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Critically important antimicrobial (CIA) use

Whast are CIAs (Critically Important Antibiotics)?
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Antibiotics play a vital role in both human and animal health. And as there are only a limited number of classes of antibiotic available, it is critical that we preserve the efficacy of those classes available to us. Some classes are particularly important for human medicine, and these critically important antibiotics are used in cases where no other antimicrobial will be effective. Critically important antibiotics or CIAs are antibiotics that are critically important to human health and are often used as an antibiotic of last resort when no other antibiotic treatments are effective. There are a variety of classifications however, as to what exactly a critically important antibiotic is.
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The World Health Organisation have categorised antimicrobials as being either important, highly important, or critically important to human health. The critically important group reported by the WHO includes fluoroquinolones, third and fourth generation cephalosporins, and also macrolides, certain penicillins, and others. The European Medicines Agency has directed the Antimicrobial Expert Group to assess the critically important antimicrobials and categorise them as either low-risk to public health or a higher risk to public health. The low-risk antimicrobials include macrolides and narrow spectrum penicillins, with the higher risk critically important antimicrobials including fluoroquinolones, third and fourth generation cephalosporins, and colistin.
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Fluoroquinolones, third and fourth generation cephalosporins, and colistin are recognised as the most important of the critically important antimicrobials. And in veterinary medicine, it is generally these classes of antibiotic that are classed as the highest priority critically important antibiotics, or HP-CIAs.
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The Responsible Use of Medicines in Agricultural Alliance published the Targets Task Force document in 2017 with detailed antimicrobial usage targets, specific to individual livestock species. HP-CIAs were highlighted in the reduction targets for all major farm animal species, demonstrating the importance of reduced HP-CIA usage across all livestock species. The Veterinary Medicines Directorate annually published the Antimicrobial Resistance and Sales Surveillance report or VARSS report detailing antimicrobial sales figures for all livestock species. The 2017 report highlights the current level of HP-CIA usage specific to individual livestock species, and also provides an estimated percentage reduction in HP-CIA usage from 2016, and demonstrates dramatic reductions for many sectors.
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For further information on critically important antimicrobials, NOAH, the VMD VARSS report, and RUMA all provide valuable resources.

When discussing why we prescribe, we also have to look at what we prescribe. In this video, Robert Hyde explains what critically important antibiotics (CIAs) are.

Certain antibiotic classes are categorised by the World Health Organisation (WHO) as critically important antibiotics for human use, of which several are designated as ‘highest priority critically important antibiotics’ (HP-CIA). The WHO list of critically important antimicrobials can be found here.

CIAs are usually used as a last resort, in cases where no other antibiotic would be effective. In veterinary medicine, antibiotics are categorised in the same way; it is the same antimicrobials that are classed as critically important for both veterinary and human medicine. These are:

  • 3rd/ 4th generation cephalosporins.
  • Fluoroquinolones.
  • Colistin.

Each livestock species has their own specific antimicrobial usage targets, but they all include the need to reduce the use of HP-CIA’s. This has been successful since 2016, where there has been a dramatic decrease in their usage.

If you would like further reading on this topic, take a look at the see also section, where the articles suggested in the video from NOAH, the VARRS report, RUMA, and EMA can be found.

You should now feel confident with the theory behind AMR and why AMS is so important. However, AMS is not always easy to implement. The next steps will introduce you to some challenges that might be faced in achieving good antimicrobial stewardship.

Please find a downloadable copy of the PowerPoint slides used in the video in the downloads section below.

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Antimicrobial Stewardship in Veterinary Practice

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