Reserved Antibiotics

Reserved antibiotics

Compiled by Alok Bains

Appropriate use of antimicrobials and their access are priorities to control antimicrobial resistance (AMR). World Health Organisation (WHO) developed the AWaRE classification of antibiotics in 2017 and released it in 2018 under the essential medicines list (EML). It is a useful tool to monitor consumption and optimise antibiotic use and curb antimicrobial resistance (AMR). The AWaRe classification of antibiotics was revised in 2021 that has 258 antibiotics.

WHO proposed a novel metric for antimicrobial use: the AWaRe index. AWeRe classification of antibiotics classifies antibiotics into three groups. These are:

1. Access group: This group is created with the aim to improve access and to promote the appropriate use of these antibiotics. These antibiotics are active against common sensitive pathogens. They are recommended as a first choice or second choice to treat infections. The standard quality of these antibiotics should be affordable and widely available. A total of 87 antibiotics are in this group, some examples are Amoxicillin, Ampicillin, Amoxicillin + clavulanic acid, Ampicillin + sulbactam, Chloramphenicol, Cloxacillin, dicloxacillin, Oxacillin, doxycyclin, Gentamycin, Metronidazole, Secnidazole, Ornidazole, Sulphamethoxazole, Trimethoprim, Tetracycline, Tinidazole, etc.

2. Watch group: This group is created with the aim is to monitoring important antibiotics. These antibiotics are critically important antimicrobials for human medicines. They have higher toxicity concerns and/or resistance potential. These antibiotics are divided into two groups as essential first and second choices to treat the specific infection. It includes a total of 141 antibiotics. Some examples are Cefaclor, Cefamandole, Cefixime, Cefoxitin, Ciprofloxacin, Clomocycline, Erythromycin, Fusidic acid, Kanamycin. Levofloxacin, Minocyclin, Neomycin, Norfloxacin, Ofloxacin, Oxytetracycline, Piperacillin, Streptomycin, Tobramycin, Vancomycin, etc.

3. Reserve group:

   It includes antibiotics to be preserved to retain their effectiveness against bacteria when commonly used antibiotics failed. They are ‘last resort’ antibiotics when other antibiotics/alternatives have failed. They are reserved to treat confirmed or suspected infections due to multi-drug-resistant organisms. They are used for critical priority or high-priority pathogens identified by the World Health Organisation such as carbapenem-resistant Enterobacteriaceae. The Reserve group includes new antibiotics. They are reserved for complex infections or MDR. These antibiotics should be accessible but their use should be for highly specific patients if other antibiotics failed or are not suitable. The National and International stewardship programs shall monitor and use these antibiotics. They shall report to authorities about the utilization of these antibiotics. These activities of stewardship programs will preserve the effectiveness of these antibiotics.

   There are 29 antibiotics under the reserve group. These are Aztreonam, Carumonam, Cefiderocol, Ceftaroline, Ceftazidime-avibactam, Ceftobiprole, ceftolozane + tazobactam, Colistin (oral), Dalbavancin, dalfopristin + quinupristin, Daptomycin, Eravacycline, Faropenem, Fosfomycin (injection), Iclaprim, Imipenem + cilastatin + sulbactam, lefamulin, Linezolid, Meropenem + Vaborbactam, Minocycline (injection), Omadacycline, Oritavancin, Plazomicin, Polymyxin B (injection), Polymyxin B (oral), tedizolid, Telavancin, Tigecycline.

Ceftazidime-avibactam, meropenem-vaborbactam, and plazomicin are relatively new antibiotics included in the reserve group. They were approved by the US Food and Drug Administration in February 2015.

Advantages of Reserved antibiotics:

1. Reserved antibiotics are included as individual medicine having a favourable risk-benefit profile and proven activity against critical pathogens.

2. Supports high-level understanding to prescribe antibiotics,

3. Help prescriber to select suitable antibiotics,

4. Improves antibiotic prescribing quality,

5. Improve patient outcomes and reduce the risk of complications,

6. Reduction in unnecessary, misuse and overuse of antibiotics,

7. Easy Estimation of the Use of Narrow-spectrum Antibiotics and broad-spectrum antibiotics. It helps to optimize antibiotic use and to define goals for further improvement in quality.

8. Availability of effective antibiotics in life-threatening infections,

9. Availability of antibiotics when the risk to develop resistance is high,

10. Availability of antibiotics when commonly used antibiotics failed to act,

11. Slow down Antimicrobial resistance progress,

12. Make sure the availability of effective antibiotics for the next generation.

    Compiled by: Alok Bains