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Cited by 68Antibiotic Use and ResistancePharmaceutical Practices and Patient OutcomesHealthcare cost, quality, practices

Global trends in inappropriate use of antibiotics, 2000–2021: scoping review and prevalence estimates

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Mulchandani, Ranya, Tiseo, Katie, Nandi, Arindam, Klein, Eili, Gandra, Sumanth, Laxminarayan, Ramanan, Van Boeckel, Thomas·2025·BMJ Public Health
DOI 10.1136/bmjph-2024-002411PMC PMC12121568
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Abstract

Introduction: Inappropriate antibiotic use is a major driver of antimicrobial resistance. However, the scope of literature and its prevalence across world regions remain largely unknown, as do the most common indicators and study designs used. In this study, we summarised the current literature on inappropriate use of antibiotics by world regions. We also provided the first global estimates of the overall amount of antibiotics that are potentially used inappropriately each year. Methods: We considered both patient and provider-mediated inappropriate antibiotic use. We reviewed 412 studies published between 2000 and 2021 and used beta regression and marginal contrasts to compare prevalence of inappropriate use by study design, indicator, world region, and national income level. Country-level sales of antibiotics from 2022 were combined with inappropriate antibiotic use estimates derived from two study designs (clinical audits and patient interviews) and one indicator (lack of indication) to estimate the amount of antibiotics inappropriately used globally. Results: Clinical audits (50.1%, 208/412) and ‘non-prescription’ use (37.1%, 153/412) were the most common study design and indicator, respectively, used to estimate inappropriate antibiotic use. Inappropriate antibiotic use prevalence was ~6% higher in low-income and middle-income than in high-income countries. However, this difference disappeared after accounting for a proxy of access to care: physicians per capita. Globally, based on clinical audits, patient interviews and lack of indication, the estimated proportion of inappropriate antibiotic use was 29.5%, 36.5% and 30.8%, respectively, with an average of ~30% (~13 000 000 kg) the equivalent of the annual antibiotic consumption in China. Conclusions: Inappropriate antibiotic use is highly prevalent across all countries regardless of national income level, with a third of global antibiotic consumption potentially due to unnecessary prescription (‘lack of indication’). Antibiotic stewardship efforts and defining internationally standardised indicators are needed to track progress in reducing the occurrence of inappropriate antibiotic use where necessary, as well as identifying gaps in access to care.

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  • Decisions based solely on clinical observation or fever risk increase inappropriate antibiotic use.

    “Decisions based solely on clinical observation or fever risk increase inappropriate antibiotic use (25, 46).”

    From Understanding antibiotic decision-making for bovine respiratory disease: a survey of UK farm veterinarians (2026) · cites this paper as [46]

    The Discussion (page unavailable) says lack or underuse of diagnostic services may contribute to inappropriate non-prescription antibiotic use. That lends limited support to the concern about decisions made without diagnostics, but the paper does not identify decisions based solely on clinical observation or fever risk as causes, and its statement is hedged rather than definitive. (LLM, conf=0.78)

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Authors
Mulchandani, R., Tiseo, K., Nandi, A., Klein, E., Gandra, S., Laxminarayan, R., & Van Boeckel, T.
Affiliations
  • ETH Zurich (CH)
  • Population Council (US)
  • Johns Hopkins University (US)
  • Washington University in St. Louis (US)
  • Princeton University (US)
  • Health Geography and Policy Group, ETH Zurich, Zurich, Switzerland
ORCID
Venue
BMJ Public Health
Publisher
BMJ
Published
2025-01
Volume
3
Issue
1
Pages
e002411
ISSN
2753-4294 (ISSN-L)
DOI
10.1136/bmjph-2024-002411
PMC
PMC12121568
OpenAlex
W4410762366
Cited by
68
References
3
Citations by year
2026: 50 · 2025: 18
FWCI
45.44
Type
journal article
Language
en
Open access
Licence
Locations
  • BMJ Public Health (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
  • Zurich Open Repository and Archive (University of Zurich) (submittedVersion, cc-by)
  • Zurich Open Repository and Archive (University of Zurich)
Funders
  • European Union (874850)
  • Bill & Melinda Gates Foundation (INV-055356)
  • National Science Foundation (CCF1918628)
  • The Swiss National Science Foundation Eccellenza Fellowship (181248)
  • Branco Weiss Foundation (n/a)
Topics
  • Life Sciences › Immunology and Microbiology › Applied Microbiology and Biotechnology › Antibiotic Use and Resistance
  • Health Sciences › Medicine › Geriatrics and Gerontology › Pharmaceutical Practices and Patient Outcomes
  • Health Sciences › Health Professions › General Health Professions › Healthcare cost, quality, practices
Keywords
inappropriate antibiotic use, antimicrobial resistance, global prevalence, antibiotic sales, clinical audit, patient interviews, non-prescription antibiotic use, access to physicians, antibiotic stewardship

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