Hospital antibiotic prescribing patterns in adult patients according to the WHO Access, Watch and Reserve classification (AWaRe): results from a worldwide point prevalence survey in 69 countries
Open accessAbstract
OBJECTIVES: The WHO Access, Watch and Reserve (AWaRe) classification has been developed to support countries and hospitals in promoting rational use of antibiotics while improving access to these essential medicines. We aimed to describe patterns of worldwide antibiotic use according to the AWaRe classification in the adult inpatient population. METHODS: The Global Point Prevalence Survey on Antimicrobial Consumption and Resistance (Global-PPS) collects hospital antibiotic use data using a standardized PPS methodology. Global-PPS 2015, 2017 and 2018 data, collected by 664 hospitals in 69 countries, were categorized into AWaRe groups to calculate proportional AWaRe use, Access-to-Watch ratios and the most common indications for treatment with selected Watch antibiotics. Only prescriptions for systemic antibiotics on adult inpatient wards were analysed. RESULTS: Regional Access use ranged from 28.4% in West and Central Asia to 57.7% in Oceania, whereas Watch use was lowest in Oceania (41.3%) and highest in West and Central Asia (66.1%). Reserve use ranged from 0.03% in sub-Saharan Africa to 4.7% in Latin America. There were large differences in AWaRe prescribing at country level. Watch antibiotics were prescribed for a range of very different indications worldwide, both for therapeutic and prophylactic use. CONCLUSIONS: We observed considerable variations in AWaRe prescribing and high use of Watch antibiotics, particularly in lower- and upper-middle-income countries, followed by high-income countries. The WHO AWaRe classification has an instrumental role to play in local and national stewardship activities to assess prescribing patterns and to inform and evaluate stewardship activities.
The claims and statistics of this paper haven’t been checked yet.
Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.
Integrity signals
Registry
Cites
Statistics
Claims the paper makes
The claims and statistics of this paper haven’t been checked yet.
Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
Data were collected using a structured checklist that was pre-tested and developed based on the WHO data abstraction form and WHO AWaRe 2023 classification.
“Data were collected from the prescriptions of the outpatients, using a structured checklist that was pre-tested and developed based on the WHO data abstraction form for selected drug use indicators, and WHO AWaRe 2023 antibiotics classification framework7,8.”
From Antibiotic-prescribing patterns in outpatient departments from a tertiary care hospital in Manipur using WHO AWaRe classification (2025) · cites this paper as [7]
The Methods (Data analysis; page not provided) confirm that the paper uses the WHO AWaRe framework, but specify the 2019 classification, not the 2023 version. The Methods (Data collection; page not provided) describe a standardized survey of hospitalized patients, not outpatient prescriptions collected with a pre-tested checklist based on a WHO data abstraction form. (LLM, conf=0.88)
Experimental — accuracy not yet measuredWHO recommends at least 600 encounters for investigating drug use in healthcare facilities.
“WHO recommends at least 600 encounters (prescriptions), with greater number, if possible, for investigating drug use in healthcare facilities7.”
From Antibiotic-prescribing patterns in outpatient departments from a tertiary care hospital in Manipur using WHO AWaRe classification (2025) · cites this paper as [7]
The Methods (Data collection) describes a point-prevalence survey of hospital antimicrobial prescribing, and the Discussion (Limitations) discusses participation and representativeness. Neither states that WHO recommends at least 600 encounters for investigating drug use in healthcare facilities; searches for the 600-encounter threshold and a minimum sample size found no supporting passage in our copy. (LLM, conf=0.72)
Experimental — accuracy not yet measured
Self-check
Percentages, sums and reported differences re-computed from the paper’s own numbers.
The self-check needs the paper’s full text.
