Antibiotic Prescribing and Antimicrobial Resistance in Outpatient Facilities in Missan Province, Iraq: A Cross-Sectional Study

Abstract

Iraqi evidence linking antibiotic prescribing indicators to resistance data is scarce. This cross-sectional study evaluated outpatient prescribing using the WHO/INRUD core indicators and characterised antimicrobial resistance in Missan Province, Iraq. Twelve facilities were studied in 2023: four each of primary healthcare centres, hospital outpatient departments and private clinics. 1,847 consecutive prescriptions from January–June 2023 were reviewed against these indicators and the WHO AWaRe classification; during July–December 2023, 380 specimens from prospectively recruited adults were cultured and tested by disk diffusion per CLSI M100, with extended-spectrum beta-lactamase (ESBL) production and methicillin resistance confirmed phenotypically. Analyses used ANOVA and chi-square tests (P < 0.05). All five indicators fell outside WHO reference values: antibiotics were prescribed at 68.4% of encounters (95% CI 66.3–70.5%; reference 30%) and injections at 24.2% (reference 10%), with 3.2 ± 0.9 medicines per encounter; 40.7% of medicines were generic and 66.4% of prescriptions conformed to the national essential medicines list. Private clinics performed worst and primary healthcare centres best on every indicator, antibiotic prescribing differing by 10.4 percentage points. At least 36.5% of antibiotics were Watch group and none Reserve. 284 specimens (74.7%) were culture-positive: Escherichia coli 90 (31.7%), Staphylococcus aureus 53 (18.7%) and Klebsiella pneumoniae 41 (14.4%). ESBL production occurred in 34.4% of E. coli and 46.3% of K. pneumoniae, and methicillin resistance in 31.1% of S. aureus. Prescribing greatly exceeded WHO reference values, most markedly in private clinics, alongside substantial resistance among common pathogens; stewardship across public and private outpatient care with sustained surveillance is required.