The World Health Organization’s AWaRe (Access, Watch, Reserve) program is a set of guidelines and associated resources to aid in the safe and effective use of antibiotics, thus contributing to antimicrobial stewardship.¹ The program includes an antibiotic book,² classification system,¹ and indicators to monitor antibiotic use.^1,3 The AWaRe classification came about in 2017 and undergoes updates every 2 years.³

How does the AWaRe system work?

• The AWaRe classification system groups antibiotics into 3 categories (Access, Watch, or Reserve) based on their impact on antimicrobial resistance. 
• The AWaRe antibiotic book² provides recommendations for choosing antibiotics, doses, and treatment durations for common infections across a variety of care settings and environments. For instance, relative to wound care, there are sections on cellulitis, burn wound-related infections, wound- and bite-related infections, sepsis, bacterial osteomyelitis, septic arthritis, and necrotizing fasciitis, among others.² 
• The AWaRe program helps countries worldwide monitor antibiotic consumption and the impact of their antimicrobial stewardship policies. 

What do the AWaRe categories mean?

• Access

Antibiotics designated as “access” are considered generally safe, are inexpensive, and have a lower risk of resistance. They are recommended as first-line treatments for many common infections.^1,3 These antibiotics are generally of a narrower spectrum and lower cost and tend to be widely available.

• Watch

Antibiotics with a label of “watch” are considered critically important, but should only be used for specific indications as they have a higher risk of resistance or toxicity.^1,3 Watch antibiotics may be more appropriate for sicker patients in a hospital setting with careful monitoring in place to avoid overuse or misuse.⁴ 

• Reserve

These antibiotics that are “reserved” as a last resort, typically for life-threatening infections caused by multi-drug resistant bacteria. 

How does AWaRe relate to other guidance programs?

It is important to distinguish this as a tool different than that provided by local antibiograms and regional microbiologic data. Authors have opined that the AWaRe system has research questions still left unanswered, such as how to adapt the WHO’s guidance for locality-specific needs, how to define when broader-spectrum coverage is appropriate, how to integrate risk assessment into decision making, and how to appropriately consider best practices in severe infections or in vulnerable or complex patient populations.⁴

Thus, the AWaRe system is one of many important sets of guidance and data to consider when supporting antimicrobial stewardship. It behooves providers to learn more about multiple reputable sources, including those from the WHO, the Centers for Disease Control and Prevention (CDC), and state, local, and facility-specific data. Of note, the CDC recently highlighted a September 2024 United Nations High-level Meeting on Antimicrobial Resistance, which set a goal of reducing deaths secondary to antimicrobial resistance by 10 percent by 2030.⁵ The CDC also has a “Be Antibiotics Aware” educational program that targets both consumers and prescribers.⁵

Conclusion

In additional to facility and local guidance, regional, national, and global authorities are all working to improve antimicrobial stewardship. Wound care providers can familiarize themselves with these resources to add to their knowledge of how they can be a part of preventing and managing antimicrobial resistance in their patients and communities.

References

1.         World Health Organization. WHO AWaRe system for antimicrobial stewardship. Accessed March 2025. https://www.who.int/teams/surveillance-prevention-control-AMR/control-and-response-strategies/AWaRe#:~:text=The%20WHO%20AWaRe%20system%20is,the%20antimicrobial%20stewardship%20practical%20toolkit

2.         World Health Organization. The WHO AWaRe (Access, Watch, Reserve) antibiotic book. Accessed March 2025. https://iris.who.int/bitstream/handle/10665/365135/WHO-MHP-HPS-EML-2022.02-eng.pdf?sequence=1

3.         World Health Organization. AWaRe classification of antibiotics for evaluation and monitoring of use, 2023. Accessed March 2025. https://www.who.int/publications/i/item/WHO-MHP-HPS-EML-2023.04#:~:text=Overview,consumption%2520being%2520Access%2520group%2520antibiotics.-2023.04%23:~:text=Overview,consumption%2520being%2520Access%2520group%2520antibiotics

4.         Zanichelli V, Sharland M, Cappello B, Moja L, Getahun H, Pessoa-Silva C, Sati H, van Weezenbeek C, Balkhy H, Simão M, Gandra S, Huttner B. The WHO AWaRe (Access, Watch, Reserve) antibiotic book and prevention of antimicrobial resistance. Bull World Health Organ. 2023 Apr 1;101(4):290–6. doi: 10.2471/BLT.22.288614. Epub 2023 Feb 10. PMCID: PMC10042089.

5.         US Centers for Disease Control and Prevention. Antibiotic Use and Stewardship in the United States, 2024 Update: Progress and Opportunities. Accessed March 2025. https://www.cdc.gov/antibiotic-use/hcp/data-research/stewardship-report.html