Increasing the use of the WHO AWaRe system in antibiotic surveillance and stewardship programs in low- and middle-income countries

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Saleem, Zikria and Sheikh, Samia and Godman, Brian and Haseeb, Abdul and Afzal, Shairyar and Qamar, Muhammad Usman and Imam, Mohammad Tarique and Almarzoky Abuhussain, Safa S. and Sharland, Mike (2025) Increasing the use of the WHO AWaRe system in antibiotic surveillance and stewardship programs in low- and middle-income countries. JAC-Antimicrobial Resistance. ISSN 2632-1823 (In Press) (https://doi.org/10.1093/jacamr/dlaf031)

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Abstract

Introduction: Antimicrobial resistance (AMR) presents a major global health threat, driven in part by the inappropriate use of antibiotics including in lower- and middle-income countries (LMICs). Improving the quality of antibiotic use is a key rationale for the development of the World Health Organization (WHO) AWaRe system. There is a need to review the uptake of the AWaRe system since its launch to guide future practice. Method: A literature search was conducted between 2017, the launch of AWaRe, and 2024. Inclusion criteria were studies that reported on antibiotic use in LMICs using the AWaRe system. Results: 85 studies were included in the review. 56.4% focused on antibiotic use trends, with 28.2% reporting on prescribing patterns. 51.7% of the studies included inpatients. Only 14.1% of studies reported meeting the 2024 United Nations General Assembly AMR (UNGA) recommended target of at least 70% of human antibiotic use being Access antibiotics, with a concerning trend of overuse of Watch antibiotics (68.2% of studies). Dispensing practices revealed significant dispensing of antibiotics without prescriptions especially in Pakistan and Bangladesh. Watch antibiotics were more available but also more expensive than Access antibiotics. Conclusion: Encouragingly, many LMICs are now reporting antibiotic use via the AWaRe system, including in ASPs. Wide variation exists in the proportion of AWaRe antibiotics used across LMICs, with overuse of Watch antibiotics. There is an urgent need for targeted AWaRe based ASPs in LMICs to meet recent UNGA recommendations. Improving the use, availability and affordability of Access antibiotics is essential to combat AMR.

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