Long-term public antibiotic awareness campaign significantly reduced inappropriate antibiotic use in pediatric primary care settings.

Introduction: Serbia, like most countries in Southern Europe, has faced persistently high rates of antibiotic consumption. Previous analyses revealed that most antibiotics were prescribed inappropriately, mainly for influenza-like illnesses. Methods: The first short term media antibiotic awareness campaign (AAC) was held in 2011 and 2014 respectively. Shortly after, in November 2015, the Serbian Ministry of Health launched a nationwide public AAC. The campaign adapted the European Centre for Disease Prevention and Control (ECDC) and World Health Organization (WHO) communication platforms, methodological frameworks, and promotional materials under the motto "Careful with Antibiotics." Results: In addition to 423 media features, the campaign encompassed professional education, as well as the development of national guidelines and regulations. Educational activities targeting the public and healthcare professionals (2,119 pediatricians, 428 nurses, and 6,083 pharmacists) were guided by prior analyses of pediatric antibiotic consumption. Over 6 years, 8,750 brochures, 5,500 posters, and more than 3,000 other educational materials were distributed to 158 primary-care centers, pharmacies and in public places nationwide. Long-term campaign interventions resulted in a 32.8% reduction in the number of systemic antibiotic prescriptions per 1,000 children between 2015 and 2021. The most pronounced declines were observed among younger children (2-23 months and 2-11 years respectively) aligning with the main target group of the educational efforts, which focused on young children, including preschool and early school-aged children, who had the highest baseline prescribing rates. Excluding the common cold, the significant decreases were recorded for pharyngitis, tonsillitis, otitis media, and bronchitis, conditions that previously accounted for most inappropriate antibiotic use. From 2011, Serbia's maximum 61% reduction in pediatric antibiotic prescription rates ranks among the most pronounced in Europe. Despite a gradual shift toward broader-spectrum agents, the Access-group share remained around 60% throughout most of the observation period. Conclusion: Serbia's long-term, multisectoral stewardship campaign achieved one of the largest and most sustained declines in pediatric antibiotic consumption across Europe.