Updates and Challenges for WHO Antibiotic Targets

Investigators reviewed patterns of antibiotic consumption in each of the WHO Access, Watch, and Reserve (AWaRe) categories over a span of 15 years and documented changes.

Policy changes regarding antibiotic stewardship may be needed to reach the World Health Organization (WHO) antibiotic consumption and access targets, according to study results recently published in The Lancet Infectious Diseases.

The WHO Access, Watch, and Reserve (AWaRe) classification aims to balance appropriate antibiotic access and stewardship by categorizing antibiotics into 3 groups: Access, Watch, and Reserve. Access antibiotics are used as first- or second-line therapies and should be widely available, affordable, and high-quality. Watch antibiotics are only recommended for specific indications because of their higher potential of antimicrobial resistance. Reserve antibiotics are last-resort antibiotics, where use needs to be highly tailored and monitored to avoid resistance.

Using these classifications, the appropriateness of antibiotic consumption at the national and global level can be indicated indirectly. Currently, WHO has a national-level target for Access antibiotics to account for ≥60% of overall antibiotic consumption by 2023; however, the global patterns of consumption of essential medicines and how the global increase in antibiotic consumption will affect the WHO target are still not understood. Therefore, this analysis aimed to identify the change in patterns of antibiotic consumption in each of the AWaRe categories across countries over 15 years.

Using quarterly national sample survey data obtained from IQVUA, antibiotic consumption was classified into AWaRe categories for 76 countries between 2000 and 2015. Using these data, researchers measured the proportion of antibiotic use in each category and calculated the ratio of Access antibiotics to Watch antibiotics (access-to-watch index) for each country.

Results show a rapid increase in the consumption of Watch antibiotics, with a more modest rise in Access antibiotics during the study period. The global per-capita consumption of Watch antibiotics increased by 90.9% compared with an increase of 26.2% in Access antibiotics. Low- and middle-income countries (LMICs) showed a greater increase in Watch antibiotic consumption (165%) than high-income countries (HICs) (27.9%). Globally, the access-to-watch index decreased by 38.5%: 46.7% in LMICs and 16.7% in HICs. Of the 41 LMICs included, 37 (90%) showed an access-to-watch decrease in their relative consumption. Finally, the number of countries where Access antibiotics represented ≥60% of their total antibiotic consumption (the WHO national-level target) decreased from 50/66 (76%) countries in 2000 to 42/76 (55%) countries in 2015.

Overall, the study authors concluded that, “Without policy changes, the WHO national-level target of at least 60% of total antibiotic consumption being in the Access category by 2023, will be difficult to achieve.”


Klein EY, Milkowska-Shibata M, Tsenf KK, et al. Assessment of WHO antibiotic consumption and access targets in 76 countries, 2000-15: an analysis of pharmaceutical sales data [published online July 24, 2020]. Lancet Infect Dis. doi:10.1016/S1473-3099(20)30456-4