Antibiotic consumption data for Pakistan were retrieved from the comprehensive IQVIA MIDAS database, which consolidates pharmaceutical sales data, as reported in a recent study by Klein et al [9]. The data covered the period from 2016 to 2023 and included retail pharmacy sales, capturing estimated use trends for antibiotics across the country. The sales data, recorded in estimated grams of active ingredients, were systematically converted into DDD using the Anatomical Therapeutic Chemical classification system and methodologies recommended by the WHO Collaborating Centre for Drug Statistics Methodology. The DDD conversion accounted for variations in the route of administration (oral and parenteral) for each molecule.

Antibiotic molecules were classified according to the Anatomical Therapeutic Chemical or DDD Index 2026 [23]. For combination drugs, components were broken into their individual active molecules, and consumption was attributed to the main antibiotic molecule based on its 1 daily dose. Antibiotic consumption rates were calculated as DID, enabling cross-year and cross-population comparison. Population data for Pakistan were sourced from the World Bank and national government statistics.

The study analyzed 13 antibiotic classes, including macrolides, cephalosporins, fluoroquinolones, carbapenems, tetracyclines, and others. Variables included annual DIDs for each antibiotic class, percentage changes from 2016 to 2023, and projections (2024‐2028).

Antibiotic classes were categorized as increasing, decreasing, or stable based on percentage changes in DIDs. Classes with changes >10% were considered increasing, <−10% as decreasing, and between −10% to 10% as stable. This operational threshold was adopted by the authors as a pragmatic balance between clinical relevance and statistical sensitivity. Data cleaning, statistical analyses, and data visualization were performed using R software (version 4.3.2; R Foundation for Statistical Computing; Posit) and Microsoft Excel. For each antibiotic class, linear regression models were applied to evaluate trends from 2016 to 2023. Slope coefficients indicated the rate of annual change. Future antibiotic use (2024‐2028) was projected using the coefficients from linear regression models. The projections assumed a consistent linear trend in use, with results expressed in DIDs. A +10% or −10% SE margin was incorporated to reflect potential variability due to external factors such as policy changes and AMR management programs. Line graphs with distinct markers were used to show historical trends and projections. Bar charts were used to compare percentage changes, emphasizing significant trends.

Ethics approval for the study was obtained from the Research Ethics Committee of the Department of Pharmacy Practice, Faculty of Pharmacy, Bahauddin Zakariya University, Multan (BZU-FOPDPP-2456). Participant consent was not required as the study was based on aggregated sales data and did not involve human participants or identifiable personal information. All data were aggregated and anonymized, ensuring compliance with ethical standards for research.

This study analyzed antibiotic consumption trends in Pakistan from 2016 to 2023, with projections through 2028, highlighting critical insights into patterns of use and their implications for AMR and ASP. The findings align with global trends but also underscore the unique challenges faced by LMICs, such as Pakistan, in managing antibiotic consumption [24]. The total antibiotic consumption in Pakistan was measured at 12.88 billion DDDs, reflecting a 17% increase since 2016. This trend parallels global findings, where antibiotic consumption rose by 20.9% during a similar period, although the growth rate was slower compared to the 35.5% increase observed from 2008 to 2015 [25]. However, the COVID-19 pandemic significantly impacted global antibiotic use, leading to temporary reductions, particularly in high-income countries, where outpatient antibiotic use is dominant [9,26-28]. In Pakistan, as in other LMICs, a rebound was observed postpandemic, with consumption exceeding prepandemic levels by 2023, driven by unregulated access and increased reliance on broad-spectrum antibiotics [28,29].

