Rethinking the WHO AWaRe classification: the need for more detailed guidance.

The World Health Organization's Access, Watch, and Reserve (AWaRe) classification promotes appropriate antibiotic use and is widely adopted as a global indicator of antimicrobial use (AMU) quality. This paper highlights key limitations of the AWaRe classification system, using Japan as a case study. The global targets for the proportional use of "Access" antibiotics (60%-70%) lack epidemiological justification and may not fully capture regional disease patterns to reflect regional disease patterns. Furthermore, inconsistencies in drug classification and the influence of long-term prescriptions can distort Access category percentages. As most countries do not monitor prescription duration in AMU surveillance, global comparisons using the current AWaRe framework may be misleading. This paper suggests a careful reassessment of AMU surveillance methodology or the AWaRe classification itself to ensure meaningful evaluation of antibiotic stewardship efforts worldwide. Funding: This article was funded by a research grant from the Ministry of Health, Labour and Welfare (JP23HA2002) and JSPS KAKENHI grant number JP23K18396 and the funders did not play any role in writing the manuscript.