Development of AWaRe antibiotic quality indicators for optimal use

Background: The World Health Organization (WHO) AWaRe (Access/Watch/Reserve) book gives detailed guidance on the optimal use of antibiotics across primary care and hospitals for adults and children with the aim of improving the quality of use. Objectives: To develop universally applicable, model sets of appropriate and feasible quality indicators based on the WHO AWaRe system for primary care, hospital, and general indicators for optimal antibiotic use. Methods: Indicators from a scoping review were revised to focus on clinical infections in the AWaRe book. They were assessed using consensus techniques through two rounds each of the Global Delphi Technique and RAND/UCLA Appropriateness Method, evaluating appropriateness and feasibility at national and global levels respectively. In Round 1 of each method, panellists rated clarity and suggested revisions or new indicator. Round 2 results are reported. Findings: There were 102 quality indicators (Primary Care: 46; Hospital: 39; General: 17) included in Round 2 of the Delphi Technique and 136 indicators (Primary Care: 56; Hospital: 60; General: 20) in Round 2 of the RAND/UCLA method, which are presented as model sets of indicators. From these broad sets, 12 indicators from the Delphi Technique and 31 indicators from the RAND/UCLA method were rated both appropriate and feasible with agreement respectively. Conclusion: These model AWaRe-based, universally applicable quality indicators can be locally adapted to improve the optimal use of antibiotics and inform global and country specific antimicrobial stewardship programs (AMS).