Antibiotic prescribing patterns among outpatients using the who aware classification in health facilities in Tete and Sofala, Mozambique: a cross-sectional study

Abstract Background Antibiotic overuse is a major driver of antimicrobial resistance (AMR), a global public health concern, particularly in sub-Saharan Africa where a high burden of infectious diseases and predominantly empirical diagnosis contribute to inappropriate use. The World Health Organization (WHO) AWaRe (Access, Watch, Reserve) classification supports rational prescribing by enabling the monitoring of antibiotic use patterns. However, data on AWaRe-based antibiotic use in Mozambique, especially in outpatient settings, remain limited. This study aimed to evaluate antibiotic prescribing patterns among outpatients using the WHO AWaRe classification in health facilities in Tete and Sofala, Mozambique. Methods Secondary data from outpatient prescriptions at two health facilities in Mozambique, Health Center No. 3 in Tete Province and Caia District Hospital in Sofala Province, were analyzed. Patients of all ages attended between November 2025 and January 2026 with at least one antibiotic prescribed were included (n = 387). Antibiotic prescribing patterns were evaluated using the WHO AWaRe classification and WHO/INRUD prescribing indicators. Results Among the 387 prescriptions included, a total of 435 antibiotics were prescribed. Most patients received one antibiotic (89.4%), while 6.7% received two and 3.9% received three or more. Cotrimoxazole was the most frequently prescribed antibiotic (42.8%), followed by amoxicillin (20.2%) and metronidazole (11.3%). According to the AWaRe classification, 85.7% of antibiotics belonged to the Access group and 12.4% to the Watch group, with no prescriptions from the Reserve group. All antibiotics were prescribed by their generic names and were included in the essential medicines list. Total antibiotic consumption was 121.91 DDD/1,000 inhabitants/day, with amoxicillin (50.22) and ciprofloxacin (23.59) showing the highest utilization rates. Conclusion Antibiotic prescribing among outpatients in this study met the WHO target for the Access group, indicating overall alignment with recommended practices. However, the use of Watch antibiotics, particularly macrolides, highlights the need to strengthen antimicrobial stewardship efforts to ensure more rational use. The implementation of WHO recommendations, including the AWaRe classification, together with improved adherence to clinical guidelines and targeted training of healthcare providers, is essential to optimize prescribing practices in outpatient settings.