Stewardship is aimed at the wrong half: rich countries use the resistance drugs, LMICs need them

An analysis published in the Lancet Public Health reports that antibiotic overuse is concentrated in high-income settings, which consume the largest volumes of the drugs used to treat drug-resistant infections ^[1]. Many lower-income countries still cannot get those drugs, despite accounting for more than 80% of estimated global need ^[2] - which means a stewardship agenda built on "use less" is addressed to the half of the world that is already over-supplied.

The findings reach operators here through an opinion piece published by STAT rather than the paper itself, so the specifics below are secondhand ^[12]. The argument the piece makes about mechanism is worth separating from the accounting. Underuse is not only an equity gap: when the right antibiotic is unavailable, infections are more likely to go untreated and spread, or to be treated with a suboptimal drug, which raises the risk of treatment failure and creates selective pressure for resistant strains to survive and become harder to treat ^[3].

The measurement frame is the World Health Organization's AWaRe classification, which sorts antibiotics into Access (first-line drugs for common infections, meant to be widely available), Watch (broader-spectrum drugs carrying higher resistance risk), and Reserve (last-resort treatments for multidrug-resistant infections) ^[4]. In 2024 the U.N. General Assembly committed to ensuring at least 70% of global human antibiotic use comes from the Access group by 2030 ^[5]. The study's contribution is a denominator: first estimates of optimal antibiotic use for 186 countries, built from infectious disease burden, resistance levels and local context ^[6].

Against that denominator the global headline looks fine and the distribution does not. Worldwide, 77% of antibiotic use came from the Access group ^[7], seven percentage points clear of the 2030 target ^[13]. But among the 67 countries with consumption data, nearly three quarters - mostly wealthier ones - were using more antibiotics overall than clinically required, and almost all were using more Watch antibiotics than needed ^[8]. That is roughly 50 countries over-consuming ^[14]. Meanwhile the countries with the heaviest infectious disease and resistance burdens, predominantly lower-income, were estimated to need substantially more Watch and Reserve use than wealthier countries ^[9], contradicting the working assumption that LMICs mainly need Access drugs ^[10].

Two operational consequences follow. First, a national Access share above 70% is not evidence of appropriate prescribing; a country can hit the target while over-using Watch drugs, and the study's country-level estimates are what would show that. Second, the fix on the underuse side is procurement, registration and supply of Watch and Reserve drugs, not consumption restraint - the opinion piece frames stewardship and access as mutually dependent rather than opposed ^[11].

Watch the coverage gap: consumption data existed for 67 of the 186 countries modelled, leaving 119 with modelled need and no measured use ^[15]. Watch whether the 2030 Access-share commitment ^[5] acquires a need-adjusted companion metric, and whether the countries estimated to need more Watch and Reserve supply ^[9] appear in procurement plans rather than only in stewardship guidance.