Broad-spectrum penicillins and fluoroquinolones were the most consumed antibiotic classes in Pakistan, accounting for 37.7 DID each in 2023. This heavy reliance on broad-spectrum antibiotics is consistent with trends observed in other LMICs such as India and Bangladesh, where similar patterns have been linked to limited diagnostic capacity and the widespread availability of over-the-counter antibiotics [9,30,31]. In contrast, reserve antibiotics, including carbapenems, oxazolidinones, and glycylcycline, showed dramatic increases in use. These trends highlight the growing demand for last-line antibiotics in critical care settings, reflecting rising resistance to first-line therapies [13,32]. Several factors contribute to the accelerated rise in antibiotic use in developing countries, including environmental, socioeconomic, and cultural determinants, with economic growth appearing to be the most influential driver in lower-income settings [9]. During the COVID-19 pandemic, antibiotic sales also increased considerably due to empirical use in the setting of diagnostic uncertainty and concerns about bacterial coinfections [33]. The projected escalation in the use of macrolides and cephalosporins (2.25 DID to 5.78 DID and 2.86 DID to 4.75 DID, respectively) reflects an increasing dependence on broad-spectrum antibiotics. This growing dependence on Watch group antibiotics deviates from the WHO’s recommended target of maintaining at least 60% of total consumption within the Access category, potentially accelerating the selection of multidrug-resistant pathogens [33].

Economic growth, urbanization, and health care infrastructure gaps are significant drivers of antibiotic overuse in Pakistan. As seen in other middle-income countries, rising gross domestic product and rapid urbanization often correlate with increased antibiotic consumption [34]. However, this growth comes at the expense of proper regulatory oversight, leading to widespread misuse. In Pakistan, the lack of robust ASPs and weak enforcement of prescription-only antibiotic policies exacerbate the problem [6,12,35]. The WHO’s Access, Watch, and Reserve (AWaRe) classification system has been pivotal in promoting rational antibiotic use globally [36]. However, in Pakistan, as in many LMICs, the Watch and Reserve categories dominate consumption, reflecting poor alignment with the AWaRe recommendations [25]. In contrast, high-income countries have successfully reduced the use of high-risk antibiotics such as fluoroquinolones through stringent regulatory warnings and public awareness campaigns [9,37]. The rising consumption of fluoroquinolones and reserve antibiotics in Pakistan highlights the urgent need for similar regulatory interventions [17]. This study underscores the critical need for comprehensive ASPs tailored to the local context [38]. Strengthening regulatory frameworks, enhancing diagnostic capacity, and promoting public awareness are essential to curbing antibiotic misuse [39,40]. Investments in preventive measures, such as improved water, sanitation, and hygiene infrastructure, along with robust vaccination programs, could also significantly reduce the burden of infectious diseases and, consequently, the need for antibiotics in Pakistan [41,42].

The major findings of the study are as follows:

While the data in this report provide valuable insights, they have inherent limitations. First, the IQVIA MIDAS data primarily capture retail pharmacy sales and do not include hospital procurement or inpatient use, which may lead to underrepresentation of antibiotics predominantly used in hospital settings (eg, carbapenems and glycopeptides) or for severe infections. No distinction was made between prescription-only and over-the-counter antibiotics, as consumption estimates were derived from aggregated sales data. Second, the dataset lacks indication-level, health care setting–level, and prescriber-level information, preventing analysis of the clinical context or appropriateness of antibiotic use. Third, the projections for 2024 to 2028 assume linear trends, which may not account for unforeseen policy changes, health care developments, or epidemics. The study does not address regional variations within Pakistan, which could provide additional insights into localized drivers of antibiotic use. Additionally, the study focused exclusively on human antibiotic consumption, excluding veterinary and agricultural use, which are critical components of a One Health approach to AMR. Future research should integrate these dimensions to provide a more comprehensive understanding of antibiotic use trends.

The findings of this study highlight the urgent need for targeted interventions to optimize antibiotic use in Pakistan. The high reliance on broad-spectrum and reserve antibiotics, coupled with the rapid rebound in consumption after the pandemic, underscores the importance of strengthening ASPs and regulatory oversight. By aligning national policies with global frameworks following UNGA recommendations, Pakistan can mitigate the risks of AMR and ensure sustainable antibiotic use.