AWaRe Antibiotic list 2022 (Access, Watch & Reserve classification)

You might be aware of the UK's current five year plan to tackle antimicrobial resistance, which builds on the previous one.

As part of this, for the years 2022/23 and 23/24 all hospital Trusts have been given new targets, which are to reduce their use of broader-spectrum antibiotics from the WHO's 'Watch' and 'Reserve' categories. (WHO's AWaRe scheme puts antimicrobials into three categories of increasing level of concern, called Access, Watch and Reserve). For UK use, the 'Watch' category includes drugs like co-amoxiclav, clarithromycin / erythromycin / clindamycin, ciprofloxacin and cephalosporins, while the 'Access' category includes drugs like penicillin, amoxicillin, gentamicin, nitrofurantoin, flucloxacillin, trimethoprim and co-trimoxazole. There is a full list in the attachment.

Over recent years the proportion of our antibiotic use that has comprised Watch and Reserve drugs has fallen from nearly 50% to just over 40%, but in recent months as we have emerged from the pandemic our use has increased significantly and is currently over the target.

In general, our audits and benchmarking work do not suggest that we use antibiotics unnecessarily (although we must remain vigilant on that), but there are sometimes opportunities to use narrower-spectrum agents from the WHO's 'Access' category rather than broader-spectrum 'Watch' or 'Reserve' agents, and that is what we must do if we are to meet our target and make our contribution to attempts to control resistance.

Just to be clear, hospitals are not being asked to reduce overall antibiotic use (it would be nice if they could, but most of the c.15% reduction in UK antimicrobial consumption since 2016 has come from primary care) - we are being asked to use narrower-spectrum drugs that are less likely to promote resistance. The target is based on the amount of Watch and Reserve drugs we get through, denominated by a measure of activity. There is no target for Access drugs.

Co-amoxiclav is, by far, our most-used 'Watch' antibiotic, so realistically to achieve our target we need to take every opportunity to use drugs from the 'Access' list rather than co-amoxiclav where it is appropriate to do so. The same applies to clarithromycin, cefuroxime, ciprofloxacin and so on, but we use much less of these in the first place.

There will be various initiatives to address this, and we might amend some of our guidelines, but meanwhile please could we ask you to be mindful of this and to use narrower-spectrum 'Access' antibiotics in preference to broader spectrum 'Watch' and 'Reserve' antibiotics where you can.

In particular:

  • we generally advocate flucloxacillin rather than co-amoxiclav for skin and soft tissue infections
  • we generally advocate doxycycline or amoxicillin rather than co-amoxiclav for infective exacerbations of COPD
  • for community acquired pneumonia, only the more severe cases require co-amoxiclav, and you don't need to add a macrolide unless there are particular reasons for concern about 'atypical' infection
  • for patients with UTI who can be treated orally we generally advocate nitrofurantoin, trimethoprim, pivmecillinam or fosfomycin, not co-amoxiclav; sometimes giving a single dose of IV gentamicin can give you the confidence to continue with PO treatment pending culture results
  • reaching for co-amoxiclav (or anything for that matter) in the hope that it will sort out an unexplained high CRP is generally a bad idea
  • we usually advocate single-dose surgical prophylaxis
  • for most simple infections we advocate 5 day rather than 7 day courses

But. Obviously we don't wish to compromise safety in the name of a target. If co-amoxiclav or another 'Watch'/'Reserve' antibiotic is the right drug, use it. There are comprehensive guidelines on the intranet which can help.

Antimicrobial resistance can seem like a distant threat or a global problem that individually we can't do much about, but it is real and getting worse. The spectre of untreatable infections is often bandied about but the more urgent concerns are failure of prophylaxis leading to worse surgical outcomes, failure of the empiric treatment regimes that support cancer treatment, and the creeping need for drugs that are more toxic, or less convenient, or more expensive.

Thank you for reading this far. If you're interested, we put together a quarterly report on Trust antimicrobial use that can be found on this page. 

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