Germany faces antibiotics shortage as STI rates rise

• Low supply of two antibiotics used against STIs
• Shortage comes as STIs see a steep rise
• Gay and bisexual men among those most at risk

BERLIN - German health workers say gay and bisexual men may be particularly impacted by a shortage of two antibiotics used to treat syphilis, chlamydia and gonorrhea, at a time when many European countries are battling a steep rise in such infections.

The current supply available under publicly-covered insurance can only cover 50% of the demand for doxycycline and azithromycin, according to Cologne-based DAHKA, a national association of pharmacies specialised in HIV and hepatitis treatment.

The vast majority of Germans use public insurance to cover their medical costs.

Here's what you need to know.

Why is there a shortage?

While doxycycline and azithromycin treat many conditions other than STIs, such as respiratory tract infections, the former is commonly prescribed against chlamydia and syphilis, while azithromycin is used to treat gonorrhea and chlamydia.

Berlin-based association of HIV specialist doctors, dagnä, said the main factor behind the shortage is likely the way Germany buys its drugs – a structural issue that also caused a severe shortage of HIV prevention drugs in early 2024.

Many manufacturers make these antibiotics but German procurement rules dictate, with some exceptions, that only the company offering these medications at the lowest price qualify for public coverage of patient costs.

Few suppliers qualify as a result, and nearly all of them manufacture outside of Europe, said Heiko Karcher, a Berlin-based doctor and board member at dagnä. 

This can become a particular problem when those companies experience supply issues - which is becoming increasingly common, added Karcher.

"Even small disruptions in the supply chain can lead to serious bottlenecks," he told Context.

It means patients with public health insurance -  which make up about 90% of all those insured in Germany - are struggling to get hold of the drugs.

German pharmacies told local media they could see the antibiotics listed as available in the Netherlands but not in Germany.

Why are health experts worried?

These shortages come as STI cases have been on the rise in Germany and other European Union countries since the early 2010s – a surge that has also increased the demand for these antibiotics.

Gonorrhea cases rose by 48% to more than 70,000 in the EU between 2021 and 2022, while syphilis cases surged by 34% to more than 35,000, and chlamydia cases by 16% to more than 216,000, according to the European Centre for Disease Prevention and Control's latest figures reported last March.

If left untreated, STIs such as chlamydia, gonorrhea and syphilis can lead to serious health complications, including neurological and cardiovascular issues in the case of syphilis, and infertility for chlamydia and gonorrhea.

Who is most vulnerable?

Doctors say gay and bisexual men may be particularly vulnerable to the shortage given the high incidence of these STIs among this population. 

Men who have sex with men account for just over 85% of the 6,330 syphilis cases with traceable origin registered in Germany in 2022, according to the Robert Koch Institute for infectious diseases.

Karcher said the lack of access to doxycycline and azithromycin poses particular risk for patients allergic to other treatments, and might force doctors to prescribe drugs with stronger side effects.

What has the government said?

Sören Haberlandt, a spokesperson for the German health ministry, confirmed in an email statement that there was an ongoing supply shortage "for certain antibiotics".

He added that the government is working with drugs manufacturers, pharmacists and doctors "to alleviate the shortages."

Haberlandt said Berlin is considering incentives to manufacture more drugs in Europe and is looking at diversifying supply chains to "increase the security of supply of medicines."

Drugs shortages – and particularly antibiotics – have become increasingly common in Germany and across the world, according to the WHO.

On Friday, Germany's Federal Institute for Drugs and Medical Devices registered supply shortages for 457 medications.

Last year, the German parliament passed legislation to reshore production, but critics say the recent shortages in antibiotics for children, cancer treatment and HIV prevention pill PrEP show the need for long-term solutions.

"Patients have a right to the most effective and best therapy," said Karcher. "It cannot be that they have to settle for makeshift solutions."

(Reporting by Enrique Anarte; Editing by Sadiya Ansari.)