Essential medicines and health products

WHO releases the 2019 AWaRe Classification Antibiotics

1 October 2019 – The 2019 WHO AWaRe Classification Database was developed on the recommendation of the WHO Expert Committee on Selection and Use of Essential Medicines. It includes details of 180 antibiotics classified as Access, Watch or Reserve, their pharmacological classes, Anatomical Therapeutic Chemical (ATC) codes and WHO Essential Medicines List status. It is intended to be used as an interactive tool for countries to better support antibiotic monitoring and optimal use.

The database also lists those antibiotics whose use is not recommended by WHO – namely fixed-dose combinations of multiple broad-spectrum antibiotics that lack evidence-based indications for use or recommendations in high-quality international guidelines. Use of these antibiotics should be actively discouraged through several measures.

AWaRe classifies antibiotics into three stewardship groups: Access, Watch and Reserve, to emphasize the importance of their optimal uses and potential for antimicrobial resistance.

ACCESS GROUP ANTIBIOTICS

This group includes antibiotics that have activity against a wide range of commonly encountered susceptible pathogens while also showing lower resistance potential than antibiotics in the other groups. The Access group includes 48 antibiotics, 19 of which are included individually on the WHO Model List of Essential Medicines as first- or second -choice empiric treatment options for specified infectious syndromes.

WATCH GROUP ANTIBIOTICS

This group includes antibiotics that have higher resistance potential and includes most of the highest priority agents among the Critically Important Antimicrobials for Human Medicine and/or antibiotics that are at relatively high risk of selection of bacterial resistance. Antibiotics in Watch group should be prioritized as key targets of stewardship programs and monitoring. The Watch group includes 110 antibiotics, 11 of which are included individually on the WHO Model List of Essential Medicines as first- or second -choice empiric treatment options for specified infectious syndromes.

RESERVE GROUP ANTIBIOTICS

This group includes antibiotics and antibiotic classes that should be reserved for treatment of confirmed or suspected infections due to multi-drug-resistant organisms. Antibiotics in Reserve group should be treated as “last resort” options, which should be accessible, but their use should be tailored to highly specific patients and settings, when all alternatives have failed or are not suitable. These medicines could be protected and prioritized as key targets of national and international stewardship programs involving monitoring and utilization reporting, to preserve their effectiveness. 22 antibiotics have been classified as Reserve group. Seven Reserve group antibiotics are listed individually on the WHO Model List of Essential Medicines.

Why WHO developed AWaRe

Improving use of antibiotics through antibiotic stewardship is one of the key interventions necessary to curb the further emergence and spread of antimicrobial resistance (AMR). It is also important for ensuring appropriate treatment.

For that reason, WHO in 2017 introduced the Access, Watch, Reserve (“AWaRe”) classification of antibiotics in its Essential Medicines List. The classification is a tool for antibiotic stewardship at local, national and global levels with the aim of reducing antimicrobial resistance.

Improving use of antibiotics for universal health coverage

Access to quality, safe and affordable medicines and health products is a key contribution to Universal Health Coverage (UHC) and the triple billion target set by WHO’s 13th General Program of Work (GPW). Within the 13th GPW is an indicator, based on AWaRe, which specifies a country-level target of at least 60% of antibiotic consumption being from medicines in the Access Group. This indicator was included to monitor access to essential medicines and progress towards UHC.

Measuring antibiotic consumption, e.g. by quantifying the use of antibiotics in each of the AWaRe categories (relative or absolute) allows some inference about the overall quality of antibiotic use in a given country. Countries should first compare national / regional antibiotic use using absolute consumption data, and then relative use according to AWaRe categories. The combination of both absolute and relative consumption by category allows simple benchmarking (e.g. an overuse of Watch antibiotics can become immediately apparent and a reduction in Watch antibiotics can be identified as a target for antibiotic stewardship interventions) and assessment of trends over time (to evaluate the impact of interventions).

The AWaRe Classification Database can assist policy makers in adopting AWaRe as a tool to support setting performance targets and guide optimal use of antibiotics in countries. This tool can also be adopted by clinicians to monitor antibiotic use and implement surveillance activities at local level, and inform the development of antibiotic treatment guidelines.