The WHO AWaRe Classification of Antibiotics Explained

Antibiotics are among the most widely used medicines globally, but their increasing use has accelerated a public health crisis: antimicrobial resistance. When bacteria are exposed to antibiotics, they can adapt and evolve, making standard treatments ineffective. To help manage this growing threat, the World Health Organization (WHO) developed the AWaRe classification system. AWaRe stands for Access, Watch, and Reserve. Introduced as part of the WHO Essential Medicines List (EML) in 2017, this framework categorises antibiotics based on their spectrum of activity, the risk of resistance, and the need for careful stewardship. It serves as a practical tool for clinicians, policymakers, and procurement officers worldwide to balance access to effective treatment with the need to preserve these vital medicines for the future.

The Access Group

The Access group contains antibiotics that are generally recommended as first-line treatments for common, everyday infections. These medicines are typically narrow-spectrum, meaning they target specific bacteria rather than killing a wide range of microorganisms indiscriminately. Because they are highly effective for common infections, carry a lower risk of driving antimicrobial resistance, and are generally affordable, they are considered essential for basic healthcare. Examples include medicines like amoxicillin, a widely used penicillin-type antibiotic. The WHO has set a global target for at least 60% of all antibiotic use to come from the Access group. This target aims to reduce the unnecessary reliance on broader-spectrum agents and ensure that standard treatments remain effective for as long as possible.

The Watch Group

The Watch group includes antibiotics that have a higher potential for driving antimicrobial resistance. These medicines are generally broader-spectrum and are often prescribed when Access antibiotics are not suitable, have failed, or for specific severe infections. Because of their increased resistance risk, the WHO recommends that Watch antibiotics be used as targeted therapy for specific clinical syndromes rather than routinely for standard infections. Some medicines in this group are also subject to monitoring for adverse effects. Health systems and hospitals are encouraged to closely monitor the use of these antibiotics to ensure they are prescribed only when genuinely indicated. By restricting their routine use, healthcare providers can help slow the development of resistant bacteria while still ensuring patients receive appropriate care for more complex infections.

The Reserve Group

The Reserve group consists of antibiotics that should only be used as a last resort. These medicines are reserved for severe, life-threatening infections caused by bacteria that are resistant to multiple other antibiotics, often referred to as multidrug-resistant organisms. Because resistance to these antibiotics is a major global concern, their use is typically restricted to highly specialised healthcare settings. They are usually prescribed only when other options have been exhausted or when a patient is known to have a specific resistance pattern confirmed by laboratory testing. The Reserve group serves as a crucial safety net for modern medicine. To preserve their effectiveness, the use of these antibiotics is heavily monitored by hospital antimicrobial stewardship teams, and they are not typically available for routine outpatient prescriptions.

Guiding Prescribing and Procurement Worldwide

Beyond influencing individual prescribing decisions, the AWaRe classification helps governments and health systems design their public health policies. At the national level, the categories inform the development of standard treatment guidelines and essential medicines lists. For procurement officers, AWaRe helps prioritise which antibiotics to keep in stock, ensuring a steady supply of Access medicines while limiting the bulk purchase of Watch and Reserve groups to specialised facilities. This targeted approach to procurement helps manage healthcare budgets and prevents the overuse of potent antibiotics.

In South Africa, the South African Health Products Regulatory Authority (SAHPRA) and the National Department of Health align antibiotic regulations with stewardship principles to manage resistance, and tools like HealthSA allow users to search for registered medicines to verify their regulatory status. Globally, the AWaRe framework supports the overarching goal of antibiotic stewardship by ensuring that patients receive the right antibiotic, at the right time, while safeguarding the long-term effectiveness of these critical medicines.