Many Countries Overusing Potent Antibiotics, Fuels Growing Resistance

Antibiotic resistance is accelerating as many countries rely on too many powerful, poorly targeted antibiotics, while other places still fail to get the exact medicines patients need. A new large-scale international analysis published in The Lancet Public Health lays out why this mismatch matters—and offers a way to quantify what “optimal” antibiotic use should look like for every country.

Led by researchers at City St George’s, University of London, and the University of Oxford, the study builds the first global framework designed to estimate both the quantity and the mix of antibiotics required to treat bacterial infections across different healthcare and resistance conditions. Instead of focusing only on consumption totals, it links antibiotic use to clinical infection burden and antimicrobial resistance risk.

The work uses the World Health Organization’s AWaRe classification system: Access, Watch, and Reserve antibiotics. Access antibiotics are intended for common infections with comparatively lower resistance risk. Watch antibiotics cover a wider range of conditions but raise more concerns about safety and resistance selection. Reserve antibiotics are last-line options for multi-drug resistant infections and are critical when resistance is already entrenched.

To tailor recommendations, the team analyzed data from 186 countries, territories, and areas representing 99.8% of the global population. They clustered settings into peer groups based on similar infection burdens, resistance patterns, socioeconomic factors, and healthcare access, then used the lowest-use, lowest-death countries in each group as benchmarks for what appropriate antibiotic use should achieve.

In 2019, the researchers estimate that about 43 billion days of antibiotics were needed globally—roughly one antibiotic course per person per year—to treat bacterial infections appropriately. They calculate that 77% of antibiotic use should come from the Access category, suggesting the internationally agreed 70% Access target is broadly plausible.

However, country-level performance diverges sharply from what is needed. In the available data from 67 countries, nearly three-quarters used more antibiotics overall than estimated optimal levels. Nearly every country (99%) prescribed too many Watch antibiotics, the class most strongly associated with antibiotic resistance pressures.

Alarmingly, 60% of countries were still using antibiotics that WHO guidance indicates should no longer be routinely prescribed. At the same time, underuse is also widespread: 42% used fewer Access antibiotics than optimal, and 52% prescribed too little Reserve therapy, risking inadequate treatment for life-threatening drug-resistant infections.

The findings point to a practical strategy: reduce unnecessary Watch prescribing, expand reliable access to essential Access antibiotics, and ensure Reserve antibiotics are available when highly resistant infections require them. The study also argues that improving access for vulnerable populations will require coordinated local and national action, including better procurement, affordability, and antibiotic stewardship monitoring.