Antibiotic Shortages in Pediatrics

Medication shortages are increasingly common and severe in the United States and are a serious health threat. Medication shortages occur when reduced supply of a drug influences how it is prepared, dispensed, or prescribed by pharmacies or providers.¹ According to the US Food and Drug Administration (FDA), most shortages are caused by quality and manufacturing problems.² Consequences of shortages include rationing limited supplies, delays in therapy, medication errors, use of less-efficacious alternatives, and death.³ Recently, critical drugs like sodium chloride and amino acids have been on shortage, exacerbated by damage to manufacturing plants by natural disasters like Hurricane Maria. Although shortages have affected virtually all classes of medications, antimicrobial shortages are common and account for 15% of all drug shortages.^1,4 

Medication shortages can force clinicians to treat patients with suboptimal therapy, which, in turn, can lead to poor outcomes. Examples relating to antimicrobial agents are when a penicillin shortage led to use of second-line therapies for neurosyphilis, an intravenous trimethoprim-sulfamethoxazole shortage led to alternative therapies for Pneumocystis jiroveci infections, an acyclovir shortage led to use of alternative antiviral therapy for herpes encephalitis, and shortage of amikacin led to alternative antibiotic combinations for multidrug-resistant Gram-negative infections. Most infectious disease physicians surveyed through the Emerging Infections Network reported that antibiotic shortages had adversely affected patient outcomes in their practice because of use of inferior, more-toxic, or costly alternatives.¹ A recent shortage of piperacillin-tazobactam affected 88 of 107 hospitals in the MedMined Clinic Research Database and led many institutions to prescribe alternative antibiotics in place of piperacillin-tazobactam.⁵ Hospitals that used more alternative antibiotics had higher rates of hospital-onset Clostridium difficile infection among adult patients.⁵ Few evaluations of the impact of antimicrobial shortages on children have been performed. During a recent cefepime shortage, many pediatric institutions recommended the use of piperacillin-tazobactam in place of cefepime. At 1 children’s hospital, this resulted in higher rates of acute kidney injury, which is associated with piperacillin-tazobactam and vancomycin combination therapy.⁶ 

The number of companies supplying the third-generation cephalosporin, cefotaxime, has dwindled in recent years until only 1 company was supplying cefotaxime by 2016, as reported by the American Society of Health System Pharmacists drug shortage Web site.⁷ Other companies that previously supplied cefotaxime made a business decision to discontinue production because of an increase in the price of the raw materials. The single-remaining supplier was unable to keep up with the demand for cefotaxime, leading to a national shortage.

The cefotaxime shortage has disproportionately affected infants, compared with older patients. This is because a comparable cephalosporin, ceftriaxone, that can be used in older children, is generally not used in infants <2 months of age because of increased risk of kernicterus and calcium-ceftriaxone vascular deposits. Because of limited supply, the American Academy of Pediatrics recommended in February 2015 that clinicians use ceftazidime in place of cefotaxime in infants <2 months of age with proven or suspected infections because of Gram-negative bacilli, particularly meningitis.⁸ Use of broad-spectrum therapies in place of cefotaxime may select for drug-resistant bacteria and have adverse consequences on patients’ microbiomes. At each of our institutions, the cefotaxime shortage has led to restricted indications for its use and review of alternative regimens.

To examine the impact of the cefotaxime shortage on hospitalized children nationwide, we evaluated cefotaxime use, a surrogate for drug availability, among children’s hospitals within the Pediatric Hospital Information System network. The change in cefotaxime use was quantified for each hospital between 2014 and 2015 and 2016 through quarter 2, 2017. Cefotaxime use declined by 81%, from 28.8 to 5.6 days of therapy per 1000 patient days between 2014 and 2017, while replacement antibiotic use increased (Fig 1). However, the shortage was not experienced equally among hospitals. There was great variation in the extent to which cefotaxime use declined, for all hospitalized children and for infants <60 days of age with a diagnosis of meningitis (Fig 2).

In the United States, medication shortages are common but may not affect all hospitals equally. An example of inequity is demonstrated by the ongoing cefotaxime shortage, which has led to decreased use of cefotaxime in pediatric hospitals. However, when evaluated at the institutional level, there was significant variation in use (and by implication, uneven availability) of cefotaxime among individual hospitals.

Variation in supplies of critical medications may be due to differences in patient populations, drug use patterns, supply chain management, existence of antimicrobial stewardship programs, and restrictions on use of short-supply drugs. In 2011, the IMS Institute for Healthcare Informatics reported that some states are impacted more than others by drug shortages and attributed this to differences in per capita usage of short-supply products.⁴ This variability in drug shortage impact seems unjust. More research is needed to identify optimal strategies for preventing and managing shortages of critical medications, which are likely to continue.

The extent to which medication shortages have affected outcomes in children should be better evaluated. The shortages of antimicrobial agents are especially problematic given that fewer antimicrobial agents are FDA approved for use in neonates, infants, and children, compared with adults, and finding safe, alternative agents during shortages is therefore challenging. Antimicrobial stewardship champions frequently manage the rationing of short-supply drugs and are valuable resources during medication shortages, even for classes other than antimicrobial agents. Stewards have substantial experience in helping to prioritize patients who should receive agents with limited supply, identifying therapeutic alternatives, developing clinical guidelines that incorporate alternative therapies, and communicating with providers about shortages and judicious prescribing. Additionally, antimicrobial shortages may lead to unintended consequences that have benefits. These include opportunities for more judicious antimicrobial use, wider stewardship efforts, and evaluation of replacement drug safety in pediatric populations (eg, ceftriaxone use in young infants).

There must be interventions to address the problem of critical medication shortages, including increased awareness of the problem and more advocacy and political will to increase FDA oversight of the manufacturing of critical medications. Manufacturers should be required to disclose to the medical community their manufacturing sites, products, and volume, and sole-source medications should not be produced in a single plant. Direct government involvement in the manufacturing of critical medications should be explored. Lastly, manufacturers should receive incentives to continue making products like antibiotics, for which there are small markets, because although these drugs may not be profitable, they are lifesaving.

 
• FDA

  US Food and Drug Administration