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August '25 Infectious Diseases Update

Posted by Doug Black, PharmD., Ann Lloyd, PharmD. on Aug 12th 2025

Article of the Month (Editors' Choice)

Amoxicillin crystalluria and amoxicillin-induced crystal nephropathy: a narrative review. Kidney Int 2025;107:33-43.

By Douglas J. Black, PharmD

  • Amoxicillin crystalluria (AC) is the precipitation of amoxicillin into amoxicillin trihydrate crystals in the urine. Amoxicillin-induced crystal nephropathy (ACIN) is acute kidney injury (AKI) caused by tubular obstruction of these crystals.
  • AC is usually observed in patients receiving high dose intravenous amoxicillin (≥8-12 grams/day). 
  • AC results from supersaturation of amoxicillin in urine. Factors that influence urinary amoxicillin concentration include dose, rate of infusion, hypovolemia (i.e., low urinary flow), and pH (amoxicillin solubility decreases as urine becomes more acidic). Oral absorption of amoxicillin is nonlinear and saturable, limiting the likelihood of crystal formation.
  • The prevalence of AC during high dose intravenous amoxicillin therapy is 24.0-41.0%. The prevalence of AICN is difficult to quantify. Median delay between amoxicillin exposure and diagnosis of AICN is 3.0-5.5 days, with considerable variability.
  • AC is usually clinically asymptomatic. However, the sudden onset of macroscopic hematuria with cloudy urine should suggest the disorder. It may also be associated with dysuria, cystitis-like symptoms, or back pain. Amoxicillin crystals in urine can rarely be observed with the naked eye.
  • No validated diagnostic criteria for AICN exist, in part due to these challenges:
    • The variable temporal association of amoxicillin exposure and onset of AICN limits its usefulness.
    • Many patients do not develop hematuria, and laboratory identification of urine crystals may not be available.
    • Excluding other causes of AKI (e..g, sepsis, amoxicillin-induced acute interstitial nephritis) can be difficult.
  • Treatment of AICN include optimization of fluid status, reduction of amoxicillin infusion rate or more frequent administration of lower doses, and possibly urinary alkalinization.
  • Patients with AICN generally recover kidney function relatively rapidly after discontinuing amoxicillin, but up to 40% require renal replacement therapy.

New or Updated Practice Guidelines

Dispersible Artemether-Lumefantrine Tablets

  • Dispersible artemether-lumefantrine* tablets (Coartem Baby, Riamet Baby) were approved by Swissmedic in July for newborns and infants (2 to <5 kilograms).
  • Developed in collaboration with Medicines for Malaria Venture. Eight African countries participated in the assessment and are expected to issue rapid approvals.
  • The ratio between artemether and lumefantrine in the dispersible tablets is 1:12 (rather than the 1:6 in adult tablets) to account for higher artemether exposure in infants under 5 kilograms.

Core Competencies for Stewardship Teams

  • A recent study identified a standardized set of competencies for Antimicrobial Stewardship (AMS) teams. 
  • Using a modified Delphi technique to achieve consensus, 58 AMS experts from 20 countries answered a series of questionnaires in 15 domain areas. 
  • The 15 domains included: the objectives of AMS; management of infection; microbiology diagnostics; pharmacology of antimicrobial agents; general principles of antibiotic use; structure and position of AMS; AMS interventions; AMS in special settings; surveillance and monitoring; behavior change and communication; infection prevention and control; quality management and patient safety; support; communication with patients and the general public; and governance/policy framework.
  • Through the consensus process, a list of 88 competencies was developed. The competencies are intended to be used to optimize AMS programs globally as well as in education efforts. AMS teams can conduct an internal evaluation to ensure each competency is achieved by at least one team member. Clin Microbiol Infect. 2025;31(8):1313-1320. 

