Almost all countries overuse antibiotics, contributing to drug resistance: Analysis
A global analysis published in a peer-reviewed public health journal found that most countries are overusing antibiotics relative to their actual clinical need, worsening antimicrobial resistance (AMR).
The study built a benchmarking framework across 186 countries, grouping them into peer clusters by poverty level, infectious-disease burden, resistance patterns, and health-system strength, and comparing each country's antibiotic use against the lowest-use, best-outcome benchmark within its own cluster.
Roughly three-quarters of countries were found to overuse antibiotics overall; 99% overused "Watch" category antibiotics; and 60% of countries continued to prescribe antibiotics that the World Health Organization (WHO) considers obsolete and no longer fit for prescription.
Over half of the countries studied were simultaneously found to underuse "Reserve" category antibiotics, pointing to a global mismatch between antibiotic availability and actual need — with low- and middle-income countries facing higher infection burdens often lacking access to the very antibiotics they need most.
Roughly 43 billion antibiotic courses were estimated to be needed globally in a reference year, of which about 77% should ideally fall in the "Access" category, closely aligned with a global policy target.
WHO AWaRe Classification of Antibiotics
The WHO's Access, Watch, Reserve (AWaRe) classification, introduced in 2017, sorts more than 180 antibiotics into three tiers based on their resistance potential and appropriate clinical use, and is designed to guide rational prescribing and reduce inappropriate use of broad-spectrum and last-resort drugs.
Key Details
- Access antibiotics (e.g., amoxicillin) — narrow-spectrum, first-line drugs for common infections, with low resistance potential; recommended to form at least 70% of antibiotic use by 2030 per a UN General Assembly-endorsed target
- Watch antibiotics — broader-spectrum drugs (e.g., higher-generation cephalosporins, fluoroquinolones) with higher resistance potential, meant to be reserved for specific indications
- Reserve antibiotics — last-resort drugs (e.g., carbapenems, colistin) for multidrug-resistant infections, meant to be used sparingly and protected through stewardship
- In 2024, the UN General Assembly agreed that the AWaRe framework should form the basis of global antibiotic use surveillance, with the 70% Access-group target by 2030
The study directly measures country-level deviation from AWaRe-recommended prescribing patterns — showing that most countries over-rely on Watch antibiotics (undermining the 70%-Access target) while a majority also fail to make adequate use of Reserve antibiotics when genuinely needed.
Antimicrobial Resistance (AMR) as a Global Health Threat
AMR occurs when bacteria, viruses, fungi, and parasites evolve to resist the drugs designed to kill them, driven substantially by antibiotic overuse and misuse in humans, livestock, and agriculture. WHO has designated AMR among the top global public health threats.
Key Details
- Overuse of Watch and obsolete antibiotics accelerates selection pressure for resistant bacterial strains, while underuse of Reserve antibiotics in genuinely resistant infections leads to preventable deaths in resource-poor settings
- The "One Health" approach — linking human health, animal health, agriculture, and environmental sectors — is the internationally endorsed framework (adopted by WHO, FAO, and WOAH) for tackling AMR holistically
- India operationalises this through its National Action Plan on Antimicrobial Resistance (NAP-AMR, 2017), modelled on the WHO Global Action Plan on AMR (2015), built around six strategic priorities including improving awareness, strengthening surveillance, and infection prevention
The study's finding that antibiotic misuse is "nearly universal" reinforces the rationale behind India's One-Health-based NAP-AMR and similar national plans worldwide — overuse of Watch/obsolete drugs and gaps in appropriate Reserve-drug access are precisely the two failure modes such national plans are designed to correct.
India's Regulatory Tools Against Antibiotic Misuse
India regulates over-the-counter antibiotic sale through Schedule H1 of the Drugs and Cosmetics Rules, 1945, backed by public-awareness campaigns aimed at curbing self-medication with antibiotics.
Key Details
- Schedule H1 was notified in August 2013 and came into force from March 2014; it lists antibiotics (including higher-generation cephalosporins, carbapenems, and certain anti-tubercular drugs) that cannot legally be sold without a doctor's prescription, and pharmacies must maintain a separate register recording patient and prescriber details for such sales
- The "Red Line" campaign, run by the Ministry of Health and Family Welfare, marks prescription-only antibiotics with a red line on packaging and urges the public not to use red-line-marked medicines without a doctor's prescription
- India remains among the world's largest consumers of antibiotics by volume, with prior research flagging disproportionately high use of Watch-category antibiotics relative to Access-category use compared to WHO-recommended ratios
The global study's finding that most countries over-consume Watch antibiotics mirrors India-specific research showing a skew toward Watch-category consumption — underscoring why Schedule H1 and the Red Line campaign target exactly this category of drugs for prescription-only control.
- Study scope: 186 countries benchmarked by peer-cluster analysis of antibiotic use
- ~75% of countries found to overuse antibiotics overall; 99% overused Watch-category antibiotics; over 50% underused Reserve-category antibiotics
- 60% of countries still prescribed antibiotics WHO considers obsolete
- Estimated global need: ~43 billion antibiotic courses in the reference year, ~77% ideally from the Access category
- UN-endorsed global target (2024): at least 70% of global antibiotic use from the Access group by 2030
- WHO AWaRe classification introduced: 2017; covers 180+ antibiotics across Access, Watch, and Reserve tiers
- India's Schedule H1 (prescription-only antibiotic control): notified August 2013, effective March 2014
- India's National Action Plan on AMR: launched 2017, following the One Health approach