A cross-sectional evaluation of rational antibiotic prescribing in Kabul based on WHO indicators

Inappropriate antibiotic use is a major driver of antimicrobial resistance (AMR), particularly in low- and middle-income countries. To improve rational prescribing, the World Health Organization (WHO) developed core prescribing indicators and the AWaRe antibiotic classification. Evidence from Afghanistan remains scarce, especially in outpatient settings. This cross-sectional prescription audit was conducted from June to December 2024 in six public and private hospitals in Kabul. Prescriptions were sampled from outpatient departments of internal medicine, pediatrics, surgery, and ENT. Of 623 prescriptions screened, 306 (49.1%) contained at least one antibiotic and were analyzed using WHO prescribing indicators and the AWaRe classification. Data were processed with SPSS v25. A total of 374 antibiotics were prescribed, with an average of 1.5 per prescription. The most common agents were ceftriaxone (19.9%), metronidazole (16.0%), ciprofloxacin (12.4%), and amoxicillin (11.4%). Generic prescribing accounted for 63.3%, while 42.7% of prescriptions included parenteral antibiotics. All antibiotics were from the National Essential Medicines List. AWaRe analysis showed Watch antibiotics (58.6%) predominated, while Access antibiotics (41.4%) were underused; no Reserve antibiotics were prescribed. No culture and sensitivity testing supported prescribing. Antibiotic prescribing in Kabul outpatient settings substantially exceeded WHO standards, with high reliance on broad-spectrum Watch-group agents, injectables, and non-generic formulations. These findings underscore the urgent need for Antimicrobial Stewardship Programs, prescriber training, and improved diagnostic capacity to ensure rational antibiotic use and contain AMR in Afghanistan.