Substitution advice for antibiotics in shortage

3 minute read

Temporary advice from Therapeutic Guidelines provides alternative options when first-line treatments are unavailable.

GPs have been issued detailed advice on antibiotics to use if the first-line treatment isn’t available, amid ongoing shortages.   

The new guide by Therapeutic Guidelines addresses current shortages for antibiotics such as amoxicillin plus clavulanic acid, cefaclor, cefalexin, phenoxymethylpenicillin, sulfamethoxazole and trimethoprim. 

Alternatives for each condition in the guideline are listed in order of preference based on antimicrobial stewardship principles, and it states that the decision on which to use comes down to availability and clinical judgement. 

“Only consider prescribing the listed alternatives 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,” it notes. 

“Shortage of oral liquid formulations of some antibiotics is particularly an issue,” it adds. “To enable the preferred antibiotic to be used in children when an oral liquid formulation is not available, the summary table also includes temporary advice developed by The Society of Hospital Pharmacists of Australia, from Don’t Rush To Crush, on the suitability of crushing or dispersing oral solid-dose formulations.” 

Other recommendations that may affect children were: 

  • Acute otitis media in children: the guide confirms that while it’s generally preferred not to use antibiotics unless needed, amoxicillin is first line treatment if they are. If amoxicillin is not available, then prescribe cefuroxime, cefalexin, trimethoprim plus sulfamethoxazole or amoxicillin plus clavulanate in that order of preference. 
  • Acute pharyngitis/tonsilitis in children at risk of rheumatic heart disease and rheumatic fever – first line antibiotic is phenoxymethylpenicillin or benzathine benzylpenicillin; then amoxicillin, cefalexin, cefuroxime in that order of preference. 
  • Community acquired pneumonia in children: first line is amoxicillin; then cefuroxime, azithromycin, clarithromycin or doxycycline in that order of preference. 
  • Infected bites and other wounds caused by teeth (including human, cat, dog): first line is amoxicillin+clavulanate; if not available, then metronidazole plus doxycycline or trimethoprim+sulfamethoxazole; or ciprofloxacin plus clindamycin; or moxifloxacin. 
  • Erysipelas without systemic symptoms: first line is phenoxymethylpenicillin; then dicloxacillin or flucloxacillin; then cefalexin or clindamycin. 
  • Cellulitis without systemic symptoms:
    • If Streptococcus pyogenes is suspected based on clinical presentation: first line is phenoxymethylpenicillin; then dicloxacillin or flucloxacillin; cefalexin or clindamycin. 
    • If Staphylococcus aureus is suspected based on clinical presentation: first line is dicloxacillin or flucloxacillin – neither of these is in shortage. 

Current advice on supplies indicated that (depending on the form and dosage) cefaclor should start to become available from October, and cefalexin and phenoxymethylpenicillin from late July. 

The guidance was developed by the Antibiotic Primary Care Expert Group in consultation with the Department of Health and Aged Care and the TGA. 

There are Serious Scarcity Substitution Instruments (SSSI) in place for cefaclor, cefalexin and phenoxymethylpenicillin, allowing pharmacists to dispense another dosage form or strength of the same antibiotic, without requiring the prescriber’s approval. 

Amoxicillin products, which were in short supply until recently, are now returning to the shelves and most brands are available. The SSSI for amoxicillin has now lapsed. 

Dosage instructions are provided in the summary table, with more detailed advice available on the Therapeutic Guidelines website

Antibiotic prescribing in primary care: Therapeutic Guidelines summary table 2023 

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