High-income regions use more antibiotics despite lower requirement than low-income regions, and most regions use more antibiotics, particularly those with high potential for resistance, than is optimal, according to a study which the investigators characterize as the first to quantify global antibiotic use by the WHO AWaRe program classifications.1
The AWaRE program classifies antibiotics as Access, Watch and Reserve; with Access agents intended as first- or second-line choices for common infections and considered to have low potential for resistance.Watch antibiotics have higher potential for resistance and are recommended for particular infections, and those in the Reserve class are considered "last-resort," and for multidrug-resistant infections.
In 2024, the UN General Assembly High-level Meeting on antimicrobial resistance (AMR) supported the WHO recommendation that Access antibiotics should comprise 70% of global antibiotic use by 2030.This study's investigators point out, however, that no method for deriving country-level targets was included in the recommendation.
“Although this usage target provides an important global benchmark, it does not account for large differences between countries in terms of infection burden, antibiotic resistance, population demographics, and health-care provision," observed Aislinn Cook, DPhil candidate, Antibiotic Policy Group, School of Health and Medical Sciences, City St George's, University London, London, UK, and colleagues.
To establish a method to estimate optimal national-level antibiotic use, the investigators divided 186 countries, territories, and areas (CTAs) into four peer group "clusters" based on sociodemographic factors, infection burden, and resistance incidence.Within each group, they identified benchmark CTAs with low antibiotic use and low infection mortality. From 2019 data on infection burden, they estimated optimal total daily doses per 1,000 inhabitants per day (DID). The DID of Reserve antibiotics was estimated from resistance burdens, and Watch antibiotics from the number of infections for which they are indicated per AWaRE. Optimal Access DID was equated to what remained from the total.
"Benchmarking by cluster should enable individual CTAs in each cluster to compare their antibiotic use to that of a contextualised reference," remarked Marianne AB van der Sande, MD, MPH, PhD, Global Health, Julius Centre for Primary Care and Health Sciences, University Medical Center Utrecht, Utrecht, Netherlands, and Daniel Valia, MD, MSc, in an accompanying editorial.2
"Cook and colleagues also make a strong case for not only assessing the distribution of antibiotic use by AWaRe category but also considering total use adjusted for infectious disease incidence, as this measure give a better indication of potential overuse or underuse and should help ensure that antibiotic use is matched to actual needs," van der Sande and Valia suggest.
What You Need to Know
High-income countries overuse antibiotics the most, with 87% of the wealthiest-income cluster's countries exceeding their estimated optimal total antibiotic use.
Nearly all surveyed countries (99%) overused Watch antibiotics—those with higher resistance potential—while many simultaneously underused Reserve antibiotics (54%) and Access antibiotics (42%), the safer, first-line options.
Since the global 70% Access-antibiotic-use target doesn't account for country-level differences in infection burden and resistance, the researchers propose a cluster-based benchmarking method so countries can compare themselves to similar peers rather than a single global standard.
Although the investigators' estimates for the 186 CTAs were extrapolated from multiple data sets such as the 2021 Global Burden of Diseases, Injuries, and Risk Factors Study, comprehensive antibiotic usage data was only available from 67 CTAs. For those, they reported that 48 (72%) used higher total antibiotic volumes than were estimated as optimal.
They found that overuse was most frequent in high-income settings: 33 (87%) of 38 CTAs in the highest-income cluster exceeded the estimated optimal total DID.Watch antibiotic use exceeded optimal levels in 66 (99%) of the 67 CTAs; while 36 (54%) used lower volumes of Reserve antibiotics, and 28 (42%) used lower volumes of Access antibiotics than the estimated optimal amounts.
"Addressing unnecessary use of total, Not Recommended, and oral Watch antibiotics in primary care, given that primary care accounts for around 90% of human antibiotic use, will be a crucial part of future antibiotic policy and stewardship intervention, alongside improving access for patients on the basis of unmet needs," declare Cook and colleagues.
References
1. Cook A, Cooper B, Thorn M, et al. Estimating optimal levels of WHO Access, Watch Reserve (AWaRe) antibiotic use in 186 countries, territories, and areas on the basis of clinical infection and resistance burden. Lancet Public Health. 2026; 11: e476-486. https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(26)00103-9/fulltext. Accessed July 27, 2026.
