How antibiotic shortages contribute to resistance and how to turn the tide
When thinking about the behaviours that must change to preserve our antibiotics, we may primarily think about our actions as patients, health-care workers, patients, farmers and consumers. But the “behaviours” – or rather norms and praxis – of the actors in the manufacturing and supply chain of antibiotics are also extremely important.
Professor Enrico Baraldi from the Department of Civil and Industrial Engineering at Uppsala University is leading the preparations for a workshop on this theme. We caught up with him to learn more.
Why is this workshop needed?
Shortages of common old antibiotics are a growing problem globally. Some types of penicillin that have been around for ages may suddenly become very difficult to find in several countries because of limited production capacity in relation to worldwide needs. This happened with benzathine penicillin in 2015. Other antibiotics may experience more or less long shortages because of disruptions in the very few plants that produce their active ingredients, as happened with piperacillin-tazobactam in 2017 due to an accident in a Chinese factory.
When an antibiotic is out of stock, patients usually receive suboptimal alternatives, such as broader spectrum ones, which may lead to more serious side effects, for instance for our bacterial flora, or lead to longer period of recovery. Or, in the worst case, there may be no alternative antibiotic available at all. Missing a specific antibiotic in the treatment arsenal may also require doctors to prescribe other antibiotics, which should instead be preserved for use only on more serious and/or resistant infections. Therefore, antibiotics shortages can contribute to accelerating antibiotic resistance.
All in all, shortages of common established antibiotics cause both unnecessary suffering to patients and considerable costs in healthcare systems – in terms of more expensive alternatives and increased morbidity, as well as of more resistance in the long term", says Professor Enrico Baraldi, Uppsala University.
What are the norms and praxis in the chain of production, logistics and supply that must change?
There are many complex reasons behind antibiotics shortages: If you consider the single case of shortage, then you see only the tip of the iceberg, namely a specific event such as a decision made by a selling company to withdraw a product from a specific country. It could also be a sudden surge in demand that suppliers could not meet, or an unfortunate and more or less “unpredictable” accident at a factory.
However, behind the single events there are more stable and structural reasons, or you may say problems, that afflict the antibiotics field at several levels, to a point that we can talk about “root causes”. These kind of causes include insufficient economic incentives for antibiotics suppliers, due to low unit margins and uncertainty in exchanged volumes, rigid production systems, inefficient logistics, unbalances in the supply sector and lack of collaboration between stakeholders. These problems become very obvious in fragile supply chains, in the sense that they are stretched geographically to distant places which causes increased supply risks. The dependency on single sources can create bottlenecks. You can say that antibiotics shortages depend on how the existing (limited) economic incentives interplay with key decision-making process inside many organizations about for instance their investments, sourcing countries, market-entry and market-exit, as well as with their routines for instance in external communication, inventory management and logistics", says Professor Enrico Baraldi.
This is a big subject! What do you hope the workshops participants will bring with them home from the discussions at Uppsala Health Summit?
During the workshop we will discuss the pros and the cons of three potential solutions to address antibiotics shortages: i.e 1) more transparency in supply chains, II) better economic incentives (both reimbursements and more certainty), and III) investments to upgrade the production system. A first potentially interesting result from the workshop is to see if there are differences in how different stakeholders – e.g., industry, healthcare and policy – and experts from different countries view these three solutions.
If there is an interest in implementing these solutions, it is important that the various stakeholders are aware also of the discrepancies in their views, their potential and their limitations. As collaboration among various stakeholders is essential to tackle a complex problem like antibiotic shortages, I hope that the representatives from various stakeholders attending the workshop can see this as a first step towards building collaborations such as the Swedish cross-sectoral platform PLATINEA, which gathers 16 parties from industry, public authorities, academia and healthcare.*
It would be a great success if this meeting could spark discussions to initiate the establishment of international collaboration platforms of this kind. In fact, many of the root causes of antibiotics shortages are of such a character that they should be tackled collaboratively at international, indeed global level", says Professor Baraldi.
*PLATINEA members MSD and Recipharm are sponsoring Uppsala Health Summit 2021 on antimicrobial resistance and behaviour change (editor's note)