Quantifying optimal AWaRe antibiotic use patterns in hospitals with a new benchmarking tool applied to cross-sectional point prevalence survey data from 10 countries

Hospitals are places where life-saving medicines are dispensed daily, but the very tools that cure infections can also create new problems when used too freely. Antibiotics, the drugs that kill bacteria, are under threat because bacteria are learning to resist them. When doctors prescribe these medicines too often or choose the wrong kind, they speed up this resistance, leaving patients with infections that no drug can stop. To manage this global crisis, the World Health Organization created a simple sorting system called AWaRe. It divides antibiotics into three groups: "Access" drugs, which are first-line treatments and less likely to cause resistance; "Watch" drugs, which are broader and carry a higher risk of resistance; and "Reserve" drugs, which are kept for the most dangerous cases. The goal for the world is to ensure that at least 70 percent of all antibiotic use falls into the Access category by 2030. However, knowing the target is one thing, and knowing whether a specific hospital is hitting it is another. Without a way to measure what "correct" use looks like for a specific place, with its own unique mix of diseases and bacteria, it is difficult to tell if a hospital is overusing powerful drugs or underusing the safer ones.

A team of researchers has built a new tool to solve this measurement problem, creating a way to compare what hospitals are actually prescribing against what they should be prescribing based on global guidelines and local realities. They applied this tool to data collected from thousands of patients in ten different countries, ranging from Brazil and the Philippines to Russia and Nigeria. The researchers did not just look at how many antibiotics were used; they built a detailed model that asked, "Given the types of infections these patients have, the severity of their illness, and the local risk of drug-resistant bacteria, what would the ideal prescription pattern look like?" They then compared this ideal pattern against the real-world data collected on a single day in each hospital. The result was a clear picture of the gap between reality and the recommended standard.

The study found that in almost every country surveyed, hospitals were using far fewer Access antibiotics than they should have been, while relying too heavily on the Watch category. For adult patients, the researchers calculated that in most nations, the observed use of Access antibiotics was significantly lower than the expected amount, while Watch antibiotics were used at levels far exceeding what the guidelines suggested. In some cases, the actual use of Watch antibiotics was more than five times higher than what the model predicted as necessary. This pattern held true for both adults and children, suggesting a global trend of reaching for broader-spectrum drugs even when simpler, safer options would likely work. The researchers noted that this overuse was not random; it was concentrated in specific situations, such as treating surgical wounds, skin infections, and pneumonia.

To understand the scale of this issue, the team looked at the numbers in absolute terms. They found that in countries like the Philippines and Nigeria, the amount of Watch antibiotics actually used was roughly five times higher than the amount that would be expected if doctors were following the guidelines perfectly. In Brazil, the gap was even wider for the most powerful Watch drugs, with observed use starting at nine times the expected level in 2017 and dropping to four times the expected level by 2022, showing a slow but real improvement. However, for the Access antibiotics, the situation was the opposite: hospitals were using less than half of what the model said they should be using in several countries. This suggests that the problem is not just about using too many strong drugs, but also about failing to use enough of the right, safer drugs.

The researchers also looked at how these patterns changed over time, using data from five countries collected between 2015 and 2022. They found that while there were some signs of improvement in the use of the most powerful Watch drugs in Brazil, the overall picture remained stubborn. The ratio of observed to expected use for Access and Watch antibiotics did not show a clear trend toward the ideal target across the five nations. This lack of change suggests that without targeted intervention, hospitals are unlikely to correct these prescribing habits on their own. The study highlighted that the specific infections driving the overuse varied by country. For instance, in the Philippines, the biggest opportunities to reduce unnecessary Watch antibiotic use lay in how surgical prophylaxis and pneumonia were treated. In Iran, the focus for improvement was also on surgical prophylaxis.

This new tool is designed to be adaptable. It does not just tell a hospital that it is using too many drugs; it tells them exactly where the problem lies. By breaking down the data by specific infection types and antibiotic categories, hospital administrators can see that perhaps their skin infection protocols are fine, but their pneumonia treatments are skewed toward the wrong drugs. The researchers emphasize that their model accounts for local factors, such as the prevalence of drug-resistant bacteria in a specific region, which makes the "expected" target realistic for that location. This is a crucial distinction, as a target that makes sense in one country might be impossible or dangerous in another due to different local disease patterns.

The study also addressed why these discrepancies exist. The authors suggest that local clinical guidelines, which sometimes differ from the global WHO recommendations, and the actual availability of certain drugs play a role. In some places, doctors might feel compelled to use broader drugs because they are unsure if the local bacteria are resistant to the simpler ones. In other cases, the cost or availability of the Access drugs might be an issue, though the data showed that in some countries like Zambia, Access drugs were actually used more than expected, hinting that local context is complex. The researchers were careful to note that their findings are based on a snapshot of time—a single day of data collection in each hospital—so they cannot capture seasonal changes or long-term trends within a single facility. However, by combining data from many hospitals over several years, they were able to identify consistent patterns that are unlikely to be random errors.

Ultimately, this research provides a roadmap for fixing antibiotic use. It moves beyond vague calls to "use antibiotics wisely" and offers a concrete method to measure progress. By identifying the specific gaps between what is happening and what should be happening, hospitals can prioritize their efforts. If a hospital knows that its surgical prophylaxis is driving up its Watch antibiotic numbers, it can focus its training and policy changes there. The tool allows for the setting of specific, evidence-based targets for each hospital, tailored to its own disease burden and resistance risks. The findings confirm that while the global goal of 70 percent Access antibiotic use is a useful benchmark, the path to getting there requires understanding the local landscape. The data shows that we are currently far from that goal in many parts of the world, but with a clear view of the gap, the work to close it can begin in a more focused and effective way.