Antibiotic prescription rates by infectious disease specialists during and after the COVID-19 pandemic in Iran: an interrupted time series analysis

The COVID-19 pandemic disrupted healthcare systems globally and altered antibiotic prescribing patterns. Iran has high antibiotic consumption and also experienced changes during the pandemic, but prescribing patterns after the pandemic are less clear. This study assessed antibiotic prescription rates by infectious disease specialists in Iran during and after the pandemic. Longitudinal data were accessed from the national electronic prescription database from September 2020 to September 2024. An interrupted time-series analysis was conducted to evaluate the effect of COVID-19 on antibiotic prescriptions. Prescriptions were expressed as monthly rates per 100,000 population. Six antibiotics frequently prescribed during COVID-19 were analyzed by World Health Organization Access, Watch and Reserve (AWaRe) categories. The 48-month study period was divided into 24 months during and 24 months after the pandemic. A total of 3,243,799 antibiotic prescriptions were analyzed. Seasonal variation was significant only for Watch antibiotics, with higher prescribing in colder months. Reserve antibiotics prescription rates showed a positive long-term trend. The end of the pandemic (September 2022) was associated with increased prescribing across all three AWaRe categories. Among individual agents, we identified long-term decreasing trends for azithromycin and doxycycline but increasing for all others. Reserve antibiotics prescription increased during the pandemic, and this trend continued post-pandemic. Colder seasons saw higher prescription rates for ceftriaxone, co-amoxiclav, and amoxicillin, but lower for doxycycline. After the pandemic, doxycycline prescribing increased, whereas it declined for ceftriaxone, co-amoxiclav, and amoxicillin. Overall antibiotic prescribing increased shortly after acute phase of the COVID-19 pandemic was declared to be over, and the Reserve antibiotic increase has persisted, while patterns varied by drug class. These findings highlight the need for targeted stewardship to optimize antibiotic use in the post-pandemic period.