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 Table of Contents  
Year : 2022  |  Volume : 66  |  Issue : 3  |  Page : 352-354  

Access–Watch ratio based on access, watch, and reserve classification of antibiotics in public health facilities of Tamil Nadu

1 Research Assistant, Department of Community Medicine, ESIC Medical College and PGIMSR, Chennai, Tamil Nadu, India
2 Assistant Professor, Department of Community Medicine, ESIC Medical College and PGIMSR, Chennai, Tamil Nadu, India

Date of Submission23-Feb-2022
Date of Decision17-Jun-2022
Date of Acceptance12-Jul-2022
Date of Web Publication22-Sep-2022

Correspondence Address:
Isha Sinha
ESIC Medical College and PGIMSR, K.K Nagar, Chennai, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijph.ijph_274_22

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The rise in cases of antibiotic resistance can be mainly attributed to the overuse and misuse of antibiotics. To address this issue, the WHO launched Access, Watch, and Reserve (AWaRe) classification of antibiotics in 2017 as a surveillance tool. Many countries have adopted it to monitor and optimize their antibiotic usage. However, implementation of it is yet not seen at a very appreciable level. Through this survey, we tried to explore the prescribing pattern of antibiotics based on the WHO AWaRe classification in selected secondary and tertiary care health facilities of Tamil Nadu. In-patient case sheets were audited in selected departments across 18 health facilities in six districts. Proportionately higher use of the watch group of antibiotics was found in all the districts. A lower access–watch ratio suggests the need for judicious implementation of such tools to safeguard this life-saving good and ensuring its sustainability.

Keywords: Antibiotics use, hospitals, WHO access, watch, and reserve classification

How to cite this article:
Sinha I, Kanth K, Krishnamoorthy Y, Gopichandran V. Access–Watch ratio based on access, watch, and reserve classification of antibiotics in public health facilities of Tamil Nadu. Indian J Public Health 2022;66:352-4

How to cite this URL:
Sinha I, Kanth K, Krishnamoorthy Y, Gopichandran V. Access–Watch ratio based on access, watch, and reserve classification of antibiotics in public health facilities of Tamil Nadu. Indian J Public Health [serial online] 2022 [cited 2023 Mar 26];66:352-4. Available from:

Antibiotics are an inseparable part of modern medical practice. From minor infectious diseases to advanced surgical or cosmetic procedures, it is difficult to imagine any treatment without them. However, with the increasing antimicrobial resistance, that renders antimicrobials ineffective against the targeted organism, it is imperative to safeguard this common good. To optimize antimicrobial usage, the WHO expert committee on the selection and use of essential medicine developed the Access, Watch, and Reserve (AWaRe) classification of antibiotics in 2017. This classification was further updated in 2021 with the addition of 78 more antibiotics taking the total to 258.[1] This tool can act as a standard for monitoring and surveillance of antibiotic usage and help policymakers to plan necessary interventions.

It classifies antibiotics into three categories: Access, Watch, and Reserve. Few antibiotic combinations belong to the “not recommended” group. The access group of antibiotics includes those that are commonly used as a first or second choice for a wide spectrum of commonly known pathogens. These are less susceptible to the development of antibiotic resistance. The watch group of antibiotics is those which are considered “Critically Important Antimicrobials for Human Medicine” and they also have a higher risk of developing antibiotic resistance. The reserve group of antibiotics is those which are used or reserved for specific treatments such as multidrug-resistant infections. These drugs should be available but opted as a “last resort” when all other choices have failed. In the triple billion targets set to achieve universal health coverage, the WHO has proposed a country-specific target that is aimed to achieve 60% of antibiotic consumption from access groups of antibiotics.[2] Our aim through this survey was to assess the antibiotic prescribing pattern in selected secondary and tertiary public health-care facilities of Tamil Nadu based on the WHO AWaRe classification.

