AMR.Solutions

AWaRe antibiotic usage – Is 70% Access a good target?

Dear All: An important and instructive analysis of optimal global antibiotic usage targets has just been published in Lancet Public Health. To follow the plot, here are the links you need:

  • The new paper: Cook et al.: “Benchmarking AWaRe: estimating optimal levels of AWaRe antibiotic use in 186 countries, territories and areas based on clinical infection and resistance burden”
  • Background on AWaRe: WHO 2025: “AWaRe classification of antibiotics for evaluation and monitoring of use”, WHO Reference number B09489.
    • AWaRe uses a 3-level scheme to classify >250 antibiotics as Access (first-line agents for most infections), Watch (for more resistant infections), or Reserve (for the most difficult infections).
    • Of the 42 antibiotics on the 2025 Essential Medicines List (EML), 21 (50%) are Access, 12 (29%) are Watch, and 9 (21%) are Reserve.
  • What is good usage? A 70% target for Access usage was endorsed at the 2024 UN General  Assembly High-Level Meeting on AMR (UNGA HLM AMR):
    • Go here to access the final declaration; jump to article 64 on page 10 where it says: “Ensure, by 2030, that the use of World Health Organization Access group antibiotics is expanded from the 2023 global target, and in that regard, taking into account national contexts, aim to achieve at least 70 per cent overall human antibiotic use globally, through investing in and strengthening stewardship programmes”
      • Importantly, the declaration proposed this as a general target. There was recognition that one size would NOT fit all but no guidance was given on deriving the best target for any given country.
    • For more on the UNGA HLM, see both the 1 Oct 2024 newsletter (“HLM on AMR at UNGA: The end of the beginning”) and the amr.solutions general resource page about that meeting.

 
So, you ask — why 70% usage as Access antibiotics? How do we know that such a target is appropriate? In fact, the 70% estimate was basically a finger-in-the-air guess – seemed in the ballpark, but it was recognized at the time that work was needed to explore this in detail;

  
—
With that as background, we come to the new paper. Here’s a brief outline of the research reported by Aislinn Cook and her colleagues:

  • The authors sought to use data from public datasets from the year 2019 (thus avoiding COVID-related distortions) to estimate an appropriate level of usage of Access antibiotics vs. Watch-Reserve for different countries.
  • The broad idea was to find a way to correlate Access-Watch-Reserve usage with what you’d expect to need to treat different infection and resistance burdens.
  • The authors took 2 approaches to finding a model:
    • A statistical model based on factors plausibly related to antibiotic need such as known infectious disease burden, local rates of resistance, and such.
    • A comparative benchmarking method in which countries (referred to in the paper as CTAs for “countries, territories, and areas”) were clustered by broad sociodemographic and healthcare characteristics and then benchmarked vs. each other.
  • The statistical model approach was a flop: variation in Access-Watch-Reserve usage was not readily explained by (i.e., not well correlated with) estimates from a collection of plausible covariates.
  • The benchmark-to-peers approach did, however, work (within limits) – and let’s look at what they found.

 
First, let’s consider the way that countries were clustered to allow for benchmarking for the analysis. As shown in this figure, the authors settled on 4 clusters that can be seen to broadly follow a pattern of moving from higher (Cluster 4) to lower (Cluster 1) income countries:

Cook 2026 - Four clusters of expected antibiotic usage

 
Within each cluster, they then estimate volumes of antibiotics needed for each country in terms of use of Access (green), Watch (yellow), or Reserve (Red) based on their infection and antibiotic resistance burden. There is a pattern here: Notice how Clusters 1 and 2 (the LIC/LMIC clusters) tend to both need more Access antibiotics but also more Watch antibiotics than are used in cluster 3 and 4 (the MIC/HIC clusters):

The y-axis is measure termed DID: Defined Daily Doses per 1,000 inhabitants per Day.
 
 
OK, so that’s estimated optimal usage — but how does that compare to current usage? Well, the next figure shows what happened when the authors compared actual usage (y-axis) with this theoretical optimal usage (x-axis). Alert: The x- and y-axis scales are not the same across figures … you need to find the line of identity shown by the dashed line on each figure to know whether any given dot is above or below the line.
 
With that in mind as you read the figures, we can see that for the countries with actual usage data:

  • Actual total usage exceeds optimal (black figure),
  • Actual Access usage (green figure) is scattered about the line of identity but actually tracks it pretty well,
  • Watch usage exceeds optimal (yellow figure, most dots are above the line), and
  • Reserve usage is inadequate (red figure, most dots are below the line)!
Cook 2026 - Actual vs. optimal usage of AWaRe abx by cluster

 
 
And now for the answer to the question about UNGA HLM target! Is 70% a good number? Remarkably, it does indeed turn out to have been a good guess! The actual best estimate from these data for the average % of global use that should be Access is 77% (95% CI, 71-83%) … so really close.
 
