The Prescribing Pattern of Antibiotics Agents in Adult Population Using WHO AWaRe Classification in a Tertiary Care Hospital

Abstract

The utilization of antibiotics for the treatment of infections is increasing; however, their misuse or overuse can lead to resistance. The WHO AWaRe classification groups antibiotics into Access, Watch, and Reserve to improve use and reduce resistance. This study aims to determine the antibiotic prescription pattern using the WHO AWaRe classification and assess the knowledge of the prescribing physicians regarding AWaRe classification in a tertiary care hospital. A descriptive cross-sectional study included 180 prescriptions from various departments that contain atleast one antibiotic. Antibiotics were grouped based on the WHO AWaRe classification system. A structured questionnaire was used to assess the knowledge among prescribing physicians. Data was analysed using descriptive statistics. Out of 228 antibiotics prescribed, 40.4% were from Access group, 37.3% from Watch group, 0.4% from Reserve group, and 21.9% were from Not Recommended from WHO. Cephalosporins and tetracyclines were the most prescribed classes of antibiotics. Only 39.1% of surveyed physicians were familiar with AWaRe, with varying knowledge levels. Most supported increased education and use of AWaRe to improve prescribing. The study shows good use of Access antibiotics but highlights gaps in generic prescribing and AWaRe system awareness. Implementing an antibiotic stewardship program can enhance antibiotic use and reduce resistance.

Keywords

Introduction

Table 1. Patients Demographic

Indication for prescribed antibiotics: Respiratory tract infections and acute febrile illnesses were the most common indications for antimicrobial use, each accounting for 27.2% (n=49). These were followed by gastrointestinal infections at 14.4% (n=26), ear, nose, and throat (ENT) infections at 11.7% (n=21), urinary tract infections at 8.9% (n=16), and skin and soft tissue infections at 5.6% (n=10). Other indications accounted for 5.0% (n=9) and included dengue fever, jaundice, hyponatremia, anaemia, and uncontrolled diabetes mellitus (DM) (Figure 01).

Figure 1. Indication for prescribed antibiotics

Commonly prescribed antibiotics: The prescriptions were classified into those containing a single antibiotic, which accounted for 74.4% (n=134), and those containing multiple antibiotics, which accounted for 25.5% (n=46). (Figure 02).

Figure 2. Antibiotics per prescription

Table 2. Commonly prescribed antibiotics

Prescribing indicators: The results for various indicators, including dose, dosing frequency (interval), duration of therapy, antibiotics prescribed with generic name and injection, the average number of antibiotics per encounter and antibiotics prescribed from EML are presented in Table 03.

