AWaRe is a tool developed by the World Health Organization (WHO) to to help countries improve antibiotic treatment, increase access and reduce resistance (

AWaRe was introduced in 2017 as a new categorization of antibiotics to guide prescriptions and treatment while monitoring consumption. The three categories are:

  • Access which indicates the antibiotic of choice for each of the 25 most common infections. These antibiotics should be available at all times, affordable and quality-assured.

  • Watch which includes most of the “highest-priority critically important antimicrobials” for human medicine and veterinary use. These antibiotics are recommended only for specific, limited indications.

  • Reserve antibiotics that should only be used as a last resort when all other antibiotics have failed.

WHO suggests that countries should increase the proportion of access antibiotics to correspond to at least 60% of total national consumption

abxaware is an R package that contains a list of antibacterial drugs for systemic use (ATC group J01) and the corresponding AWaRe classification plus functions to aggregate and visualise antibiotic use according to AWaRe.

The classification data frame (abx_aware, see Appendix) contains both the latest 2019 WHO classification, the English classification (Budd 2019) and our own adaptation to Danish guidelines.

In the Danish classification, which is default in abxaware functions, two drugs have been moved up one level: amoxicillin and beta-lactamase inhibitor from access to watch and meropenem from watch to reserve. Additionally, two drugs (sulfapyridine and sulfadiazine) that are unclassified by WHO are included in the Danish AWaRe classification in order to cover nearly all antibiotics used in Danish hospitals.

Preparing data

To create a plot like the one above, you need a data frame with at least two columns: ATC code and amount. The ATC code is the unique drug identifier, and the amount variable is the amount of drug with this ATC code used. Amount is normally given in defined daily dose (DDD) units, but other measures may be used. Additionally, the data frame may include variables for time period and organisational unit allowing for creation of faceted time series plots. Note that only drugs with a complete ATC code with 7 characters can be classified, and that not all drugs have been classified. Unclassifiable drugs appear in the outputs as “other” unless ignore.other = TRUE.

In the following examples we will use the abx_sales data frame. In addition to the atc and ddd columns, abx_sales has a time variable (month) and two unit variables (region and hospital). That is, for each month, atc group and hospital in one of five Danish regions the amount of drug used is found in the ddd variable.

#> Rows: 51,999
#> Columns: 7
#> $ region   <chr> "Hovedstaden", "Hovedstaden", "Hovedstaden", "Hovedstaden", "…
#> $ hospital <chr> "Amager og Hvidovre Hospital", "Amager og Hvidovre Hospital",…
#> $ hosp     <chr> "AHH", "AHH", "AHH", "AHH", "AHH", "AHH", "AHH", "AHH", "AHH"…
#> $ month    <date> 2015-01-01, 2015-01-01, 2015-01-01, 2015-01-01, 2015-01-01, …
#> $ atc      <chr> "J01AA02", "J01AA12", "J01CA01", "J01CA02", "J01CA04", "J01CA…
#> $ ddd      <dbl> 105.00, 25.00, 143.45, 294.32, 90.99, 796.68, 5.00, 283.33, 5…
#> $ drug     <chr> "doxycycline", "tigecycline", "ampicillin", "pivampicillin", …

Plotting data

This code creates a single one-dimensional plot.

         atc = atc, 
         ddd = ddd)
#> Aggregating data using the "dk" AWaRe classification

awr_plot() automatically aggregates data and prints a message telling which classification was used, WHO, UK or DK. By default, the DK classification is used, but the method can be specified using the method argument.

awr_plot(abx_sales, method = 'who')
#> Aggregating data using the "who" AWaRe classification

awr_plot(abx_sales, method = 'uk')
#> Aggregating data using the "uk" AWaRe classification

The default method for an R session may be specified in advance as an option, for example: options(abxaware.method = 'who').

