There is increasing global use of antibiotics marked by the World Health Organization (WHO) for monitoring because of the likelihood of resistance to them. This trend will make it harder to meet the 2023 antibiotic consumption targets set by the WHO, raising concerns about the spread of antibiotic resistance.

Measures to support antibiotic monitoring and optimal use are essential for curbing the emergence and spread of antimicrobial resistance. In 2017 the WHO introduced the Access, Watch, Reserve (AWaRe) classification of antibiotics in its Essential Medicines List. Antibiotics in the Access category are first- or second-line therapies for common infections. Those in the Watch category have higher resistance potential. The Reserve group consists of last-resort antibiotics for targeted use in multidrug-resistant infections.

An international team led by researchers at the Center for Disease Dynamics, Economics & Policy (CDDEP) in Washington, DC, USA used antibiotic sales data obtained from the healthcare information company IQVIA to study patterns of antibiotic consumption in 76 countries between 2000 and 2015. They found that growth in consumption of Watch antibiotics was nearly four times greater (90.9%) than that of Access antibiotics (26.2%). The increase in Watch antibiotic consumption was much greater in low- and middle-income countries (LMICs) (165%) than in high-income countries (27.9%).

The number of countries in which Access antibiotics constituted at least 60% of total antibiotic consumption fell from 50 of 66 countries in 2000 to 42 of 76 countries in 2015. Nearly all LMICs showed a decline in the consumption of Access antibiotics compared with Watch antibiotics. The total global increase in the consumption of Watch antibiotics was found to be mainly driven by India and China.

A number of factors have likely driven the increase in consumption of Watch antibiotics in LMICs, says corresponding author Eili Klein of the CDDEP. “Economic growth has led to increased consumption of Access and Watch antibiotics in LMICs — however, policies and programs to regulate the use of Watch antibiotics have not developed at an adequate rate.”

He notes that several LMICs, including Algeria and Tunisia, have relatively high consumption of Access antibiotics, comparable to high-income countries with substantial stewardship programs. This suggests improvements in the Access-to-Watch ratio are possible regardless of a country’s GDP.

The study is not without limitations, as the researchers point out that some regions such as sub-Saharan Africa were excluded from the analysis due to lack of data, and continuous data for all years up to 2015 were not available for some countries.

Nevertheless, the study rings a warning bell that without policy changes, the WHO’s national-level target of 60% of total antibiotic consumption being in the Access category by 2023 will be difficult to achieve. 

“Ultimately, greater investment in infrastructure, regulations and leadership is needed to improve prescribing practices,” says Klein. “Limiting the spread of antimicrobial resistance is not often prioritized at the same level as higher profile diseases in low-resource healthcare systems.”

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