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

Antimicrobial consumption surveillance is central to strategies addressing antimicrobial resistance (AMR), yet indicators for benchmarking national performance remain debated. We evaluated whether applying the WHO Access, Watch and Reserve (AWaRe) classification provides a more meaningful assessment of antimicrobial stewardship than conventional defined daily dose (DDD)-based metrics.

European antimicrobial consumption surveillance data from 2019 to 2024 were examined to compare country performance using conventional DDD-based indicators and Access-based metrics. Country rankings were interpreted in relation to antimicrobial resistance epidemiology and AMR-attributable mortality, and the strenghts and limitations of each surveillance approach were assessed.

Application of the AWaRe classification substantially reshaped country rankings compared with DDD-based metrics and showed closer alignment with resistance epidemiology and AMR-attributable mortality. Countries with higher proportions of Access-group antibiotics, rather than lower overall antimicrobial consumption, demonstrated more favourable stewardship profiles. DDD-based indicators may underestimate appropriate prescribing practices, including high-dose short-course regimens and early intravenous-to-oral switch strategies, as illustrated by examples from the United Kingdom and Japan.

AWaRe should be considered a stewardship and governance tool rather than a punitive performance indicator and interpreted alongside antimicrobial resistance data, case mix, and clinical outcomes. Integrating risk-stratified, outcome-informed indicators into surveillance frameworks may better support antimicrobial stewardship policies, harmonize benchmarking across Europe, and improve strategies to reduce AMR.