Alignment of national standard treatment guidelines with WHO AWaRe recommendations for adult primary care infectious diseases : implications for antimicrobial stewardship

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Arooj, Huda and Saleem, Zikria and Majeed, Abdul and Jamil, Emmama and Campbell, Stephen M. and Dona, Daniele and Ubaid, Umama and Afzal, Shairyar and Godman, Brian and Sharland, Mike (2026) Alignment of national standard treatment guidelines with WHO AWaRe recommendations for adult primary care infectious diseases : implications for antimicrobial stewardship. Journal of Antimicrobial Chemotherapy, 81 (4). ISSN 0305-7453 (https://doi.org/10.1093/jac/dkag099)

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Abstract

Introduction: Aligning national standard treatment guidelines (STGs) with WHO AWaRe Book recommendations where appropriate is a key antimicrobial stewardship goal. Antibiotic recommendations in national STGs vary significantly, creating gaps that require evaluation to help address rising AMR rates. Methods: We analysed adult STGs from 24 countries in six WHO regions for 11 infections commonly seen across countries in the primary care section of the WHO AWaRe Book. These included acute otitis media (AOM), pharyngitis, sinusitis, community-acquired pneumonia (CAP), chronic obstructive pulmonary disease, lower urinary tract infections, gastroenteritis (bloody and non-bloody), oral and dental infections, skin and soft tissue infections and enteric fever. National STGs were compared with WHO AWaRe recommendations to assess alignment of first-line antibiotic recommendations. Results: 522 different first-line oral antibiotic regimens were collected from the different STGs in 24 countries across 6 WHO regions. Access antibiotics were recommended in 65.7% of the regimens, while Watch antibiotics accounted for 34.3% of first-line recommendations globally, with limited recommendations of Reserve antibiotics. The Western Pacific Region (76.4%), showed the highest proportions of Access group antibiotic recommendations. Infection-specific analysis showed significant variation in alignment, with a higher alignment for enteric fever, non-bloody gastroenteritis and cystitis, and a lower alignment for CAP, oral and dental infections, and AOM (P = 0.0089). Conclusion: First-line antibiotic recommendations in adult STGs showed moderate alignment with WHO AWaRe Book treatment guidance, with regional variability. Aligning first-line recommendations with the WHO AWaRe Book guidance in primary care would assist stewardship programmes.

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