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New advice for ‘unprecedented’ antibiotics shortage


Jolyon Attwooll


10/07/2023 4:32:13 PM

With ongoing supply issues, Therapeutic Guidelines has released a guide for prescribers on alternatives in the absence of first-line therapies.

amoxicillin
There are a number of antibiotics, including amoxicillin (pictured above), that have been in short supply since the pandemic began. (Image: AAP Photos)

New advice designed to guide prescribers during the current shortage of certain key antibiotics has been published by Therapeutic Guidelines.
 
Developed by the Antibiotic Primary Care Expert Group, the information is now in the Therapeutic Guidelines’ primary care summary table, which is designed to support antimicrobial stewardship.
 
‘Following the COVID-19 pandemic, several antimicrobials used to treat infections in primary care are in short supply, causing significant challenges in practice with implications for patient safety and antimicrobial stewardship,’ the Therapeutic Guidelines website states.
 
It said the advice was put together in consultation with the Department of Health and Aged Care (DoH) and the Therapeutic Goods Administration (TGA).
 
According to Therapeutic Guidelines, the alternative antibiotics in the primary care summary table ‘should only be considered if first-line treatment is unavailable as the alternatives may be less efficacious, have a suboptimal spectrum of activity and have a less favourable harm–benefit profile’.
 
The table, designed as a reference for managing common conditions, states that the new advice lists alternative antibiotics in order of preference ‘based on antimicrobial stewardship principles’.
 
‘The decision on which alternative antibiotic to use in an individual patient depends on availability and patient-specific factors,’ it says.
 
Antibiotic shortages recently highlighted by the TGA include amoxicillin, cefalexin, phenoxymethylpenicillin, sulfamethoxazole, and trimethoprim among others.
 
Melanie Rosella is an editor at Therapeutic Guidelines who coordinated the advice from the Antibiotic Primary Care Expert Group.
 
She told newsGP that the new guidance is not intended to be permanent.
 
‘The summary table will continue to be updated as the antibiotic guidelines are updated; however, the additional column on alternatives to use if there is a shortage of first-line therapy is only temporary,’ she said.
 
‘We are hoping to remove this advice once the current unprecedented situation of multiple concurrent shortages resolves.
 
‘We are liaising with the TGA for the signal to remove this advice.’
 
Ms Rosella said the main Therapeutic Guidelines website should remain prescribers’ principal reference point.
 
‘This product provides detailed and up-to-date advice including second-line treatment options and management of special patient groups, [such as] penicillin hypersensitivity,’ she said.
 
‘The summary table is intended to be a quick reference guide, highlighting infections that are particularly relevant to primary care, including those which are self-limiting and/or have a viral aetiology and do not need antibiotics.’
 
Several infections where symptomatic treatment is often most appropriate, such as rhinosinusitis, otitis media in children, pharyngitis, and bronchitis, are included in the table.
 
Ms Rosella said it is important to be aware of variations in antibiotic stock levels and advised checking with local pharmacies before prescribing an alternative to first-line therapies.
 
‘The pharmacist can also assist with navigating alternative access pathways to obtain first-line therapy,’ she said.
 
She also acknowledged that details for specific conditions in the main Therapeutic Guidelines advice do not include references to shortages.
 
‘The expert group writing for the antibiotic guidelines have always felt it was not appropriate to include alternatives specifically for use in a shortage situation in the guidelines, to avoid detracting from first-line therapy and antimicrobial stewardship principles,’ she said.
 
‘For some infections, second-line treatment options and options for special patient groups are given in the guidelines and these options may be considered as an alternative to first-line therapy in a shortage situation, but have not specifically been selected for this purpose.
 
‘For example, for erysipelas without systemic symptoms, phenoxymethylpenicillin is recommended first-line, and cefalexin is recommended for most patients with delayed non-severe hypersensitivity to penicillins.
 
‘However, if phenoxymethylpenicillin was in shortage and the patient did not have penicillin hypersensitivity, dicloxacillin or flucloxacillin are the preferred alternatives because they are effective against the relevant pathogen [Streptococcus pyogenes] but have a narrower spectrum of activity than cefalexin.’
 
Ms Rosella also stresses that many of the products affected by the current supply shortage are oral liquid formulations aimed at children.
 
She says that in some cases it may still be possible to prepare a liquid using an oral tablet or capsule, and pointed to the Don’t Rush to Crush resource – developed by the Society of Hospital Pharmacists of Australia – for further advice.
 
‘GPs can liaise with the patient’s local pharmacist about the suitability of this approach for an individual patient, to enable administration of first-line therapy,’ she said.
 
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