Age-Specific Trends in the Prescription of Systemic Antibiotics, 2010–2024

The cautious and targeted deployment of antibiotics reduces the development of resistance. Compared with the rest of Europe, Germany’s use of antibiotics in the outpatient setting is low (1). Between 2010 and 2018 the volume of prescriptions declined gradually (2). Strong declines in prescription numbers were seen from 2010 to 2019, especially in children <2 years of age (−46 %) and aged 2–5 years (−53%), indicating an increasingly cautious use of antibiotics (3). Europe-wide, the lowest consumption figures to date were observed as a result of the COVID-19 pandemic in 2020 and 2021, and so was a reduced circulation of respiratory pathogens as a result of containment measures (1). Our study aimed to update prescribing trends in Germany for systemic antibiotics by age group between 2010 and 2024.

Methods

Our study was based on outpatient drug prescription data from all statutory health insurers. The methods including the classification of groups of active ingredients were published in this journal earlier (2). The annual prescription rate of systemic antibiotics was calculated as the number of dispensed antibiotics per 1000 insurance scheme members overall and by age group (2). The annual number of insurance scheme members comes from the KM6 statistic of Germany’s Federal Ministry of Health (www.bundesgesundheitsministerium.de/themen/krankenversicherung/zahlen-und-fakten-zur-krankenversicherung/mitglieder-und-versicherte.html). The absolute size of age groups in the age segment 0–14 years was estimated on the basis of their relative distribution in the national population.

Results

Prescription rates across all age groups underwent a continuous decline between 2010 and 2019, from 559 to 414 prescriptions per 1000 insurance scheme members (−26%), and by substantial falls in 2020 (305/1000, −26% to 2019) and 2021 (277/1000, −33% to 2019) (Figure 1). The relative reductions in prescription rates in 2020 and 2021 compared with 2019 were most strongly pronounced in age groups 2–5 years (2020, 343/1000: –48%; 2021, 322/1000: –51%) and 6–9 years (225/1000: –43%; 140/1000: −64%).

Figure 1

Age-group-specific prescription rates of systemic antibiotics per 1000 insurance members in 2010–2024. Age groups are reported in years.

2023 (418/1000) and 2024 (426/1000) showed a rise in prescriptions across age groups, back to a level comparable with 2019 (Figure 1). The age groups 2–5, 15–64, and ≥65 years approached the prescription levels of 2019. In those aged 0–1 years, however, the prescription rate fell by about 20%. Relevant increases were observed for 6–9 year olds (2023 versus 2019: +33%; 2024: +30%) and 10–14 year olds (2023: +9%; 2024: +44%, Figure 1).

The antibiotic classes basic penicillins, cephalosporins, and macrolides/lincosamides showed the highest prescription rates and the pattern of their trend closely followed the overall prescription rate (Figure 2). The use of fluoroquinolones fell substantially up to 2021 and has remained low since (22–26/1000). Differences in the prescription spectrum between 2019 and 2024 were seen especially as regards the more pronounced dominance of basic penicillins (2019: 92/1000; 2024: 104/1000), a change in the ranking of cephalosporins (2019: 82/1000; 2024: 71/1000) and macrolides/lincosamides (2019: 74/1000; 2024: 85/1000), and a greater importance of aminopenicillin combinations/staphylococcal penicillins (2019: 36/1000; 2024: 64/1000, Figure 2); in 2024, 93% of these were amoxicillin+beta-lactamase inhibitors (data not shown).

Figure 2

Annual nationwide ingredient-specific prescription rates of systemic antibiotics per 1000 insurance scheme members in 2010–2024

Discussion

After continuous declines in prescription rates until 2019 and substantial pandemic-related reductions—presumably primarily because of a reduced circulation of respiratory pathogens—prescribing rates were marginally higher in 2024 than in 2019 (+3%). With substantial declines in antibiotic use in 2020/2021 and an increase in the following years, Germany follows the European trend but overall its use was relatively low (1). In 2023, higher outpatient antibiotic prescription rates were observed in 23 countries and lower rates in four countries (1).

