Antibiotics | Implementing Electronic Prescription Policies to Promote Rational Antibiotic Use—Insights from Bulgaria

This study systematically evaluates the impact of mandatory electronic prescription (e-Rx) implementation in Bulgaria on community antibiotic sales, analyzes antibiotic use trends through WHO AWaRe classification, and provides empirical evidence on policy instruments and behavioral changes, offering novel insights for antibiotic stewardship and antimicrobial resistance (AMR) control.

 

Literature Overview
This article, 'Antibiotic Consumption at the Community Level: The Potential of a Single Health Policy Instrument to Assist Appropriate Use—Insights from Bulgaria', published in the journal Antibiotics, reviews and summarizes community antibiotic sales trends in Bulgaria during 2022 to Q1 2025, along with the phased implementation of the e-prescription policy. The study analyzes multidimensional challenges during e-Rx implementation using IQVIA sales data and policy documents from the National Health Information System, combined with participatory methods.

Background Knowledge
Antibiotic overuse remains a critical driver of global antimicrobial resistance (AMR). As an EU member state, Bulgaria exhibits contrasting antibiotic consumption patterns compared to Europe's overall downward trend, particularly showing increasing use in primary community healthcare. Despite multiple public education campaigns, outcomes have been limited. Consequently, Bulgaria launched a mandatory electronic prescription (e-Rx) policy in October 2023 to enhance prescription transparency, reduce duplicate dispensing and inappropriate use, and establish a data-tracking foundation for antibiotic stewardship. Using the classic health policy triangle model (Gill Walt framework), this research examines e-Rx implementation across four dimensions—policy content, process, context, and key stakeholders—and its impact on community antibiotic use. The study offers both practical and theoretical value for understanding digital health policies in antibiotic management.

 

 

Research Methods and Experiments
This study employs a retrospective observational design, integrating quantitative sales data analysis with policy document reviews. It utilizes antibiotic sales data from IQVIA Bulgaria and prescription records from the National Health Information System. The research period spans from 2022 to Q1 2025. Data are stratified by quarter, year, and WHO AWaRe classification. Feedback on e-Rx implementation from prescribing physicians, community pharmacists, and policymakers is collected through participatory methods.

Key Conclusions and Perspectives

• The mandatory electronic prescription (e-Rx) policy demonstrates early promise in reducing community antibiotic consumption in Bulgaria, with a 10% decrease (approximately 1.1 million packages) in total sales between 2022 and 2024
• AWaRe classification analysis reveals Access group antibiotics declined by 74%, Watch group by 55%, and Reserve group by 67%, indicating gradual alignment toward more rational prescribing practices
• While short-term statistical significance remains unachieved, the e-Rx system shows clear advantages in traceability, standardization, and preventing duplicate prescriptions, potentially supporting long-term rational use
• Initial implementation faced multiple challenges including inefficient prescription workflows, insufficient patient awareness, inconsistent drug coding, and system downtime risks, which improved through phased training and technical support
• The study emphasizes integrating e-Rx systems into broader One Health national action plans to achieve cross-sectoral governance and AMR containment

Research Significance and Prospects
This research provides empirical evidence for evaluating digital prescription policies in Bulgaria and other Eastern European countries. Future studies should combine diagnostic and microbiological data to assess e-Rx's long-term impact on AMR patterns. Integration of e-Rx with clinical decision support systems and antimicrobial use feedback mechanisms is recommended to enhance policy effectiveness. As a structural health policy instrument, electronic prescriptions could become pivotal in promoting rational drug use and reducing antimicrobial resistance transmission.

 

 

Conclusion
This study systematically evaluates changes in community antibiotic sales following e-Rx implementation in Bulgaria, analyzing policy pathways, execution challenges, and initial outcomes through the policy triangle model. While sales reductions lack statistical significance, consistent trends demonstrate positive effects in curbing antibiotic misuse. The research highlights that digital health policies must align with sociocultural contexts and be embedded within comprehensive antimicrobial stewardship and One Health governance frameworks. Bulgaria should accelerate cross-sectoral AMR action plans, strengthen prescription regulation, and enhance public education to achieve sustainable antimicrobial management and resistance control.

 

Desislava Vankova, Nadia Veleva, Petya Boncheva, Zhaneta Radkova, and Silviya Mihaylova. Antibiotic Consumption at the Community Level: The Potential of a Single Health Policy Instrument to Assist Appropriate Use—Insights from Bulgaria. Antibiotics.