Trends in Outpatient Antibiotic Prescriptions Issued in Croatian Primary Healthcare, 2015–2024

OBJECTIVES: Outpatient antibiotic prescribing is a major driver of antimicrobial resistance, yet detailed long-term analyses of prescribing patterns in Croatia remain limited. This study aimed to analyze trends in outpatient antibiotic prescriptions issued in Croatian primary healthcare from 2015 to 2024, stratified by antibiotic class, substance, and the WHO AWaRe classification. METHODS: A retrospective analysis of nationwide data on antibiotic prescriptions issued in primary care outpatient settings was conducted using the data from the Central Health Information System of the Republic of Croatia. All prescriptions for ATC group J01 antibiotics issued between 1 January 2015 and 31 December 2024 were included. The primary outcome was the annual number of issued outpatient antibiotic prescriptions, described overall and by substance. Annual counts were additionally expressed as a percentage of the 2015 baseline (index year = 100%) to enable the comparison across substances with different prescribing volumes. The prescriptions were classified according to the WHO AWaRe framework. RESULTS: A total of 31,048,414 outpatient antibiotic prescriptions were issued between 2015 and 2024. Overall prescribing declined by 5.6% from 2015 to 2019, followed by a marked decrease of 21.0% in 2020, and subsequently rebounded to 3,338,235 prescriptions by 2024, a number virtually identical to pre-pandemic levels. Co-amoxiclav and azithromycin together accounted for 49.5% of all prescriptions. By 2024, prescribing third-generation cephalosporins increased by 281.9% compared to the 2015 levels, while prescribing amoxicillin decreased by 43.6% over the same period. The proportion of Access antibiotics declined from 64.7% in 2015 to 57.9% in 2024. CONCLUSIONS: The main challenge for antimicrobial stewardship in Croatia lies not only in overall prescribing volume but in prescribing composition. Targeted interventions are needed to reduce reliance on broad-spectrum agents and promote the use of narrower-spectrum first-line alternatives.