E-DRUG: WHO updates Essential Medicine List (4)
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Dear E-druggers,
I was asked to write a commentary on the antibiotic advice in the new WHO
EML which I reprinted below. For me it's a welcome step towards WHO
engagement in antibiotic stewardship but there is still a long way to go.
*Comment*:
Unexpectedly, the new edition of the WHO essential medicines list - a
critical document that helps countries prioritize key medicines - included
for the first time much-needed basic guidance on antibiotic stewardship
aimed at low- and middle-income settings. This welcome guidance addresses
the reality that antimicrobial resistance (AMR) has the potential to do the
most harm in developing world settings among vulnerable patients who rarely
benefit from key tools such as microbiology and second-line antibiotics. In
the 20th WHO Model List of Essential Medicines, WHO placed antimicrobials
in tiers according to how permissive or restrictive their use should be.
Such tiering serves as a welcome signal that WHO is becoming more deeply
engaged in antibiotic stewardship, an activity which has barely been on the
radar in most of the world.
Unfortunately, the actual implementation of stewardship - at the hospital
and country level - will not be simple and will require far more than this
initial advice. One key concern is that, in the developing world, bacterial
infections have a much greater impact on human health and overly
restrictive antibiotic policies could place lives at risk. For example, in
rural Africa, far more children still die from lack of access to simple
antibiotics - for bloodstream infections, for example - than from
antibiotic resistance and zealous stewardship should not be done at the
expense of the most vulnerable.
Therefore, stewardship must be introduced
very carefully and not limit the availability of antibiotics to patients
requiring urgent antimicrobials. So, beyond the simple tiered antibiotic
groupings that were proposed in the new essential medicines list, WHO must
do far more to provide nuanced guidance, tools and communication on
stewardship that is geared toward the concerns and needs of the developing
world. It is hinted in the executive summary that such guidance is a
priority for WHO, and it would be welcomed.
At this time, there are very few published experiences with antibiotic
stewardship in the developing world, and more practical experiences need to
be shared in international meetings and journals. This will help WHO in its
process. Models that have been adopted in the U.S. and Europe - premised on
the existence of high-quality microbiology labs and infectious
diseases/pharmacist specialists - will not be applicable. The truth is that
in the development of specific guidance on stewardship strategies for low-
and middle-income countries, the WHO is late to the game. But huge
opportunities exist in the next few years, and WHO is well-positioned and
trusted to be the source of such critical material. The grouping of
antibiotics into tiers to guide more appropriate use represents an
important step in this process and an important step for global public
health.
Richard A. Murphy, MD, MPH
Division of Infectious Diseases, Harbor-UCLA Medical Center
Assistant Professor of Medicine, UCLA
Global Health Committee, Infectious Diseases Society of America
Richard Murphy <ramurphy@gmail.com>