To split data by organisational unit, provide a unit variable:

         unit = region)
#> Aggregating data using the "dk" AWaRe classification

Likewise, to create a time series plot, provide a time variable:

         time = month)
#> Aggregating data using the "dk" AWaRe classification

Or combine time and unit to create faceted time series plots.

         time = month, 
         unit = region, 
         ncol = 1)
#> Aggregating data using the "dk" AWaRe classification

         time = month, 
         unit = hospital, 
         ncol = 2)
#> Aggregating data using the "dk" AWaRe classification

The horizontal line represents the median percentage use of antibiotics in the access group. In case of non-random variation over time, the line is dashed, otherwise solid. To test for non-random variation two rules are employed for unusually long runs of consecutive data points on the same side of the centre line and unusually few crossings of the centre line respectively (Anhøj 2014)). If one or both test are positive, this may be taken as a signal that non-random variation (e.g. trends, shift, or cyclic patterns) is present.

To add title, subtitle, caption etc. to a plot, use the labs function from ggplot2. See ?awr_plot for details on other arguments.

         time = month,
         ignore.other = TRUE,
         silent       = TRUE) +
  ggplot2::labs(title   = 'Use of antibiotics in Danish hospitals 2015-2020',
                x       = 'Month',
                caption = 'Created with abxaware for R')

Aggregating data

As mentioned, data are automatically aggregated before plotting with awr_plot(). If no time and unit arguments are provided, data will be aggregated by AWaRe class. However, when specifying a time and/or a unit argument data will be further aggregated accordingly. Aggregation is performed “behind the scenes” by the awr_aggregate() function. When plotting, only one time and/or one unit variable is allowed. But awr_aggregate() allows for indefinitely many (unnamed) grouping variables.

#> Aggregating data using the "dk" AWaRe classification
#> # A tibble: 1 × 5
#>       total reserve     watch    access other
#>       <dbl>   <dbl>     <dbl>     <dbl> <dbl>
#> 1 25286569. 997134. 10693833. 13592934. 2668.
#> Aggregating data using the "dk" AWaRe classification
#> # A tibble: 5 × 6
#>   region         total reserve    watch   access other
#>   <chr>          <dbl>   <dbl>    <dbl>    <dbl> <dbl>
#> 1 Hovedstaden 9964511. 572993. 3764616. 5624234. 2668.
#> 2 Midtjylland 4692156. 132510. 2405504. 2154141.    0 
#> 3 Nordjylland 2278616.  36727. 1030179. 1211710.    0 
#> 4 Sjælland    3369530.  71470. 1479130. 1818930.    0 
#> 5 Syddanmark  4981757. 183433. 2014403. 2783921.    0
#> Aggregating data using the "dk" AWaRe classification
#> # A tibble: 1,580 × 8
#>    region      hospital             month       total reserve watch access other
#>    <chr>       <chr>                <date>      <dbl>   <dbl> <dbl>  <dbl> <dbl>
#>  1 Hovedstaden Amager og Hvidovre … 2015-01-01  9079.    273. 4241.  4565.     0
#>  2 Hovedstaden Amager og Hvidovre … 2015-02-01 12092.    471. 5256.  6366.     0
#>  3 Hovedstaden Amager og Hvidovre … 2015-03-01 19271.    771. 8432. 10068.     0
#>  4 Hovedstaden Amager og Hvidovre … 2015-04-01  7700     518. 3546.  3636.     0
#>  5 Hovedstaden Amager og Hvidovre … 2015-05-01 10184.    496. 4348.  5340.     0
#>  6 Hovedstaden Amager og Hvidovre … 2015-06-01 12168.    381. 5338.  6449.     0
#>  7 Hovedstaden Amager og Hvidovre … 2015-07-01 11990.    462. 4752.  6776.     0
#>  8 Hovedstaden Amager og Hvidovre … 2015-08-01 11113.    642. 4438.  6033.     0
#>  9 Hovedstaden Amager og Hvidovre … 2015-09-01 13148.    350. 4961.  7837.     0
#> 10 Hovedstaden Amager og Hvidovre … 2015-10-01 12731.    249. 5283.  7198.     0
#> # … with 1,570 more rows


  • World Health Organisation (2019). Adopt AWaRe.

