Evaluating Antimicrobial Stewardship Deficits and WHO AWaRe Alignment in Conflict-Affected Tertiary Hospitals: A Quantitative Study from Sana’a, Yemen

In hospitals around the world, doctors face a constant, high-stakes balancing act. When a patient arrives with a fever or an infection, the physician must decide immediately whether to prescribe an antibiotic. The goal is to choose a drug that kills the specific bacteria causing the illness without harming the patient or the environment. To help guide these decisions, the World Health Organization created a simple sorting system called AWaRe. It groups antibiotics into three categories based on how likely they are to cause bacteria to become resistant to treatment. The first group, called "Access," contains standard, narrow-spectrum drugs that are effective for common infections and are the preferred first choice. The second group, "Watch," includes broader, stronger drugs that work against a wider range of bacteria but carry a higher risk of encouraging resistance if used too often. The final group, "Reserve," holds the most powerful, last-resort medicines, which should be saved only for the most dangerous, drug-resistant infections. The global health community has set a clear target: at least sixty percent of all antibiotic use should come from the Access group. When doctors rely too heavily on the Watch or Reserve groups, they risk creating "superbugs" that no existing medicine can kill, a crisis that threatens to make routine surgeries and infections deadly again.

In the war-torn city of Sana'a, Yemen, this global challenge plays out in a setting where the usual tools for making safe medical decisions are often missing. A recent study examined how doctors in two major hospitals there—one public and one private—prescribed antibiotics to patients admitted to their wards. The researchers looked at nearly four hundred patient records from the intensive care units, surgery departments, and internal medicine wards over the course of a year. They wanted to see if the doctors were following the global guidelines, whether they were testing patients for specific bacteria before choosing a drug, and how well they kept records of their decisions. The findings reveal a system operating almost entirely on guesswork, driven by necessity rather than choice, where the most powerful antibiotics are used as a default safety net because the diagnostic tools to do otherwise are unavailable.

The audit uncovered a stark reality: the vast majority of antibiotics given to these patients belonged to the "Watch" group, the category that carries a higher risk of driving resistance. Specifically, nearly two-thirds of all prescriptions fell into this Watch category, while the preferred "Access" drugs made up only about a quarter of the total. The most frequently prescribed single drug was ceftriaxone, a broad-spectrum antibiotic, which accounted for more than a quarter of all medications given. This heavy reliance on broad-spectrum drugs was not a matter of preference but of circumstance. The study found that almost every single prescription was "empirical," meaning the doctor started the treatment without knowing exactly which bacteria was causing the infection. In fact, in only three out of the nearly four hundred patient records did the medical file contain any evidence that a lab test had been done to identify the specific germ or to check which drugs it was sensitive to. Without these test results, doctors cannot switch from a broad, powerful drug to a narrower, safer one once the infection is identified. They are forced to keep patients on the broad-spectrum "Watch" drugs for the entire duration of their stay.

The situation was further complicated by the fact that most patients received multiple antibiotics at the same time. More than sixty percent of the patients were given two or more different antimicrobial drugs concurrently. This practice, often called defensive medicine, happens when doctors feel they must cover every possible type of bacteria to ensure the patient survives, especially when they cannot confirm the diagnosis. The study showed that this pattern of using multiple broad-spectrum drugs was consistent across both the public and private hospitals, regardless of how the hospitals were run or funded. The only major difference between the two facilities was in how well they kept their records. The private hospital, which used an electronic system to track patient data, had nearly complete documentation of why a drug was chosen and what the treatment plan was. In contrast, the public hospital, which relied on paper charts, had significant gaps in its records, with many files missing crucial details about the diagnosis or the specific drug instructions. However, even the better record-keeping at the private hospital did not change the fact that doctors there were prescribing the same broad-spectrum drugs in the same way as their counterparts in the public sector.

The researchers concluded that the root of the problem is a severe lack of diagnostic support. In a functioning health system, a doctor would take a sample of blood or urine, send it to a lab, and wait for the results to guide the treatment. In these Yemeni hospitals, that process is largely broken. Without routine lab tests, doctors cannot know if a patient has a simple infection that a mild drug could cure or a complex one requiring a heavy hitter. Consequently, they default to the strongest available options to ensure safety. The study found that the use of the most powerful "Reserve" antibiotics was low overall, but when they were used, it was often in severe cases like trauma or neurological issues, though sometimes without clear proof that they were strictly necessary. The authors emphasize that simply giving doctors guidelines or better record-keeping is not enough to fix this. The system is missing the fundamental infrastructure needed to identify infections, such as reliable laboratories and the ability to track local patterns of bacterial resistance. Until hospitals can routinely test patients to see which bacteria are present and which drugs will kill them, doctors will continue to rely on broad-spectrum antibiotics, accelerating the global crisis of drug resistance in a region that can least afford it.