Access to essential antibiotics is a central public health objective. The 2024 UN General Assembly set a target for 70% of global antibiotic use to derive from the Access category of the WHO Access, Watch, Reserve (AWaRe) framework. However, there is a critical need for a standardized methodology to estimate appropriate antibiotic use levels at a national level based on the burdens of disease, resistance, and specific local contexts. This study seeks to develop and implement a burden-adjusted framework to estimate the optimal levels of AWaRe antibiotic use for 186 countries, territories, and areas (CTAs).
Utilizing comprehensive global datasets, including the Global Burden of Diseases, Injuries, and Risk Factors Study 2021 and the Global Research on Antimicrobial Resistance project, the study clustered the 186 CTAs based on sociodemographic factors, infection burden, and resistance incidences through a latent class model. Benchmark CTAs with low antibiotic use and low infection mortality rates were identified within each cluster. The optimal total defined daily doses (DDD) per 1000 inhabitants per day (DID) for each CTA were then estimated for 2019 based on their infection burden. Watch and Reserve antibiotic uses were determined through relevant resistance burdens and definitions provided by the WHO AWaRe antibiotic guidance.
The study estimated that, in 2019, 43 billion DDD (95% CI 35.4 billion–57.7 billion) of antibiotics were required across the 186 CTAs, with the Access group optimally comprising 77% (95% CI 71–83) of this need. Lower-income CTAs exhibited higher requirements for Watch and Reserve antibiotics compared to those in higher income categories. At optimal levels, 81.7% (95% CI 80.3–82.9) of global Watch antibiotic needs and 80.7% (95% CI 68.5–88.9) of global Reserve needs would be necessitated by the two lowest-income clusters. Among the 67 CTAs with available antibiotic use data, 72% (48 CTAs) were found to use higher volumes than the estimated optimal.
The findings yield insights into optimal AWaRe antibiotic consumption for the 186 CTAs. Adjusting for specific needs at the CTA level aligns with the UN General Assembly's guidance on maintaining 70% of global antibiotic use from the Access group. This benchmarking allows for detecting both overuse and underuse of AWaRe antibiotics in individual CTAs, thus facilitating informed national policies to enhance antibiotic stewardship.
Equitable and appropriate access to essential antibiotics is crucial within the framework of the Sustainable Development Goals. Launched by the WHO in 2017, the AWaRe system categorizes over 250 antibiotics into groups based on efficacy and potential for resistance: Access antibiotics like amoxicillin, Watch antibiotics indicated for specific infections, and Reserve antibiotics reserved for multidrug-resistant infections.
Previous discussions at the 2024 UN General Assembly established that the AWaRe system should guide global antibiotic surveillance, promoting the Access group as 70% of overall global use. While substantial studies have reported antibiotic usage trends, comprehensive methods for estimating optimal national levels by the AWaRe group were lacking.
This study introduces a systematic method for establishing target ranges of antibiotic use in defined daily doses (DID) based on the infection and resistance burden at the national level, taking sociodemographic and health system infrastructure into account. These estimates provide a first for the 186 CTAs to be benchmarked, allowing for data-driven policymaking.
The commitments from the UN General Assembly clearly delineate global antibiotic target frameworks. This study provides a methodology for estimating optimal antibiotic use specific to national contexts while highlighting the disparities in both overuse and the essential access to antibiotics. Understanding these discrepancies will aid the development of national action plans and improve health outcomes across varying healthcare systems.
For each of the 186 CTAs, the optimal antibiotic use volumes were expressed as DID for total AWaRe groups, utilizing comprehensive data reflecting infection and resistance burdens. These estimates consider sociodemographic factors influencing antibiotic needs.
A breadth of data was drawn from sources including the IQVIA MIDAS Database, which provided sales information to translate volumes into DDD. Additional infection incidence and mortality data were sourced from the Global Burden of Diseases study and other global health databases.
A Bayesian multivariate ecological regression model was utilized to relate national characteristics with antibiotic use volumes across AWaRe groups. The analysis also involved developing a benchmarking approach to derive optimal antibiotic use levels structured by peer CTA characteristics. The study calculated expected Watch and Reserve needs based on active resistance cases and identified optimal usage from benchmark CTAs within each socio-economic cluster, comparing them against actual usage data for validation.