Many countries are using too many powerful and inappropriate antibiotics, fuelling antibiotic resistance concerns, while millions lack access to the specific drugs they need. That is according to a major international study of antibiotic use published today in The Lancet Public Health.
Research led by City St George’s, University of London and University of Oxford developed the first global framework that estimates how many and which type of antibiotics each country needs to treat their infections.
Antibiotics are grouped by the World Health Organization (WHO) into three categories, known as the “AWaRe” system:
‘Access’ antibiotics are used for most common infections and have a lower resistance risk.
‘Watch’ antibiotics have a broader spectrum, are used for specific infections and come with higher safety and resistance concerns.
‘Reserve’ antibiotics are last resort antibiotics used to treat multi-drug resistant infections.
In 2024, world leaders at the United Nations agreed that at least 70% of antibiotic use worldwide should come from the Access group by 2030. However, no method previously existed to determine the right balance of antibiotics for any individual country.
To address this, researchers analysed global data from 186 countries, territories and areas (CTAs), representing 99.8% of the global population. They grouped these countries into ‘peer groups’ based on similar infection burdens, resistance patterns, socioeconomic characteristics and healthcare access.
Within each group, countries with the lowest antibiotic use and the fewest infection-related deaths were used as benchmarks to determine what optimal antibiotic use should look like for similar countries. They then estimated optimal levels of Access, Watch and Reserve antibiotics required in each setting based on infection and resistance burdens.
The team calculated that in 2019, around 43 billion days of antibiotics were needed globally, averaging out to roughly one antibiotic course per person per year, to treat all bacterial infections appropriately. They found that 77% of global antibiotic use should be Access antibiotics, suggesting the UN’s 70% target is reasonable.
Although higher-income countries currently use the most Watch and Reserve antibiotics, the study estimates that more than 80% of the world’s optimal need for these medicines lies in lower-income countries, where infectious disease and antimicrobial resistance burdens are highest.
The researchers then compared their estimates with real-world antibiotic use data from 67 countries where this data was available. Nearly three-quarters (72%) of countries analysed were using more antibiotics in total than needed, and almost every country (99%) prescribed too many Watch antibiotics, which contribute the most to antibiotic resistance. Worryingly, 60% of countries were still using antibiotics that the WHO considers should no longer be prescribed.
At the same time, 42% of countries were using fewer Access antibiotics than estimated optimal levels, and more than half (52%) were not using enough Reserve antibiotics than estimated to be needed. This means patients with life-threatening drug-resistant infections might not be receiving the specific treatments they need.
The findings suggest that many countries could improve antibiotic use by reducing unnecessary Watch antibiotic prescribing while increasing access to essential Access antibiotics, and ensuring availability of Reserve antibiotics for patients with highly resistant infections.
Aislinn Cook, lead author and Senior Research Fellow in Infectious Diseases Epidemiology at City St George’s, University of London, said:
“Our findings show the world faces a double challenge – while some antibiotics are being overused, millions of people may still lack access to the medicines they need to treat their infections.
“We have developed the first practical way for countries to estimate how much of each type of antibiotic their populations need based on infection burden and antibiotic resistance. This framework can help move the conversation beyond measuring antibiotic consumption to matching antibiotic use with public health need. This can support countries to develop more targeted policies to reduce overuse while ensuring sustainable access to effective antibiotics.”
The team emphasise that improving access to antibiotics for the most vulnerable populations will require action at both local and national levels. This includes ensuring that quality-assured antibiotics are available and affordable in frontline healthcare settings, while national governments ensure that the right antibiotics are procured and supplied in sufficient quantities. The researchers also highlight the need for better monitoring of antibiotic use to identify areas of overuse and underuse, and for national targets based on local data that align antibiotic use more closely with public health and clinical need.
Dr Koen Pouwels, Associate Professor in Health Economics at University of Oxford Nuffield Department of Primary Care Health Sciences and co-author, said:
“Global targets such as aiming for 70% of antibiotic use to come from the WHO Access group are an important starting point, but they cannot tell countries how much of each AWaRe antibiotic group they actually need.
“By providing country-specific benchmarks, our work gives policymakers a practical way to move beyond percentage targets and make better-informed decisions about reducing overuse, improving access and strengthening antibiotic stewardship. Importantly, these benchmarks can become more ambitious over time if countries reduce infection burden, even in the face of demographic change.”
