A Global Low- and Middle-Income Country Primary Care Antimicrobial Stewardship Trial using the WHO AWaRe system (the AWaRe 1 Trial)

Principal Investigator:
Professor Mike Sharland


Vietnam, Bangladesh, Indonesia, Ghana, Nigeria

4 years (2024-2027)

The project aims to develop and validate a novel framework for future surveillance, benchmarking and population-based interventional trials of optimal antibiotic use in low- and middle-income primary care settings.

The majority of antibiotics globally are taken orally for conditions such as acute respiratory infections. Recent years have seen a troubling rise in the use of broad-spectrum antibiotics, which are more powerful and have a higher risk of leading to antibiotic resistance. The World Health Organization (WHO) has developed a classification system called AWaRe (Access, Watch, Reserve) to help guide better use of antibiotics:

  • Access (Green): Safer, less expensive, and narrow-spectrum antibiotics.
  • Watch (Yellow): Broader spectrum, generally more expensive, and with higher safety concerns.
  • Reserve (Red): Last resort antibiotics used primarily in hospital settings.

Unfortunately, about half of all antibiotic usage in LMICs involves the more critical Watch or Not Recommended categories. This misuse poses a significant threat to global health, promoting the development of antibiotic-resistant bacteria.


The AWaRe 1 Trial aims to:

  • Develop and test a new framework for how antibiotics are prescribed and used in primary care settings.
  • Establish and evaluate an educational tool for healthcare providers, helping them prescribe antibiotics more effectively based on the WHO AWaRe system.
  • Conduct a practical clinical trial to assess the effectiveness of these interventions in reducing the misuse of broad-spectrum antibiotics.

This involves creating simple, traffic-light coded tools (green for Access, yellow for Watch, red for Reserve), based on the 2022 WHO Essential Medicines List AWaRe Antibiotic Handbook, that can easily be used by healthcare professionals to make better prescribing decisions.

By educating healthcare providers and implementing a structured antimicrobial stewardship program, the trial seeks to significantly reduce inappropriate prescriptions of broad-spectrum antibiotics, thereby lowering the risk of antibiotic resistance. This approach not only aims to improve health outcomes but also to establish sustainable practices that can be adopted in similar settings worldwide.




Cape Coast Teaching Hospital

Gadjah mada

Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada

Dai Hoc Y

Hanoi Medical University


Institute for Scientific Interchange (ISI) Foundation


International Centre for Diarrheal Disease Research


King’s College London


Lagos State University College of Medicine


Radboud University


St. George’s University


University of Cape Town

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University of Oxford

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