KUALA LUMPUR, Feb 3 — Doctors have complained about essential antibiotics frequently running out in public hospitals that they said enhanced drug resistance, worsened patients’ conditions, and lengthened hospital stays.
A survey run by Dr Timothy Cheng, a specialist student at a public university in Malaysia, with 56 respondents late December 2019 and early January 2020 showed 62 per cent alleging antibiotic shortages in their Ministry of Health (MOH) hospital over the past year, with shortage defined as the interrupted supply of a single dose.
The most common type of antibiotics that government doctors claimed had run out in their hospitals were beta-lactamase inhibitors (sultamicillin, Augmentin, Tazocin etc), while other less frequent complaints of empty stocks involved cephalosporins (cefazolin, cefuroxime etc) and penicillins (amoxicillin etc). A few also alleged shortages of antibiotics like macrolides (azithromycin, clarithromycin, clindamycin, erythromycin etc), fluoroquinolones (ciprofloxacin etc), and carbapenems (meropenem and ertapenem).
Beta-lactamase inhibitors, cephalosporins, penicillins, and macrolides are common antibiotics that are even used in outpatient care as first-line treatment for common infections, such as bacterial respiratory tract infections, sexually transmitted diseases, and skin infections. Fluoroquinolones are less commonly used than those antibiotics, whereas carbapenems are only provided in intravenous form in hospitals, as they’re reserved for more serious infections.
About 68 per cent of government doctors who complained about antibiotic shortages said this happened at least once every two to six months in their public facility. Some 19 per cent claimed antibiotics ran out in their government hospital once a year.
A whopping 85 per cent of government doctors claimed that antibiotic supply shortfalls were not a new problem. Some 39 per cent alleged that antibiotic shortages have occurred in their MOH hospital for the past one to two years, while about 30 per cent highlighted it as a problem for the past three to four years. Some 15 per cent even said their facility has suffered from antibiotic shortages for more than five years.
Only 15 per cent said antibiotics running out became an issue just this year. Government doctors participated in the survey late last December and early January this year.
Over half of respondents, or about 55 per cent, complained that antibiotic shortages in their public hospital lasted from one to six months.
Nearly 80 per cent felt that the shortage of antibiotics affected their treatment of patients, while a third saw alternative drugs as being inappropriate.
Survey respondents alleged antibiotic shortages at Kuala Lumpur Hospital, Penang Hospital, Queen Elizabeth Hospital, Queen Elizabeth II Hospital, and Tawau Hospital in Sabah, Tuanku Ja’afar Seremban Hospital in Negri Sembilan, Raja Perempuan Zainab II Hospital in Kelantan, Tengku Ampuan Afzan Hospital in Pahang, and Seri Manjung Hospital in Perak.
“Some of the effects towards patients were prolonged hospital stay and deterioration of patient’s condition.
“Respondents felt that the main reasons for supply shortage were lack of hospital budget, poor planning, and shortage from the main supplier,” Dr Cheng told CodeBlue.
He also cited a senior doctor in Tuanku Ja’afar Seremban Hospital as saying that intravenous Augmentin, a basic antibiotic, has been out-of-stock for the past four months, causing the MOH hospital to use alternative drugs that can increase antimicrobial resistance and are not an ideal treatment for patients. The government doctor, according to Dr Cheng, did not wish to be named, like others in the survey because they feared reprisals for speaking to the media.
“Antibiotics are one of the most basic items a hospital can have and there is no excuse for such shortages to occur.”Dr Timothy Cheng
“Suppliers that are not delivering must be changed with immediate effect. A transparent audit system must be functioning to ensure that purchasing and supply processes are free from all forms of corruption,” Dr Cheng said.
About 67 per cent of respondents who raised complaints internally about the antibiotic shortages said their complaints were replied within a week, although it’s uncertain if this means their grouses were actually resolved. The complaints of some 21 per cent did not get any reply allegedly, while about 9 per cent received a response in a month.
Health director-general Dr Noor Hisham Abdullah, however, denied that MOH hospitals faced antibiotic shortages.
“We don’t have any shortages of supply, but we are controlling the usage indeed,” he told CodeBlue.
“Free usage of antibiotics will result in antimicrobial resistance,” he added. “We have surveillance system to look at usage and resistance nationwide.”
Dr Noor Hisham cited a 2016 study by Norazida Ab Rahman et al that found high antibiotic prescribing rates in government clinics (6.8 per cent) and, especially, private clinics (30.8 per cent) in Malaysia, with upper respiratory tract infection accounting for half of prescriptions, even though the condition is mostly viral and doesn’t need antibiotic treatment.
Deputy Health Minister Dr Lee Boon Chye said MOH has initiated an Antimicrobial Stewardship Programme in MOH hospitals and primary care facilities since 2014, which led to reduced antibiotic prescriptions, especially in the ICU.
“Supply of most antibiotics should be sufficient in everyday clinical use in the hospital,” Dr Lee told CodeBlue.
“Usually when doctor prescribes one particular antibiotic (particular brand or type) which is not immediately available, there are always alternative antibiotics (different brands and similar types) available. So shortage of antibiotics should not happen to the extent of compromising clinical practice.”
Dr Lee said broad-spectrum antibiotics like Augmentin and Unasyn have generic alternatives and are unlikely to be short of supply, while penicillins are extremely cheap and also probably not running out. Cephalosporins have five to six alternative drugs, be they original or generics.
As for fluoroquinolones, according to Dr Lee, most are cheap and off-patent drugs that have no reason to be lacking in public hospitals either. The use of carbapenems in government hospitals, meanwhile, is highly restricted because they are the latest group of antibiotics.
“For your information, there is no new group of antibiotics for (bacterial infections) being discovered after carbapenem more than 10 years ago. There is already carbapenem-resistant bacteria, which is a significant health issue,” Dr Lee told CodeBlue.
“Some antibiotics which may be short are the latest generation of penicillin-like drugs (not ordinary penicillin) which are still under patent— but their usage is also very restrictive and reserved for some resistant bacteria.”