This document is a comprehensive guide published by the World Health Organization (WHO) in 2022. Its primary purpose is to provide simple, evidence-based guidance on the use of antibiotics for common infections in both adults and children. The book is designed as a practical tool to improve antibiotic prescribing globally and to combat the growing threat of Antimicrobial Resistance (AMR).
Here is a breakdown of its key components:
1. Core Concept: The AWaRe Classification
The entire book is built around the AWaRe classification system, which categorizes antibiotics into three groups based on their impact on antimicrobial resistance and their appropriate use:
- ACCESS: This group includes antibiotics that have a narrow spectrum of activity (target specific bacteria), a good safety profile, lower cost, and a lower potential for driving resistance. They are recommended as the first- or second-choice empiric treatment for most common infections. The WHO has a global target that at least 60% of total antibiotic consumption should come from the Access group.
- WATCH: This group includes broader-spectrum antibiotics that have a higher potential for driving bacterial resistance. They are recommended only for specific, more severe infections where the causative pathogens are likely to be resistant to Access antibiotics.
- RESERVE: This group includes “last-resort” antibiotics that should be used only for the treatment of confirmed or suspected multidrug-resistant infections. They are critical and must be preserved for the most difficult-to-treat cases to maintain their effectiveness.
The system is often visualized as a traffic light: Access (Green), Watch (Orange), and Reserve (Red).
2. Main Aims and Scope
- Improve Prescribing: To reduce inappropriate antibiotic use, which is a major driver of AMR. This includes guidance on when NOT to use antibiotics (“No Antibiotic Care”).
- Promote Stewardship: To encourage the use of Access antibiotics whenever possible and reduce the inappropriate use of Watch and Reserve antibiotics.
- Provide Practical Guidance: To offer clear, concise recommendations on the choice of antibiotic, dose, route of administration, and treatment duration for over 30 common infections.
- Support Global Health: The book is intended for use in high-, middle-, and low-income countries and is designed to complement, not replace, existing national guidelines.
3. Structure and Content
The book is meticulously structured for ease of use:
- Introduction and Background (Chapters 1-3):
- Explains the urgent need for the book due to the AMR crisis.
- Details the principles and methods used to develop the recommendations.
- Includes a crucial chapter on antibiotic allergies, emphasizing that true allergies are rare and that over-diagnosis can lead to the use of less effective, broader-spectrum antibiotics.
- Infection-Specific Chapters (Chapters 4-40):
These are divided into two main sections:- Primary Health Care: Covers common infections seen in outpatient settings (e.g., bronchitis, pharyngitis, sinusitis, otitis media, urinary tract infections, mild skin infections).
- Hospital Facility: Covers more severe infections requiring hospital management (e.g., sepsis, meningitis, severe pneumonia, intra-abdominal infections, osteomyelitis).
- For each infection chapter, the book provides a standardized format:
- Key Messages: A quick summary of the most important points.
- Definition: Of the infection.
- Diagnosis: Guidance on clinical presentation and relevant diagnostic tests.
- Most Likely Pathogens: Lists the common bacteria or viruses causing the infection.
- Treatment:
- “No Antibiotic Care”: Explicitly states when symptomatic treatment alone is sufficient (e.g., for most cases of acute bronchitis and viral pharyngitis).
- Symptomatic Treatment: Recommends pain and fever relievers like ibuprofen and paracetamol.
- Antibiotic Treatment: When antibiotics are indicated, it provides First-Choice (usually Access) and Second-Choice options, along with precise dosing for adults and children and recommended treatment duration.
- Reserve Antibiotics Section (Chapters 41-48):
- Provides an overview and dedicated chapters on the use of last-resort antibiotics (e.g., cefiderocol, linezolid, polymyxins), stressing the principles for their responsible use.
- Dosing Guidance (Chapters 49-50):
- Separate chapters with comprehensive dosing tables for adults and children.
4. Key Themes and Emphasis
- “No Antibiotic Care”: The book repeatedly stresses that many common infections (especially respiratory ones) are viral and self-limiting. It provides clear criteria for when to avoid antibiotics, which is a central strategy for stewardship.
- The “Think D8” Principle: Before prescribing, health workers are encouraged to consider: Diagnose, Decide (if an antibiotic is needed), Drug (which one, using AWaRe), Dose, Delivery (route), Duration, Discuss (with the patient), and Document.
- Simplicity and Standardization: The guidance aims to simplify choices, for example, by recommending the same Access antibiotic (like amoxicillin) for multiple different infections and promoting the shortest effective treatment duration.
- Traffic-Light System: The use of green (Access), orange (Watch), and red (Reserve) coding throughout the book provides an immediate visual cue to the prescriber about the appropriateness of the antibiotic.
5. Target Audience
The book is intended for all healthcare workers who prescribe or dispense antibiotics, including:
- Physicians
- Nurses
- Pharmacists
- Community Health Workers
- Health care policy-makers and program managers
In summary, the WHO AWaRe Antibiotic Book is a vital global health tool designed to standardize and improve antibiotic prescribing practices. By promoting the rational use of antibiotics through the AWaRe framework, it aims to ensure these life-saving medicines remain effective for future generations while providing the best possible care for patients today.
