The efficacy of most of the medicines usually remains the same even if used for prolonged periods and by many people. Antibiotics are an important exception. This is because of the gradual rise in anti-microbial resistance.
To reduce the spread of antimicrobial resistance, the WHO has developed a tool to help global, regional and national decision-making on the use of antibiotics.
The AWaRe tool classifies antibiotics into three groups: Access, Watch and Reserve. It indicates which antibiotics should be used for common or serious infections, which ones should be used sparingly and which ones only as a last resort.
The drugs in this group are the first or second choice antibiotics. They offer the best therapeutic value, while minimising the potential for resistance. These are the antibiotics of choice for each of the 25 most common infections. They should be available at all times, affordable and quality assured.
These are the first or second choice antibiotics, only indicated for a specific, limited number of infective syndromes which are more prone to be a target of antibiotic resistance. They are thus prioritised as targets of stewardship programmes and monitoring.
The list includes most of the “highest-priority critically important antimicrobials” for human medicine and veterinary use. These antibiotics are recommended only for specific, limited indications.
These are the “last resort” antibiotics used for highly selected patients (life-threatening infections due to multi-drug resistant bacteria) when all other antibiotics have failed. They are closely monitored and prioritised as targets of stewardship programmes to ensure their continued effectiveness.
Nearly 60% of antibiotics in the Access group are more often available as oral formulations while this percentage is lower in the two other groups. 40% of Watch antibiotics have oral formulations; the number is only 10% in the Reserve group.
The first-choice antibiotics are usually the best option in terms of effectiveness, harms and potential for resistance. Under some circumstances, a second-choice antibiotic is also recommended as an alternative option. They tend to be generally broader-spectrum antibiotics with higher resistance potential or less favourable risk–benefit ratios. Both first and second choices have specific indications for which they have been recommended.
The overall goal is to reduce the use of Watch group and Reserve group antibiotics, and to increase the use of Access antibiotics where availability is low.
In 2017, WHO reviewed twenty-one common infective syndromes and selected the most appropriate first and second-choice antibiotic choices for each of the syndromes. The antibiotics were categorised following the AWaRe principles.
Currently, not all antibiotics are included in the AWaRe framework. Some of these may be included in future editions of the AWaRe classification.
60% from Access by ‘23
The WHO said that by 2023, 60% of all antibiotics consumed must come from the Access group, which has the lowest risk of developing resistance. It added that reaching this target will result in not only better use of antibiotics but also reduced costs and increased access.
• Monitor and report antibiotic use in community and hospitals using the AWaRe categories for evaluation, benchmarking and setting targets.
• Adopt the AWaRe index as part of national antibiotic stewardship programmes to improve access to essential antibiotics.
• Ensure local and national guidelines consider the WHO Essential Medicines List and apply the AWaRe categories in their recommendations for the optimal use of antibiotics.
• Incorporate the AWaRe categories into pre- and in-service training for health-care professionals.
• Monitor and report antibiotic use in the veterinary and agricultural fields according to the WHO list of medically important antimicrobials and the AWaRe categorization.