Cites
Extended-Spectrum β-Lactamases: a Clinical Update
Paterson, D. L., & Bonomo, R. A. (2005) · Clinical Microbiology Reviews · doi:10.1128/cmr.18.4.657-686.2005 · Cited by 3,495 · see citing works
Global increase and geographic convergence in antibiotic consumption between 2000 and 2015
Klein, E. Y., Van Boeckel, T. P., Martinez, E. M., Pant, S., Gandra, S., Levin, S. A., Goossens, H., & Laxminarayan, R. (2018) · Proceedings of the National Academy of Sciences · doi:10.1073/pnas.1717295115 · Cited by 3,232 · see citing works
Self-citationAccess to effective antimicrobials: a worldwide challenge
Laxminarayan, R., Matsoso, P., Pant, S., Brower, C., Røttingen, J.-A., Klugman, K., & Davies, S. (2016) · The Lancet · doi:10.1016/s0140-6736(15)00474-2 · Cited by 1,465 · see citing works
Crump, J. A., Sjölund-Karlsson, M., Gordon, M. A., & Parry, C. M. (2015) · Clinical Microbiology Reviews · doi:10.1128/cmr.00002-15 · Cited by 1,165 · see citing works
Versporten, A., Zarb, P., Caniaux, I., Gros, M.-F., Drapier, N., Miller, M., Jarlier, V., Nathwani, D., Goossens, H., Koraqi, A., et al. (2018) · The Lancet Global Health · doi:10.1016/s2214-109x(18)30186-4 · Cited by 671 · see citing works
Self-citationWi, T., Lahra, M. M., Ndowa, F. J., Bala, M., Dillon, J. R., Ramón-Pardo, P., Eremin, S., BOLAN, G. A., & Unemo, M. (2017) · PLoS Medicine · doi:10.1371/journal.pmed.1002344 · Cited by 601 · see citing works
Multidrug-resistant bacterial infections in U.S. hospitalized patients, 2012-2017.
Jernigan, J. A., Hatfield, K. M., Wolford, H., Nelson, R. E., Olubajo, B., Reddy, S. C., McCarthy, N., Paul, P., McDonald, L. C., Kallen, A., et al. (2020) · New England Journal of Medicine · doi:10.1056/nejmoa1914433 · Cited by 577 · see citing works
Antibiotic stewardship in low- and middle-income countries: the same but different?
Cox, J. A., Vlieghe, E., Mendelson, M., Wertheim, H., Ndegwa, L., Villegas, M. V., Gould, I., & Levy Hara, G. (2017) · Clinical Microbiology and Infection · doi:10.1016/j.cmi.2017.07.010 · Cited by 529 · see citing works
Self-citationKlein, E. Y., Milkowska-Shibata, M., Tseng, K. K., Sharland, M., Gandra, S., Pulcini, C., & Laxminarayan, R. (2021) · The Lancet Infectious Diseases · doi:10.1016/s1473-3099(20)30332-7 · Cited by 500 · see citing works
Hsia, Y., Lee, B. R., Versporten, A., Yang, Y., Bielicki, J. A., Jackson, C., Newland, J. G., Goossens, H., Magrini, N., Sharland, M., et al. (2019) · The Lancet Global Health · doi:10.1016/s2214-109x(19)30071-3 · Cited by 350 · see citing works
Self-citationFridkin, S. K., Edwards, J. R., Courval, J. M., Hill, H., Tenover, F. C., Lawton, R. M., Gaynes, R. P., & McGowan, J. E. (2001) · Annals of Internal Medicine · doi:10.7326/0003-4819-135-3-200108070-00009 · Cited by 280 · see citing works
An international cross-sectional survey of antimicrobial stewardship programmes in hospitals
Howard, P., Pulcini, C., Hara, G. L., West, R. M., Gould, I. M., Harbarth, S., & Nathwani, D. (2014) · Journal of Antimicrobial Chemotherapy · doi:10.1093/jac/dku497 · Cited by 277 · see citing works
Sharland, M., Gandra, S., Huttner, B. D., Moja, L., Pulcini, C., Zeng, M., Mendelson, M., Cappello, B., Cooke, G., Magrini, N., et al. (2019) · The Lancet Infectious Diseases · doi:10.1016/s1473-3099(19)30532-8 · Cited by 238 · see citing works
Self-citationAnsari, F., Erntell, M., Goossens, H., & Davey, P. G. (2009) · Clinical Infectious Diseases · doi:10.1086/644617 · Cited by 233 · see citing works
Self-citationHsia, Y., Sharland, M., Jackson, C., Wong, I. C. K., Magrini, N., & Bielicki, J. A. (2018) · The Lancet Infectious Diseases · doi:10.1016/s1473-3099(18)30547-4 · Cited by 206 · see citing works
Mendelson, M., Røttingen, J., Gopinathan, U., Hamer, D. H., Wertheim, H. F. L., Basnyat, B., Butler, C., Tomson, G. B., & Balasegaram, M. (2015) · The Lancet · doi:10.1016/s0140-6736(15)00547-4 · Cited by 205 · see citing works
