# Responding to and managing antibiotic shortages: a qualitative study with experts and opinion leaders

## TL;DR

Experts from around the world discuss how to manage antibiotic shortages using political, legal, and technological strategies.

## Contribution

The study identifies context-specific PESTELI factors influencing antibiotic shortages and proposes mitigation strategies.

## Key findings

- Political engagement and legal measures, like allowing pharmacist substitutions, help manage shortages.
- Transparency from pharmaceutical companies and economic incentives are needed to address supply chain issues.
- Technological tools for forecasting shortages and sociological communication strategies are critical for effective management.

## Abstract

We investigated the current mitigation strategies undertaken in different regions to manage antibiotic shortages through in-depth expert interviews.

Purposive sampling was used to identify stakeholders with expertise in managing antibiotic supply chains, access, and shortages between August 2023 and April 2024. Consented participants were interviewed using a semi-structured interview guide developed using the PESTELI (political, economic, sociological, ecological, technological, legal, industry) framework. Data collection and analysis were iterative and recursive, using constant comparison.

Participants who were interviewed (n=16) had local, national, and global roles in managing and studying access, supply, and demand chain management from Europe, South Africa, India and USA. Political engagement on antibiotic shortages is reported to facilitate effective mitigation strategies, especially in areas where there is strong evidence of government investment. Legal measures have also been used; for example, pharmacists in the UK being given rights to automatically substitute antibiotics on prescriptions and negotiating with pharmaceutical companies for greater transparency on the challenges in manufacturing. Economic incentives are currently missing and are recognised as being a driver for lack of engagement on this topic from pharmaceutical industry. Greater transparency is required from the pharmaceutical companies on the manufacturing chain issues that may lead to shortages. Technologically there is a major gap in systems to forecast and manage antibiotic shortages. Sociological elements include adopting appropriate communication to not cause panic buying and hoarding by organisations when there is an impending shortage. Legislative changes are linked to the political and economic barriers for cohesive systems to manage the antibiotic manufacture and supply chain in relation to shortages.

Currently there are limited interventions to respond to and manage shortages. The antibiotic manufacture and supply chain is complex and under influence of PESTELI indicators which will need to be understood and addressed in different contexts and regions.

Lack of access to antibiotics has been identified a major contributor to the emergence of antibiotic resistance. The drivers for antibiotic shortages are complex. We conducted interviews of key stakeholders (n=16) involved in national and global antibiotic supply chain management, to explore the main drivers for current shortages and existing mitigation strategies undertaken in different regions. Participants were interviewed using a semi-structured interview guide developed using the PESTELI (political, economic, sociological, ecological, technological, legal, industry) framework. Political engagement on antibiotic shortages was reported to facilitate effective mitigation strategies. Legal measures have also been used; for example, pharmacists in the UK given rights to use alternative agents. Pharmaceutical companies need to provide greater transparency on manufacturing issues that may lead to shortages. Economic incentives are required at all levels and are currently missing. Need for technological mechanisms to predict antibiotic shortages is needed. Sociological elements include adopting appropriate communication to not cause panic buying and hoarding by organisations when there is an impending shortage. Understanding context specific factors contributing to antibiotic shortages can aid in the development and adoption of mitigation strategies and tools for forecasting shortages and their optimised management.