(275) Outpatient Use of Antibiotics in Iran: A National study using claim data from 2014 to 2019

Background: Targeting outpatient antibiotic use and prescribing patterns may be necessary to optimize antibiotic use in a country.

Objectives: This study aims to investigate the frequency and pattern of outpatient antibiotic use in Iran using claim data.

Methods: •

Design: We conducted a cross-sectional observational study using claim data from Iran.
• Setting: Data on outpatient medication reimbursements from one of the two main insurance organizations in Iran between 2014 and 2019 were used
• Exposures: All records of J01 (WHO ATC/DDD system (2020)) antibiotics that were prescribed, dispensed and reimbursed in the outpatient setting were retrieved and cleaned.
• Main outcome measures: The study outcomes were the Frequency (prescribing rate, per beneficiaries and per patient), pattern (DU90%, WHO AWaRe categories (2023) and concurrent use) and amount of antibiotic used.
• Statistical Analysis: Antibiotic prescribing rate as prescriptions per 1000 beneficiaries per year, and annual consumption amount as WHO defined daily doses (DDDs) per 1000 beneficiaries per day (DID) were calculated.

Results: Antibiotics were prescribed in 32.1% and 29.7% of the prescriptions in 2014 and 2019, respectively. The antibiotic prescribing rate was 986.4, 1184.4, and 587.2 per 1000 beneficiaries per year in 2014, 2016, and 2019, respectively. The prescription to patient ratio was 223.5 and 206.3 per 100 patients in 2014 and 2019, respectively. Three of the seven DU-90% antibiotics were from the 'Watch' category in all years. The percentage of 'Access' antibiotics in annual consumption decreased from 45.46% in 2014 to 42.19% in 2019. Cefixime and azithromycin were the most frequently used antibiotics, accounting for 43.7% and 47.6% of annual DID in 2014 and 2019, respectively. In 2014, 2016, and 2019, 19.05%, 18.5%, and 12.01% of prescriptions, respectively, included two or more types of antibiotics. Injectable benzylpenicillin was prescribed concurrently with an oral form of either azithromycin, cefixime, amoxicillin or amoxicillin-clavulanic acid in 8%, 6.7% and 6.3% of the prescriptions in 2014, 2016 and 2019, respectively.

Conclusions: This outpatient consumption study based on claims does not demonstrate the same steady growth in antibiotic consumption observed in a previous national-level study on wholesale data in Iran. It is important to consider the potential impact of non-reimbursed or non-prescription use, as well as gray-market sales, which are not reflected in the claim data. The increased use of "watch" agents and other indicators of inappropriate antibiotic use in outpatient settings in this study should be taken seriously as they may be predictors of emergence of antimicrobial resistance.