This survey was conducted in Tamil Nadu, a state in southern India. Tamil Nadu is a model state for many health indicators in the country and is the only state that has an exclusive department of public health for primary health care.[1] This is possible due to the rigorous health sector reforms that have been implemented and improved by both the main regional political parties that have ruled the state alternatively.[2] For this survey, six districts of Tamil Nadu were selected two each from the high, middle, and low Human Development Index categories. One medical college and two secondary level hospitals were selected from each district making a total of 18 facilities. Five departments in each facility were assessed including General Medicine, General Surgery, Obstetrics and Gynecology, Pediatrics, and Orthopaedic.

Assuming a 50% antibiotic prescription based on standard guidelines with a 95% confidence level and 10% relative precision, the sample size obtained was 400. To adjust for multistage sampling a design effect of two was considered taking the total sample size to 800. Assuming that 50% of in-patient case sheets will have an antibiotic prescription, 20 case sheets were sampled from each department. Consecutive sampling was done to collect data from case sheets of patients admitted to the selected wards. Data analysis was carried out using IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY, USA: IBM Corp. Summary statistics including frequency counts and percentages were computed based on districts and departments selected.

It was found that no antibiotic was prescribed from the reserve group for any of the sampled patients. We excluded unclassified antibiotics and those which belonged to the “not recommended” group. Data were then sorted into district wise and the proportion of antibiotics used in the access category and watch category was calculated separately. Access–watch ratio was then calculated.

The result depicts a description of data collected, list of antibiotics prescribed in health facilities based on AWaRe classification, and district-wise access–watch ratio. Approximately, 300 data were collected from each district making a total of 1832 samples. Most of the participants belonged to the age group of 26–60 years (53.6%). Out of the total, 29% of the data were collected from the general medicine department, followed by obstetrics and gynecology (23%), while the least was recorded from the orthopedics department (14%). The description of data is provided in [Table 1].
Table 1: Description of study samples from in-patient wards in various health facilities of Tamil Nadu (n=1832)

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A total of 1227 (67%) inpatient records had antimicrobial prescriptions. Among the watch group of antibiotics, it was observed that cefotaxime (42%) was the most prescribed antibiotic followed by ceftriaxone (27%). Among the access group of antibiotics, amoxicillin was the most prescribed (10%), while the least prescribed was gentamicin (0.2%).

It was found that all districts had strikingly low levels of access–watch ratio, ranging from 0.3 in Pudukkottai to 0 in Salem and Theni. The watch group of antibiotics depicted a higher proportion of prescriptions varying from 76.6% to 98.4%. This is depicted in [Table 2].
Table 2: Prevalence of antibiotics usage based on the WHO access, watch, and reserve classification in surveyed districts of Tamil Nadu

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Through this survey, we tried to assess the antimicrobial prescription pattern based on the WHO-recommended AWaRe classification. The access–watch ratio was found to be low in all the selected districts. The usage of access antibiotics was found to be much lower than the recommended 60% by the WHO. It was noted that third-generation cephalosporins had a higher prescription rate among all the antibiotics.

Many countries have made a responsible attempt to assess their antimicrobial usage using the AWaRe classification. A survey from acute care hospitals in Australia using AWaRe classification and priority antibiotic list suggested a significantly higher level of access to antibiotic prescription (70% based on AWaRe classification). Researchers emphasized on the significance of such tools as a guide to optimize antimicrobial usage.[3] The usage of access antibiotics in this study was higher than those found in our survey. This suggests the need for diligent use of such surveillance tools in all low- and middle-income country settings.

A study from Kazakhstan depicted a significant change in the trend of antibiotic prescription in 2017 and 2019. There was a decrease in access antibiotic prescriptions (39% to 30%), while there were a significant rise in watch antibiotics (61% to 68%) prescriptions.[4] The high use of watch antibiotics in this study is comparable to our study, indicating it is an emerging problem.

