Oral antibiotics prescribing patterns and associated diarrhea risk: Public health implications.

BACKGROUND

Inappropriate antibiotic use contributes to antimicrobial resistance and adverse drug reactions (ADR), including antibiotic-associated diarrhea (AAD), underscoring the importance of WHO AWaRe recommendations for rational prescribing. Clinical evidence supports the use of specific probiotic strains to reduce AAD risk, with strain-specific recommendations that should be adapted to regional contexts.

OBJECTIVES

To assess oral antibiotic consumption in the Republic of North Macedonia (2011-2022), evaluate prescribing patterns according to the WHO AWaRe classification, identify antibiotics associated with a higher burden of AAD, and determine the availability of evidence-supported probiotics for AAD prevention.

DESIGN

Observational pharmaco-epidemiological study integrating antibiotic utilization data, pharmacovigilance signals, and evidence synthesis from systematic reviews and market analysis.

METHODS

Reimbursed oral antibiotic data (ATC J01) were obtained from the National Health Insurance Fund. Gastrointestinal ADR reports were extracted from EudraVigilance and FAERS. Diarrhea risk was estimated using SmPC frequency categories and normalized pharmacovigilance indicators. Systematic reviews and meta-analyses were used to identify probiotic strains with evidence for AAD prevention, and online pharmacy surveys assessed market availability.

RESULTS

Penicillins and cephalosporins predominated in antibiotic use. Amoxicillin/clavulanic acid, cefixime, and clindamycin ranked highest for diarrhea risk based on combined utilization and pharmacovigilance indicators. Saccharomyces boulardii and Lactobacillus rhamnosus GG showed the strongest evidence for AAD prevention. Considerable variability was observed in probiotic product composition and reporting across the market.

CONCLUSION

Findings highlight antibiotics with higher AAD-related public health burden and support antimicrobial stewardship strategies, including evidence-based probiotic co-administration.