Now, it is also going to be true that the global average of ~70% will not be correct for all countries: countries would need to use local data to refine the estimate of the volume of antibiotics needed for their population and infection burden. But these country-specific estimates (as well as a sense of comparables from other countries) are a very powerful starting point!
 
Fascinating! The analysis by Cook et al. has some limitations due to assumptions that were necessarily needed in the modeling, but its great strength is that it exists and can become the foundation for further research and action.
 
A particular observation that has global importance is that Watch antibiotics are generally overused and Reserve are underused. This has very interesting implications for stewardship and access! It is unfortunate that anxiety about excess use (and probably cost concerns) keep new antibiotics from being used promptly. If you want to read further on this topic, consider these newsletters:

  • 19 Aug 2021: “Ex-US new antibiotic access: Multi-year delays, even in Europe!”
  • 7 Apr 2025: “UNSLAP: You reach for the antibiotic … and it’s not there!”
  • 24 Apr 2026: “DTR Gram-negative infections: Are new antibiotics making a difference?”

 
Well done to the authors — this fundamental research will be used for years to come.
 
All best wishes, –jr

John H. Rex, MD | Chief Medical Officer, F2G Ltd. | Operating Partner, Advent Life Sciences. Follow me on Twitter: @JohnRex_NewAbx. See past newsletters and subscribe for the future: https://amr.solutions/blog/. All opinions are my own.

John’s Top Recurring Meetings
Virtual meetings are easy to attend, but regular attendance at annual in-person events is the key to building your network and gaining deeper insight. My personal favorites for such in-person meetings are below. Of particular value for developers, the small meeting format of BEAM’s AMR Conference (March) and GAMRIC (September-October; formerly, the ESCMID-ASM conference series) creates excellent global networking. IDWeek (October) and ECCMID (April) are much larger meetings but also provide opportunities for networking with a substantial, focused audience via their Pipeline sessions. Hope to see you there!

  • [LATE-BREAKER ABSTRACTS close today] 22-24 Sep 2026 (Lisbon, Portugal): The 2nd GAMRIC, the Global AMR Innovators Conference (London, UK). Formerly the ESCMID-ASM (or ASM-ESCMID depending on location) Joint Conference on Drug Development for AMR, 2026 will be the 11th year for this series that is now under the joint sponsorship of CARB-X, ESCMID, BEAM Alliance, GARDP, LifeArc, Boston University, and AMR.Solutions. The ongoing series employs the successful format of prior meetings with a single-track meeting and substantial networking time. The 2025 meeting was a sell-out success: a written summary is here and the videos are here. Registration for the 2026 meeting is now open and the near-final program is here: in addition to a keynote lecture by Karen Bush on the threat to beta-lactams due to the emergence of PBP3 mutations, there are sessions on funding, access, program design for narrow-spectrum agents such as phage, development for pediatrics, and more. Registration is ongoing; the main abstract submission window is closed but late-breaker abstracts will be accepted 8-22 July 2026.
  • 21-24 Oct 2026 (Washington, DC, USA): IDWeek 2026, the annual meeting of the Infectious Diseases Society of America. I would expect the program to continue to provide a substantial opportunity to present a product to a large audience (see also adjacent note about ESCMID) as well as opportunities to present at an IDWeek Pipeline Session. Go here to register.
  • 23-24 Mar 2027 (Basel, Switzerland): The 10th AMR Conference (3-4 Mar 2026) is now over and offered a rich program that included a 10-year retrospective (we’ve done a lot!), regulatory updates, discussions of how to pursue development in China, and much more … in addition to being a superb opportunity for networking! I am told the session videos will soon be available on the conference website.
  • 9-13 April 2027 (Stockholm, Sweden): ESCMID Global 2027, the annual meeting of the European Society for Clinical Microbiology and Infectious Diseases. Details won’t be out for some months, but the website is here. I do know that the meeting schedule will again include a Science Policy Forum on Friday 9 April 2027 (see here the newsletter about the 2026 science policy forum) and all who are interested in Pull incentives and the antibiotic ecosystem should plan to be there!)..

