Liquid amoxicillin shortage causes concern, doctors say, but there are alternatives

Doctors and pharmacists said they’re concerned about a national shortage of the liquid form of the antibiotic amoxicillin — which is commonly prescribed for children’s infections — but they say alternatives can be just as effective.

Doctors say tablets and capsules can be converted into a liquid form, or other antibiotics can be prescribed, so the shortage shouldn’t affect care. But some medical professionals may not be following those guidelines, potentially leading to complications, experts say.

Dr. Eve Meltzer Krief, with Huntington Village Pediatrics, said her staff sometimes calls multiple pharmacies to find the liquid form of amoxicillin, which is the version most common for children, who can’t swallow large capsules or tablets, which would also be choking hazards.

"In 25 years of practice, we’ve never had a shortage of amoxicillin before,” she said.

Amoxicillin is widely prescribed for adult and pediatric bacterial infections, although not for viral infections like the flu, respiratory syncytial virus (RSV) or COVID-19.

But Meltzer Krief said the large number of those viral infections this season, as well as of the common cold, may be a reason for the increased demand for amoxicillin. Viral infections can lead to bacterial infections, such as ear or sinus infections, or bacterial pneumonia, she said.

Meltzer Krief worries about an increase in viral infections — including of COVID-19 — in the weeks to come, and that could lead to more bacterial infections, she said.

Northwell Health has “some supply” of liquid amoxicillin, but it’s “very difficult to get” and “the supply chain is not in a good place,” said Lisa Mulloy, Northwell’s chief pharmacy officer.

“The capsules are still available,” she said. “They are just smaller allocations. Because they [suppliers] know the suspension [liquid] is not available, they’re pacing themselves with allocation of the capsules.”

Other approaches

Pharmacists can grind tablets and then reconstitute the resulting powder with sterile water to create a liquid, Mulloy said. They can also give instructions to create liquid forms of the drug at home, including by opening up capsules, she said.

The American Academy of Pediatrics on Monday recommended that pediatricians who can’t find the liquid prescribe the tablets or capsules, which can then be crushed or opened and mixed with liquids or foods like applesauce; or chew tabs, which can be split. The academy also issued guidance for alternative drugs for certain conditions.

Dr. Jennifer Lighter, a pediatric infectious disease specialist and director of the pediatric antimicrobial stewardship program of NYU Langone Health, recently issued guidance to pediatricians about similar approaches.

But, she said, last week a child was hospitalized at an NYU Langone hospital in Manhattan with a bone infection after the family couldn’t find liquid amoxicillin that had been prescribed for strep throat. The bacteria had traveled through the child’s blood and infected the bones, she said.

“This is not common, but this can happen when prescriptions aren’t filled,” Lighter said. “But that should not have happened because the family could have been prescribed an alternative antibiotic, or another formulation of amoxicillin could have been filled.”

Although some pharmacies have run out of liquid amoxicillin, others still have supply — for now.

Howard Jacobson, owner of Rockville Centre Pharmacy and West Hempstead Pharmacy, said he’s had problems placing full orders of all forms of amoxicillin, not just the liquid form, but the pharmacies “have not been out of stock to the point where we could not fill a prescription at the point of sale.”

The pharmacy is “allocated a small supply each week,” he said.

CVS said in a statement Friday: “In the event an individual CVS Pharmacy store is temporarily out-of-stock, our pharmacy teams assist patients in locating the product at other nearby locations and work with prescribers to determine potential alternatives.”

The pharmacy chain is “working with manufacturers to replenish supply as quickly as possible,” the statement said.

'Inappropriate uses' cited

Dr. Aaron Glatt, chairman of medicine and chief of infectious diseases at Mount Sinai South Nassau hospital in Oceanside, said “part of the reason we have these shortages — part, not all of it — is inappropriate uses.”

Doctors too often prescribe antibiotics when they’re not needed, including to prevent a bacterial infection stemming from a virus, he said. In reality, he said, prescribing the antibiotic could make it more likely that if there is a bacterial infection, the infection would be resistant to amoxicillin.

“Unfortunately the studies show 30 to 50 percent of the antimicrobial prescribing in the outpatient setting is probably inappropriate,” he said. “And I think that’s a low estimate.”

The Food and Drug Administration website lists five manufacturers of amoxicillin in a liquid base, and for four, the reason for the shortage is listed as “demand increase for drug.”

The fifth company, Swiss-based Sandoz, said in a statement that “significant demand uptake” is one reason, along with other factors, such as “manufacturing capacity constraints, scarcity of raw materials, and the current energy crisis.”

The company is adding shifts in its manufacturing plant and taking other steps to increase production, the statement said.

By David Olson

david.olson@newsday.com@DavidOlson11

David Olson covers health care. He has worked at Newsday since 2015 and previously covered immigration, multicultural issues and religion at The Press-Enterprise in Southern California.