Higher prescription rates in 2023/2024 affected exclusively the age group 6–14 years. In view of the continuous reduction in the use of antibiotics in this age segment between 2010 and 2019, this probably reflects a temporary change in age-specific disease trends. Children aged 6–14 years in 2024 were 2–10 years old in 2020/2021 and thus the age groups with the most pronounced prescription declines in the pandemic years, presumably in particular because of a substantial decline in the circulation of respiratory pathogens. A pronounced rise in infections with sometimes severe disease courses especially in children was observed in the winter seasons 2022/2023 and 2023/2024 for disease caused by Group A streptococci (4). Furthermore in 2023–2024 an accumulation of mycoplasma infections was seen in the normally affected school children and adolescents as well as in all other age groups—on a scale hitherto unobserved (5). Additionally, in 2024 a substantial rise in cases of pertussis in age groups 0–19 years was observed, according to notifications under the German Infection Protection Act (www.survstat.rki.de/). Further research regarding this trend as a result of the COVID-19 pandemic is required, as is close observation of future age-specific antibiotic prescribing trends. The same applies to the great increase in prescription rates of aminopenicillin combinations/staphylococcal penicillins in 2021–2024. It is conceivable that supply bottlenecks for penicillin V and amoxicillin and their substitution with amoxicillin in combination with beta-lactamase inhibitors contributed to this development. Such supply bottlenecks since the autumn of 2022 applied in particular to dosage forms or preparations used in children (www.bfarm.de/DE/Arzneimittel/Arzneimittelinformationen/Lieferengpaesse).

The declining rate of fluoroquinolone prescriptions owing to warnings of severe adverse effects should be emphasized as a positive development (2). In spite of the growing importance of basic penicillins, the proportion of these substances in Germany is low compared with the Scandinavian countries (1) and thus points at savings potentials for broader-spectrum antibiotics.

Jakob Holstiege, Roland Tillmann, Patrick M. Meyer Sauteur, Milan Hartmann, Kerstin Klimke, Manas K. Akmatov, Claudia Kohring, Doreen Müller, Maike Below

Zentralinstitut für die kassenärztliche Versorgung, Berlin (Holstiege, Hartmann, Klimke, Akmatov, Kohring, Müller, Below) [e-mail]

Praxis für Kinder- und Jugendmedizin, Bielefeld (Tillmann)

Infektiologie und Spitalhygiene, Universitäts-Kinderspital und Forschungszentrum für das Kind, Zürich, Schweiz (Meyer Sauteur)

Conflict of interest statement
RT is a spokesperson and board member of Ärztenetz Bielefeld [Bielefeld Doctors‘ Network], ABS-Netzwerk Bielefeld [Antibiotic Stewardship Network Bielefeld], ABS-Netzwerk Westfalen-Lippe [Antibiotic Stewardship Network Westphalia-Lippe], and the AG Antibiotic Stewardship ambulante Pädiatrie [working group Antibiotic Stewardship in Outpatient Pediatrics] (BVKJ, DGPI). He received honoraria for training events from BVKJ, DGPI, BMG, DSAI.

The remaining authors declare that no conflict of interest exists.

Manuscript received 17 June 2025, revised version accepted on 31 July 2025

Translated from the original German by Birte Twisselmann PhD.

Cite this as:
Holstiege J, Tillmann R, Meyer Sauteur PM, Hartmann M, Klimke K, Akmatov MK, Kohring C, Müller D, Below M: Age-specific trends in the prescription of systemic antibiotics, 2010–2024. Dtsch Arztebl Int 2026; 123: 59–60. DOI: 10.3238/arztebl.m2025.0146

References

1. European Centre for Disease Prevention and Control. Antimicrobial consumption in the EU/EEA (ESAC-Net) – Annual Epidemiological Report 2023. Stockholm: ECDC; 2024. Stockholm, November 2024.

2. Holstiege J, Schulz M, Akmatov MK, Kern WV, Steffen A, Bätzing J: The decline in outpatient antibiotic use—an analysis of nationwide prescription data from 2010 to 2018. Dtsch Arztebl Int 2020; 117: 679–86

3. Holstiege J, Bätzing J, Akmatov MK, et al.: Rückgang der ambulanten Antibiotikaverordnungen bei Kindern und Jugendlichen in Deutschland 2010–2019. Regionale Entwicklung in den deutschen KV-Regionen. Monatsschrift Kinderheilkunde 2022; 170: 392–402

4. Mutevelli J, Singer R, Dörre A, et al.: Epidemiologie der Gruppe-A-Streptokokken – Deutschland 2023–2024. Epid Bull 2024; 12: 3–9 .

5. Meyer Sauteur PM, Beeton ML, ESGMAC Mycoplasma pneumoniae Surveillance (MAPS) study group: Global spatiotemporal dynamics of Mycoplasma pneumoniae re-emergence after COVID-19 pandemic restrictions: An epidemiological and transmission modelling study. Lancet Microbe 2025; 6: 101019