A Scoping Review of Antibiotic Prescribing Patterns Using the WHO AWaRe Classification in Diverse Healthcare Settings: A Global Perspective
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ABSTRACT
Background: The World Health Organization’s (WHO) Access, Watch, and Reserve (AWaRe) classification is a pivotal tool for monitoring antibiotic consumption and promoting stewardship. Objective: This scoping review synthesizes findings from empirical studies employing the AWaRe framework to map global antibiotic prescribing patterns and identify key trends and challenges.
Methods: A focused analysis of seven peer-reviewed studies from diverse geographical regions (India, Denmark, Indonesia, England, Burkina Faso, Mozambique) and healthcare settings (outpatient, inpatient, community) was conducted. Data on AWaRe category proportions, adherence to the WHO target (≥60% Access antibiotics), commonly prescribed agents, and study recommendations were extracted and thematically analyzed.
Results: A stark contrast was observed between high-income countries (HICs) and low- and middle-income countries (LMICs). Studies from HICs (Denmark, England) demonstrated better alignment with the WHO target (55-61% Access antibiotics), supported by established stewardship programs and national AWaRe adaptation. In contrast, LMIC studies consistently reported suboptimal Access group usage (1.6%-38% in India, 31.6% in Indonesia) and a concerning predominance of Watch group antibiotics (37%-98.4%), predominantly third-generation cephalosporins like ceftriaxone. Excessive injectable use and low generic prescribing were additional problems identified in LMIC settings.
Conclusion: The AWaRe classification effectively reveals problematic prescribing patterns, highlighting a significant global inequity in rational antibiotic use. While HICs show progress through policy integration and monitoring, LMICs face systemic challenges including diagnostic limitations and empirical over-reliance on broad-spectrum agents. Successful implementation requires contextual adaptation of the AWaRe framework, strengthening of diagnostic and regulatory infrastructure, and its integration into sustainable, funded antimicrobial stewardship programs, particularly in resource-limited settings.
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