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J Antimicrob Chemother. 2019 Jul 30. pii: dkz321. doi: 10.1093/jac/dkz321. [Epub ahead of print]

Adaptation of the WHO Essential Medicines List for national antibiotic stewardship policy in England: being AWaRe.

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HCAI & AMR Division, National Infection Service, Public Health England, London, UK.
English Surveillance Programme for Antimicrobial Utilisation and Resistance (ESPAUR), London, UK.
NHS Improvement, Patient Safety Domain, London, UK.
St George's University of London, London, UK.
Department of Health and Social Care Scientific Advisory Committee on Antibiotic Prescribing, Resistance and Healthcare-Associated Infection (APRHAI), London, UK.
University Hospital Southampton NHS Foundation Trust, University of Southampton, Southampton, UK.
Leeds Teaching Hospitals, University of Leeds, Leeds, UK.
UCLH NHS Foundation Trust, London, UK.



Appropriate use of and access to antimicrobials are key priorities of global strategies to combat antimicrobial resistance (AMR). The WHO recently classified key antibiotics into three categories (AWaRe) to improve access (Access), monitor important antibiotics (Watch) and preserve effectiveness of 'last resort' antibiotics (Reserve). This classification was assessed for antibiotic stewardship and quality improvement in English hospitals.


Using an expert elicitation exercise, antibiotics used in England but not included in the WHO AWaRe index were added to an appropriate category following a workshop consensus exercise with national experts. The methodology was tested using national antibiotic prescribing data and presented by primary and secondary care.


In 2016, 46/108 antibiotics included within the WHO AWaRe index were routinely used in England and an additional 25 antibiotics also commonly used in England were not included in the WHO AWaRe index. WHO AWaRe-excluded and -included antibiotics were reviewed and reclassified according to the England-adapted AWaRE index with the justification by experts for each addition or alteration. Applying the England-adapted AWaRe index, Access antibiotics accounted for the majority (60.9%) of prescribing, followed by Watch (37.9%) and Reserve (0.8%); 0.4% of antibiotics remained unclassified. There was unexplained 2-fold variation in prescribing between hospitals within each AWaRe category, highlighting the potential for quality improvement.


We have adapted the WHO AWaRe index to create a specific index for England. The AWaRe index provides high-level understanding of antibiotic prescribing. Subsequent to this process the England AWaRe index is now embedded into national antibiotic stewardship policy and incentivized quality improvement schemes.

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