Global Antibiotic Use Benchmarking: Nearly All Countries Overuse Watch Antibiotics, Study Finds
Key Points
Researchers developed a burden-adjusted framework to estimate optimal AWaRe antibiotic use for 186 countries, territories, and areas (CTAs).
In 2019, global optimal antibiotic need was estimated at 43.0 billion defined daily doses (DDDs), with 77% from the Access group.
Among 67 CTAs with actual use data, 72% used higher total volumes than optimal; 99% overused Watch antibiotics, while 54% underused Reserve antibiotics.
High-income countries had the highest overuse, while lower-income countries had greater need for Watch and Reserve antibiotics but often underused them.
The UN target of 70% global Access antibiotic use appears appropriate based on these estimates.
Study Snapshot
Design: Modeling study using latent class analysis to cluster 186 CTAs; benchmark-based estimation of optimal antibiotic use by AWaRe category.
Data sources: GBD 2021, Global Research on Antimicrobial Resistance project, World Bank, IQVIA MIDAS (actual use for 67 CTAs).
Primary outputs: Optimal total DDD per 1000 inhabitants per day (DID); optimal Access, Watch, Reserve DID; comparison to actual use.
Funding: Wellcome Trust (ADILA Project).
What the study asked
In 2024, the UN General Assembly set a target that by 2030, 70% of global antibiotic use should come from the Access group of the WHO AWaRe classification. However, no evidence-based method existed to determine what optimal antibiotic use should look like for individual countries. This study, published in The Lancet Public Health, aimed to develop a framework to estimate national-level optimal AWaRe antibiotic use based on each country's infection burden, resistance levels, and sociodemographic context, and to compare those estimates with actual prescribing data.
Why the question matters
The AWaRe classification categorizes antibiotics into Access (first-line, low resistance risk), Watch (broader-spectrum, higher resistance risk), and Reserve (last-resort for multidrug-resistant infections). Inappropriate use—especially overuse of Watch and underuse of Reserve—drives antimicrobial resistance (AMR) while leaving patients with resistant infections untreated. Global estimates suggest AMR directly caused 1.27 million deaths in 2019. Setting realistic, context-specific targets for each antibiotic class is a critical step toward national stewardship policies that balance access and conservation.
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（from WHO website)
How the study was conducted
Researchers from multiple institutions analyzed data from the Global Burden of Disease (GBD) 2021 study, the Global Research on Antimicrobial Resistance (GRAM) project, and the World Bank to cluster 186 countries, territories, and areas (CTAs) into four peer groups using a latent class model. The clustering considered sociodemographic index, infection burden (disability-adjusted life years from infections), and incidence of resistance.
Within each cluster, CTAs with the lowest total antibiotic use and lowest infection mortality were designated as benchmarks. For each CTA, the optimal total defined daily doses per 1000 inhabitants per day (DID) was estimated based on infection burden. Reserve DID was estimated from resistance burden data; Watch DID from the number of infections requiring Watch antibiotics as per the WHO AWaRe antibiotic book; and Access DID as the remaining volume. For 67 CTAs where actual 2019 antibiotic use data were available from IQVIA MIDAS, the researchers compared optimal estimates with actual consumption.
What the study found
Globally, the model estimated that 43.0 billion DDD (95% CI 35.4 billion–57.7 billion) of antibiotics were needed in 2019 across the 186 CTAs, equivalent to roughly one course per person. Of this total, 77% (95% CI 71–83) would optimally be from the Access group, supporting the feasibility of the UN 70% target.
Importantly, lower-income CTAs required a larger share of Watch and Reserve antibiotics: the two lowest-income clusters accounted for 81.7% of global Watch need and 80.7% of global Reserve need. However, actual use patterns were starkly different. Among the 67 CTAs with available data:
48 (72%) used higher total antibiotic volumes than estimated optimal;
66 (99%) used more Watch antibiotics than optimal;
36 (54%) used lower volumes of Reserve antibiotics than optimal;
28 (42%) used lower volumes of Access antibiotics than optimal;
In the highest-income cluster, 33 of 38 CTAs (87%) exceeded optimal total DID.
The study also noted that 60% of countries still prescribed antibiotics that WHO had recommended for phasing out.
What the results mean
The findings reveal a double problem: overuse of Watch antibiotics, which fuels resistance, and underuse of Reserve antibiotics, which leaves patients with resistant infections untreated. The mismatch between need and consumption is geographically unequal. High-income countries, despite lower infection burdens, consume the most Watch and Reserve antibiotics, while lower-income countries—where the need is greatest—often have insufficient access to these critical drugs.
The authors emphasize that the framework provides a tool for countries to identify specific areas of overuse and underuse within their own healthcare systems, moving beyond global averages to locally relevant benchmarks.
Important limitations
The study is a modeling exercise and depends on the quality and completeness of input data. Actual antibiotic use data were only available for 67 CTAs, predominantly higher-income nations, limiting the direct validation of optimal estimates in lower-income settings. The clustering and benchmarking approach may also mask within-country heterogeneity. Additionally, optimal estimates do not account for all local factors such as antibiotic availability, formulary restrictions, or clinical practice variation.
Implications for policy and practice
The framework offers a method for national health authorities to set evidence-based targets for AWaRe antibiotic use. For high-income countries, the priority is reducing overuse of Watch antibiotics. For lower-income countries, the challenge is twofold: ensuring adequate access to Reserve antibiotics for resistant infections while avoiding inappropriate use of Watch agents. The study supports the WHO and UN goals for global antibiotic stewardship and provides a starting point for tailored national action plans.
Funding and trial registration
This study was funded by the Wellcome Trust through the Antibiotic Data to Inform Local Action (ADILA) project. The authors declared no conflicts of interest. The study was not a clinical trial; no registration number applies.
References
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 Aug;11(8):e476-e486. doi: 10.1016/S2468-2667(26)00103-9. PMID: 42480563.