Variation in antibiotic prescribing across English primary care from 2021 to 2024

Background: Antimicrobial stewardship remains central to efforts to address antimicrobial resistance, with primary care accounting for the majority of antibiotic prescribing in England. Although reductions in prescribing were observed during the coronavirus pandemic, patterns in the subsequent recovery period remain incompletely characterised. Understanding both national trends and regional variation in antibiotic use under the current commissioning structure may inform targeted quality improvement initiatives. Methods: A retrospective secondary analysis of publicly available NHS primary care prescribing data was undertaken using data obtained via OpenPrescribing. Monthly antibiotic prescribing data from January 2021 to December 2024 were analysed across 107 NHS commissioning areas. Prescribing intensity was defined as antibiotic prescription items per 1,000 registered patients per month. National trends were summarised using annual mean monthly prescribing rates. Regional variation was assessed descriptively using distribution metrics, including quartiles, standard deviation, maximum-to-minimum ratios, and annual ranking of commissioning areas. Persistence of extreme prescribing positions was evaluated across the four-year period. Results: National mean monthly antibiotic prescribing increased from 1.53 items per 1,000 registered patients in 2021 to 1.81 in 2023, before declining to 1.42 in 2024. The largest year-on-year change occurred between 2023 and 2024, with a reduction of 21.5%. Substantial regional variation was observed in all years. In 2023, prescribing ranged from 1.08 to 2.87 items per 1,000 registered patients per month, corresponding to a 2.67-fold difference between commissioning areas. Several areas appeared among the highest or lowest prescribing regions in all four years analysed, indicating persistence of extreme relative positions. Conclusions: Community antibiotic prescribing in English primary care between 2021 and 2024 demonstrated post-pandemic fluctuation and sustained regional variation across commissioning areas. Persistent differences in prescribing intensity suggest opportunities for regionally informed stewardship initiatives and performance benchmarking within the current healthcare administrative framework.