My Oh My! Antibiotics in Short Supply!

Column Author: Annie Wirtz, PharmD, BCPPS | Co-Director, Antimicrobial Stewardship Program; Clinical Pharmacy Specialist, Infectious Diseases

Column Editor: Rana El Feghaly, MD, MSCI | Director, Clinical Services | Director, Outpatient Antibiotic Stewardship Program | Associate Professor of Pediatrics, UMKC School of Medicine

Antibiotics are one of the medication classes most frequently impacted by drug shortages. Drug shortages, defined as a period where the demand for a medication exceeds the available supply, can occur due to manufacturing challenges, overuse or natural disasters.¹ The federal Food and Drug Administration publishes a list of current and resolved shortages which can be accessed here.

In fall 2022, prescribers were plagued by shortages of commonly prescribed oral antibiotics, such as amoxicillin, mostly stemming from overuse during the concurrent respiratory viral surge.² Not only were the shortages challenging for prescribers and pharmacists, but they were also frustrating to parents who were unable to find antibiotics to fill their child’s prescription. Therefore, as pediatric prescribers, it is important to know how to make periods of antibiotic shortages easier to navigate for ourselves and the families we serve.

Get creative in administering antibiotics! Often while antibiotic liquids are in short supply, capsule or tablet formulations are more readily available. For older patients, consider whether pill swallowing is possible. Children’s Mercy Child Life offers many tips and instructions for pill swallowing. Consider stocking different sized candies for pill swallowing practice in appropriate patients before prescribing. There are special cups that can be purchased to make pill swallowing easier and less noticeable.  

Alternatively, consider whether antibiotic tablets can be crushed, or capsules opened. While off-label, this approach may be appropriate in certain situations. For example, amoxicillin capsules may be opened and sprinkled on a small amount of food for administration.³ Prescribers should be aware of which antibiotics should not be manipulated as manipulating some drugs may decrease efficacy or cause adverse effects. For example, antibiotics that are extended release, such as amoxicillin/clavulanate XR tablets, should not be crushed as this interferes with absorption. In addition, some antibiotics are less palatable if crushed, such as cefuroxime tablets, which are bitter. Finally, some dosage formulations are potentially hazardous when crushed, such as valganciclovir tablets.⁴ Information on administration options and available capsule/tablet sizes can be found in various drug information resources or on the package insert.

Know your best alternatives. During times of severe shortage, alternative antibiotics may need to be prescribed. The Children’s Mercy Outpatient Antibiotic Handbook is a publicly available resource that includes alternative antibiotic options to treat common pediatric infections. Often, these alternatives may be more costly, challenging to find at all local pharmacies, or have more adverse effects or a broader antibiotic spectrum of activity than necessary.¹ For example, while oral cephalosporins such as cefuroxime, cefpodoxime or cefixime are great agents for pneumonia or urinary tract infections (UTIs), they are not readily stocked by all pharmacies or covered by all insurances. Fluoroquinolones have a broad coverage and work for many infections but are associated with many adverse effects. Prescribers should select the most appropriate alternative based on infection and patient-specific factors. It is important to counsel patients and caregivers who are being prescribed a less familiar antibiotic.

An important component of managing antibiotic shortages is conserving use for the right patients and avoiding unnecessary prescribing. Use of watchful waiting for acute otitis media is an excellent treatment strategy that may save families the headache of hunting down available antibiotic supply. Prescribers often report feeling pressured to prescribe antibiotics, but recent data has shown that most parents do not plan to request antibiotic prescriptions but instead want assurance their child will improve.⁵ Available discussion tactics may help frame conversations with families when antibiotics are not needed.

Double check your dose and duration. When prescribing, ensure that the right dose and shortest duration are selected for the infection type. Avoid using higher-dosing strategies for infections when lower dosing may be adequate. For example, high-dose amoxicillin (80-100 mg/kg/day) is necessary for infections only when Streptococcus pneumoniae is a pathogen of concern (e.g., otitis media, pneumonia). Use for UTIs or streptococcal pharyngitis do not require high dose. Also, prescribe the shortest duration that is appropriate for that infection. For example, a duration of five days has been found to be adequate for uncomplicated community-acquired pneumonia or skin and soft tissue infections.^7,8  

While prescribing antibiotics during periods of shortage can be frustrating, these shortages may provide opportunities to improve antibiotic prescribing and care. Having an open dialogue with families and clearly outlined back-up plans during periods of shortages can be helpful for all parties involved.  

References: 

1. Urban V, Lee BR, Goldman JL, Duty A, Wirtz AL. Adherence to antimicrobial agent recommendations and utilization during drug shortages. Am J Health Syst Pharm. 2022;30;zxac355. 
2. SIDP statement on amoxicillin shortages and respiratory virus infections in the United States. Society of Infectious Diseases Pharmacists. Published November 4, 2022. Accessed May 22, 2023. https://sidp.org/news/12978701  
3. Amoxicillin shortage: antibiotic options for common pediatric conditions. American Academy of Pediatrics. Updated November 21, 2022. Accessed May 22, 2023. https://www.aap.org/en/pages/amoxicillin-shortage-antibiotic-options-for-common-pediatric-conditions/  
4. Oral medications that should not be crushed or altered. Lexi-Drugs. Hudson, OH: Lexicomp, 2015. Updated May 18, 2023. Accessed May 22, 2023. https://online.lexi.com/lco/action/doc/retrieve/docid/pdh_f/130347  
5. Szymczak JE, Klieger SB, Miller M, Fiks AG, Gerber JS. What parents think about the risks and benefits of antibiotics for their child’s acute respiratory tract infection. J Pediatric Infect Dis Soc. 2018;7(4):303-309. 
6. Amoxicillin. Lexi-Drugs. Hudson, OH: Lexicomp, 2015. Updated May 20, 2023. Accessed May 22, 2023. https://online.lexi.com/lco/action/doc/retrieve/docid/pdh_f/129550 
7. Hamner M, Nedved A, Austin H, et al. Improving duration of antibiotics for skin and soft tissue infections in pediatric urgent cares. Pediatrics. 2022;150(6):e2022057974. 
8. Kuitunen I, Jaaskelainen J, Korppi M, Renko M. Antibiotic treatment duration for community- acquired pneumonia in outpatient children in high-income countries – a systematic review and meta-analysis. Clin Infect Dis. 2023;76(3):e1123-e1128.