Nearly everybody has suffered from sore throat. From your own experience, you know that symptoms are often self-limited and can be cured without help of antibiotics. In fact, most cases of sore throat are caused by viruses, for which antibiotics do not work. For these reasons, the recommended first-line treatment for sore throat is watchful waiting. Symptoms usually improve within a few days without antibiotics.

Not using antibiotics in such cases may help fight antibiotic resistance. It is increasingly recognized that antibiotics are non-renewable resources that should be used wisely, carefully weighing potential benefits against the risk of antibiotic resistance and other adverse events. When used parsimoniously, antibiotics will stay effective for use in serious cases and for vulnerable populations such as infants and the elderly.

The first choice simply represents the best option in terms of effectiveness, harms and potential for resistance. In some cases, a second-choice antibiotic is also recommended. These antibiotics represent alternative options under some circumstances: they tend to be generally broader-spectrum antibiotics with higher resistance potential or less favorable risk–benefit ratios. Both first and second choices have specific indications (i.e. disease) for which they have been recommended.

Consider the two examples shown above: ear infections and kidney infections. Most cases of ear infections in children are caused by viruses (for which antibiotics are not effective) and resolve spontaneously. Antibiotics provide a small reduction in pain beyond 24 hours in about 5 of 100 children treated. This also means that 95 of 100 of children treated with antibiotic will have no relevant benefit associated with antibiotic treatment. This potential modest benefit must be weighed against the potential harms related to antibiotic use, both for the individual patient (e.g. allergic reactions and other side effects like diarrhea that will afflict one in every five patients treated). Furthermore, antibiotics also kill “good” bystander organisms with unclear long-term consequences. Antibiotic resistance is another important side effect of antibiotic treatment, that can also affect other people through transmission.

Kidney infections on the other hand require prompt medical attention. If not treated properly, a kidney infection can permanently damage your kidneys or the bacteria infection can spread to your bloodstream and put your life at risk. For this reason, it is important that a kidney infection is treated in a timely manner with effective antibiotics. For these severe infections the benefits associated with antibiotic treatment largely outweigh the side effects. However, an increasing number of people diagnosed with kidney infections have infections resistant to the standard class of antibiotic used in treatment – fluoroquinolones – severely limiting antibiotic treatment options. This resistance is partly driven by the use of fluoroquinolones for infections where other antibiotics would be preferable.

These are antibiotics are in the WATCH group, which should be monitored by health authorities to prevent spread and further emergence of antibiotic resistance. Their use should be limited to infections where they provide clear benefits over antibiotics of the ACCESS group and should be avoided for other infections. It is important to outline, that the aim is not to avoid their use completely, but to limit their use to specific situations. By not overusing WATCH group antibiotics for conditions for which we have other options, we keep them effective for situations when they are needed.

Yes, this is true for example for meningitis, a very severe disease. This is due to the fact that antibiotics have different profiles in terms of effectiveness, safety, and resistance depending on the type of infection. It is therefore possible that the same WATCH group antibiotic is second choice for one infection, first choice for another infection and not recommended for a third infection.

No. Antibiotics in the ACCESS group remain the “strongest”, most effective antibiotics for many infections. The classification in one of the AWaRe groups is based on their impact on antibiotic resistance and need for surveillance of use and is not based on differences in clinical effectiveness.