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Saskia v. Popescu, MPH, MA, CIC, is a hospital epidemiologist and infection preventionist with Phoenix Children's Hospital. During her work as an infection preventionist she performed surveillance for infectious diseases, preparedness, and Ebola-response practices. She is currently a PhD candidate in Biodefense at George Mason University where her research focuses on the role of infection prevention in facilitating global health security efforts. She is certified in Infection Control.

The Scary Reality Behind WHO's Updated Essential Medicines List

On Tuesday, June 6, 2017, the World Health Organization (WHO) announced a revision to their Essential Medicines List (EML). The EML has been around for roughly 40 years and has several sections; however, this announcement marked the biggest revision for the antibiotic section.
Currently in its 20th edition, the previous edition of the EML was released in 2015. Each EML includes two sections—one for adults and one for children. The WHO Model List of Essential Medicines (or EML) is considered a core list of the most basic medicines needed for a healthcare system to meet the minimum needs for basic patient are. The purpose of the EML is truly to provide a laundry list of medicines that are required for basic patient care and the WHO takes care to prioritize them according to efficacy, safety, and cost-effectiveness. The list is also developed based on priority health conditions that “are selected on the basis of current and estimated future public health relevance.”
Within the list, there are indicators for weight/age restrictions, special diagnostic or monitoring facility requirements, and a complimentary list that includes essential medicines for priority diseases that will also require specialized care. For example, in Medicines For Prevention of HIV-related Opportunistic Infections, there are the recommended medicines (ie, isoniazid combo, ribavirin, etc.) and the complimentary list includes oseltamivir for severe illness due to confirmed or suspected influenza infections in critically ill patients.
Each section highlights the most basic pharmaceutical requirements and includes a complimentary section to insure those common complications for specific conditions are met. Page 43 of the report even includes a list of vaccines that are recommended for all, those for certain regions, and those for some high-risk populations (ie, cholera, rabies, etc.). Overall, the EML is a comprehensive roadmap for those providing patient care—whether it be in a hospital or even in a country overall, to ensure they have the basic medicines needed to care for their patients.

What makes the recent changes so interesting and poignant is that they relate to antibiotics and highlight the challenges in drug diversity. In their press release, WHO noted that “the change aims to ensure that antibiotics are available when needed, and that the right antibiotics are prescribed for the right infections. [The change] should enhance treatment outcomes, reduce the development of drug-resistant bacteria, and preserve the effectiveness of ‘last resort’ antibiotics that are needed when all others fail.”
The EML revision includes a new group approach to antibiotics, which categorizes them into 3 categories: ACCESS, WATCH, and RESERVE. Each category includes recommendations in attempts to strengthen antibiotic stewardship; these are listed below:
  1. ACCESS: these antibiotics should be considered as the first or second choice in several syndromes and should be widely available, affordable, and quality-assured. ACCESS antibiotics include amoxicillin, cloxacillin, clindamycin, doxycycline, gentamicin, and more.
  2. WATCH: these include antibiotics that have a higher resistance potential and are only recommended as the first or second choice in specific situations, and should be monitored in stewardship programs. WATCH group antibiotics include quinolones and fluoroquinolones, carbapenems, penems, etc.
  3. RESERVE: these are antibiotics which should be treated as the last resort of accessible antibiotics and should be used in “tailored” situations when other medications have failed. RESERVE antimicrobials should be targeted in national and international stewardship programs and include aztreonam, polymyxins, 4th and 5th generation cephalosporins, etc. 
The list also added 10 antibiotics to the adult list and 12 additional ones for children. When reviewing trends in microbial resistance (you can see the FDA report here and Europe’s recent one here), it’s not surprising this revision was needed.

While there are additional recommendations regarding cancer treatments, hepatitis C medication, and more effective HIV treatment, it was this massive overhaul of the antibiotic section that has drawn attention. This extensive change to the EML highlights the dire situation that we are progressing towards in terms of microbial resistance. The EML provides the most basic medicine needed for patient care and its focus on antibiotic stewards highlights the stark reality even in the most dire of environments.
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