Hospitals in Bangladesh used World Health Organization Watch-category antibiotics in 91% of cases, despite WHO guidance that these drugs should be used only in specific situations because excessive or irrational use can rapidly drive antimicrobial resistance, according to the country’s largest national surveillance report on AMR.
The findings were published in the “Antimicrobial Resistance Surveillance Bangladesh-2025” report, described as the country’s largest national surveillance on antimicrobial resistance. The report said more than 70% of antibiotics used nationwide also belonged to the Watch category.
Under WHO classification, Access antibiotics should be the first choice for treating common bacterial infections because they are effective in most routine infections and carry a relatively lower risk of resistance. Watch antibiotics are recommended only for specific indications, while Reserve antibiotics are meant as a last option when other drugs are no longer effective.
The national AMR survey report said 91% of antibiotics used in different medical college hospitals were from the Watch group. Use of the Access group, which is prioritised for common infections, was only 10%, while use of Reserve antibiotics, kept for complex multidrug-resistant infections, was 0.03%.
The survey analysed 15,844 antibiotic prescriptions, of which 48% were from intensive care units. The report said stronger antibiotics are used most often in ICUs because of critically ill patients, ventilator use, other specialised treatment devices and the need for rapid infection control. Surveillance was conducted by the government’s Institute of Epidemiology, Disease Control and Research, or IEDCR.
The report warned that growing dependence on powerful antibiotics is accelerating the spread of antibiotic-resistant organisms. It said this is making many infections harder and longer to treat, while increasing hospital stays, treatment costs and the risk of death. Critically ill patients, newborns, children and people with weakened immunity are at greater risk.
Data included in the report from the Directorate General of Drug Administration’s antimicrobial use surveillance pointed to the same trend. Analysis of nationwide data from 2019 to 2023 showed that 50% to 67% of oral antibiotics and 70% to 91% of injectable antibiotics belonged to the WHO Watch category. In contrast, 22% to 37% of oral antibiotics and 9% to 30% of injectable antibiotics were in the Access group. Use of Reserve antibiotics remained below 1%.
The report said Watch-category antibiotics have been the most used in Bangladesh since 2016. In 2023, the share among injectable antibiotics reached nearly 91%.
The report called for greater emphasis on increasing rational use of Access antibiotics and reducing unnecessary use of Watch antibiotics. It warned that overdependence on stronger antibiotics could further expand the spread of drug-resistant organisms.
AMR refers to a condition in which organisms such as bacteria, viruses, fungi or parasites develop resistance to antimicrobial medicines. As a result, infections no longer respond, or respond poorly, to drugs that were previously effective. The WHO considers AMR one of the biggest threats to global public health.
Public health experts said high use of Watch antibiotics in hospitals reflects both patient complexity and weaknesses in antibiotic management, infection control and prescribing practices. They warned that if the trend continues, resistance against currently effective powerful antibiotics will rise rapidly, making severe infections even harder to treat.
Professor Dr Zakir Hossain Habib, Chief Scientific Officer (Virology) at IEDCR and chief editor of the AMR surveillance report, told Ajker Patrika: “The survey is based on the country’s specialised hospitals, where the most complex and critically ill patients are treated. So it is natural that relatively stronger antibiotics are used more there. However, the dominance of Watch-category antibiotics across the country in the drug administration’s analysis is also worrying.”
The report said ceftriaxone, a Watch antibiotic, was the most commonly used antibiotic in hospitals. It was followed by meropenem (Watch), cefixime (Watch), amikacin (Access), vancomycin (Watch) and ciprofloxacin (Watch). Most of the most-used antibiotics therefore belonged to the Watch category.
The pattern varied by hospital department. In general wards, ceftriaxone was the most commonly used drug for comparatively less complex infections. In ICUs, the pattern differed, with meropenem of the carbapenem class used most often to control severe infections in critically ill patients.
Dr Zakir said: “Resistance among organisms in the country has risen so much that in many cases patients do not respond to Access drugs. Doctors are then compelled to use Watch-category antibiotics. However, to reduce this dependence in the long term, infection prevention and rational antibiotic use must be ensured.”
Public health experts said excessive dependence on Watch antibiotics from general infections to ICU care is rapidly increasing microbial resistance. They warned that this is creating a risk of reduced effectiveness of key antibiotics such as ceftriaxone and meropenem. Unnecessary use, taking medicines without medical advice, failure to complete prescribed courses and weak infection control in hospitals are increasing the risk of this crisis. They called for stronger antimicrobial stewardship programmes and infection prevention and control measures in hospitals.
A study published this month in the UK-based journal The Lancet Public Health said low-income and lower-middle-income countries, including Bangladesh, have the highest demand for Watch and Reserve antibiotics. Experts said the sharp rise in Watch antibiotic use in hospitals is the combined result of disease complexity, irrational drug use and weak infection control systems. As resistance has grown, Access drugs are no longer effective in many cases, forcing doctors to use Watch-category antibiotics.
Dr Fazle Rabbi Chowdhury, deputy director and research fellow of an international research project at the University of Edinburgh in the United Kingdom and associate professor in the Department of Internal Medicine at Bangladesh Medical University, told Ajker Patrika: “Critically ill patients are taken to ICUs, so Watch-group antibiotics, and when necessary even Reserve-group antibiotics, have to be used there. Although Watch-group use in ICUs may not be irrational, it should be reduced as much as possible. But if Watch-group antibiotics are being used at this level in general wards, that is certainly worrying. In many patients, common antibiotics are no longer working, forcing doctors to give stronger drugs. This is the result of many years of irrational antibiotic use.”
Dr Fazle Rabbi Chowdhury said culture testing, which measures the presence and level of harmful bacteria in a sample, should be done before prescribing antibiotics whenever possible, whether in hospitals or in the community. He said the situation could improve if ideal antibiotic-use policies were followed consistently for 10 to 12 years.
Senior public health expert Professor Dr Abu Jamil Faisal told Ajker Patrika that after the IEDCR report, the relevant physicians should also be asked on what rationale these antibiotics were used. He said action should be taken after reviewing that information and that the sale of antibiotics without a prescription must be strictly stopped.