review · Clinical Microbiology and Infection
The World Health Organization Model List of Essential Medicines categorises antibiotics into Access, Watch, and Reserve groups under the AWaRe framework to address antimicrobial resistance. The 2023 classification covers empiric guidance on 41 essential antibiotics across more than 30 clinical infections in primary care and hospital settings, while categorising an additional 257 non-essential antibiotics for monitoring and stewardship. This framework evaluates clinical evidence to determine first- and second-choice antibiotic selections for specific infections, aiming to encourage the use of Access antibiotics or no antibiotics when appropriate. These evaluations inform practical resources, including the AWaRe antibiotic book and associated smartphone applications. Ultimately, the system provides guidance to help countries update national essential medicines lists, revise prescribing guidelines, supervise medicine use, and preserve the long-term effectiveness of existing treatments.
Antimicrobial resistance poses a severe threat to global healthcare. By establishing evidence-based first- and second-line treatments for common clinical conditions, the AWaRe framework assists healthcare systems in reducing inappropriate antibiotic prescribing. Implementing these standards helps clinicians, health facilities, and governments preserve the long-term efficacy of critical medicines while ensuring patients maintain access to effective, life-saving therapies.
The framework enables the deployment of applied clinical decision-support tools, including the AWaRe antibiotic book and connected smartphone applications. The primary users are hospital and primary healthcare prescribers, health facility managers, and national policymakers responsible for essential medicine lists and prescribing standards. Because these recommendations are already embedded in functioning digital applications and reference manuals, the underlying guidance is already applied and ready for immediate adoption in healthcare settings.
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The WHO Model List of Essential Medicines (EML) prioritizes medicines that have significant global public health value. The EML can also deliver important messages on appropriate medicine use. Since 2017, in response to the growing challenge of antimicrobial resistance, antibiotics on the EML have been reviewed and categorized into three groups: Access, Watch, and Reserve, leading to a new categorization called AWaRe. These categories were developed taking into account the impact of different antibiotics and classes on antimicrobial resistance and the implications for their appropriate use. The 2023 AWaRe classification provides empirical guidance on 41 essential antibiotics for over 30 clinical infections targeting both the primary health care and hospital facility setting. A further 257 antibiotics not included on the EML have been allocated an AWaRe group for stewardship and monitoring purposes. This article describes the development of AWaRe, focussing on the clinical evidence base that guided the selection of Access, Watch, or Reserve antibiotics as first and second choices for each infection. The overarching objective was to offer a tool for optimizing the quality of global antibiotic prescribing and reduce inappropriate use by encouraging the use of Access antibiotics (or no antibiotics) where appropriate. This clinical evidence evaluation and subsequent EML recommendations are the basis for the AWaRe antibiotic book and related smartphone applications. By providing guidance on antibiotic prioritization, AWaRe aims to facilitate the revision of national lists of essential medicines, update national prescribing guidelines, and supervise antibiotic use. Adherence to AWaRe would extend the effectiveness of current antibiotics while helping countries expand access to these life-saving medicines for the benefit of current and future patients, health professionals, and the environment.
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DOI: 10.1016/j.cmi.2024.02.003
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