Antibiotic shortages hit general practices

For RACGP Rural Chair Associate Professor Michael Clements, the current antibiotics shortages remind him of places far removed from his Townsville general practice.
 
‘The only time I’ve personally experienced having to make decisions like this was when I was in the military,’ he told newsGP.
 
‘When I was overseas, it would make sense that we would deploy with a limited number of medications, and so we had to choose second and third best choices for our patients, but that was understandable.’
 
However, with the Therapeutic Goods Administration (TGA) flagging shortages for a rising number of commonly prescribed antibiotics, including amoxicillin, cefalexin and metronidazole, Associate Professor Clements says new challenges are emerging for general practice.
 
‘Not only are we trying to follow appropriate guidelines and give the most appropriate medication to our patients, we now have to balance that with an up-to-date knowledge of stock and supply issue shortages,’ he said.
 
‘We’ve been blessed up to this stage of having good access to the medications that are appropriate.’
 
This month, the TGA declared a Serious Scarcity Substitution Instrument (SSSI) for most oral amoxicillin medications due to ‘manufacturing issues at a major supplier leading to unexpected increases in demand for alternative suppliers’ – a shortage mostly affecting paediatric prescriptions.
 
The SSSI is provisionally in place until 31 May 2023, allowing pharmacists to provide a substitute amoxicillin medication without prior approval from the prescriber when the prescribed one is unavailable.
 
The TGA advises prescribers to ‘consider the current shortage of amoxicillin when prescribing’ but ‘to continue to follow best-practice prescribing’.
 
It also warns prescribers not to alter prescribing practice to second-line antibiotic treatments ‘without strong clinical indications for doing so’, as well as advising them to be aware patients could be offered a substitute product.
 
Associate Professor Magdalena Simonis, a member of the RACGP Expert Committee – Quality Care (REC–QC), is sanguine about the current supply situation.
 
‘It’s not desperate at this stage, we’ve got a good range of antibiotics that we can choose from,’ she told newsGP.
 
However, she has noted an increase in the amount of time dealing with changes to medications and notes the importance of good communication in the circumstances.
 
‘It just represents again the importance of that interaction of the pharmacist with the GP … and how that needs to be upheld,’ Associate Professor Simonis said.
 
‘You don’t want to be in a situation [where] the pharmacist makes a decision without discussing with the GP.
 
‘Certainly, if you’ve had someone who’s had multi-resistant urinary tract infection, you want to make sure that you’re selecting the right substitute for that patient, and that requires conversations.’
 
As well as amoxicillin, Associate Professor Clements reports his Townsville practice being affected by a shortage of trimethoprim, commonly prescribed for UTIs.
 
He says the shortages could be helpful in shifting focus away from antibiotic prescription.
 
‘We need to work harder about antibiotic stewardship, we need to think more about whether we can manage with non-pharmacological means,’ he said.
 
‘There are many infections that perhaps will get better without antibiotics. Otitis media is a good example of that, and perhaps these shortages will prompt us to be stricter.’
 
Associate Professor Clements also raises concerns with pharmacy prescribing.
 
‘At the same time we’re dealing with shortages, we’re dealing with antibiotic stewardship and trying to prescribe less and less, we’ve had state governments looking to expand use of these drugs in cases where there’s no clinical evidence to prove that such an antibiotic would be necessary,’ he said.
 
There have also been significant increases in demand, as well as supply issues, reported for certain antibiotics overseas, including the UK and the US.
 
According to Associate Professor Clements, the current situation may have longer-term implications for clinical care if it continues.
 
‘We’ve got to remember that our therapeutic guidelines have been largely based on what’s been available,’ he said.
 
‘It may now mean that if these shortages are going to continue, then we need to look at how our guidelines are written and to make sure that we’ve got alternatives.’
 
Further government intervention, including more local manufacturing of medications, may be needed to mitigate supply issues, Associate Professor Clements suggests.
 
‘One of my questions to [the TGA or Department of Health], is “what’s the plan?”’ he said.
 
‘I haven’t seen much written yet in terms of whether this is just the way things will be forever, or if this is a short-term effect.
 
‘I’d like to get insight into that, so that we can adjust and plan from there.’
 
Outside of those antibiotics, other high-profile shortages include a shortfall of diabetes medications such as semaglutide (sold as Ozempic) and dulaglutide (sold as Trulicity).
 
The TGA is currently reporting shortages for 361 medications, of which 48 are critical.
 
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