Antibiotic consumption in Europe, 2019-2024: Being AWaRe is not about using less

Area of Science:

• Public Health
• Infectious Disease Epidemiology
• Health Services Research

Background:

• Antimicrobial consumption surveillance is crucial for combating antimicrobial resistance (AMR).
• Current metrics like defined daily doses (DDDs) inadequately assess prescribing quality for international comparisons.
• Benchmarking national performance in antimicrobial stewardship remains a challenge.

Purpose of the Study:

• To evaluate the utility of the World Health Organization's AWaRe (Access, Watch, Antibuse, Reserve) classification as a metric for antimicrobial stewardship.
• To compare country performance rankings using DDDs versus the AWaRe classification.
• To assess the alignment of stewardship metrics with AMR epidemiology and outcomes.

Main Methods:

• Analysis of European surveillance data from 2019-2024.
• Application of the WHO AWaRe classification to consumption data.
• Comparison of country rankings based on DDDs and AWaRe categories.
• Correlation of stewardship metrics with AMR epidemiology and mortality data.

Main Results:

• The WHO AWaRe classification significantly alters national performance rankings compared to DDDs.
• Higher proportions of Access group antibiotics correlate with better stewardship outcomes.
• Volume-based DDD metrics may unfairly penalize appropriate prescribing strategies.
• AWaRe-based rankings show closer alignment with resistance patterns and AMR-attributable mortality.

Conclusions:

• The WHO AWaRe classification offers a more nuanced approach to antimicrobial stewardship surveillance than volume-based metrics.
• AWaRe should be viewed as a governance tool, not a punitive score, and used alongside resistance and outcomes data.
• Integrating risk-stratified, outcome-informed indicators is essential for effective AMR reduction strategies and harmonized EU stewardship.