Figure 3. Classification of antibiotics as per WHO AWaRe classification

Table 5. Pooled analysis of the Knowledge of AWaRe Classification questionnaire

DISCUSSION

Antibiotics are essential tool against bacterial infections, saving countless lives by effectively controlling and treating disease. However, when they are misused through overuse, incorrect prescribing, or improper patient adherence they contribute to the growing threat of AMR, making infections harder to treat and increasing the risk of severe illness and death. Monitoring prescribing patterns is essential to promote rational use and guide stewardship efforts. In the present study, males (50.5%) and females (49.5%) were nearly equally represented among those prescribed antibiotics, indicating no significant gender disparity in usage. These findings are consistent with those reported by Jokandan SS et al.,^[8] who observed a slight male predominance but no substantial difference in antibiotic use between genders. The lack of significant gender disparity may be due to the fact that infections are common across both sexes, and treatment decisions are generally based on the nature and severity of the infection rather than on patient gender. Age-wise distribution showed most patients were aged 19–38 years (44.4%), followed by 39–58 years (35%), similar to findings by Jokandan SS et al.,^[8] who also identified younger adults as the primary recipients of antibiotic prescriptions. This may reflect higher infection exposure and healthcare use among younger adults due to occupational and lifestyle factors^[8]. Additionally, younger adults tend to self-report symptoms earlier and demand quicker relief, often prompting empirical prescriptions. Their increased mobility and social interaction further increase their infection risk. Without adequate diagnostic confirmation, this pattern could drive unnecessary antibiotic use and long-term resistance. General Medicine accounted for the highest proportion of antibiotic prescriptions (58.3%), followed by Respiratory Medicine (24.4%) and ENT (11.7%). This departmental distribution aligns with findings from a tertiary care hospital study in Andhra Pradesh, where Medicine and Pediatrics departments showed high antibiotic utilization, mainly due to the management of febrile illnesses and respiratory infections. The significant contribution of respiratory illnesses to antibiotic use emphasizes the need for targeted stewardship interventions in these departments^[9]. The distribution of prescriptions between outpatient (51.7%) and inpatient (48.3%) settings was nearly balanced. This is comparable to data from a study in Mudenda et al.,^[10] which reported outpatient prescriptions at 53.6% and inpatient at 36.4%. These findings highlight the pervasive use of antibiotics across both hospital settings, emphasizing the importance of monitoring in both areas. Outpatients often receive empirical antibiotics for mild infections, sometimes without diagnostic confirmation, increasing the risk of inappropriate use. In contrast, inpatients typically require broader-spectrum agents for severe or hospital-acquired infections. The complexity of care and longer hospital stays in IP settings further elevate the AMR risk. Therefore, both settings require tailored stewardship strategies and regular prescription audits to ensure rational antibiotic use. Respiratory tract infections and acute febrile illnesses were the most common indications for antibiotic use (27.2% each), followed by gastrointestinal (14.4%) and urinary tract infections (8.3%). Similar trends were noted by Mudenda et al.,^[10] where respiratory infections (26.3%) were most common, followed by gastrointestinal and ENT infections. The high rate of respiratory infections may reflect factors like air pollution, socioeconomic conditions, and empirical antibiotic use, highlighting the need for improved diagnostics and prescriber education. Cephalosporins (29.4%) were the most frequently prescribed antibiotic class, followed by BL/BLI and tetracyclines. This aligns with findings from BGS Hospital, Bangalore, where cephalosporins accounted for 32.44% of prescriptions. The prevalent use of broad-spectrum agents, particularly third-generation cephalosporins and BL/BLI is concerning giving their association with rising antimicrobial resistance (AMR).  These broad-spectrum antibiotics are useful, but using them too much can make bacteria stronger and harder to treat. This underscores the urgent need for robust antibiotic stewardship programs to promote rational prescribing and curb resistance trends^[11]. The most commonly prescribed individual antibiotics in our study were Doxycycline (12.3%) Clarithromycin (7.5%), and Ceftriaxone (6.6%), along with fixed-dose combinations (FDCs) such as Cefoperazone + Sulbactam (8.3%). This finding is supported by the study by Rathinavelu et al.,^[12] where Ceftriaxone was also the most frequently prescribed antibiotic, followed by Amoxicillin + Clavulanic acid and Azithromycin. The frequent use of broad-spectrum antibiotics, driven by their wide coverage, empirical use, and diagnostic uncertainty, contributes to AMR by disrupting microbial balance and promoting resistant strains. This reduces antibiotic effectiveness, limits treatment options, and increases the risk of treatment failure and prolonged illness. Our study showed rational antibiotic prescribing with an average of 1.26 antibiotics per prescription and a lower overall drug count (3.48), indicating reduced polypharmacy compared to Chenchula et al^[13]. Generic prescribing was observed in 37.71% of cases, better than previous studies but still below the WHO target of 100%. Antibiotic use was high (86.85%), as was injection use (43%). Notably, adherence to the WHO-EML was 100%, reflecting strong compliance with national guidelines. While medicine selection and EML adherence were strengths, improvements are needed in generic and injectable antibiotic use^[13]. The result of WHO AWaRe classification system align with those of Negi G et al.,^[5] which also utilized the WHO AWaRe classification in a tertiary care setting. Both studies found a substantial proportion of prescriptions in the Access and Watch categories, with 40.4% in Access in our study, compared to 57.6% in Negi et al.,^[5] and 37.3% in Watch, similar to their finding of 38.27%. These results reflect a common trend towards reliance on broad-spectrum antibiotics, raising concerns about potential resistance due to overuse. Both studies highlight the importance of promoting appropriate prescribing practices to ensure that Access antibiotics are prioritized while reducing unnecessary Watch antibiotic use. The present study reveals that 21.9% of prescribed antibiotics belonged to the Not Recommended category, with a predominant contribution from fixed-dose combinations (FDCs) such as Amoxicillin + Potassium Clavulanate, Cefoperazone + Sulbactam, and Ceftriaxone + Sulbactam. These findings closely align with the study by Kakumba JM et al.,^[14] which reported that 20.3% of antibiotics prescribed in their study setting were also from the Not Recommended group. The consistency of these results across different regions and time periods highlights a significant and ongoing concern regarding irrational antibiotic prescribing practices. FDCs continue to dominate the Not Recommended category. Notably, Cefoperazone + Sulbactam appears in both our data and in the study by Bhardwaj A et al.,^[15] despite having minimal justification based on pharmacological synergy or robust clinical outcomes. The persistently high proportion of Not Recommended antibiotic use may be attributed to several factors, including a lack of awareness of the WHO AWARE classification among prescribers, the continued marketing and availability of irrational FDCs, and inadequate implementation of AMSP at both institutional and policy levels. The present study involved 23 prescribers from the General Medicine department, including both senior residents (47.8%) and faculty members (52.2%). Despite their roles in frontline patient care, awareness of the WHO AWaRe classification was limited, only 39.1% of participants had heard of the classification system, and 54.5% were unfamiliar with its use. Similar knowledge gaps in antibiotic prescribing were reported by Negi et al.,^[5] contributing to inappropriate antibiotic use. Both their findings and ours indicate a moderate level of awareness about AWaRe classification among healthcare professionals. This can be due to the factors such as limited training, high workloads, and inconsistent implementation of AMR guidelines. These challenges highlight the need for focused education programs and more effective integration of AMR protocols into daily clinical practice. With the widespread use of antibiotics and rising issues with the increase of AMR in developing countries, it is important to help physician better understand and adopt tools like AWaRe classification for antibiotics which is the key step toward more responsible and effective antibiotics prescribing. The physicians preferred AWaRe classification tool in the study conducted by Hassan H et al.,^[16] for better antibiotic selection, supporting the successful implementation of AMSP. In our study, while most participants correctly identified Amoxicillin (Access) and Linezolid (Reserve) classification, accuracy for other antibiotics was inconsistent (40–60%), which is consistent with findings from Mudenda et al^[10] in Zambia. Despite these knowledge gaps, 77.7% of participants supported the implementation of the AWaRe classification, and all respondents expressed support for the need for further education. Similar positive attitudes towards educational interventions were noted by Priyadharsini et al^[17]. These results point out to the importance of targeted education and awareness initiatives to promote appropriate antibiotic use, which could significantly improve prescribing practices and contribute to combating AMR.

