Speaker's Highlight

• Don Sin University of British Columbia, St. Paul Hospital (Canada)
  Kenneth R. Chapman Toronto General Hospital Research Institute (Canada)
• Parameswaran Nair McMaster University (Canada)
  Carolyn Calfee UCSF (U.S.A.)
• Gregory P. Downey University of Colorado School of Medicine (U.S.A.)
  David A. Schwartz University of Colorado School of Medicine (U.S.A.)
• Neil Schluger Tuberculosis Control Branch, California Department of Public Health (U.S.A.)
  Nick Kim Critical Care & Sleep Medicine, University of California San Diego (U.S.A.)
• Nicola Hananiah Baylor College of Medicine (U.S.A.)
  Jae-Joon Yim Seoul National University College of Medicine (Republic of Korea)
• Koichiro Asano Tokai University School of Medicine (Japan)
  Diahn-Warng Perng Taipei Veterans General Hospital (Taiwan)
• Konstantinos Kostikas University of Ioannina (Greece)
  Karin Klooster University Medical Center Groningen (Kingdom of the Netherlands)

• Tackling Antibiotic Resistance in Community-Acquired Pneumonia

  Community-acquired pneumonia remains one of the most common reasons Australians end up in hospital, and the pressure to prescribe antibiotics quickly is intense. At the same time, surveillance data from the Australian Commission on Safety and Quality in Health Care shows resistance trends creeping upward for key oral agents, making everyday prescribing decisions more fraught than they once were.

  For GPs in suburban Melbourne, rural practices in Tasmania, and hospital teams in Brisbane alike, the challenge is balancing timely empirical treatment against the long-term cost of resistance. The conversation is shifting from simply picking the right drug to building a smarter system around prescribing, diagnostics, and prevention.

  The Shifting Microbiology of Pneumonia Down Under

  Streptococcus pneumoniae still tops the list of bacterial culprits identified in Australian adults with community-acquired pneumonia, but its susceptibility profile has quietly transformed. Penicillin non-susceptibility and rising macrolide resistance, particularly in serotypes not covered by the current 13-valent conjugate vaccine, have changed what "first-line" really means on a script pad at 6pm in Adelaide.

  Atypical organisms continue to matter too. Mycoplasma pneumoniae circulates in waves through schools and university campuses, and Legionella species occasionally surface after air-conditioning maintenance in high-rise Sydney buildings or following outbreaks linked to potting mix in Queensland. Knowing which pathogens are locally active each season, rather than relying on textbook assumptions, is now part of competent respiratory care.

  Why Resistance Is Creeping Up in the Community

  Most antibiotic use still happens outside hospitals, and the bulk of it begins in general practice. Each winter, patients with a productive cough stream into bulk-billing clinics, often requesting "something strong" before they have even had a set of observations taken. Repeat courses for the same patient, broad-spectrum agents selected for convenience, and pressure to keep people out of the emergency department all add up to selection pressure on the microbiome.

  Australian wastewater surveillance, coordinated through groups such as the Antimicrobial Resistance Initiative, has shown resistant Escherichia coli and Klebsiella signatures in catchment areas around Perth and the Gold Coast, reflecting community carriage rather than just hospital-acquired strains. The message is clear: resistance is not a problem confined to Royal Prince Alfred or The Alfred, it is sitting in households across the country.

  Diagnostic Stewardship Before Therapeutic Stewardship

  Rapid point-of-care testing has finally arrived in primary care. CRP testing at the bedside, urinary antigen assays for pneumococcus and Legionella, and multiplex PCR panels available through private pathology providers in cities like Canberra and Darwin are reshaping the early phase of pneumonia assessment. A GP in western Sydney who can show a patient a CRP of 18 mg/L has a much easier conversation about why a script may not be needed.

  Chest imaging remains essential, particularly to rule out complications in older patients and those with comorbidities. Combined with careful clinical assessment, diagnostics turn the prescribing question from "which drug?" to "is a drug needed at all?" This shift sits at the heart of Australia's National Antimicrobial Stewardship Initiative, which has been quietly rolling out toolkits through Primary Health Networks for several years.

