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

Background There 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. Methods We 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 IQVIA 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. Results Among 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. Interpretation Similar 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.