Some experts are encouraging clinicians to see the amoxicillin shortage through pink-colored glasses.
The ongoing shortage, which was first reported in October and was prompted by a surge in demand linked in part to influenza and respiratory syncytial virus (RSV), could be an opportunity for clinicians to refine their prescribing practices and avoid unnecessary and potentially harmful orders for the medication, they say.
Antibiotics are often prescribed to patients who do not need them. In many cases, patients’ symptoms are caused by viral infections, not bacteria, so antibiotics do not help.
Even when symptoms resolve after a patient takes an antibiotic, the drug may have had nothing to do with their improvement.
“Seems like a good time to remind people that the vast majority of respiratory infections are caused by viruses and that antibiotics like amoxicillin do absolutely nothing for them except give people diarrhea. Time to double-down on assessment; use antibiotics only when needed,” Jason Gallagher, PharmD, with Temple University School of Pharmacy in Philadelphia, posted on Twitter last week.
When antibiotics are not helping, they still may cause harm. Treatment with antibiotics entails risks for antibiotic resistance, infection with Clostridioides difficile, and side effects, such as rashes and ― as Gallagher noted ― diarrhea.
Dr Michael Cosimini
“They say ‘never let a good shortage go to waste,’ ” Michael Cosimini, MD, a pediatrician at Oregon Health and Science University, Portland, tweeted about the lack of amoxicillin last month.
Cosimini offered his thoughts about “improving our amoxicillin prescribing patterns” in pediatrics and encouraged colleagues to do so.
For example, he highlighted guidelines that state that antimicrobial therapy is not routinely required for preschool-aged children with community-acquired pneumonia (CAP) because most cases are caused by viral pathogens.
And trials show that when antibiotics are used for CAP, a shorter treatment duration, such as 5 days, rather than the standard 7 to 10 days, can be sufficient.
“As physicians, a shortage like this is an opportunity to do our best in the short term, as well as reflect on our current practice and make changes for the better in the long run,” Cosimini told Medscape Medical News.
Amoxicillin is the most commonly prescribed antibiotic in the outpatient setting and is the first choice among antimicrobial agents for common infections, such as otitis media, strep throat, and pneumonia, he said. “We use it frequently, so even small changes could go a long way to improve our prescribing practice,” Cosimini said.
Inappropriate Antibiotic Prescribing May Be Common
A 2021 statement on antibiotic stewardship from the American Academy of Pediatrics (AAP) declared that while antibiotics have saved countless lives, they can also cause harm and are frequently used inappropriately.
“One in 5 pediatric ambulatory visits result in an antibiotic prescription, accounting for nearly 50 million antibiotic prescriptions annually in the United States, at least half of which are considered inappropriate. [Acute respiratory tract infections] account for more than two-thirds of antibiotic prescriptions for children, at least one-third of which are unnecessary,” according to the society.
Outpatient antibiotic stewardship efforts could focus on clinical encounters in which the medications could be avoided altogether, the AAP suggests.
“Examples include antibiotic prescribing for nonspecific upper respiratory infection, bronchiolitis, acute bronchitis, asthma exacerbation, or conjunctivitis,” the group says.
Given the epidemiology of bacterial infections seen in ambulatory care settings that warrant antibiotic therapy, researchers conservatively estimate “that antibiotic prescribing could be safely reduced by 30%,” the statement notes.
That said, treatment decisions are not always clear cut.
“Certain infections in children, such as ear infections and lung infections, can be caused by viruses, bacteria, or both at the same time,” Cosimini said. “As such, it is very difficult to know which children benefit from which antibiotics.”
Watching, Waiting, Vaccinating
Pediatricians know that many children with ear infections will get better without antibiotics. “Parents should know that their doctor may suggest watching an ear infection without antibiotics, as is the recommendation from the AAP,” Cosimini said.
Data indicate that doctors are not following this practice as often as they could be, however, he said.
When antibiotic treatment is needed during the shortage, agents other than amoxicillin suspension can be used.
“Even though amoxicillin suspension is our go-to antibiotic for many infections, there are effective alternative options,” Cosimini said. “Children’s Hospital of Philadelphia has a good list for doctors looking for alternatives.”
Another approach to reducing the use of antibiotics in the future involves preventing infections through vaccination.
Research shows that routine childhood vaccines may have averted millions of respiratory and ear infections. And because bacterial infections can follow viral infections, the annual flu vaccine and COVID-19 vaccines “are also great tools to reduce antibiotic use,” Cosimini said.
A Turn to More Toxic Options?
The shortage of amoxicillin oral powder for suspension was reported by the US Food and Drug Administration and the American Society of Health-System Pharmacists (ASHP) in October.
On November 4, the Society of Infectious Diseases Pharmacists (SIDP) issued a statement on the amoxicillin shortage, noting that increased demand for the drug coincided with a surge in respiratory viral infections, including RSV and influenza, among children.
“Though supportive care is the mainstay of treatment for viral infections, antibiotics may be indicated for the treatment of superimposed bacterial infections, including pneumonia and acute otitis media,” the SIDP statement says. “While alternative antibiotics may be available depending on the indication, many have a broader spectrum of activity, increased toxicity, and excess cost relative to amoxicillin. Furthermore, it is anticipated alternatives may soon become in short supply as well, given increased usage.”
SIDP “encourages the judicious use of antibiotics” and supports watch-and-wait strategies and the use of the shortest effective duration of therapy when appropriate.
Michael Ganio, PharmD, senior director of pharmacy practice and quality for ASHP, monitors around 250 drug shortages at any given time.
The amoxicillin shortage, while not “overly worrisome,” stands out because of how widely the drug is used and the fact that the shortage appears to have been sparked by an increase in demand rather than supply chain or manufacturing quality problems that more typically lead to shortages, he said.
Unlike some other shortages, the amoxicillin shortfall largely does not involve disrupting a medication regimen that someone was already receiving, and substitutions should be available.
“That said, it’s very, very disruptive to parents or a caregiver when you have a sick child who needs an antibiotic and it’s not available,” Ganio said.
Can a Poster Change Practice?
In an unrelated move, the US Agency for Healthcare Research and Quality last month published new resources and strategies to reduce inappropriate antibiotic use in ambulatory care settings.
One of the tools is a poster that doctors can print and hang in their office. It states: “We commit to only prescribing antibiotics when they will help you. Taking antibiotics when you do not need them will NOT make you better. You will still feel sick, and the antibiotic may give you a skin rash, diarrhea, or a yeast infection.”
Jeffrey A. Linder, MD, MPH, a general internist and researcher at Northwestern University’s Feinberg School of Medicine in Chicago, helped develop some of the approaches to improve prescribing practices in primary care.
Linder explained on a recent episode of the Freakomics, M.D. podcast that the poster can be key.
One reason clinicians may prescribe antibiotics inappropriately is because they assume ― perhaps erroneously ― that patients want and expect them. By addressing the issue up front by displaying the poster, they may be able to “short circuit” that type of thinking.
A minority of patients do expect antibiotics. “But the vast majority of patients are thinking, ‘I don’t feel well, I want to know what’s going on, and I want to know how to feel better and what’s going to happen.’ “
For their part, patients can tell their doctor that they only want an antibiotic if they really need it, Linder said.
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