Antibiotic prescribing appropriateness by diagnosis in village clinics in rural Shandong China from 2021 to 2023

Inappropriate antibiotic prescribing in primary care remains a major and modifiable driver of antimicrobial resistance, particularly in rural China. This study aimed to analyze trends, patterns and appropriateness of antibiotic prescribing in village clinics. We collected and analyzed monthly data from 95 clinics across six townships in Shandong Province (April 2021–September 2023). Cross-sectional and temporal trend analyses were used to assess antibiotic prescribing rate (APR) and prescribing appropriateness (inappropriate, potentially appropriate, and appropriate). Antibiotic classes were categorized using the World Health Organization Anatomical Therapeutic Chemical and AWaRe classifications. Further, seven common infectious conditions were evaluated with quality indicators from the European Surveillance of Antimicrobial Consumption project and Chinese guidelines. Among 334,042 prescriptions, 20% included antibiotics, of which 56.3% were deemed inappropriate. Over 30 months, the overall APR decreased from 20.4 to 15.7%, while the proportion of prescriptions considered inappropriate remained high and variable. For acute upper respiratory infection (AURI), the APR was 49.1%, exceeding the acceptable threshold. For cystitis/other urinary infection, 68% of prescribed antibiotics were not guideline-concordant and 63.2% belonged to Watch-group. Antibiotic prescribing decreased with increasing age, and substantial variation in inappropriate prescribing was observed across townships. Overall reductions in antibiotic prescribing have not necessarily led to improved prescribing appropriateness, underscoring the need to shift toward targeted, condition-specific antimicrobial stewardship and to strengthen clinical capacity in village clinics.