Prescribing patterns of antibiotics according to the WHO access, watch, and reserve (AWaRe) classification in the pediatric outpatient department: A prospective study.

Objectives: Antimicrobial resistance (AMR) poses a significant global health threat, disproportionately affecting young children, especially in low- and middle-income countries. The World Health Organization (WHO) introduced the Access, Watch, and Reserve (AWaRe) classification system to guide responsible antibiotic prescribing. This study evaluates antibiotic prescribing patterns in pediatric outpatient departments in Pakistan using the WHO AWaRe framework. Methodology: A prospective, cross-sectional, multicentric study was conducted in four urban Level two teaching hospitals affiliated with Aga Khan University Hospital in Pakistan. Data was collected monthly for one year (August, 2023 - July, 2024), involving pediatric patients aged one month to twelve years. Prescriptions were categorized into AWaRe groups, with frequencies analyzed by clinical indication and patient age. Results: Of 1,802 pediatric encounters analyzed, antibiotics were prescribed in 529 cases (29.4%), predominantly orally (77.9%). Azithromycin (19.5%) and Amoxicillin-Clavulanic acid (19.1%) were the most commonly prescribed agents. Watch antibiotics represented 69.2% of prescriptions, significantly exceeding WHO recommendations (≤40%). Antibiotic prescription rates varied substantially by diagnosis, being highest for enteric fever (89.6%), sepsis (82.4%), and UTIs (75.0%), with notable inappropriate prescribing for viral conditions such as URTIs (33.2%), acute febrile illness (31.7%), and bronchiolitis (31%). Narrow-spectrum Access antibiotics were underutilized (29.7%), while Reserve antibiotics were rarely prescribed (1.1%). Conclusion: This study concludes that the poor implementation of AWaRe among pediatricians in Pakistan indicates urgent need for multiple interventions. There is a dire need to improve antibiotic prescribing practices, ranging from antibiotic prescription policies, training of pediatricians in antibiotic use, AWaRe implementation, and regular monitoring in the form of clinical audits.