On 18 June 2019, the World Health Organization (WHO) launched a global campaign urging governments to adopt a tool to reduce the spread of antimicrobial resistance, adverse events and costs.
Most medicines remain effective even if used by many people for prolonged periods. Unfortunately, antibiotics are an important exception as they can become ineffective because of anti-microbial resistance (AMR).
Antibiotic resistance refers to the ability of microorganisms to withstand the effects of an antibiotic.
Bacteria are said to develop resistance when they are no longer inhibited or killed by the antibiotics.
Inappropriate use of antibiotics favors the emergence and spread of antibiotic resistance, amplifying natural ability of bacteria to resist.
In order to keep antibiotics effective, we need to take them only when needed and strictly as directed by the doctor.
The AWaRe tool was developed by the WHO Essential Medicines List to contain rising resistance and make antibiotic use safer and more effective.
With the 2017 update of the Model List of Essential Medicines, WHO proposed a new classification of antibiotics, the AWaRe classification (Access, Watch, Reserve), in the context of a comprehensive review of the optimal antibiotic choices for many common infectious syndromes in adults and children. The AWaRe classification aims to help prescribers, pharmacists, antibiotic stewards and policy makers to address the AMR challenge.
Access – antibiotics that represent first or second-line for empirical treatment of common infectious syndromes based on a systematic assessment of the available evidence and that have a favorable safety profile with a low propensity to further aggravate AMR. All Access antibiotics are part of the EML core list, meaning that these antibiotics should be widely available in all settings (while still making efforts to ensure their appropriate use). Many penicillins belong to this class.
Watch – antibiotics that present a higher potential to negatively impact AMR. Some Watch group antibiotics are also included in the EML core list since they are the most effective options for a limited group of well-defined clinical syndromes, but their use should be tightly monitored and restricted to the limited indications.
Fluoroquinolones, which are unfortunately commonly used in many settings, belong to the Watch group as their use should be avoided for indications for which they are no longer first or second choice.
Reserve – “last-resort” antibiotics, that have activity against multi (MDR)- or extensively (XDR) resistant bacteria, and therefore represent a valuable, non-renewable resource that should be used as sparingly as possible. Some of the newly approved antibiotics (e.g. ceftazidime-avibactam) fall into this class, as do some of the older “rediscovered” antibiotics (e.g. polymyxins).
Discouraged antibiotics – this fourth category – mostly including antibiotic combinations – was developed in the 2019 EML update. Some antibiotics, such as certain fixed dose combinations of antibiotics, do not have any reasonable indications for the treatment of infectious diseases in humans and may negatively impact AMR and patient safety.
The overall goal is to reduce the use of Watch Group and Reserve Group antibiotics (the antibiotics most crucial for human medicine and at higher risk of resistance), and to increase the use of Access antibiotics where availability is low.
Evidence shows that to promote responsible use of antibiotics, Access antibiotics should make up at least 60% of national consumption. This will not only result in better use of antibiotics but also in reduced costs and increased access. Reaching this threshold by 2023 will contribute to countries’ achieving health related targets of the sustainable development goals.
By using AWaRe as an index to measure antibiotic consumption in different
health care settings, countries will gain an insight into the use of antibiotics at
national level. Once these benchmarks have been established, policy makers
will have the tools to adjust consumption to local needs and prescribers will
have clear guidance on what to prescribe when.
At present, 65 countries collect this data and only 29—less than half—have reached the 60 percent goal.
Of the ten most populous countries, only Brazil tracks antibiotic consumption and has achieved the 60 percent goal. The Russian Federation is also tracking consumption—a critical step in eventually achieving the 60 percent goal.
In 20 countries, antibiotics in the Access list comprise 50-60 percent of total consumption—signifying that only moderate adjustments in consumption are needed.
Link to the WHO news release:
Link to the AWaRe website:
Link to Essential Medicines website:
Link to Global Essential Medicines website: