Quantifying optimal AWaRe antibiotic use patterns in hospitals with a new benchmarking tool applied to cross-sectional point prevalence survey data from 10 countries
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Background
Both over- and under-antibiotic use pose major global health challenges, yet there is no consensus on how to quantify deviations from optimal prescribing or set evidence-based targets. We developed a benchmarking tool for inpatient antibiotic use and evaluated its application in 10 countries.
Methods
We developed decision-tree models to estimate expected empiric antibiotic use for 11 indications, based on the WHO AWaRe book for two age groups: 28 days to ≤12 years and >12 years. We parameterised the models using country-specific antimicrobial resistance estimates in the 10 countries and cross-sectional Global Point Prevalence Survey (Global-PPS) case-mix data from 2021 for 10 countries and from 2015–2022 in a subset of five countries. We then compared estimated expected antibiotic use with observed empiric use (from Global-PPS) in defined daily doses for adults and days of therapy for children, across indications and AWaRe categories.
Findings
In 2021, among patients aged >12 years, in all countries but one, observed empiric Access antibiotic use, as a proportion of total antibiotic use, was lower than expected and empiric Watch antibiotic use was higher than expected. Similar patterns were observed in all countries but one in patients aged 28 days to ≤12 years. The magnitude of discrepancies between expected and observed Access and Watch antibiotic use varied across indications and countries. The median observed-to-expected ratios of usage across countries ranged from 0.3–0.8 for Access antibiotics, and 0.7–5.3 for Watch antibiotics in patients aged >12 years in 2021. Temporal trends from repeated surveys from 2015 to 2022 showed little change in observed-to-expected ratios for Access and Watch antibiotics.
Interpretation
This benchmarking tool uses Global-PPS data to quantify differences between observed antibiotic use and WHO AWaRe recommendations. Our tool can be adaptable to local guidelines, provides policy-relevant estimates of expected antibiotic use to support monitoring, procurement planning, and targeted stewardship intervention.
Funding
This study is part of the ADILA project supported by the Wellcome Trust (222051/Z/20/Z). The Global-PPS is supported by bioMérieux. bioMérieux is the sole private partner of the Global-PPS and had no role or responsibility in the study design, data collection, data analysis, data interpretation or writing the report.
Research in context
Evidence before this study
Monitoring antimicrobial use and benchmarking observed against expected antimicrobial usage given local disease burden and prescribing guidelines has the potential to help optimise antimicrobial use. We searched PubMed on 3 August 2026 for articles published since 1 January 2020, using the search terms: (((Benchmark) AND (Expected)) AND (Antimicrobial)) AND (Hospital). Among 37 studies retrieved, we found eight that benchmarked observed antimicrobial use against an estimate of expected use in hospital settings for interhospital comparison, all of which were conducted in high-income countries (the United States, United Kingdom, Finland and Japan). A range of statistical approaches including indirect standardisation, risk-adjusted regression, and generalised linear mixed models were used to estimate expected antibiotic use. Notably, none of these studies estimated the expected use based on antibiotic treatment guidelines, drug availability and risk of antimicrobial resistance (AMR) in the study population.
Added value of this study
We developed a novel tool for estimating expected empirical antibiotic use based on the World Health Organization (WHO) guidelines while accounting for local disease burden, risk of antibiotic resistance, drug availability and patient severity. We developed decision tree models informed by the recommended empirical antibiotic treatment for ten common infection syndromes and surgical prophylaxis for hospital settings in the WHO’s AWaRe antibiotic book. The models were informed by data from the Global Point Prevalence Survey (Global-PPS) to estimate expected antibiotic use by AWaRe category in both relative (as a proportion of total use) and absolute measures. These estimates were used to benchmark the observed antibiotic use in the same cohort. We then calculated observed-to-expected ratios to quantify the deviation of the observed antibiotic use from the expected use, given reported local disease burden, and demonstrated the utility of these ratios for monitoring changes in antibiotic usage patterns over time. The findings indicated that Watch antibiotic use was substantially higher than would be expected if the surveyed hospitals had followed the WHO empirical antibiotic prescription guidelines, and there were improvements in Watch plus antibiotic usage for patients with age >12 years over the study period.
Implications of all the available evidence
This new analytical tool could enable hospitals to assess deviations in empiric antibiotic use relative to the expected use in both absolute terms (e.g. measures in defined daily doses and days of therapy) and proportional measures (out of the total antibiotic use) by AWaRe category. This tool can also be readily adaptable to incorporate local treatment guidelines. By identifying specific AWaRe categories and clinical indications where observed use deviates most from expectations, the framework provides a new tool to support the prioritisation of targeted antimicrobial stewardship interventions. Moreover, this tool could be used to monitor antibiotic use patterns in hospitals over time and identify possible cost savings.
