Who this list is for

The adapted UK-AWaRe list provides information for healthcare policy and guideline development teams, researchers and healthcare professionals in primary and secondary care in the UK.

Background

The UK-AWaRe classification is based on the World Health Organization (WHO) classification (1) of antibiotics and has 3 main parts. These are:

• Access
• Watch
• Reserve

See (2, 3, 4) for more information.

Some antibiotics do not fit into one of these 3 classifications. For example those that are only used to treat very specific conditions. These are classed as “Other”.

Access

Access antibiotics are those with a narrow spectrum of activity, fewer side effects, lower costs, and importantly lower resistance potential. These are first or second choice antibiotics recommended for empiric treatment of the most common infections and should be widely available. That is to say, these antibiotics should offer the best therapeutic value while minimizing the potential for resistance.

Watch

Watch antibiotics have a higher resistance potential and are broader-spectrum antibiotics. These are first or second choice antibiotics indicated for a limited number of infective syndromes. As these antibiotics are considered to have a higher potential for selection of AMR, their use should be carefully monitored.

Reserve

Reserve antibiotics are “last resort” antibiotics, including new antibiotics. These are used for highly selected patients (life-threatening infections due to multi-drug-resistant bacteria) and are closely monitored and prioritized as targets of stewardship programmes to ensure continued effectiveness.

Figure 1: An image summarising the Access, Watch and Reserve categories.

Development of the UK-AWaRe categories

In 2024, a multi-disciplinary group of medical, nursing, pharmacy and policy experts with infection expertise from across the 4 Nations led a modified Delphi consensus process for the classification of each of the antibiotics in routine use in primary and secondary care in the UK. The review considered antibiotic resistance profiles, antibiotic prescribing and stewardship practice in the UK. This was carried out in response to updates to the WHO AWaRe categories in 2023 (1) and to provide a UK whole-nation approach. Prior to this, in 2019, England had developed its own England-AWaRe classification (5), with other UK nations also adapting the WHO classifications or using the England-adapted list. 

The process included a nationwide survey with contributions from healthcare professionals across the 4 UK nations. Two structured workshops were held a core working group (see Acknowledgments) to review the World Health organization (WHO) AWaRe classification. Recommendations were discussed, and a consensus reached on how to adapt the WHO AWaRe list for the UK.

The full project findings are published in the peer-reviewed manuscript in JAC-AMR journal.

List of UK-AWaRe antibiotic classifications

The list of UK Access, Watch, Reserve, and Other antibiotics consensus classification is presented in Table 1.

Where possible, formularies, guidance, and pathways within organisations should encourage the empirical use of Access antibiotics, with Watch and Reserve antibiotics used second line. 

The most significant change within the adapted 2024 classification compared to the England-adapted 2019 classification is the move of first generation cephalosporins (Cefadroxil, Cefalexin, Cefazolin and Cefradine) from the Watch category to Access category. This change was made based on resistance potential, antibiotic use (as a first-line treatment or main oral option for community upper urinary tract infections), with lower Clostridioides difficile (C. difficile) risk than other cephalosporins, and value as an alternative for patients with non-severe or unverified penicillin allergies. This change only applies to the first generation cephalosporins, all other cephalosporins remain in the Watch or Reserve categories. The change in category does not mandate increased use of cephalosporins or require change to existing clinical guidance.

In 2024, the second 5-year UK national action plan (NAP) for antimicrobial resistance (AMR) 2024 to 2029 was published. Target 4b of the NAP aims to achieve 70% of total use of antibiotics from the Access category across the human healthcare system, based on the UK-AWaRE categories. Antibioitic usage data based on the WHO AWaRe categories will continue to be reported to WHO to allow benchmarking of the UK against other countries internationally.

Table 1: List of the UK Access, Watch and Reserve, and Other antibiotics consensus categories, with comparison to England-adapted 2019 AWaRe categories, presented alphabetically by antibiotic [note 1]

Note 1

Where categories between 2024 UK-adapted and 2019 England-adapted categories differ, these have been referenced with a hashtag (#).

