AWaRe antibiotic prescribing for common acute infections in low-middle income countries: a patient level analysis using IQVIA prescriber surveys from Pakistan, Egypt and Indonesia

BackgroundThere is limited large-scale and high-quality data on antibiotic prescribing in low- and middle- income countries (LMICs), particularly in the private sector. Here we use healthcare surveys to assess antibiotic prescribing levels and the factors influencing prescribing decisions for common infections in primary care and outpatient settings, predominantly within the private sector, in Pakistan, Egypt, and Indonesia. MethodsWe analysed surveys completed by prescribers in Pakistan, Egypt, and Indonesia, collected in primary care and outpatient settings, predominantly within the private sector, by IQVIA between 2017 and 2021, namely IQVIAs proprietary Medical Data Index (Medical Index of Pakistan (MIP), Egypt Medical Data Index (EMDI) and Indonesia Medical Data Index (IMDI)). IQVIA market research information reflects estimates of real world activity and should be treated accordingly. We evaluated antibiotic prescribing categorized by WHO AWaRe and Essential Medicines List (EML) classifications for common infections. We used mixed-effects regression analyses to identify factors influencing prescribing decisions. ResultsAmong the 384,975 infection-related health consultation records analysed, antibiotics were prescribed overall in 82.0% of consultations in Pakistan, 81.2% in Egypt, and 69.1% in Indonesia. Watch antibiotics accounted for 70.2% of all antibiotic prescriptions in Pakistan, 52.9% in Egypt, and 53.6% in Indonesia. Non-WHO EML antibiotics accounted for 26.8% of prescriptions in Pakistan, 39.9% in Egypt, and 33.0% in Indonesia. Consultations for patients presenting with lower respiratory tract infections, urinary tract infections, multiple infections, or differentiated fever had higher odds of receiving any or a Watch antibiotic. Consultations by respiratory-related specialists in Pakistan and Egypt and by most specialities in Indonesia were more likely to receive Watch antibiotics. InterpretationSimilar patterns of very high levels of total and Watch antibiotic prescribing for most common acute infections - including those that generally do not require any antibiotics - were identified among prescribers in primary care and outpatient settings within the private sector in Pakistan, Egypt, and Indonesia. What is already known on this topicO_LIPakistan, Egypt, and Indonesia are densely populated lower-middle income countries (LMICs), with a significant burden of antimicrobial resistance (AMR). However, evidence on antibiotic prescribing patterns and their drivers in primary care, particularly in the private sector, is limited C_LI What this study addsO_LIAntibiotic prescribing for common infections in primary care in Pakistan, Egypt, and Indonesia was very high, with antibiotics given in 70-80% of patient consultations. C_LIO_LIDespite WHO AWaRe book guidance recommending Access antibiotics or no antibiotics for most of these conditions, Watch antibiotics were frequently prescribed. C_LIO_LIHigh antibiotic prescribing appeared to be the norm, with low variability across prescribers, infections, and specialisations; C_LI How this study might affect research, practice or policyO_LIUrgent interventions are needed to address antibiotic overprescribing, which appears to have become routine in primary care and outpatient private healthcare in LMICs. C_LI