  • Mike Sharland et al. (2019). Encouraging AWaRe-ness and discouraging inappropriate antibiotic use – the new 2019 Essential Medicines List becomes a global antibiotic stewardship tool. Lancet Infect Dis. 2019.

  • Emma Budd et al. (2019). Adaptation of the WHO Essential Medicines List for national antibiotic stewardship policy in England: being AWaRe, Journal of Antimicrobial Chemotherapy.

  • Ines Pauwels et al. (2021). Hospital antibiotic prescribing patterns in adult patients according to the WHO Access, Watch and Reserve classification (AWaRe): results from a worldwide point prevalence survey in 69 countries, Journal of Antimicrobial Chemotherapy.

  • Jacob Anhøj, Anne Vingaard Olesen (2014). Run Charts Revisited: A Simulation Study of Run Chart Rules for Detection of Non-Random Variation in Health Care Processes.

Appendix: Table for mapping ATC codes to AWaRe groups

atc atc_level generic_name aware_who aware_uk aware_dk
J01AA 4 Tetracyclines
J01AA01 5 demeclocycline watch
J01AA02 5 doxycycline access access access
J01AA03 5 chlortetracycline watch watch
J01AA04 5 lymecycline watch watch watch
J01AA05 5 metacycline watch watch
J01AA06 5 oxytetracycline watch watch watch
J01AA07 5 tetracycline access access access
J01AA08 5 minocycline reserve watch reserve
J01AA09 5 rolitetracycline
J01AA10 5 penimepicycline
J01AA11 5 clomocycline
J01AA12 5 tigecycline reserve reserve reserve
J01AA13 5 eravacycline reserve reserve
J01AA14 5 sarecycline
J01AA15 5 omadacycline
J01AA20 5 combinations of tetracyclines watch
J01AA56 5 oxytetracycline, combinations
J01BA 4 Amphenicol antibacterials, systemic
J01BA01 5 chloramphenicol access watch access
J01BA02 5 thiamphenicol access access
J01BA52 5 thiamphenicol, combinations
J01CA 4 Penicillins with extended spectrum
J01CA01 5 ampicillin access access access
J01CA02 5 pivampicillin access access
J01CA03 5 carbenicillin watch watch
J01CA04 5 amoxicillin access access access
J01CA05 5 carindacillin
J01CA06 5 bacampicillin access access
J01CA07 5 epicillin
J01CA08 5 pivmecillinam access access access
J01CA09 5 azlocillin watch watch
J01CA10 5 mezlocillin watch watch
J01CA11 5 mecillinam access access
J01CA12 5 piperacillin watch watch watch
J01CA13 5 ticarcillin watch watch watch
J01CA14 5 metampicillin
J01CA15 5 talampicillin
J01CA16 5 sulbenicillin watch watch
J01CA17 5 temocillin watch watch watch
J01CA18 5 hetacillin
J01CA19 5 aspoxicillin
J01CA20 5 penicillins with extended spectrum combinations
J01CA51 5 ampicillin, combinations access
J01CE 4 Beta-lactamase sensitive penicillins
J01CE01 5 benzylpenicillin access access access
J01CE02 5 phenoxymethylpenicillin access access access
J01CE03 5 propicillin
J01CE04 5 azidocillin
J01CE05 5 pheneticillin watch watch
J01CE06 5 penamecillin access access
J01CE07 5 clometocillin access access
J01CE08 5 benzathine benzylpenicillin access access access
J01CE09 5 procaine benzylpenicillin access access access
J01CE10 5 benzathine phenoxymethylpenicillin
J01CE30 5 beta-lactamase sensitive penicillin combinations
J01CF 4 Beta-lactamase resistant penicillins
J01CF01 5 dicloxacillin access access
