Development of AWaRe quality indicators for optimal antibiotic use
This study developed and prioritized a set of 20 core, feasible quality indicators based on the WHO AWaRe framework to support optimal antibiotic use and inform stewardship programs across primary care, hospital, and general healthcare settings.
Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). This is an AI-generated explanation of a preprint that has not been peer-reviewed. It is not medical advice. Do not make health decisions based on this content. Read full disclaimer
Antibiotics are among the most powerful tools modern medicine possesses, capable of turning fatal infections into manageable illnesses. Yet, their effectiveness is not infinite. When these drugs are used too often or for the wrong reasons, the bacteria they are meant to kill learn to survive them, rendering the medicines useless. This growing threat, known as antimicrobial resistance, has led health organizations worldwide to seek better ways to guide doctors on when and how to prescribe these life-saving drugs. To help, the World Health Organization created a system called AWaRe, which sorts antibiotics into three groups: Access, Watch, and Reserve. The Access group contains the standard, first-line drugs that should be used for most common infections. The Watch group includes drugs that are effective but carry a higher risk of encouraging resistance, so they should be used with more caution. The Reserve group holds the strongest, last-resort medicines, which are saved for the most dangerous cases where other options have failed. The goal is to ensure that the majority of antibiotic use stays within the Access group, preserving the strength of the other groups for when they are truly needed.
Despite having this clear guidance, many countries lack a practical way to measure whether doctors are actually following it. Knowing that a guideline exists is different from knowing if it is being followed in a busy clinic or a crowded hospital. Without a way to track performance, it is difficult to identify problems or improve care. A team of researchers set out to solve this by creating a specific set of measuring tools, known as quality indicators, that are directly tied to the AWaRe system. They wanted to build a list of questions that a hospital or a country could ask itself to see if it was using antibiotics correctly. These questions needed to be simple enough to answer with available data but specific enough to show exactly where improvements were needed.
To build this list, the researchers gathered a large group of experts from around the world, representing different regions and medical specialties. They started with a long list of potential questions gathered from previous studies and refined them through a careful, multi-step process. First, they asked the experts to review the questions for clarity and to suggest changes. Then, the experts rated each question on two main criteria: whether it was the right thing to measure, and whether it was actually possible to measure it in real-world settings, from well-resourced hospitals to clinics in low-income countries. This process involved two rounds of rating and discussion, ensuring that the final list reflected a strong agreement among the global community of experts.
The result was a comprehensive set of 136 potential indicators covering infections treated in primary care, hospitals, and at a general population level. These indicators looked at specific situations, such as whether a patient with a sore throat was given the right type of antibiotic, or whether a patient with a severe infection received the correct dose and duration of treatment. The researchers found that while almost all the indicators were considered appropriate and relevant, fewer were considered easy to measure in every setting. In primary care, for example, many experts felt that while a question was important, the data needed to answer it might not be readily available in all countries. This highlighted a gap between knowing what good care looks like and having the tools to measure it.
To make the list more useful for immediate action, the team then prioritized the indicators, selecting a smaller group of twenty core questions that would serve as the most essential starting point. This core list included ten questions for primary care, eight for hospitals, and two for general population monitoring. These selected questions focused on the most common infections, such as respiratory infections, ear infections, and urinary tract infections, and checked if the right antibiotic was chosen, if the dose was correct, and if the treatment lasted for the right amount of time. For instance, one key indicator for primary care measures the proportion of patients with a respiratory infection who are given a standard, first-line antibiotic, while another checks if patients with a severe infection are receiving the stronger, more specialized drugs only when necessary.
The study concludes that these new indicators provide a solid foundation for countries to begin monitoring and improving their antibiotic use. By using these specific, agreed-upon measures, health systems can move beyond guessing and start tracking their progress with precision. The researchers emphasize that while the list is ready, its success depends on local adaptation. Countries will need to adjust how they collect the data to fit their own resources and systems. The ultimate goal is to create a culture where antibiotic use is constantly evaluated and improved, ensuring that these vital medicines remain effective for future generations. The work represents a significant step forward in turning global guidelines into local action, offering a clear path for doctors and health officials to follow in the fight against drug-resistant infections.
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