Trends in antifungal use characteristics in primary care in Spain, 2019 to 2024: a nationwide study

BACKGROUND: Antifungal resistance is a growing global concern in the context of antimicrobial resistance. Although primary care is the main setting for managing superficial fungal infections, national evidence on antifungal consumption in Spain remains limited. This study analyzes the characteristics of antifungal use in Spanish primary care. METHODS: A retrospective observational study was conducted using data from the Primary Care Clinical Database of the Spanish Ministry of Health. The study included individuals assigned to primary care with at least one antifungal dispensation per year between 2019-2024. Consumption was measured as Defined Daily Doses (DDD) per 1,000 inhabitants per day (DHD), following the WHO ATC/DDD methodology. Trends were analyzed by sex, age, municipality size, income level, country of birth, and employment status, using annual percentage change (APC) estimated through joinpoint regression models. RESULTS: From 2019 to 2024, antifungal DHD in Spanish primary care increased significantly overall (APC: 8.4% 6.2-10.5; p<0.001 for both sexes); the number of individuals with ≥1 dispensation declined in 2020 and then stabilized (APC: 5.3% 2.0-8.6; p=0.004). Use was consistently higher in women, especially among pensioners (with a widening gap after 2020), unemployed individuals, those with very low income, and those born in Spain; D01A led consumption. Significant APC values were observed across all age, country of birth, employment, municipality size, and income strata, with the largest increases in active workers, small and medium municipalities, males <15 years, and foreign-born. CONCLUSIONS: Systematic monitoring of antifungal consumption in primary care is key to anticipating shifts in epidemiology and guiding antifungal stewardship. This study provides the first nationwide assessment of outpatient antifungal use in Spain from 2019 to 2024, offering critical evidence for public health planning and antimicrobial resistance mitigation.