  Upcoming meetings of interest to the AMR community:

  • 22 July (virtual, 2-3.30p CET): The WHO AMR Department and the WHO GAP-r (Global Accelerator for Pediatric Formulations) are hosting an industry dialogue on pediatric and neonatal antibiotic development. The discussion will cover timing of pediatric and neonatal studies, extrapolation from adult data, feasibility of trial designs in children and neonates, and variability in regulatory expectations across jurisdictions. This topic is a long-standing source of frustration for developers (see the 7 Apr 2021 newsletter: “Developing antibiotics for children: There are no easy answers”) and I am glad to see WHO convening discussions on ways to facilitate pediatric work! Go here to register.
  • 27 July (virtual, 2-3.30p CET): Inaugural webinar of the WHO Bacteriophage Community of Practice (CoP), a global platform for knowledge exchange across the bacteriophage ecosystem. You can register for the webinar here. You will also want to join the CoP itself — for this, you need a free account WHO Integrated Health Services (IHS) Hub account; look for  “WHO AMR Community Exchange” and then for the “Bacteriophage group” under “Explore our groups.”
  • [NEW] 13-14 Aug 2026 (virtual and in person, Rockville, Maryland): NIAID-sponsored workshop entitled “Improving Clinical Outcomes for Mucormycosis and Other Rare Mold Infection.” The title is a good summary of the meeting. The focus on fungal infections but the implications of the discussion are potentially broader. How can we accumulate data on rare infections? How much data is enough? Are ideas such as Bayesian support for small pivotal datasets acceptable? Should be a good discussion! Go here to register.
  • [NEW] 31 Aug 2026 (virtual, 2-4p CET): WHO Dialogue with antibiotic developers on optimal evidence generation across the lifecycle. This 2-h session will be a virtual dialogue on the challenges such as fragmented regulatory requirements, trade-offs in clinical trial design, and gaps between evidence generated for regulatory approval and that needed to inform clinical use and stewardship. This session continues WHO’s efforts to use their convening power to shape the global conversation about how to improve the way(s) we advance new drugs from idea to the pharmacy. The agenda is not yet public but it’s clear that it will be a very interactive session: when you go here to register, you are asked about your experience(s) and have an opportunity to volunteer to present during the session.
  • 22-24 Sep 2026 (Lisbon, Portugal): GAMRIC  the Global AMR Innovators Conference. See list of Top Recurring meetings, above..
  • 10-18 Oct 2026 (Annecy, France, residential in-person program): ICARe (Interdisciplinary Course on Antibiotics and Resistance) … and 2026 will be the 10th year for this program. Patrice Courvalin orchestrates content with the support of an all-star scientific committee and faculty. The resulting soup-to-nuts training covers all aspects of antimicrobials, is very intense, and routinely gets rave reviews! Registration for 2026 is now open and runs through June 21, 2026. Go here to register!
  • 21-24 Oct 2026 (Washington, DC, USA): IDWeek 2026. See list of Top Recurring meetings, above.
  • [Early bird registration closes 30 July] 10-13 November 2026 (Madrid, Spain): The International Society for Infectious Diseases (ISID) has announced its 21st International Congress on Infectious Diseases (ICID). Register and view the preliminary program here (Early bird closes 30 July 2026); abstract deadline is 28 April 2026.
  • 27-29 Jan 2027 (Las Vegas, USA): IMARI (Interdisciplinary Meeting on Antimicrobial Resistance and Innovation) sponsored by IDSA and ASM. Abstract submissions are open through 19 Aug; registration and housing will open later this summer.
  • 23-24 Mar 2027 (Basel, Switzerland): The 11th AMR Conference sponsored by the BEAM Alliance. See list of Top Recurring meetings, above.
  • 9-13 April 2027 (Stockholm, Sweden): ESCMID Global 2026, the annual meeting of the European Society for Clinical Microbiology and Infectious Diseases. See Recurring Meetings list, above.
  • ??? Mar 2028 (yes, that’s 2028, with location TBD): The 2028 Gordon Research Conference (GRC, https://www.grc.org/) entitled “Antibacterials of Tomorrow to Combat the Global Threat of Antimicrobial Resistance” and its related Gordon Research Seminar (GRS) for young doctoral and post-doctoral researchers will be sometime in March 2028. The organizers hope to coordinate dates and location with the 2028 BEAM-AMR meeting. Details to follow — mark your calendar!

Self-paced courses, online training materials, and other reference materials:

