UK-AWaRe: The latest updates to our classification system for antibiotics in the United Kingdom

By Professor Diane Ashiru PhD , Lead Pharmacist for AMR and HCAI at UKHSA and Chair of ESPAUR

I am pleased that the new UK adaptation of the World Health Organization's (WHO) AWaRe classification has now been published. It marks an important milestone in our nation's approach to antimicrobial stewardship. This comprehensive update, developed through a modified Delphi-style consensus process, represents a unified approach across all 4 nations of the UK, replacing previous nation-specific adaptations.

A collaborative achievement

This initiative, commissioned by the Advisory Committee on Antimicrobial Prescribing, Resistance and Healthcare Associated Infection (APRHAI) through the English surveillance programme for antimicrobial utilisation and resistance (ESPAUR) committee, brought together medical, nursing, pharmacy and policy experts from across the UK. I would like to thank all of those involved - their collective expertise was crucial in developing a classification system that reflects our healthcare system's unique needs while aligning with international standards.

Key changes and implications

The most notable change in the new classification is the repositioning of first-generation cephalosporins into the UK Access category, previously classified as Watch in 2019. This significant shift expands treatment options for patients with certain allergies, such as penicillin sensitivity, and aligns with the 2023 WHO AWaRe classification. Getting a consensus on this change was a challenge as it was acknowledged by some of the expert panel that local concerns about changing classification of these antibiotics may exist, but that getting a UK-wide consensus should be the priority concern.? Importantly, this reclassification doesn't mandate increased cephalosporin use or require changes to existing clinical guidance.

Supporting national AMR objectives

The new classification system directly supports Target 4b of the second 5-year UK national action plan for antimicrobial resistance (2024-2029), which aims to achieve 70% of total antibiotic use from the Access category across human healthcare. Currently, England stands at 64.1% (2023 assessment), showing the work still needed to reach this target.

Implementation and knowledge mobilisation

It is great to now have this tool published but implementation is key and I’d particularly like to mention Rachel Berry , the current Chief Pharmaceutical Officers Clinical Fellow at UKHSA who as a specialist antimicrobial pharmacist with many years’ experience in primary and secondary care, shares her thoughts on how colleagues can support the implementation of the updated tool:

Rachel stated that key actions for healthcare organisations include:

• Disseminating information through relevant committees and working groups
• Sharing classifications with frontline staff, emphasising the priority of Access antibiotics
• Reviewing local formularies and clinical pathways
• Implementing strategies to minimise Watch antibiotic use
• Establishing robust systems for monitoring Reserve antibiotic use
• Analysing prescribing data based on the new categories

International context

The UK will continue reporting antibiotic usage data based on WHO AWaRe categories, enabling international benchmarking while maintaining our domestic classification system tailored to UK healthcare needs.

Looking forward

This new classification represents more than just a categorisation system - it's a crucial tool in our ongoing fight against antimicrobial resistance. By providing clear guidance on antibiotic selection and usage, UK-AWaRe supports healthcare professionals in making informed decisions that balance immediate patient needs with long-term antimicrobial stewardship goals.

Together, we can work towards containing and controlling AMR, supporting the UK's 20-year AMR vision.

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