Rising infections lead to global shortage of antibiotics

A spike in bacterial infections after countries lifted pandemic restrictions has led to shortages of antibiotics such as penicillin and amoxicillin, highlighting the precarious state of global supply chains.

Of the 35 countries whose data the WHO collects, 80 percent have some kind of antibiotic shortage related to amoxicillin, said Lisa Hedman, leader of the WHO’s drug supply and access group. The United Kingdom submitted “Serious shortage protocols” last week that allowed pharmacists to prescribe alternative formulations of antibiotics after an increase in infections such as group A strep.

During the pandemic, lower demand for antibiotics, combined with tight supply chains, led drugmakers to reduce production. But as many countries experience their first unrestricted winter in two years, supply pressures and regulatory requirements are making it difficult for companies to grow and alleviate shortages, health experts said.

The shortage has also occurred because “the countries did not anticipate that they were going to give us respiratory infections [so hard] in the first year without masks,” Hedman said.

Where have shortages been reported?

Shortages of amoxicillin have been reported in the US and Canada, while in the EU, 25 out of 27 member states have reported short supplies of some antibiotics to the European Medicines Agency.

The impact on poorer or smaller countries is less well known, but they may be disproportionately affected, especially if their currencies have depreciated and they need to buy medicines on the open market, Hedman said.

Although the volumes may be small compared to use in developed countries, they are far from negligible. Dušan Jasovský, a pharmacist with the aid group Médecins Sans Frontières, said an estimated 5.7 million people die annually due to lack of access to antimicrobials, which include antibiotic, antifungal and antiviral drugs.

A vial of intravenous antibiotics: shortages have been reported in the US, Canada and Europe © Gado/Getty Images

Fear of raising prices acts as a “disincentive” to report shortages publicly and to the WHO, Hedman added.

Some US and European pharmacists have also reported shortages of common pain-relieving drugs such as acetaminophen as a winter wave of flu, respiratory syncytial virus (RSV) and covid-19 cases fuel demand . Ilaria Passarani, secretary general of the European Union Pharmaceutical Group, said drugs to treat infections such as tuberculosis and skin infections have also been affected.

What is causing the deficit?

Shortages of medicines, ranging from cancer drugs to anesthetics, were common at the height of COVID-19, highlighting the strain on supply chains. The war in Ukraine has further disrupted the supply of antibiotic ingredients, while rising energy costs have squeezed margins for antibiotic manufacturers.

Adrian van den Hoven, director general of the association of generic drug manufacturers Medicines for Europe, said that after two years of lockdowns it would have been difficult for antibiotic manufacturers to accurately predict the increase in demand this winter for treatments such as the solutions liquid antibiotics for children .

“A higher infectious season can be predicted, but the very high rate in children cannot be predicted,” he said.

MSF’s Jasovský said the out-of-stocks of antibiotics were “minor symptoms” of a broader “systemic challenge” affecting the entire chain from wholesalers, final-dose formulators and original manufacturers.

Number line chart showing the UK has increased medicines that cannot be exported or hoarded

Most of the world’s active pharmaceutical ingredients now come from India and China instead of Europe, he said. And there is “little transparency” regarding these materials because production processes around the world are considered proprietary information that is only visible to regulators. That “makes it difficult to do a true risk assessment to determine the areas of greatest vulnerability,” she said.

The antibiotic supply chain can take anywhere from four to six months from production to distribution. But Rajiv Shah, chief executive of UK-based wholesaler Sigma Pharmaceuticals, said the added regulatory controls meant it took longer for drugmakers to restart lines that were halted when production was curtailed during the pandemic.

Can the shortcomings be fixed?

Sandoz, one of the biggest makers of generic antibiotics, said it had increased drug production by a double-digit percentage in 2022, hiring 140 new people since September. Next year he planned to do the same, opening a factory in Austria.

But the Novartis-owned company is coming under pressure from rising costs, which are harder to pass through in the European markets that border drug prices, adding that its Asian competitors have access to cheaper fuel sources for the energy-intensive process. Costs have also skyrocketed for other essential ingredients like sugar for fermentation, an important part of the manufacturing process.

Line chart of the number of medicines whose procurement costs have risen for the UK government showing rising spikes in medicine prices suggesting greater shortages

“You can’t just throw a few extra cakes in the oven,” said the WHO’s Hedman. “When you make an antibiotic, you have to shut down and revalidate your equipment before making another. . .[shortages]it can take months to correct it.”

PGEU’s Passarani said solutions include forcing drugmakers to seek European authorization to market their medicines in all member states and creating a redistribution mechanism during a crisis.

Jasovský, the MSF pharmacist, said sharing mechanisms between countries, companies and multilateral organizations should be introduced and more should be done to diversify manufacturing capacities and improve transparency, data sharing and forecasting.

Is there a risk that shortages will increase antimicrobial resistance?

Doctors often prescribe “limited-acting” antibiotics to prevent the emergence of treatment-resistant superbugs, a growing phenomenon known as antimicrobial resistance. By targeting specific bacteria, the practice reduces the likelihood that infections will become resistant to antibiotics.

But the lack of availability of some antibiotics means that doctors and pharmacists can dispense other classes of antibiotics with a broader range of action, which are generally reserved for infections that are not cured by first-line antibiotics.

Lorenzo Moja, a scientist working on the WHO essential medicines list, said it was typical for doctors to overprescribe antibiotics for mild infections in the colder months, so the shortage is “causing additional problems in terms of endurance”.

This risks what Moja calls prescribing “inertia,” where some doctors find it difficult to re-prescribe specific antibiotics once shortages subside, threatening a proliferation of more intractable errors.

Additional reporting by Jamie Smyth in New York

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