J01CF02 5 cloxacillin access access access
J01CF03 5 meticillin
J01CF04 5 oxacillin access access
J01CF05 5 flucloxacillin access access access
J01CF06 5 nafcillin access access
J01CG 4 Beta-lactamase inhibitors, systemic penicillins
J01CG01 5 sulbactam
J01CG02 5 tazobactam
J01CR 4 Combinations of penicillins, incl. beta-lactamase inhibitors
J01CR01 5 ampicillin and beta-lactamase inhibitor access access
J01CR02 5 amoxicillin and beta-lactamase inhibitor access watch watch
J01CR03 5 ticarcillin and beta-lactamase inhibitor watch
J01CR04 5 sultamicillin access access
J01CR05 5 piperacillin and beta-lactamase inhibitor watch watch watch
J01CR50 5 combinations of penicillins
J01DB 4 First-generation cephalosporins
J01DB01 5 cefalexin access watch access
J01DB02 5 cefaloridine
J01DB03 5 cefalotin access access
J01DB04 5 cefazolin access watch access
J01DB05 5 cefadroxil access watch access
J01DB06 5 cefazedone access access
J01DB07 5 cefatrizine access access
J01DB08 5 cefapirin access access
J01DB09 5 cefradine access watch access
J01DB10 5 cefacetrile access access
J01DB11 5 cefroxadine access access
J01DB12 5 ceftezole access access
J01DC 4 Second-generation cephalosporins
J01DC01 5 cefoxitin watch watch watch
J01DC02 5 cefuroxime watch watch watch
J01DC03 5 cefamandole watch watch watch
J01DC04 5 cefaclor watch watch watch
J01DC05 5 cefotetan watch watch
J01DC06 5 cefonicid watch watch
J01DC07 5 cefotiam watch watch
J01DC08 5 loracarbef
J01DC09 5 cefmetazole watch watch
J01DC10 5 cefprozil watch watch watch
J01DC11 5 ceforanide watch watch
J01DC12 5 cefminox watch watch
J01DC13 5 cefbuperazone watch watch
J01DC14 5 flomoxef watch watch
J01DD 4 Third-generation cephalosporins
J01DD01 5 cefotaxime watch watch watch
J01DD02 5 ceftazidime watch watch watch
J01DD03 5 cefsulodin watch
J01DD04 5 ceftriaxone watch watch watch
J01DD05 5 cefmenoxime watch watch watch
J01DD06 5 latamoxef watch watch watch
J01DD07 5 ceftizoxime watch watch watch
J01DD08 5 cefixime watch watch watch
J01DD09 5 cefodizime watch watch watch
J01DD10 5 cefetamet watch watch watch
J01DD11 5 cefpiramide watch watch watch
J01DD12 5 cefoperazone watch watch watch
J01DD13 5 cefpodoxime watch watch watch
J01DD14 5 ceftibuten watch watch watch
J01DD15 5 cefdinir watch watch watch
J01DD16 5 cefditoren watch watch watch
J01DD17 5 cefcapene watch watch watch
J01DD18 5 cefteram watch watch
J01DD51 5 cefotaxime and beta-lactamase inhibitor watch
J01DD52 5 ceftazidime and beta-lactamase inhibitor reserve reserve reserve
J01DD54 5 ceftriaxone, combinations watch
J01DD62 5 cefoperazone and beta-lactamase inhibitor watch
J01DD63 5 ceftriaxone and beta-lactamase inhibitor watch
J01DD64 5 cefpodoxime and beta-lactamase inhibitor
J01DE 4 Fourth-generation cephalosporins
J01DE01 5 cefepime watch reserve watch
J01DE02 5 cefpirome watch reserve watch
J01DE03 5 cefozopran watch reserve watch
J01DF 4 Monobactams
J01DF01 5 aztreonam reserve reserve reserve
J01DF02 5 carumonam
J01DH 4 Carbapenems
J01DH02 5 meropenem watch reserve reserve
J01DH03 5 ertapenem watch reserve watch
J01DH04 5 doripenem watch reserve watch
J01DH05 5 biapenem watch watch watch