Antibiotic	England-adapted 2019 AWaRe category	UK-adapted 2024 AWaRe category
Amikacin	Watch	Watch
Amoxicillin	Access	Access
Amoxicillin/ clavulanic-acid	Watch	Watch
Ampicillin	Access	Access
Azithromycin	Watch	Watch
Aztreonam	Reserve	Reserve
Benzathine-benzylpenicillin	Access	Access
Benzylpenicillin	Access	Access
Cefaclor	Watch	Watch
Cefadroxil #	Watch	Access
Cefalexin #	Watch	Access
Cefalotin #	Watch	Access
Cefamandole	Watch	Watch
Cefazolin #	Watch	Access
Cefepime	Watch	Watch
Cefiderocol	Reserve	Reserve
Cefixime	Watch	Watch
Cefotaxime	Watch	Watch
Cefoxitin	Watch	Watch
Cefradine #	Watch	Access
Ceftaroline-fosamil	Reserve	Reserve
Ceftazidime	Watch	Watch
Ceftazidime/ avibactam	Reserve	Reserve
Ceftobiprole-medocaril	Reserve	Reserve
Ceftolozane/ tazobactam	Reserve	Reserve
Ceftriaxone	Watch	Watch
Cefuroxime	Watch	Watch
Chloramphenicol	Watch	Watch
Ciprofloxacin	Watch	Watch
Clarithromycin	Watch	Watch
Clindamycin	Watch	Watch
Colistin, intravenous	Reserve	Reserve
Colistin, oral	Reserve	Reserve
Dalbavancin	Reserve	Reserve
Dalfopristin/ quinupristin	Reserve	Reserve
Daptomycin	Reserve	Reserve
Delafloxacin	Watch	Watch
Demeclocycline #	Watch	Other
Doripenem	Reserve	Reserve
Doxycycline	Access	Access
Eravacycline	Reserve	Reserve
Ertapenem	Reserve	Reserve
Erythromycin	Watch	Watch
Fidaxomicin	Watch	Watch
Flucloxacillin	Access	Access
Fosfomycin oral	Access	Access
Fosfomycin, intravenous	Reserve	Reserve
Fusidic acid #	Access	Watch
Gentamicin	Access	Access
Imipenem/cilastatin	Reserve	Reserve
Imipenem/cilastatin/relebactam	Reserve	Reserve
Levofloxacin	Watch	Watch
Linezolid	Reserve	Reserve
Lymecycline	Watch	Watch
Meropenem	Reserve	Reserve
Meropenem/ vaborbactam	Reserve	Reserve
Methenamine	Other	Other
Metronidazole	Access	Access
Minocycline oral	Watch	Watch
Moxifloxacin	Watch	Watch
Nalidixic Acid	Other	Other
Neomycin	Watch	Watch
Nitrofurantoin	Access	Access
Norfloxacin	Watch	Watch
Ofloxacin	Watch	Watch
Oritavancin	Reserve	Reserve
Oxytetracycline	Watch	Watch
Phenoxymethylpenicillin	Access	Access
Piperacillin	Watch	Watch
Piperacillin/tazobactam	Watch	Watch
Pivmecillinam	Access	Access
Pristinamycin #	Watch	Other
Procaine-benzylpenicillin	Access	Access
Spectinomycin	Other	Other
Spiramycin	Other	Other
Streptomycin, intravenous	Other	Other
Sulfadiazine	Other	Other
Sulfamethoxazole/ trimethoprim	Access	Access
Sulfamethoxypyridazine	Other	Other
Sulfapyridine	Other	Other
Tedizolid	Reserve	Reserve
Teicoplanin	Watch	Watch
Telavancin	Reserve	Reserve
Temocillin	Watch	Watch
Tetracycline	Access	Access
Tigecycline	Reserve	Reserve
Tinidazole #	Other	Access
Tobramycin	Watch	Watch
Trimethoprim	Access	Access
Vancomycin	Watch	Watch

For queries, contact: espaur@ukhsa.gov.uk

Disclaimers

The published material is being distributed without a warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader.

This publication is based on the collective views of a multidisciplinary group of experts across the four UK nations. The recommendations contained in this publication are based on the advice of independent experts, who have considered the best available evidence, a risk–benefit analysis and other factors, as appropriate. The responsibility for the interpretation and use of the material lies with the reader.

References

1. World Health Organization. AWaRe classification of antibiotics for evaluation and monitoring of use: 2023.
2. Sharland M and others. The WHO AWaRe Antibiotic Book: providing guidance on optimal use and informing policy. The Lancet. Infectious Diseases: 2022, volume 22 , issue 11, pages 1528 to 1530.
3. UK Health Security Agency. The English Surveillance Programme for Antimicrobial Utilisation and Resistance (ESPAUR) Report 2022 to 2023 - Infographics 2023.
4. World Health Organization.  The WHO AWaRe (access, watch, reserve) antibiotic book: 2022.
5. Budd E and others. Adaptation of the WHO Essential Medicines List for national antibiotic stewardship policy in England: being AWaRe. Journal of Antimicrobial Chemotherapy: 2019, volume 74, issue 11, pages 3384 to 3389.

Acknowledgements

UK AWaRe Author and Working Group

The UK AWaRe working group includes:

• Sabine Bou-Antoun
• Rebecca Oettle
• Alistair Leonard
• Ronald Andrew Seaton
• Ben Cooper
• Berit Muller-Pebody
• Geraldine Colon Bingham
• Frances Kerr
• Kieran Hand
• Jonathan Sandoe
• Martin Llewelyn
• Naomi Fleming
• Nicholas Brown
• Nicholas Reid
• Philip Howard
• Sarah-Jayne Mckinstry
• William Malcolm
• Alicia Demirjian
• Diane Ashiru-Oredope