Current funding opportunities

  • Novo Nordisk Foundation (NNF) have an EUR 20m call for development of rapid, point-of-care diagnostics. See the 28 May 2026 newsletter for details; the deadline for expressions of interest is 7 Oct 2026.
  • CARB-X have had one funding round (8-22 April 2026); a further round is expected during 4Q 2026. There are 4 funding themes for these rounds as below.
    • Direct-acting therapeutics for infections caused by Gram-negative bacteria
    • Novel Chemistry for AMR Challenge – target-based therapeutics.
    • Non-vaccine approaches to prevent neonatal sepsis
    • Diagnostics for neonatal sepsis
  • The Horizon Europe Work Programme 2026-2027 includes at least 3 calls of interest within its Cluster 1 — see the list below.  The application window starts 10 Feb 2026 and closes on 16 Apr 2026. See also the 12 Dec 2025 newsletter about the call. Note as well that there calls for agents to prevent and/or treat viral infections.
    • HORIZON-HLTH-2027-01-DISEASE-08: Development of innovative antimicrobials against pathogens resistant to antimicrobials
    • HORIZON-HLTH-2027-02-IND-02: Portable point-of-care diagnostics
    • HORIZON-HLTH-2026-01-DISEASE-03:Advancing research on the prevention, diagnosis, and management of post-infection long-term conditions. 
  • ENABLE-2 has continuously open calls for both its Hit-to-Lead program as well as its Hit Identification/Validation incubator. Applicants must be academics and non-profits in Europe due to restrictions from the funders. Applications are evaluated in cycles … see the website for details on current timing for reviews. 
  • BARDA’s long-running BAA (Broad Agency Announcement) for medical countermeasures (MCMs) for chemical, biological, radiological, and nuclear (CBRN) threats, pandemic influenza, and emerging infectious diseases is now BAA-23-100-SOL-00004 and offers support for both antibacterial and antifungal agents (as well as antivirals, antitoxins, diagnostics, and more). Note especially these Areas of Interest: Area 3.1 (MDR Bacteria and Biothreat Pathogens), Area 3.2 (MDR Fungal Infections), and Area 7.2 (Antibiotic Resistance Diagnostics for Priority Bacterial Pathogens). Although prior BAAs used a rolling cycle of 4 deadlines/year, the updated BAA released 26 Sep 2023 has a 5-year application period that ends 25 Sep 2028 and is open to applicants regardless of location: BARDA seeks the best science from anywhere in the world! See also this newsletter for further comments on the BAA and its areas of interest.
  • HERA Invest was launched August 2023 with €100 million to support innovative EU-based SMEs in the early and late phases of clinical trials. Part of the InvestEU program supporting sustainable investment, innovation, and job creation in Europe, HERA Invest is open for application to companies developing medical countermeasures that address one of the following cross-border health threats: (i) Pathogens with pandemic or epidemic potential, (ii) Chemical, biological, radiological and nuclear (CBRN) threats originating from accidental or deliberate release, and (iii) Antimicrobial resistance (AMR). Non-dilutive venture loans covering up to 50% of investment costs are available. A closing date is not posted insofar as I can see — applications are accepted on a rolling basis; go here for more details.
  • The AMR Action Fund is open on an ongoing basis to proposals for funding of Phase 2 / Phase 3 antibacterial therapeutics. Per its charter, the fund prioritizes investment in treatments that address a pathogen prioritized by the WHO, the CDC and/or other public health entities that: (i) are novel (e.g., absence of known cross-resistance, novel targets, new chemical classes, or new mechanisms of action); and/or (ii) have significant differentiated clinical utility (e.g., differentiated innovation that provides clinical value versus standard of care to prescribers and patients, such as safety/tolerability, oral formulation, different spectrum of activity); and (iii) reduce patient mortality. It is also expected that such agents would have the potential to strongly address the likely requirements for delinked Pull incentives such as the UK (NHS England) subscription pilot and the PASTEUR Act in the US. Submit queries to contact@amractionfund.com.
  • INCATE (Incubator for Antibacterial Therapies in Europe) is an early-stage funding vehicle supporting innovation vs. drug-resistant bacterial infections. The fund provides advice, community, and non-dilutive funding (€10k in Stage I and up to €250k in Stage II) to support early-stage ventures in creating the evidence and building the team needed to get next-level funding. Details and contacts on their website (https://www.incate.net/).
  • These things aren’t sources of funds but would help you develop funding applications
    • The Global AMR R&D Hub’s dynamic dashboard (link) summarizes the global clinical development pipeline, incentives for AMR R&D, and investors/investments in AMR R&D. See also the 7 Feb 2026 newsletter (“The global funding pipeline, 2017-2023: A review”) about an excellent deep dive by the Hub team into patterns of funding over time.
    • Antimicrobial Resistance Research and Innovation in Australia is an actively updated summary that covers Australia’s AMR research and patent landscape. It is provided via collaboration between The Lens (an ambitious project seeking to discover, analyse, and map global innovation knowledge) and CSIRO (Commonwealth Scientific and Industrial Research Organisation, an Australian Government agency responsible for scientific research). Lots to explore here!
    • Diagnostic developers would find valuable guidance in this 6-part series on in vitro diagnostic (IVD) development. Sponsored by CARB-X, C-CAMP, and FIND, it pulls together real-life insights into a succinct set of tutorials.
  • In addition to the lists provided by the Global AMR R&D Hub, you might also be interested in my most current lists of R&D incentives (link) and priority pathogens (link).
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