A customer exit survey conducted on 20 community antibiotic suppliers in Vietnam depicted 59% of access antibiotic usage and 39% of watch antibiotic usage with no antibiotics from the reserve category. This is in line with the WHO recommendations.[5]

A hospital-based survey from Warangal depicted that 42.3% of prescribed antibiotics were from the access group and 57.7% from the watch group. All the prescribed cephalosporins belonged to the watch group and the access to watch index was 0.7 which is much below the preferred value of 1.5. This finding was similar to our survey in terms of more usage of cephalosporins belonging to the watch group. A low risk of adverse effects and the broad spectrum of action makes cephalosporins a preferred choice for clinicians.[6]

It is also noteworthy that, this survey was conducted in secondary and tertiary public health facilities which already have an established record system but what escapes our narrow vision is the huge private sector and the unauthorized drug dispensing pharmacies in the country. These are some of the major contributors to the inappropriate use of antibiotics in low- and middle-income countries (LMICs). A study set in eight LMICs found that Asian countries had higher antibiotic suppliers compared to African countries, out of which 90% were private providers.[7] This suggests the need for a centralized and robust surveillance system inclusive of both public and private sectors.

To our best knowledge, our survey is the first to assess antibiotic prescribing patterns in selected government health facilities in Tamil Nadu. Field-level cooperation from the hospitals and medical college authorities facilitated a smooth data collection. Although, a short data collection period may not be representative of the actual scenario. This is only a single-point cross-sectional assessment. The longitudinal follow-up to study the patterns over time will help understand the scenario better.

Antimicrobial monitoring and surveillance need to be strengthened to rationalize antimicrobial use. This will not only help to achieve the aim of universal health coverage but also help to curb the threats of antimicrobial resistance. AWaRe classification can provide a standard measure to assess antimicrobial usage and help in optimization of the same.


This study was conducted as a part of an Operations Research project with grant from the Tamil Nadu Health Systems Reforms Program administered by IIT-Madras, to study the patterns of antimicrobial use in public health facilities of Tamil Nadu. The grant was awarded to Dr. Vijayaprasad Gopichandran. The authors would like to acknowledge the contributions of Dr. Deivasigamani Kuberan, Dr. Devidas Tondare, Dr. Anuradha R, Dr. Aruna B Patil, Dr. Kala M, Dr. Venmathi E, Dr. Sathish Rajaa, Mr. Murali Krishna, and Mr. Gerald Samuel who gave their valuable inputs during the conduct of the research.

Financial support and sponsorship

Grant from the Tamil Nadu Health Systems Reforms Program administered by IIT-Madras.

Conflicts of interest

There are no conflicts of interest.

   References Top

Gaitonde R, Muraleedharan VR, San Sebastian M, Hurtig AK. Accountability in the health system of Tamil Nadu, India: Exploring its multiple meanings. Health Res Policy Syst 2019;17:44.  Back to cited text no. 1
Parthasarathi R, Sinha SP. Towards a better health care delivery system: The Tamil Nadu model. Indian J Community Med 2016;41:302-4.  Back to cited text no. 2
[PUBMED]  [Full text]  
Hillock NT, Connor E, Wilson C, Kennedy B. Comparative analysis of Australian hospital antimicrobial utilization, using the WHO AWaRe classification system and the adapted Australian Priority Antimicrobial List (PAL). JAC Antimicrob Resist 2021;3:dlab017.  Back to cited text no. 3
Zhussupova G, Utepova D, Orazova G, Zhaldybayeva S, Skvirskaya G, Tossekbayev K. Evaluation of antibiotic use in Kazakhstan for the period 2017-2019 based on WHO access, watch and reserve classification (AWaRe 2019). Antibiotics (Basel) 2021;10:58.  Back to cited text no. 4
Nguyen NV, Do NT, Nguyen CT, Tran TK, Ho PD, Nguyen HH, et al. Community-level consumption of antibiotics according to the AWaRe (Access, Watch, Reserve) classification in rural Vietnam. JAC Antimicrob Resist 2020;2:dlaa048.  Back to cited text no. 5
Peddireddy M, Mahin J, Uppu A, Padi SS. Hospital antibiotic prescribing pattern in general surgery specialty: Analysis based on the WHO access, watch and reserve (AWaRe) classification. J Pharm Res Int 2021;33:7-19.  Back to cited text no. 6
Sulis G, Gandra S. Access to antibiotics: Not a problem in some LMICs. Lancet Glob Health 2021;9:e561-2.  Back to cited text no. 7


  [Table 1], [Table 2]


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