Determinants of antibiotics misuse and overuse in high-risk countries in the European region: a multidisciplinary Delphi study.

PURPOSE: Antimicrobial-resistant (AMR) related deaths were predicted to have the greatest impact in Türkiye, Greece, Italy, and Portugal by 2050. Outpatient misuse and overuse of antibiotics are major contributors. We aimed to identify the underlying causes of inappropriate antibiotic use in outpatient settings and to develop context-specific, expert-driven solutions.

METHODS

A two-round e-Delphi process was used among experts, including primary care physicians, infectious disease specialists, ENT doctors, emergency medicine physicians, public health professionals, pharmacists, and policymakers working in outpatient settings. A 7-point Likert scale assessed 47 potential causes and 25 proposed solutions. Consensus was defined using interquartile range, median, and percent agreement. Expert agreement was assessed using Kendall's W.

RESULTS

109 experts from 52 cities in Greece, Italy, Portugal, and Türkiye participated, with a response rate of 88% (109/124) in both rounds. Consensus was reached on 6 (12.76%) causes and 21 solutions (84%). Patient-related factors, such as low health literacy, limited awareness of AMR, and expectations of rapid recovery, emerged as major contributors. System-level shortcomings, including weak regulatory enforcement and underfunded stewardship efforts, were also identified. High-priority solutions included stricter regulation of non-prescription antibiotic sales, updated national prescribing guidelines, and integration of clinical decision-support tools.

CONCLUSION

Addressing AMR in high-risk countries requires both systemic reform and individual behaviour change. While common challenges exist, national differences require tailored strategies, such as healthcare accessibility, appointment length, and physician-patient communication. Sharing best practices is critical, but context-sensitive strategies are essential to effectively address this global health threat.