Global antibiotic use misaligned with need: Watch drugs overused, Access and Reserve underused, Lancet study finds

Global antibiotic use patterns

A study published in The Lancet Public Health by researchers led by Aislinn Cook from City St George's, University of London, analyzed antibiotic consumption across 186 countries and territories. The team grouped nations into four clusters based on income, sociodemographic factors, infection burden, and resistance levels, then compared actual use against modeled appropriate use. They used the WHO's AWaRe classification, which divides antibiotics into Access (first-line, low resistance risk), Watch (higher resistance risk), and Reserve (last-resort for multi-resistant infections) categories. The global need was estimated at 43 billion defined daily doses in 2019, roughly one course per person per year. A published estimate for 2018 put actual worldwide consumption at 40.2 billion daily doses.

Overuse of Watch antibiotics

Of 67 countries with comprehensive data, 66 used more Watch-class antibiotics than the benchmark states. Switzerland served as the reference for the wealthiest cluster, Morocco for the others. Germany was among the 66 overusing Watch drugs. Tim Eckmanns from the Robert Koch Institute in Berlin said Germany consumes slightly too many antibiotics overall and significantly too many Watch antibiotics.

Overconsumption and lack of access are clearly shown in the study. This is also because guidelines in Germany often recommend Watch antibiotics when Access antibiotics would be appropriate.

Underuse of Access and Reserve antibiotics

Roughly half of the studied countries used fewer Access antibiotics than deemed appropriate, meaning first-line treatments for common infections are underutilized. A similar share used fewer Reserve antibiotics than needed for severe infections, indicating that life-saving drugs are sometimes unavailable where they are most required. The dual pattern of overuse in one category and underuse in two others creates a global mismatch that fuels resistance while leaving patients without adequate therapy.

Resistance burden

Antimicrobial resistance already causes an estimated 1.14 million deaths per year worldwide. In Germany, about 6% of all bacterial infections involve pathogens resistant to all available antibiotics, and roughly 9,700 people die annually from the direct consequences of resistant germs, according to the Robert Koch Institute. The overuse of Watch antibiotics, which carry a higher potential to select for resistant strains, accelerates this trend.

Expert commentary

Mathias Pletz from University Hospital Jena pointed to a recent distortion: many Ukrainian war wounded treated in Germany required Reserve antibiotics for bone infections with multi-resistant pathogens. That effect is not reflected in the 2019 consumption data used by the study.

Since the consumption data used refer to 2019, this specific effect is not yet included, but it fundamentally shows how susceptible this normalization is to such distortions.

The researchers stress that ensuring equitable and appropriate access to effective, essential antibiotics is central to the Sustainable Development Goals. The UN has set a target that 70% of antibiotics used should be Access-class by 2030; the study's authors estimate the appropriate share at 77%.