VASc score to stratify stroke risk in patients with ‘nonvalvular’ atrial fibrillation in the National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand clinical guidelines for the diagnosis and management of atrial fibrillation 2018. The dosing of danaparoid for treatment of heparin-induced thrombocytopenia has been updated to align with the Thrombosis and Haemostasis Society of Australia and New Zealand (THANZ) consensus statement on diagnosis and management of heparin-induced thrombocytopenia.

Dermatology guidelines

• The management of primary oral mucocutaneous herpes has been updated to include currently available topical analgesics and anaesthetics. Episodic antiviral therapy for a minor recurrence in immunocompetent adults now includes a single dose of oral famciclovir.

Neurology guidelines

• The rate of infusion of intravenous sodium valproate for the acute management of seizures has been updated in line with evidence.

Psychotropic guidelines

• A footnote to alert users to the discontinuation of trifluoperazine and fluphenazine has been added. Sources of information for psychotropic drug use during pregnancy and while breastfeeding have been updated.