The Antibiotic Resistance and Prescribing in European Children Project
Versporten, A., Sharland, M., Bielicki, J. A., et al. (2013) · The Pediatric Infectious Disease Journal · doi:10.1097/inf.0b013e318286c612 · Cited by 156 · see citing works
Self-citationGandra, S., Mojica, N., Klein, E. Y., Ashok, A., Nerurkar, V., Kumari, M., Ramesh, U., Dey, S., Vadwai, V., Das, B. R., et al. (2016) · International Journal of Infectious Diseases · doi:10.1016/j.ijid.2016.08.002 · Cited by 149 · see citing works
European Surveillance of Antimicrobial Consumption (ESAC)
Zarb, P., & Goossens, H. (2011) · Drugs · doi:10.2165/11591180-000000000-00000 · Cited by 132 · see citing works
Self-citationArias, C. A., Reyes, J., Carvajal, L. P., Rincón, S., Díaz, L., Panesso, D., Ibarra, G. L., Ríos, R., Munita, J. M., Salles, M. J. C., et al. (2017) · Antimicrobial Agents and Chemotherapy · doi:10.1128/aac.00816-17 · Cited by 116 · see citing works
Self-citationA Perspective on Invasive<i>Salmonella</i>Disease in Africa
Crump, J. A., & Heyderman, R. S. (2015) · Clinical Infectious Diseases · doi:10.1093/cid/civ709 · Cited by 112 · see citing works
the Belgian Point Prevalence Survey Study Group, Vandael, E., Latour, K., et al. (2020) · Antimicrobial Resistance and Infection Control · doi:10.1186/s13756-019-0663-7 · Cited by 71 · see citing works
Measuring antibiotic availability and use in 20 low- and middle-income countries
Knowles, R., Sharland, M., Hsia, Y., Magrini, N., Moja, L., Siyam, A., & Tayler, E. (2020) · Bulletin of the World Health Organization · doi:10.2471/blt.19.241349 · Cited by 67 · see citing works
Karlowsky, J. A., Hoban, D. J., Hackel, M., et al. (2017) · The Brazilian Journal of Infectious Diseases · doi:10.1016/j.bjid.2017.03.006 · Cited by 57 · see citing works
Ensuring universal access to old antibiotics: a critical but neglected priority
Pulcini, C., Beovič, B., Béraud, G., Carlet, J. M., Cars, O., Howard, P., Levy-Hara, G., Li, G., Nathwani, D., Roblot, F., et al. (2017) · Clinical Microbiology and Infection · doi:10.1016/j.cmi.2017.04.026 · Cited by 56 · see citing works
Fluoroquinolone-resistant tuberculosis: implications in settings with weak healthcare systems
Jabeen, K., Shakoor, S., & Hasan, R. (2015) · International Journal of Infectious Diseases · doi:10.1016/j.ijid.2015.01.006 · Cited by 46 · see citing works
Remschmidt, C., Behnke, M., Kola, A., Diaz, L. A. P., Rohde, A. M., Gastmeier, P., & Schwab, F. (2017) · Antimicrobial Resistance and Infection Control · doi:10.1186/s13756-017-0253-5 · Cited by 44 · see citing works
Larramendy, S., Gaultier, A., Fournier, J., et al. (2020) · Journal of Antimicrobial Chemotherapy · doi:10.1093/jac/dkaa514 · Cited by 32 · see citing works
Al‐Taani, G. M., Scott, M., Farren, D., Gilmore, F., McCullagh, B., Hibberd, C., McCorry, A., Versporten, A., Goossens, H., Zarb, P., et al. (2018) · Epidemiology and Infection · doi:10.1017/s095026881800095x · Cited by 27 · see citing works
Self-citationLubell, Y., Turner, P., Ashley, E. A., et al. (2011) · Tropical Medicine & International Health · doi:10.1111/j.1365-3156.2011.02837.x · Cited by 20 · see citing works
Flagged first, then by citations
Cited by
Sorted by citations
Priyadharsini, R. P., Ramasamy, K., & Amarendar, S. (2022) · Journal of Family Medicine and Primary Care · doi:10.4103/jfmpc.jfmpc_527_21 · Cited by 23 · see citing works
Peddireddy, M., Mahin, J., Uppu, A., & Padi, S. S. V. (2021) · Journal of Pharmaceutical Research International · doi:10.9734/jpri/2021/v33i41b32339 · Cited by 6 · see citing works
Christina, S., Nandeibam, R., R.L., P., Sangma, A. A., & Devi, H. S. (2025) · The Indian journal of medical research · doi:10.25259/ijmr_636_2025
“This difference reflects the positive impact of rigorous antimicrobial stewardship programmes and improved diagnostic support 14 .”