J01DH06 5 tebipenem pivoxil watch watch
J01DH51 5 imipenem and cilastatin watch reserve watch
J01DH52 5 meropenem and vaborbactam reserve reserve
J01DH55 5 panipenem and betamipron watch
J01DH56 5 imipenem, cilastatin and relebactam
J01DI 4 Other cephalosporins and penems in atc
J01DI01 5 ceftobiprole medocaril reserve reserve reserve
J01DI02 5 ceftaroline fosamil reserve reserve reserve
J01DI03 5 faropenem reserve watch reserve
J01DI04 5 cefiderocol
J01DI54 5 ceftolozane and beta-lactamase inhibitor reserve reserve reserve
J01EA 4 Trimethoprim and derivatives, systemic antibacterials
J01EA01 5 trimethoprim access access access
J01EA02 5 brodimoprim
J01EA03 5 iclaprim
J01EB 4 Short-acting sulfonamides
J01EB01 5 sulfaisodimidine
J01EB02 5 sulfamethizole access access
J01EB03 5 sulfadimidine
J01EB04 5 sulfapyridine access
J01EB05 5 sulfafurazole
J01EB06 5 sulfanilamide
J01EB07 5 sulfathiazole
J01EB08 5 sulfathiourea
J01EB20 5 short-acting sulfonamide combinations
J01EC 4 Intermediate-acting sulfonamides
J01EC01 5 sulfamethoxazole
J01EC02 5 sulfadiazine access
J01EC03 5 sulfamoxole
J01EC20 5 intermediate-acting sulfonamide combinations
J01ED 4 Long-acting sulfonamides
J01ED01 5 sulfadimethoxine
J01ED02 5 sulfalene
J01ED03 5 sulfametomidine
J01ED04 5 sulfametoxydiazine
J01ED05 5 sulfamethoxypyridazine
J01ED06 5 sulfaperin
J01ED07 5 sulfamerazine
J01ED08 5 sulfaphenazole
J01ED09 5 sulfamazone
J01ED20 5 long-acting sulfonamide combinations
J01EE 4 Combinations of sulfonamides and trimethoprim, incl. derivatives
J01EE01 5 sulfamethoxazole and trimethoprim access access access
J01EE02 5 sulfadiazine and trimethoprim access access
J01EE03 5 sulfametrole and trimethoprim access access
J01EE04 5 sulfamoxole and trimethoprim access access
J01EE05 5 sulfadimidine and trimethoprim
J01EE06 5 sulfadiazine and tetroxoprim
J01EE07 5 sulfamerazine and trimethoprim
J01FA 4 Macrolides
J01FA01 5 erythromycin watch watch watch
J01FA02 5 spiramycin watch watch watch
J01FA03 5 midecamycin watch watch watch
J01FA05 5 oleandomycin watch watch watch
J01FA06 5 roxithromycin watch watch watch
J01FA07 5 josamycin watch watch watch
J01FA08 5 troleandomycin watch
J01FA09 5 clarithromycin watch watch watch
J01FA10 5 azithromycin watch watch watch
J01FA11 5 miocamycin watch
J01FA12 5 rokitamycin watch
J01FA13 5 dirithromycin watch watch watch
J01FA14 5 flurithromycin watch
J01FA15 5 telithromycin watch watch watch
J01FA16 5 solithromycin watch
J01FF 4 Lincosamides
J01FF01 5 clindamycin access watch access
J01FF02 5 lincomycin watch watch
J01FG 4 Streptogramins
J01FG01 5 pristinamycin watch watch watch
J01FG02 5 quinupristin/dalfopristin reserve watch reserve
J01GA 4 Streptomycins
J01GA01 5 streptomycin watch watch
J01GA02 5 streptoduocin
J01GB 4 Other aminoglycosides in atc
J01GB01 5 tobramycin watch watch watch
J01GB03 5 gentamicin access access access
J01GB04 5 kanamycin watch watch
J01GB05 5 neomycin watch access watch
J01GB06 5 amikacin access watch access
J01GB07 5 netilmicin watch watch
J01GB08 5 sisomicin watch watch
J01GB09 5 dibekacin watch watch
J01GB10 5 ribostamycin watch watch
