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Using the AWaRe classification to facilitate antibiotic stewardship

November, 2019

An analysis of patterns of antibiotic use among global networks using the WHO Access, Watch and Reserve classification (AWaRe) 1


One of the main goals of the WHO global action plan on antimicrobial resistance is to optimise antibiotic use. Surveillance of antibiotic use in hospitalised children and neonates worldwide is one strategy that can help achieve this aim. This study provides data on antibiotic prescription patterns through the WHO Access, Watch, and Reserve classification (AWaRe).


  • The WHO Essential Medicines List for Children (EMLc) classifies antibiotics into three groups: Access, Watch, and Reserve. The Access group includes antibiotics recommended as first and second choice for most common clinical infection syndromes. The Watch group contains broader-spectrum antibiotic classes corresponding to the highest priority agents on the list of critically important antimicrobial drugs for human medicine. The Reserve group consists of last-resort antibiotics for targeted use in multidrug-resistant infections.
  • Point prevalence survey antibiotic prescription data were combined from two independent global networks: the Global Antimicrobial Resistance, Prescribing, and Efficacy in Neonates and Children (GARPEC) network and the Global Point Prevalence Survey on Antimicrobial Consumption and Resistance (Global-PPS) network.
  • Data were collected from 56 countries; 29 high-income countries (HICs) and 27 low-income countries (LICs).
  • 23,572 patients were included of which 18,305 were children (77.7%) and 5267 were neonates (22.3%).

Key results

In children:

  • Access antibiotic use ranged from 7.8% in China to 61.2% in Slovenia; high use was reported in Spain (59.8%) and Chile (59.0%).
  • Watch antibiotic use ranged from 23.0% in Finland to 77.3% in Iran; there was also a high use in China (74.1%), Montenegro (71.4%) and Macedonia (70.4%).
  • Reserve antibiotic use was low in all countries with the highest percentage being in Mexico (20.7%).
  • Antibiotic use for the treatment of lower respiratory tract infection:
    • In The Gambia all children with lower respiratory tract infection received Access antibiotics for treatment. In other countries the percentages ranged: Montenegro (5.6%), Russia (5.7%), China (8.2%), Saudi Arabia (17.7%), Australia (25.5%), Japan (50.0%) and The Netherlands (66.7%).
    • High use of Watch antibiotics was reported in China (76.1%) and Canada (61.5%), while Mexico had a high use of Reserve antibiotics (33.6%).

In neonates:

  • Access antibiotic use ranged from 24.2% in China to 100% in Singapore.
  • Watch antibiotic use was highest in China (64.5%).
  • Reserve antibiotic use was low in all countries with the highest being in Russia (13.9%) and Mexico (12.8%).
  • Antibiotic use for the treatment of sepsis:
    • The use of Access antibiotics was high in Australia (75.2%), Thailand (74.2%), Chile (72.2%), Nigeria (59.2%) and Mexico (50.0%), whereas it was lower in South Africa (33.3%), India (30.7%) and China (27.1%). Finland also had a low Access antibiotic use percentage (25.0%), mainly owing to the high use of unclassified antibiotics (62.5%).
    • The use of Watch antibiotics was highest in Argentina (42.9%) and lowest in Brazil (16.4%).
    • The highest use of Reserve antibiotics was reported in Serbia (23.5%) and Mexico (16.7%), and the lowest in the USA (2.9%), Greece (2.5%) and Brazil (1.0%).

A high proportion of unclassified antibiotic use was reported in children and neonates. Ceftriaxone was the most commonly prescribed antibiotic in hospitalised children in Africa, the Eastern Mediterranean, Europe, and South-East Asia. Sulfamethoxazole–trimethoprim was most common in the Americas and the Western Pacific region. In neonates, gentamicin and ampicillin were commonly prescribed in most regions.

Commenting on the study results, Professor Mike Sharland of St George’s University, London said:

“Although there are many reasons why there are these variations, from a clinical perspective there is no justification for using such a wide variation of broad-spectrum antibiotics – including ‘Watch’ antibiotics such as azithromycin – to treat pneumonia in young children, for example.

This measure will allow health authorities to identify areas of concern and is an important starting point in the simple stewardship interventions that are crucial on a national and global level.

Since the WHO has now called for the 60% Access ambition, it is most important that we encourage improved access to Access antibiotics to treat infections in children globally if we are to tackle the problem of antibiotic resistance.” 2


  1. Hsia Y, Lee BR, Versporten A, et al. Use of the WHO Access, Watch, and Reserve classification to define patterns of hospital antibiotic use (AWaRe): an analysis of paediatric survey data from 56 countries. Lancet Glob Health. 2019;7:e861–e871.
  2. St George’s University of London. News and features. New measure shows antibiotics prescribed for children in hospitals around the world. Available from: (Accessed: July 2019).

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