On this article a pediatrician places the 2022-2023 amoxicillin scarcity into perspective.
Authored By: Michael Cosimini, M.D.
Article Posted 22 December 2022
There’s at the moment a shortage of amoxicillin suspension associated to elevated demand within the context of a giant uptick in pediatric respiratory tract infections. This can be a good time to debate the dear function it performs in pediatrics, and options to the treatment.
Amoxicillin is an aminopenicillin which requires much less frequent dosing and broadens our gram adverse spectrum over pure penicillin. It is a superb streptococcal drug, nicely tolerated, and as such is our go to for a lot of pediatric respiratory tract infections together with acute otitis media, streptococcal pharyngitis and group acquired pneumonia
With the amoxicillin scarcity we discover ourselves needing to be artistic with administration like utilizing opened capsules or crushed tablets. At occasions we’re utilizing various medicines. There are specific alternatives to consider from the AAP mentioned in addition to some normal stewardship recommendations right here beneath.
Acute Otitis Media (AOM)
AOM might be viral, bacterial and infrequently each. Decision with out antibiotics is widespread and there’s room for watchful ready particularly in kids two years of age and older. Suppurative issues like mastoiditis are rare, however could also be decreased in kids with non-severe displays by antibiotics albeit at a excessive quantity wanted to deal with. As of the 2013 AAP guidelines we have now particular suggestions for watchful ready in kids with non-severe circumstances. This consists of unilateral AOM in kids over six months of age and bilateral or unilateral in kids two years of age and older. Information displaying a lack of increase in this practice for the reason that pointers counsel we’re underusing this technique.
S. pneumoniae, M. catarrhalis and non-typeable H. influenzae are the three most vital bacterial pathogens. Resistance mechanisms to know are (1) modification of the penicillin binding proteins for S pneumoniae, and (2) beta-lactamases produced by some H. influenzae and all M. catarrhalis isolates.
First line therapy is with “excessive dose” (80-100 mg/kg/day divided BID) amoxicillin with the purpose of hitting increased minimal inhibitory concentrations for S. pneumoniae. This doesn’t cowl for the beta-lactamase producing gram negatives, however M. catarrhalis typically resolves with out therapy and is unlikely to trigger issues.
A urged substitute to amoxicillin attributable to shortages is amoxicillin-clavulanic acid (Augmentin) on the similar amoxicillin dose. Need a scorching tip? Use the suspension with decrease clavulanate focus! The draw back is that you’re utilizing a drug that has a wider spectrum for gram negatives, anaerobes and Staphylococcus aureus. There’s additionally marginally more diarrhea with the addition of clavulanate.
Outdoors a scarcity, amoxicillin-clavulanic acid is the primary line drug when a affected person has had amoxicillin within the final 30 days otherwise you suspect a beta-lactamase producer. H influenzae is suspected within the context of otitis with purulent conjunctivitis based mostly on older studies of conjunctival cultures on sufferers with otitis and conjunctivitis. There’s some regional variation and that is used as the primary line in some facilities.
One other advisable various is ceftriaxone (Rocephin) which is a superb drug for all three micro organism famous above. It may be given as a single 50 mg/kg (max 1000 mg) dose however once more is a broader spectrum drug than is required for the job. Given the problem of giving oral medicines to toddlers I can see the enchantment of this injectable possibility.
Group Acquired Pneumonia (CAP)
Pediatric group acquired pneumonia is usually viral and for the reason that now archived 2011 IDSA CAP guidelines commentary with out antibiotics is given as an possibility for the preschool age group. This suggestion is good to know when it’s not clear if CAP or one other higher respiratory tract an infection or decrease respiratory tract an infection is the analysis. Crucial current improvement is a number of studies, principally within the toddler age vary, displaying shorter programs of amoxicillin are as efficient as longer programs. My favourite was SAFER which was a randomized placebo managed trial out of Canadian emergency rooms of kids with chest X-ray findings per pneumonia displaying 5 days amoxicillin + 5 days placebo was as efficient as 10 days amoxicillin for medical remedy at two to a few weeks. This examine displays sufferers just like these I might diagnose with CAP outpatient if not a bit extra extreme.
Proving the bug chargeable for decrease respiratory tract infections in children is tough. Crucial “typical” pathogen is once more S. pneumoniae. Different much less generally seen bacterial pathogens in a pediatric inpatients surveillance examine have been S. aureus, S. pyogenes and H. influenzae. Mycoplasma pneumoniae is usually detected particularly after 5 years of age however the utility of treatment in kids is uncertain.
Like AOM crucial micro organism for CAP is S. pneumoniae and the advisable various is once more amoxicillin-clavulanic acid. On this a part of the suggestions cefdinir is named out particularly as much less efficient for S. pneumoniae. Why? As a “third technology cephalosporin” you would possibly suspect it could be a superb pneumococcal drug like ceftriaxone however it’s poorly absorbed, highly protein and has a short half life making it seemingly inferior to amoxicillin for this vital micro organism.
Azithromycin stays an possibility for wholesome outpatient grownup CAP per IDSA guidelines, however isn’t talked about in its place right here for pediatrics. Not a drug I really like for CAP given fairly important macrolide resistance in S pneumoniae in a lot of the US.
Group A Streptococcal Pharyngitis
The massive second of stewardship for this bug is a diagnostic one. A carrier state is common although estimates range broadly. Absent a medical image constant group a strep pharyngitis, a optimistic fast strep check results in inappropriate therapy. We principally shouldn’t be testing children underneath three and children with an apparent viral trigger like sore throat that comes with cough and rhinorrhea.
The precise mandatory size of remedy for teenagers is an open query. 10 days is a historic standard we have now not but shook regardless of large declines in isolates that trigger rheumatic fever. I nonetheless deal with for 10 days per present AAP redbook with the 50 mg/kg as soon as day by day dosing.
Group A strep is taken into account uniformly inclined to beta-lactam antibiotics and as such the advisable remedies are penicillin or amoxicillin to cowl strep with an in any other case slender spectrum.
The logical selection within the context of this scarcity of amoxicillin is to return to the primary line penicillin both oral or IM. Sure, penicillin, the drug we have now been utilizing for the reason that Forties, nonetheless has a job right now for greater than Syphilis!
Cephalexin is advisable for kids with non-anaphylactic allergy to penicillin. Clindamycin and azithromycin are potential choices for PCN allergic sufferers however charges of resistance to macrolides and clindamycin are increasing in invasive streptococcal infections.
I hope a few of this helps if you find yourself contemplating various medicines on your toddlers with respiratory tract infections. Right here is to having our amoxicillin suspension again someday within the new 12 months!
ABOUT THE AUTHOR
Dr. Cosimini an assistant professor of pediatrics at Oregon Well being and Science College.
He’s the creator of Empiric antibiotic card game which is a card sport for studying guideline based mostly antibiotic use. His research facilities round greatest practices for well being professionals training utilizing severe card and board video games with the GAMER collaborative.
He’s a medical editor and contributor to Pediatrics Reviews and Perspectives (PedsRAP).
He might be discovered on twitter @michaelcosimini and Mastodon at mstdn.social/@EmpiricGame.
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