- Authors
- Pauwels, I., Versporten, A., Drapier, N., Vlieghe, E., Goossens, H., the Global-PPS network, Koraqi, A., Hoxha, I., Tafaj, S., Cornistein, W., Quiros, R., Hojman, M., Ghazaryan, L., Horne, K., Cairns, K., Doukas, F., Gottlieb, T., Sermijn, E., Verhamme, K., Brands, C., Van Herendael, B., Filippin, L., Vandewal, W., Konopnicki, D., Maillart, E., Teixeira Lopes, L., Papin, P., Smits, I., Jansens, H., Bartholomeus, S., Van den Abeele, A.-M., Steyaert, S., Piette, A., Buyle, F., Cartuyvels, R., Jonckheere, S., Wybo, I., Vanneste, L., Mathieu, D., Firre, E., Westelinck, V., Gadisseux, P., Dugernier, T., Bafort, K., Gonissen, V., Vanderper, V., Gabriels, P., Weekers, F., Michel, P., Van Liedekerke, A., Costers, M., Catry, B., Dedeic-Ljubovic, A., Gales, A. C., Matos Porto, A. P., Figueiredo Costa, S., Keuleyan, E., Beidi, A., Cissohko, Y., Blakwe, H., Batchaya Basile, N., German, G. J., Lutes, S., Boswell, J., Mertz, D., Nguyen, T., MacLaggan, T., Landry, D., Ang, A., Thirion, D. J. G., Frenette, C., Émond, Y., Roberts, J., Chang, S., Kosar, J., Valiquette, L., Dutrisac, G., Afra, K., McGeer, A., Carrier, M., Grant, J., Labarca, J., Carvajal, C., Lin, H., Wang, Q., Yang, J., Yang, W., Cortes, J. A., Villalobos-Vindas, J., Ramírez-Valverde, C., Horvatic, J., Pristas, I., Paphitou, N., Rummukainen, M.-L., Froissart, A., Vanhems, P., Pagava, K., Korinteli, I., Brandt, T., Gaertner, J., Enimil, A., Roilides, E., Hajdú, E., Sengupta, S., Singh, S., Patil, P., Poojary, A., Soltani, J., Pouladfar, G., Jafarpour, Z., Alinia, C., Ameen, H., Fitzgerald, D., Paul, M., Maor, Y., Strahilevitz, J., Chowers, M., Temkin, E., Luca, A., Ishibashi, N., Gu, Y., Darwish Elhajji, F., Karabukayeva, A., Raka, D., Kambaralieva, B., Zarakauska, L., Zarb, P., Hernandez Chena, B. E., Gonzalez-Diaz, E., Corona-Meléndez, J., Torres Erazo, D. S., Loza-Jalil, S. E., Molina, J., Candelas, J. A., Mijovic, G., Duborija-Kovacevic, N., Jong, E., Kluytmans, J., van Elzakker, E., Schweitzer, V., Davies, N., Iregbu, K., Nwajiobi-Princewill, P., Nwafia, I., Fasuyi, T., Aboderin, A., Elikwu, C. J., Fadeyi, A., Ola-Bello, O., Oduyebo, O., Adedosu, A. N., Ekuma, A., Shaqiri, E., Saleem, Z., De Los Reyes, M. R., Tavares, L., Kim, N. J., Rachina, S., Alharthi, A. R., Enani, M., Faried, O., Mirghani, M., Carevic, B., Radulovic, L., Dragovac, G., Tan, S. H., Taljaard, J., Chibabhai, V., Joiner, J., Caston, J. J., Núñez-Núñez, M., Martínez-Marcos, F. J., Ojeda-Burgos, G., Menendez, M. D., Retamar, P., Corzo, J. E., Rattanaumpawan, P., Salou, M., Mnif, B., Oncul, A., Babigumira, P. A., Olweny, J., Marshall, E., McCorry, A., Aldeyab, M., Khanna, P., Gormley, C., Maloney, S., Cooper, M., Blackburn, L., Gessner-Wharton, M., Vu, L., Greer, N., Gawrys, G., Kronmann, L., Rios, E., Hudson, M., & Lindholm, D. A.