Antimicrobial Shortages (US)

  • New shortages this month:
  • Resolved shortages this month:
    • Rifapentine 150 mg tablets (25 July 2025)
    • Ciprofloxacin injection (22 July 2025)
  • Antimicrobial drugs or vaccines in continued reduced supply or unavailable due to increased demand, manufacturing delays, product discontinuation by a specific manufacturer, or unspecified reasons: 
    • Antibacterial drugs:
      • Aminoglycosides:
        • Gentamicin injection (22 Feb 2021)
      • Bacitracin ophthalmic ointment 500 units/ (12 Sep 2024)
      • Cephalosporins:
        • Cefazolin injection (4 Jun 2018)
        • Cefdinir 300 mg capsules (29 Jun 2023)
        • Cefdinir 125 mg/5 , 250 mg/5 oral suspension (29 Jun 2023)
        • Cefotaxime injection (10 Jun 2015)
          • FDA is allowing temporary importation of product from SteriMax in Canada, in conjunction with Provepharm Life Solutions and its distributor Direct Success.
      • Chloramphenicol injection (9 Oct 2023)
      • Fluoroquinolones:
        • Levofloxacin injection in D5W (29 May 2024)
        • Levofloxacin oral solution, 25 mg/ (15 Sep 2023)
        • Moxifloxacin 400 mg tablets (6 Dec 2023)
      • Glycopeptides, glycolipopeptides, lipopeptides:
        • Vancomycin injection (1 Jun 2015)
      • Lincosamides
        • Clindamycin phosphate injection (25 Jun 2015)
      • Macrolides, azalides:
        • Azithromycin oral suspension, 1 packets (20 Nov 2024)
        • Erythromycin lactobionate injection (23 Apr 2025)
      • Neomycin and Polymyxin B sulfates GU irrigant (25 Jun 2023)
      • Nitrofurantoin oral suspension (5 Jun 2018)
      • Nitroimidazoles:
        • Metronidazole injection (20 Oct 2021)
      • Oxazolidinones:
        • Linezolid injection (16 Oct 2024)
      • Penicillins:
        • Amoxicillin, all oral formulations (18 Oct 2022)
        • Amoxicillin-clavulanate, all oral formulations (17 Nov 2022)
        • Dicloxacillin 250 mg, 500 mg capsules (18 Aug 2021)
        • Penicillin G benzathine injection (1 Feb 2023) Availability update
        • Penicillin G benzathine/Penicillin G procaine (31 Mar 2023) Availability update
        • Penicillin VK oral solution 250 mg/5 (17 May 2023)
        • Penicillin VK 250 mg, 500 mg tablets (17 May 2023)
      • Rifaximin 200 mg tablets (11 Apr 2024)
    • Antifungal drugs: 
      • Amphotericin B Lipid Complex (5 Aug 2022)
      • Ibrexafungerp 150 mg tablets (3 Dec 2024)
    • Antimycobacterial drugs: 
      • No current shortages
    • Antiparasitic drugs:
      • Mefloquine 250 mg tablets (14 May 2024)
      • Nitazoxanide oral susp 100 mg/5 (15 Feb 2024)
    • Antiviral drugs: 
      • Oseltamivir 30 mg, 45 mg, 75 mg capsules (1 Nov 2022)
      • Oseltamivir powder for oral suspension (1 Nov 2022)
      • Peginterferon alfa-2a (Pegasys) (8 Jan 2025)
      • Ribavirin for inhalation solution (23 May 2023)
  • Antimicrobial drugs recently discontinued: 
    • Bezlotoxumab injection (31 Jan 2025, by Merck)
    • Posaconazole oral susp 40 mg/ (Dec 2023, by Merck)
    • Sulfacetamide 10%/Prednisolone acetate 0.2% oph ointment (Aug 2023 by Allergan, sole supplier)
    • Penicillin G procaine 600,000 units/ injection (Jun 2023)
    • Ritonavir oral solution 80 mg/ (Jan 2023)
  • For more information including estimated resupply dates, see ASHP Drug Shortages website.
  • Data shown are current as of 8 August 2025.
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