  Applying Australian Empirical Guidelines With Judgement

  The Australian Therapeutic Guidelines: Antibiotic provide a sensible, locally curated framework. For outpatients without comorbidities, amoxicillin remains the workhorse, with doxycycline or a macrolide reserved for atypical presentations. Patients with significant comorbidities step up to amoxicillin-clavulanate, often with a macrolide add-on, and those requiring admission move to intravenous ceftriaxone plus azithromycin at major centres like the Royal Brisbane and Women's Hospital.

  The harder calls involve patients who have already had recent antibiotics, those returning from Southeast Asia with potential exposure to multidrug-resistant organisms, and older residents of aged care facilities where local resistance patterns can be very different from the community average. Guideline-concordant care is a starting point, not a substitute for clinical reasoning and knowledge of local antibiograms.

  Vaccination as a Resistance-Reduction Strategy

  Every avoided case of pneumonia is a case that does not need an antibiotic. Pneumococcal vaccination, funded under the National Immunisation Program for older Australians, Aboriginal and Torres Strait Islander adults, and people with certain medical conditions, has measurably reduced invasive pneumococcal disease. Annual influenza vaccination further cuts the viral precursor that so often opens the door to secondary bacterial infection.

  GPs in places like Broome and Cairns report that conversations about vaccination with Aboriginal and Torres Strait Islander patients have become more nuanced and culturally safe, drawing on resources from the National Aboriginal Community Controlled Health Organisation. Stronger coverage, particularly in remote communities served by the Royal Flying Doctor Service, reduces both infection pressure and the need for empirical antibiotics where follow-up can be difficult.

  Special Populations Worth Thinking About Differently

  In remote and very remote areas, evacuation logistics mean that the threshold for admission and for broader-spectrum therapy is understandably lower. Telehealth links through the Royal Flying Doctor Service and state-based retrieval services support clinicians making these calls, but the local antibiogram and the patient's recent treatment history carry extra weight.

  Aged care deserves its own mention. Following the Royal Commission into Aged Care Quality and Safety, facilities have sharpened their focus on early recognition of deterioration and appropriate prescribing. Pneumonia in a 90-year-old resident of a Melbourne nursing home is a different proposition from the same diagnosis in a previously well 45-year-old visiting a walk-in clinic in Parramatta, and the antibiotic plan should reflect that.

  Stewardship That Extends Beyond the Hospital

  Antimicrobial stewardship is no longer the sole territory of infectious diseases physicians and pharmacists at tertiary hospitals. Primary Health Networks across Australia are funding practice visits, audit tools, and peer comparison dashboards so that GPs can see how their prescribing compares with that of their colleagues. The shift from a punitive audit culture to a supportive, data-driven conversation has been pivotal.

  Pharmacists in community settings, including those providing MedsChecks and participating in quality use of medicines programs maximised by Medicare, are also catching interactions, redundant prescriptions, and opportunities to de-escalate therapy. The combined effect of these small interventions, multiplied across millions of consultations, is what real-world resistance containment looks like.

  Practical Steps for Everyday Prescribers

  • Review recent antibiotic history before choosing empirical therapy and consider a delayed prescription strategy for low-risk patients.
  • Use point-of-care CRP where available to support a "no antibiotic" or "watchful waiting" decision in lower respiratory tract infections.
  • Check the current local antibiogram through your Primary Health Network or pathology provider, particularly in aged care or high-turnover settings.
  • Document the indication, review date, and intended duration clearly so the next clinician can stop or de-escalate treatment confidently.
  • Strongly recommend pneumococcal and annual influenza vaccination to eligible patients, framing it as part of the treatment plan.
  • Engage practice pharmacists and practice nurses in reviewing repeat prescriptions for older patients on long-term antibiotics.
  • Report unexpected treatment failures or unusual resistance patterns to your local public health unit to strengthen surveillance.

  The path forward in Australian respiratory medicine is not about rationing antibiotics or creating barriers for patients who genuinely need them. It is about using better diagnostics, sharper prescribing, and stronger prevention to keep community-acquired pneumonia manageable. Every script written thoughtfully, and every vaccination offered in a routine consult, is a quiet contribution to keeping common infections treatable for the next generation.

  Richard Russell Nuffield Department of Clinical Medicine, University of Oxford (United Kingdom)
• Mona Bafadhel King’s College London (United Kingdom)
  David Jackson Guy’s and St Thomas’ Hospital, King’s College London (United Kingdom)
• James Chalmers University of Dundee (United Kingdom)
  David Price University of Aberdeen (United Kingdom)