The Ongoing Crisis of Antibiotic Overuse in European Primary Care

Antibiotic overuse remains a stubborn challenge across Europe, particularly in primary care where general practitioners (GPs, also known as family doctors) handle the majority of prescriptions. Despite decades of awareness campaigns and policy efforts, unnecessary prescribing continues to fuel antimicrobial resistance (AMR), a growing threat that claims tens of thousands of lives annually in the European Union and European Economic Area (EU/EEA). Recent research underscores that while consumption has stabilized or slightly declined in some nations, the continent as a whole is off track for ambitious 2030 reduction targets set by the European Council.

Primary care accounts for around 80-90% of antibiotic use in many countries, often for viral respiratory tract infections (RTIs) like colds and sore throats where antibiotics offer no benefit. This pattern persists due to a complex mix of clinical, patient-related, and systemic factors that hinder GPs from shifting to more prudent practices.

Current Landscape: Antibiotic Consumption Statistics

According to the latest European Centre for Disease Prevention and Control (ECDC) data for 2024, the EU/EEA population-weighted mean for total antibiotic consumption stood at 20.3 defined daily doses (DDDs) per 1,000 inhabitants per day, a 2% increase from the 2019 baseline. Community settings, dominated by GP prescriptions, contributed the bulk at approximately 18.8 DDDs, with wide variations: Greece and Turkey topped lists at over 30 DDDs, while Sweden and the Netherlands hovered below 12.

The EU's 2030 goals include slashing human antibiotic use by 20% from 2019 levels (to under 16 DDDs) and boosting 'Access' antibiotics (first-line, narrow-spectrum) to over 65% of total volume. Progress is uneven—Northern Europe leads with low consumption, but Southern and Eastern countries like Romania, Malta, and Greece lag, with broad-spectrum ratios exceeding 10:1 versus the EU average of 5.5:1. In the UK, primary care prescribing fell 2% year-on-year to 12.3 DDDs but remains above targets amid rising resistance.

Spotlight on Recent Research: Malta's Systematic Review as a Microcosm

A pivotal 2025 systematic review by Brian Fenech and Daniel Gaffiero from the University of Derby and Maltese health authorities analyzed over a dozen studies on GP and pharmacist behaviors in Malta, a high-consumption outlier at 22.9 DDDs total (20.9 community) in 2023. Malta exemplifies broader European challenges, where community prescribing drives 90%+ of use. The review, framed by socio-ecological and COM-B (Capability, Opportunity, Motivation-Behavior) models, pinpoints interconnected barriers preventing stewardship uptake.

While Malta-specific, findings echo surveys from Poland, Germany, the Netherlands, and UK, revealing universal hurdles in primary care. For instance, a 2026 Dutch-German border study confirmed clinical symptoms outweigh patient or guideline factors in prescribing decisions for upper RTIs.

Diagnostic Uncertainty: The Primary Clinical Hurdle

GPs often face ambiguous symptoms in short consultations (typically 10 minutes), leading to precautionary prescribing. Without rapid point-of-care tests (POCTs) like C-reactive protein (CRP) for RTIs, distinguishing bacterial from viral causes is guesswork. The Malta review notes beliefs that 'viral infections progress to bacterial' drive 50-90% unnecessary RTI scripts continent-wide.

In Southern Europe, limited POCT access exacerbates this; Northern countries like Sweden integrate CRP routinely, correlating with 50% lower use. Step-by-step: GPs assess symptoms (fever, duration), weigh risks (e.g., pneumonia), but uncertainty tips toward antibiotics to avoid complications.

Patient Pressure and Expectations

Patients frequently demand antibiotics, viewing them as quick fixes for viral ills. Surveys show 30-55% of GPs concede due to 'doctor shopping' fears or rapport maintenance. In Malta, 55% reported patient requests as key; Romania sees OTC sales filling gaps. Cultural norms—antibiotics as 'strong medicine'—persist despite campaigns.

Real-world example: During winter peaks, Italian and Spanish GPs report doubled pressure. Explanations help: Educate on viral self-resolution (7-10 days), symptom relief (paracetamol, hydration), and AMR risks (personal/family future infections untreatable).

Systemic and Time Constraints in Primary Care

Overburdened systems amplify issues. Short consults limit shared decision-making; private practice incentives favor volume. Malta highlights indemnity insurance pushing defensive prescribing—GPs fear lawsuits for withholding. Walk-in models in Greece/Romania bypass continuity.

• Limited IT for audits/feedback
• OTC loopholes (e.g., 'emergency' sales in 7+ countries)
• Weak pharmacist-GP collaboration

UK Pharmacy First shifted minor ailment scripts, reducing GP load by 14% for UTIs.

Knowledge Gaps and AMR Misconceptions

Many GPs undervalue personal AMR impact, seeing it as 'hospital problem'. Malta survey: 55% avoided amoxicillin due to perceived resistance (actual <5%). Older GPs less guideline-adherent; habits favor broad-spectrum (e.g., amoxicillin-clavulanate).

Training gaps: Stewardship education sporadic. Interventions like e-learning boost compliance 20-30%.

Defensive Practices and Commercial Influences

Fear of medico-legal repercussions—rare but potent—prompts 'just in case' scripts. Malta links to insurance premiums; similar in Italy. Pharma marketing sways private GPs. Habitual reliance on familiar drugs resists narrow-spectrum shifts.

Regional Variations: North vs South Europe

Sweden (10 DDDs): Strong stewardship, POCT ubiquity, patient education. Greece (38+): OTC norms, tourism pressures. UK: Peer comparison letters cut prescribing 3%; Netherlands: Guidelines + feedback halved RTI scripts.

Consequences: The AMR Public Health Toll

Overuse drives resistance: 35,000+ EU/EEA deaths yearly; projected rise without action. UK: 13% resistant infections surge despite 2% use drop. Economic: €4M/year Malta alone; Europe-wide billions in extra care.

Stakeholders: Patients face untreatable infections; hospitals overwhelmed; vets note One Health links (animal use spillover).

Effective Solutions: Proven Stewardship Strategies

Successes abound. Delayed prescribing (give script but advise wait) cuts use 40% without harm. UK letters: 3% drop. Social marketing in Malta: 10% reduction.

• POCT rollout (CRP, strep tests)
• Audits/feedback dashboards
• GP-pharmacist teams for minor ailments
• Patient materials explaining no-benefit scenarios
• Policy: OTC bans, sick-note reforms

For details on Malta findings, see the full systematic review. ECDC's latest report offers country data.

Photo by Viktor Forgacs - click ↓↓ on Unsplash

Future Outlook: Pathways to 2030 Targets

Europe must accelerate: Harmonized surveillance (EU-JAMRAI), POCT subsidies, digital tools. Northern models scalable South via funding. Projections: Without change, targets missed; with stewardship, 20% cut feasible. GPs, empowered by tools and support, lead the way—prudent prescribing saves lives long-term.

Optimism lies in successes: UK 1M fewer scripts; multi-country trials show multifaceted interventions yield 10-25% drops. Collaborative One Health approach—vet/human/policy alignment—charts the course.