- Affiliations
- University of Antwerp (BE)
- Corresponding author
- Pauwels, Ines
- ORCID
- Pauwels, Ines
- Versporten, Ann
- Vlieghe, Erika
- Goossens, Herman
- Tafaj, Silva
- Cornistein, Wanda
- Quiros, Rodolfo
- Cairns, Kelly
- Doukas, Fiona
- Gottlieb, Thomas
- Sermijn, Erica
- Verhamme, Katia
- Maillart, Evelyne
- Jansens, Hilde
- Steyaert, Sophia
- Buyle, Franky
- Cartuyvels, Reinoud
- Jonckheere, Stijn
- Wybo, Ingrid
- Michel, Philippe
- Catry, Boudewijn
- Gales, Ana C
- Keuleyan, Emma
- German, Greg J
- Mertz, Dominik
- Nguyen, Tuyen
- MacLaggan, Timothy
- Ang, Anita
- Thirion, Daniel J G
- Frenette, Charles
- Valiquette, Louis
- Afra, Kevin
- McGeer, Allison
- Grant, Jennifer
- Carvajal, Camila
- Wang, Qiang
- Yang, Jing
- Yang, Wenjie
- Vanhems, Philippe
- Pagava, Karaman
- Enimil, Anthony
- Roilides, Emmanuel
- Hajdú, Edit
- Sengupta, Sharmila
- Singh, Sanjeev
- Patil, Priyanka
- Poojary, Aruna
- Soltani, Jafar
- Pouladfar, Gholamreza
- Jafarpour, Zahra
- Alinia, Cyrus
- Paul, Mical
- Strahilevitz, Jacob
- Chowers, Michal
- Temkin, Elizabeth
- Ishibashi, Noriomi
- Karabukayeva, Aizhan
- Raka, Denis
- Kambaralieva, Baktygul
- Zarb, Peter
- Jong, Eefje
- Kluytmans, Jan
- Schweitzer, Valentijn
- Iregbu, Kenneth
- Nwajiobi-Princewill, Philip
- Nwafia, Ifeyinwa
- Aboderin, Aaron
- Elikwu, Charles John
- Fadeyi, Abayomi
- Oduyebo, Oyinlola
- Ekuma, Agantem
- Saleem, Zikria
- Kim, Nam Joong
- Rachina, Svetlana
- Faried, Osama
- Dragovac, Gorana
- Taljaard, Jantjie
- Chibabhai, Vindana
- Retamar, Pilar
- Corzo, Juan E
- Rattanaumpawan, Pinyo
- Mnif, Basma
- Babigumira, Peter Ahabwe
- Aldeyab, Mamoon
- Cooper, Mandelin
- Blackburn, Laura
- Gessner-Wharton, Mallory
- Gawrys, Gerard
- Lindholm, David A
- Venue
- Journal of Antimicrobial Chemotherapy
- Publisher
- Oxford University Press (OUP)
- Published
- 2021-04-05
- Volume
- 76
- Issue
- 6
- Pages
- 1614-1624
- ISSN
- 0305-7453 (ISSN-L)
- 1460-2091
- PMC
- PMC8120336
- OpenAlex
- W3143871140
- Cited by
- 175
- References
- 30
- Citations by year
- 2026: 25 · 2025: 43 · 2024: 42 · 2023: 28 · 2022: 27 · 2021: 10
- FWCI
- 15.73
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Licence
- Locations
- Journal of Antimicrobial Chemotherapy (publishedVersion, cc-by-nc)
- PubMed Central (publishedVersion, cc-by-nc)
- PubMed (publishedVersion)
- Deposito de Investigacion Universidad de Sevilla (University of Seville) (submittedVersion, cc-by-nc)
- Huddersfield Research Portal (University of Huddersfield) (submittedVersion, cc-by-nc)
- VUBIR (Vrije Universiteit Brussel) (submittedVersion)
- Funders
- The Global Point Prevalence Survey is coordinated by the University of Antwerp
- Methusalem grant to Herman Goossens from the Flemish government
- Topics
- Life Sciences › Immunology and Microbiology › Applied Microbiology and Biotechnology › Antibiotic Use and Resistance
- Life Sciences › Biochemistry, Genetics and Molecular Biology › Molecular Medicine › Antibiotic Resistance in Bacteria
- Health Sciences › Medicine › Pharmacology › Antibiotics Pharmacokinetics and Efficacy
- Keywords
- antibiotic prescribing patterns, hospital antibiotic use, rational antibiotic use, antimicrobial stewardship, point prevalence survey, Watch antibiotics, hospitalized adults, antimicrobial resistance
- MeSH terms
- Adult, Anti-Infective Agents, Anti-Bacterial Agents, Hospitals, Humans, World Health Organization, Prevalence
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
Are you an author, or do you see a problem with this page? Request a review
