Antibiotic prescribing trends among Iranian GPs during COVID-19: a longitudinal analysis of antimicrobial resistance risks

Background Antimicrobial resistance (AMR) is a major global health threat, exacerbated by inappropriate antibiotic use. The COVID-19 pandemic disrupted prescribing behaviors worldwide. No previous study has comprehensively analyzed longitudinal antibiotic prescribing trends among Iranian general practitioners (GPs) across pre-, during-, and post-COVID periods. This study addresses this gap by examining 1,431,004 prescriptions from 73 GPs in Iran. Methods We conducted a retrospective cohort analysis using anonymized data from Iran’s National Hospital Information System (HIS), focusing on a central public clinic (representing ~ 7% of national GP prescriptions). Three periods were analyzed: pre-COVID (January 2019–December 2019), COVID (January 2020–May 2021), and post-COVID (June 2021–May 2022). Descriptive and inferential statistics (chi-square, Poisson regression, ANOVA) were used; p < 0.05 was considered significant. Results Antibiotic prescriptions rose from 107,365 (pre-COVID) to 200,433 (COVID), an 87% increase (95% CI: 82–92%; p < 0.001). Post-COVID, prescribing remained elevated (208,040; 94% above baseline). The antibiotic-to-total drug ratio doubled during COVID (7.6% to 14.4%, p < 0.001). Azithromycin use surged by 120% (p < 0.001), mainly for respiratory infections per national guidelines. Injectable penicillin G prescriptions dropped by 100% post-pandemic. Prescriptions per GP fell during COVID but rebounded after. Conclusions The sustained rise in broad-spectrum antibiotic prescribing by Iranian GPs during and after COVID-19 is likely to accelerate AMR in Iran. Urgent, locally tailored stewardship programs, GP education, and expanded rapid diagnostic testing are needed to curb unnecessary prescribing and protect public health.