CONCLUSION

This study provides valuable insights into trends in prescribing antibiotics at a tertiary care hospital through a dual approach combining prescription pattern analysis with an assessment of prescriber’s knowledge of the WHO AWaRe classification. A key positive finding was adherence to the National Essential Medicines List and a low rate of polypharmacy, reflecting rational prescribing habits. However, suboptimal use of generic names and a high rate of injectable antibiotic prescriptions highlight areas needing targeted improvement. While the encouraging use of Access antibiotics indicates progress, the predominance of respiratory tract and febrile illnesses as common indications underscores the need for improved diagnostic accuracy to reduce unnecessary empirical antibiotic use. Additionally, we observed limited awareness and inconsistent application of the AWaRe classification, particularly among early-career prescribers. Despite this, the general willingness of clinicians to adopt rational antibiotic use principles presents a promising opportunity for intervention. To further enhance prescribing quality and combat antimicrobial resistance, it is essential to implement continuous education programs, integrate AWaRe guidelines into clinical protocols, and conduct regular prescription audits as part of a robust antimicrobial stewardship program. Strengthening these strategies will support more rational antibiotic use and contribute significantly to global efforts against antimicrobial resistance. One limitation of this study is its single-center design and relatively small sample size, which may affect the generalizability and statistical power of the findings. Nonetheless, the comprehensive methodology offers valuable real-world insights into antibiotic use trends and healthcare professionals’ awareness, forming a strong foundation for future stewardship initiatives.

ACKNOWLEDGMENTS

The authors express their sincere gratitude to the physicians and staff of Siddaganga Medical College and Research Institute (SMCRI) for their cooperation and support during the data collection phase of this study.

CONFLICT OF INTEREST

The authors declare that there is no conflict of interest.

ETHICAL APPROVALS

The study was approved by the Institutional Ethics Committee of SMCRI (approval ID. SMCRI/IEC/2023-2024/48).

