how to manage while this antibiotic is in short supply for children

Antibiotic shortages have become a big challenge for child health^[1]. For example, amoxicillin and cephalexin are among the most commonly prescribed antibiotics for children, used to treat a variety of bacterial infections. Both have had shortages of their liquid formulations^[2] in recent years.

Now, another common antibiotic – azithromycin^[3] – is facing liquid formulation shortages. Parents are having to shop around at multiple pharmacies to find the antibiotic their child needs.

According to the Therapeutic Goods Administration^[4] (TGA), the shortage is expected to last until late November.

So what’s causing these shortages, and what are the alternatives if you can’t get this medicine for your child?

First, what is azithromycin for?

Azithromycin^[5], sold under brand names including Zithromax, Zithro or just Azithromycin, is one of our most patient-friendly antibiotics. It requires a dose just once daily and the courses are short (usually five days or fewer). It works against a wide range of bacteria, and it’s formulated as a liquid and a tablet.

In childhood, azithromycin is used to treat respiratory illnesses such as pertussis^[6] (whooping cough) and Mycoplasma pneumonia^[7].

Following a lull in several infectious diseases^[8] during the COVID pandemic, pertussis^[9] is now surging^[10] among Australian children^[11]. Cases of Mycoplasma pneumonia^[12] have also increased in recent months^[13]. So it’s not a good time for azithromycin liquid to be in short supply.

Azithromycin is also very useful for children living in remote Indigenous communities. It may be used to treat wet cough^[15] or Strep A sore throats^[16] (caused by group A streptococcus bacteria). If these infections are not managed, they can lead to permanent lung damage or rheumatic fever.

Further, Australia is the only high-income country where trachoma^[17] exists. This eye infection affects people living in remote Indigenous communities and can cause blindness over time. Azithromycin is the only effective antibiotic^[18] to prevent blindness from this infection.

Supply chain issues

Recent reports^[19] suggest hundreds of medicines^[20] are in short supply in Australia. These shortages reflect complex global^[21] supply chains.

Manufacturing issues or sudden increases in demand are common reasons^[22] for medicine shortages. The TGA has cited^[23] an “unexpected increase in consumer demand” as the reason for the azithromycin shortage, so the sudden return of pertussis in Australia and globally^[24] may be behind it.

Of course, the shortages affect many medicines adults take too. But the issue disproportionately affects children^[25] because they rely on on syrups and liquids^[26], which are produced less commonly than tablets. Syrup or liquid formulations may have only a single approved supplier, whereas tablets are likely to have many.

So what if you can’t get the liquid formulation?

The alternatives to azithromycin have challenges. Clarithromycin^[27] requires twice-daily dosing, the liquid form tastes bitter and, in any case, this drug is also facing a shortage^[28]. Doxycycline^[29] only comes as a tablet and is not usually given to children under eight years.

For Strep A sore throats, the alternative to azithromycin is either a longer course of oral antibiotics (20 doses versus five doses^[30]) or benzathine benzylpenicillin (Bicillin L-A^[31]), a medicine given by injection. But this latter option is painful^[32] and also in short supply^[33].

The TGA has recently announced the temporary supply of a different brand of azithromycin liquid formulation^[34] registered overseas. Let’s hope this will ease supply problems over the coming months. It will also need leadership to ensure prices are reasonable.

Are tablets an option?

Shopping around while your child is sick is likely to be difficult and frustrating.

If you can’t find a liquid formulation and you think your child can swallow a tablet, ask your doctor whether they can prescribe the tablet form.

Parents can help children learn this skill^[35] by practising swallowing tic tacs, mints or other small, similarly shaped sweets.

Trying Panadol or Nurofen tablets when a child has a fever is another option to see if they can start to swallow tablets, so you are ready to transition.

Some children as young as three can do this, but it’s not generally recommended for children until age four^[36], and most learn after six or older.

Can I split a tablet?

Healthy childhood growth means the medication dose needed for each child is always changing. Syrups and liquids are easier to measure the correct amount required based on weight for individual children.

If the correct dose is either half or one-quarter of a tablet, azithromycin tablets can be split and crushed.

Splitting tablets is less accurate though. Splitting and crushing tablets also increases the bitter flavour that the outer coating of the tablet may mask.

Tricks to mask the bitterness include mixing the crushed tablet with a teaspoon of Nutella, jam or custard.

We need solutions

Antibiotic shortages can affect any child, including our most vulnerable children across Australia.

The interconnected global supply chains with limited producers of vital antibiotics are part of the problem. Alternative suppliers need to be rapidly sought.

Additionally, Australia needs better systems for monitoring the risks of stock shortages and communicating these to reduce the impact. Communication of medicine shortages in a timely, efficient and widespread way won’t solve the problem – but it will help clinicians, parents and families navigate these challenges.

References

1. ^{^} child health (theconversation.com)
2. ^{^} liquid formulations (insightplus.mja.com.au)
3. ^{^} azithromycin (www.abc.net.au)
4. ^{^} Therapeutic Goods Administration (apps.tga.gov.au)
5. ^{^} Azithromycin (www.ncbi.nlm.nih.gov)
6. ^{^} pertussis (www.schn.health.nsw.gov.au)
7. ^{^} Mycoplasma pneumonia (www.qld.gov.au)
8. ^{^} infectious diseases (www.ncbi.nlm.nih.gov)
9. ^{^} pertussis (nindss.health.gov.au)
10. ^{^} is now surging (www.abc.net.au)
11. ^{^} Australian children (www.theguardian.com)
12. ^{^} Mycoplasma pneumonia (www.health.vic.gov.au)
13. ^{^} recent months (www.abc.net.au)
14. ^{^} PeopleImages.com – Yuri A/Shutterstock (www.shutterstock.com)
15. ^{^} wet cough (www.telethonkids.org.au)
16. ^{^} sore throats (www.rhdaustralia.org.au)
17. ^{^} trachoma (www.kirby.unsw.edu.au)
18. ^{^} antibiotic (www.sahealth.sa.gov.au)
19. ^{^} reports (www.abc.net.au)
20. ^{^} hundreds of medicines (www.smh.com.au)
21. ^{^} global (theconversation.com)
22. ^{^} common reasons (www.tga.gov.au)
23. ^{^} has cited (apps.tga.gov.au)
24. ^{^} globally (theconversation.com)
25. ^{^} disproportionately affects children (insightplus.mja.com.au)
26. ^{^} syrups and liquids (www.nps.org.au)
27. ^{^} Clarithromycin (www.nps.org.au)
28. ^{^} facing a shortage (www.theguardian.com)
29. ^{^} Doxycycline (www.healthdirect.gov.au)
30. ^{^} 20 doses versus five doses (www.rhdaustralia.org.au)
31. ^{^} Bicillin L-A (www.healthdirect.gov.au)
32. ^{^} painful (www.sciencedirect.com)
33. ^{^} also in short supply (www.ahmrc.org.au)
34. ^{^} azithromycin liquid formulation (www.tga.gov.au)
35. ^{^} learn this skill (www.youtube.com)
36. ^{^} until age four (www.rch.org.au)
37. ^{^} New Africa/Shutterstock (www.shutterstock.com)