Antibiotic Consumption at the Community Level: The Potential of a Single Health Policy Instrument to Assist Appropriate Use-Insights from Bulgaria.

Background: Antimicrobial resistance (AMR) is accelerated by inappropriate antibiotic use in community settings. While most EU countries have achieved a statistically significant reduction in antibiotic consumption, Bulgaria has shown the opposite trend. The aim of this study is to investigate the implementation of mandatory electronic prescriptions (e-Rx) for antibiotics in Bulgarian primary care and to analyse community-level sales trends (2022-Q1 2025) in the context of related policy changes. Methods: The study applied a content analysis approach to publicly available policy documents and antibiotic sales and prescription data (IQVIA Bulgaria, NHIS). Participatory approaches facilitated the contextual interpretation of the data. The Health Policy Triangle framework guided the analysis of e-Rx implementation across four dimensions: content, context, process, and key actors involved in the e-Rx policy rollout. Trends in sales were assessed before and after the policy's full enforcement in April 2024. Results: Sales data from IQVIA Bulgaria show a steady ≈10% decline in outpatient antibiotic sales from 2022 to 2024, with over 1.1 million fewer packages dispensed. Although the estimated annual and quarterly declines in community sales did not reach statistical significance in the short term, the consistent downward trajectory remains noteworthy. Conclusions: Mandatory e-Rx has shown early potential as a policy instrument to reduce antibiotic overuse in Bulgaria. It is expected to contribute to the reduction in AMR and to support the implementation of integrated national One Health policies.