Antibiotic Selection Guidelines

Introduction to the AWaRe Framework

The World Health Organization (WHO) recommends using the AWaRe framework as the primary decision-making tool for antibiotic selection, starting with Access antibiotics as first-choice agents, escalating to Watch antibiotics when necessary, and reserving Reserve antibiotics for confirmed or suspected multidrug-resistant organisms 1, 2
The WHO Expert Committee established a traffic-light system to guide every antibiotic prescription, with Access antibiotics being the default starting point for empiric therapy 1, 2, 3

Access antibiotics, such as amoxicillin, amoxicillin-clavulanate, cefalexin, and doxycycline, are narrow-spectrum agents with favorable benefit-risk ratios and lower resistance potential 1, 3, 4, 5
Watch antibiotics, including fluoroquinolones and carbapenems, have a higher risk of selecting resistant bacteria and should only be used when Access antibiotics are inadequate or local resistance patterns demand it 1, 2, 3, 5
Reserve antibiotics should be used exclusively for confirmed or suspected multidrug-resistant organisms and must be protected through intensive stewardship programs 1, 2, 6

For respiratory infections, the first choice should be amoxicillin or amoxicillin-clavulanate, with second choices including cefalexin, doxycycline, or macrolides 4, 5
For skin and soft tissue infections, beta-lactams such as amoxicillin-clavulanate or cefalexin are recommended as first-choice agents 5
For intra-abdominal infections, beta-lactam/beta-lactamase inhibitor combinations are recommended 5

The principle of spectrum narrowing should always be applied, choosing the narrowest spectrum that covers likely pathogens 8
Local resistance patterns should be considered when selecting antibiotics, with healthcare-associated infections requiring broader coverage for resistant organisms 7
The principle of parsimony should be applied, choosing the agent most frequently useful across multiple infections to facilitate procurement and enhance access 8

Reflexive broad-spectrum prescribing should be avoided, as 30-50% of antibiotic prescriptions are inappropriate 7, 8
Fluoroquinolone overuse should be avoided, as permanent disabling side effects can outweigh benefits in routine cases 4

Nosocomial pneumonia requires antipseudomonal coverage, such as cefepime, ceftazidime, piperacillin-tazobactam, or carbapenems, and may require the addition of an aminoglycoside if Pseudomonas aeruginosa is isolated 5
Penicillin allergy is rare, and most "allergies" are not contraindications, allowing for the use of penicillin in many cases 8
Bacterial diarrhea can be treated with azithromycin, which has been shown to be superior to ciprofloxacin for cholera 3