REFERENCES

1. Letša MA, Burger JR, Kotzé I. Antibiotic prescribing in public primary healthcare centres in Maseru, Lesotho. South African Journal Infectious Disease 2025;40(1):1-7.doi: 10.4102/sajid.v40i1.692.
2. 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 Journal of Public Health 2022;66(3):352-4. doi: 10.4103/ijph.ijph_274_22.
3. Pasupulati, H, Avadhanula, V, Mamilla, A, Bamini M. and Padi SSV. Antibiotic Prescribing Practices in Primary Care Settings Using 2019 WHO AWaRe Framework. Journal of Pharmaceutical Research International 2021;33(37A):58–68. doi: 10.9734/jpri/2021/v33i37A31980.
4. Meena DK, Mathaiyan, J, and Gauthaman G. WHO AWaRe strategy and antimicrobial stewardship to combat antimicrobial resistance: An Indian perspective. International Journal of Health and Allied Sciences 2022;11(1):47-53.
5. Negi G, Kb A, Panda PK. Ground level utility of Access, Watch, Reserve classification: Insights from a tertiary care center in North India. World Journal of Experimental Medicine 2023;13(5):123-33. doi: 10.5493/wjem.v13.i5.123. PMID: 38173545; PMCID: PMC10758664.
6. Mushtaq S, Javed F, Fatimah M, Jafar ZS, Zaidi ST, Firdous A et.al. Assessment of Antibiotic Prescription Pattern Using WHO Prescribing Indicators and Aware Categorization of Antibiotics. Pakistan Journal of Medical and Health Sciences 2021;15(11):2872-5. DOI: https://doi.org/10.53350/pjmhs2115112872.
7. Steward M, Eustus N, Patience C, Victor D, Billy C, Webrod M et.al. Prescribing Patterns of Antibiotics According to the WHO AWaRe Classification during the COVID-19 Pandemic at a Teaching Hospital in Lusaka, Zambia: Implications for Strengthening of Antimicrobial Stewardship Programmes. Pharmacoepidemiology 2023;2:42-53. https://doi.org/10.3390/pharma2010005.
8. Jokandan SS and Jha DK. A study of prescribing pattern of antibiotics in a tertiary care hospital – an observational study. International Journal of Pharmaceutical Sciences and Research 2019; 10(5):2285-9.
9. Khade AM., Bashir MS. M., George S., Annaldesh S., Bansod KA. Prescription pattern of antimicrobial agents in a teaching hospital of South India. International Journal of Basic & Clinical Pharmacology 2017;2(5):567–70.
10. Mudenda S, Nsofu E, Chisha P, Daka V, Chabalenge B, Mufwambi W, et al. Prescribing Patterns of Antibiotics According to the WHO AWaRe Classification during the COVID-19 Pandemic at a Teaching Hospital in Lusaka, Zambia: Implications for Strengthening of Antimicrobial Stewardship Programmes. Pharmacoepidemiology 2023;2(1):42–53.
11. Jolfaei AN, Dev AM. Prescribing Pattern of Antibiotics in Respiratory Tract Infections, BGS Global Hospitals, Bangalore, India. Journal of Biochemical Technology 2018;(2):171-5.
12. Rathinavelu M, Uppara V, Chenchu S, Bharambe DD, Kenchugundu J. Evaluation of Outpatient Antibiotic Prescribing Pattern In General Medicine Department Of A Secondary Referral Healthcare Hospital In South India. African Journal of Biomedical Sciences 2024;6(11):541-56.
13. Chenchula S, Gupta R, Gupta SK, Padmavathi R, Pathan S. Assessment of WHO core drug use indicators at a tertiary care Institute of National importance in India. Bioinformation 2022;18(10):888–93.
14. Kakumba JM, Kindenge JM, Kapepula PM, Iyamba JL, Mashi ML, Mulwahali JW, et al. Evaluation of Antibiotic Prescribing Pattern Using WHO Access, Watch and Reserve Classification in Kinshasa, Democratic Republic of Congo. Antibiotics 2023;12(8):1239. doi: 10.3390/antibiotics12081239.
15. BhardwajA, KapoorK, SinghV. Trend analysis of antibiotics consumption using WHO AWaRe classification intertiary care hospital. International Journal of Basic and Clinical Pharmacology 2020;9:1675-80.
16. Hassan H, Reghukumar A, Rajahamsan J, Harikumar S, Shanmugham M. Enhancing antibiotic stewardship: Physicians’ acceptance of AWaRe (Access, Watch, Reserve)-based microbiology reporting and its impact on judicious antibiotic selection- A cross-sectional study. GMS Hygiene and Infection Control 2025;20:1-10.
17. Priyadharsini RP, Ramasamy K, Amarendar S. Antibiotic-prescribing pattern in the outpatient departments using the WHO prescribing indicators and AWaRe assessment tool in a tertiary-care hospital in South India. Journal of Family Medicine and Primary Care 2022;11:74-8.