Essential and Forgotten antibiotics: an inventory in low- and middle-income countries

ABSTRACT Background The WHO Essential Medicines List (EML) includes 'Access' antibiotics, judged essential to treat common infections. ESGAP defined a list of 'Forgotten' antibiotics, some old and often off-patent antibiotics, which possess particular value for specific indications. Objective To investigate which EML 'Access' and 'Forgotten' antibiotics are approved at national level in a sample of low- to middle-income countries (LMICs). Methods The scientific committee used a consensus procedure to select 26 EML 'Access' and 15 'Forgotten' antibiotics. Paediatric formulations were explored for 14 antibiotics. An internet-based questionnaire was circulated to 40 LMICs representatives. Antibiotics were defined as approved if an official drug regulatory agency and/or the Ministry of Health licensed their use, making them at least theoretically available on the market. Results We surveyed 28 LMICs (Africa: 11, Asia: 11, America:6). Nine EML 'Access' antibiotics (amoxicillin, ampicillin, benzylpenicillin, ceftriaxone, clarithromycin, ciprofloxacin, doxycycline, gentamicin and metronidazole) were approved in all countries, 26/26 in more than two thirds. Among 'Forgotten' antibiotics only 1/15 was approved in more than two thirds of countries. The median number of approved antibiotics per country was 30 [interquartile range: 23-35]. 6/14 paediatric formulations (amoxicillin, amoxicillin-clavulanic acid, oral antistaphylococcal penicillin, cotrimoxazole, erythromycin and metronidazole) were approved in more than two thirds of countries. Conclusions EML 'Access' antibiotics and the most frequently used formulations for paediatrics were approved in the vast majority of the 28 surveyed LMICs. This was not the case for many 'Forgotten' antibiotics, despite their important role, particularly in areas with high prevalence of multidrug-resistant bacteria.