Faced with the threat of antimicrobial resistance, health workers are urged to reduce unnecessary prescription of antimicrobials. Clinical guidelines are expected to form the basis of prescribing. Emerging through evaluations of best practice, guidelines also create benchmarks to assess practice with metrics. To understand the relationships between guidelines and practice in the prescribing and dispensing of antibiotics, ethnographic fieldwork was undertaken in lower-level health care facilities in rural Eastern Uganda for 10 months between January and October 2020, involving direct observations during and outside of clinics and interviews with staff. In a context of scarcity, where ‘care’ is characterised by delivery of medicines, and constituted beyond algorithmic outputs, we observed clinical practice as shaped by availability of resources, and professional and patient expectations, as much as by clinical guidelines.