Improving antibiotic prescribing in LMICs: Insights from an outpatient clinic in Pakistan.

Background: Most human antibiotic use occurs in outpatient care and is a key driver of antimicrobial resistance (AMR). Although sales statistics suggest that high-income countries consume more antibiotics overall, the steepest growth is seen in low- and middle-income countries. Sales data - incomplete and non-transparent - reveal little about prescriptions to individual patients. Detailed, clinic-level data are essential for identifying targets for stewardship.We investigated antibiotic use and prescription appropriateness in an outpatient clinic in Pakistan - a country with some of the world's highest reported AMR prevalences. Methods: Patients attending an outpatient clinic near Lahore were interviewed immediately after their clinic visit and again one month later. Clinical data were collected through patient interviews, and antibiotic prescriptions were extracted from patient records. Results: Of the 983 participants, 398 (40.5 %) were prescribed antibiotics at the primary visits. Metronidazole was the single most common agent, followed by first-generation cephalosporins, fluoroquinolones, and amoxicillin-clavulanate; phenoxymethylpenicillin and amoxicillin were only minimally prescribed. One-third of prescriptions (33.2 %) were combination regimens, 90.2 % of which included metronidazole. Guideline-concordant first- or second-line choices accounted for only 23.4 % of prescriptions.Of all patients, 493 (50.2 %) attended a one-month control visit. Of these, 233 (47.3 %) also saw a practitioner during the visit; 73 of them (31.3 %) were prescribed antibiotics. Conclusions: Antibiotic prescribing was excessive and discordant with recommended first-line therapies, favouring broad-spectrum agents and combination treatments - practices likely influenced by the negligible time available per patient. Our findings highlight the need to adapt antimicrobial stewardship interventions to limited-resource contexts.