J01GB11 5 isepamicin watch watch
J01GB12 5 arbekacin watch watch
J01GB13 5 bekanamycin
J01GB14 5 plazomicin
J01MA 4 Fluoroquinolone antibacterials, systemic
J01MA01 5 ofloxacin watch watch watch
J01MA02 5 ciprofloxacin watch watch watch
J01MA03 5 pefloxacin watch watch watch
J01MA04 5 enoxacin watch watch watch
J01MA05 5 temafloxacin watch
J01MA06 5 norfloxacin watch watch watch
J01MA07 5 lomefloxacin watch watch watch
J01MA08 5 fleroxacin watch watch watch
J01MA09 5 sparfloxacin watch watch watch
J01MA10 5 rufloxacin watch watch watch
J01MA11 5 grepafloxacin watch
J01MA12 5 levofloxacin watch watch watch
J01MA13 5 trovafloxacin watch
J01MA14 5 moxifloxacin watch watch watch
J01MA15 5 gemifloxacin watch watch watch
J01MA16 5 gatifloxacin watch watch watch
J01MA17 5 prulifloxacin watch watch watch
J01MA18 5 pazufloxacin watch watch watch
J01MA19 5 garenoxacin watch watch watch
J01MA21 5 sitafloxacin watch watch watch
J01MA22 5 tosufloxacin watch watch
J01MA23 5 delafloxacin watch watch
J01MA24 5 levonadifloxacin
J01MA25 5 lascufloxacin
J01MB 4 Other quinolones in atc
J01MB01 5 rosoxacin watch
J01MB02 5 nalidixic acid watch
J01MB03 5 piromidic acid watch
J01MB04 5 pipemidic acid watch
J01MB05 5 oxolinic acid watch
J01MB06 5 cinoxacin watch
J01MB07 5 flumequine watch watch watch
J01MB08 5 nemonoxacin
J01RA 4 Combinations of antibacterials
J01RA01 5 penicillins, combinations with other antibacterials
J01RA02 5 sulfonamides, combinations with other antibacterials (excl. trimethoprim)
J01RA03 5 cefuroxime and metronidazole
J01RA04 5 spiramycin and metronidazole watch watch
J01RA05 5 levofloxacin and ornidazole
J01RA06 5 cefepime and amikacin
J01RA07 5 azithromycin, fluconazole and secnidazole
J01RA08 5 tetracycline and oleandomycin
J01RA09 5 ofloxacin and ornidazole
J01RA10 5 ciprofloxacin and metronidazole
J01RA11 5 ciprofloxacin and tinidazole
J01RA12 5 ciprofloxacin and ornidazole
J01RA13 5 norfloxacin and tinidazole
J01XA 4 Glycopeptide antibacterials
J01XA01 5 vancomycin watch watch watch
J01XA02 5 teicoplanin watch watch watch
J01XA03 5 telavancin reserve reserve reserve
J01XA04 5 dalbavancin reserve reserve reserve
J01XA05 5 oritavancin reserve reserve reserve
J01XB 4 Polymyxins
J01XB01 5 colistin reserve reserve reserve
J01XB02 5 polymyxin b reserve reserve reserve
J01XC 4 Steroid antibacterials
J01XC01 5 fusidic acid watch access watch
J01XD 4 Imidazole derivatives, antibacterial for systemic use
J01XD01 5 metronidazole access access access
J01XD02 5 tinidazole
J01XD03 5 ornidazole
J01XE 4 Nitrofuran derivatives, antibacterials for systemic use
J01XE01 5 nitrofurantoin access access access
J01XE02 5 nifurtoinol
J01XE03 5 furazidin
J01XE51 5 nitrofurantoin, combinations
J01XX 4 Other antibacterials in atc
J01XX01 5 fosfomycin reserve reserve reserve
J01XX02 5 xibornol
J01XX03 5 clofoctol watch watch
J01XX04 5 spectinomycin access access access
J01XX05 5 methenamine
J01XX06 5 mandelic acid
J01XX07 5 nitroxoline
J01XX08 5 linezolid reserve reserve reserve
J01XX09 5 daptomycin reserve reserve reserve
J01XX10 5 bacitracin
J01XX11 5 tedizolid reserve reserve reserve
J01XX12 5 lefamulin