Romanian pharmacist Lavinia Balea, MSc, quit her job to study public health and dedicate her time to shining a light on antimicrobial resistance (AMR). 

“When I was working as a pharmacist, it was hard because I knew exactly what’s happening in pharmacies across Romania,” she told Medscape News Europe. “I wanted the authorities to come and inspect pharmacies to see what’s going on because it would reveal everything. But there’s no interest to do this.”

Romanians are among the top consumers of antibiotics in Europe, with approximately one in six having taken antibiotics without a prescription. As a consequence, data from the European Centre for Disease Prevention and Control (ECDC) has found the country faces high risks of AMR, including the highest in Europe for carbapenem-resistant Klebsiella pneumoniae bloodstream infections. 

But unlike many European countries, a lot of antibiotic consumption in Romania occurs in the community, not in hospitals.

That’s because although Romanian legislation mandates that antibiotics can only be dispensed with a prescription, it allows pharmacists to give antibiotics to patients in emergency situations, when access to a doctor is not possible. 

In 2024, the government further strengthened the law in a bid to reduce excessive consumption of antibiotics by allowing pharmacists to dispense emergency antibiotics for 48 hours only if the patient or caregiver signs a declaration of responsibility, commits to seeking a medical consultation as soon as possible, and provides details about the symptoms justifying the request. 

Although the government has tightened the regulation on paper, Balea doubts it has had much impact on dispensing practices. 

“When I worked in a small town, I was forced by my manager to dispense antibiotics. My manager was not a pharmacist — on paper you need to have a pharmacist as a manager — but the pharmacy was led by a business-oriented person. It’s a systemic issue. We’re under a lot of pressure. That’s why I gave up being a pharmacist,” Balea said.

She’s not just worried about over-the-counter antibiotic sales, but also GP prescribing patterns. 

Balea’s research on antibiotic practices among community pharmacists and GPs found that GPs often prescribed unnecessary antibiotics for fear of losing patients. Also, as Balea had experienced, several pharmacists encountered pressure from managers to dispense antibiotics to meet patient expectations. 

“I was told by one GP that 20 years ago they were incentivized to prescribe antibiotics when new classes appeared on the market. If they didn’t prescribe antibiotics to their patients, they believed they weren’t a good doctor. Unfortunately, that mentality has continued. There are still patients who believe they can’t heal without strong antibiotics,” Balea explained.

A Problem Across Europe

AMR is among the top pressing global health threats, with the ECDC estimating that it is responsible for more than 35,000 deaths in the EU/European Economic Area (EEA) each year. 

The use of antibiotics without a prescription isn’t just an issue in Romania. It’s still common in several European countries, including Cyprus, Greece, Malta, Hungary, Italy, Estonia, and Spain. Over-the-counter purchasing is the most common way of obtaining antibiotics, followed by patients using leftover drugs from previous courses. 

The latest data from the ECDC showed that the region is not on track to achieve four of five targets established by the Council of the EU for 2030. In contrast to one of the targets — a 20% reduction in total annual antibiotic consumption by 2030 — antibiotic consumption actually increased in 2024. 

Malta is one of the highest antibiotic-consuming countries in Europe. By 2023, total consumption had risen to 22.9 defined daily doses (DDD) per 1000 inhabitants per day, with community-use alone standing at 20.9 DDD per 1000 inhabitants per day; nearly four times the EU/EEA mean of 5.5 DDD per 1000 inhabitants per day.

Brian Fenech, MSc, from the School of Science and a PhD candidate at the University of Derby, UK, has researched barriers to antimicrobial stewardship in antibiotic prescribing and dispensing among GPs and pharmacists in Malta. He told Medscape News Europe that although nonprescription access appears to have declined, it still occurs. 

But that’s not the only problem.

His research found that prescribing is shaped by expectations to prescribe, willingness to prescribe without clear diagnostic evidence, and habitual behaviors such as repeat or third-party prescriptions; issues that many other European countries face.

This occurs within a system that has walk-in primary care without fixed GP registration, short consultation times, and frequent location of private GP services within community pharmacies. 

“Our research suggests that awareness is not the main issue. There have been many public awareness campaigns outlining the dangers of antibiotic resistance, which may increase knowledge but don’t necessarily motivate behavior change,” he said.

“In Malta, GPs are part of a primary care system that makes cautious prescribing much harder than it should be,” he continued.

In other words, telling GPs to prescribe antibiotics less isn’t enough, and telling patients not to seek antibiotics when they have a cold is also not enough. 

Fenech said that although awareness is a powerful means of increasing people’s intentions to change, it does not always translate into actual behavioral change.

“This gap is particularly pronounced in antibiotic use because prescribing decisions are made under conditions of uncertainty, time pressure, and perceived risk,” he said. 

What Fenech would like to see is up-to-date, visible prescribing guidelines, the expansion of delayed antibiotic prescribing, rapid diagnostic tools, communication support for difficult conversations with patients, better access to community resistance data, and ideally, clearer prescribing feedback data so GPs can benchmark their antibiotic use. 

At the systems level, he’d like to see Malta implement better professional indemnity and sick-leave policies.

“One major issue is that GPs have limited consultation time, so they cannot always educate patients themselves on why they do not need antibiotics. Some GPs worry patients will take legal action due to negligence if they don’t prescribe antibiotics, and in terms of sick leave, parents need to be afforded the opportunity to provide care for their sick children without relying on antibiotics,” he explained. 

“I’d argue that antibiotic overuse is not simply a failure of individual responsibility but a reflection of broader structural and behavioral constraints,” he said. In this sense, explained Fenech, reducing inappropriate antibiotic use requires more than awareness campaigns. What's needed are interventions that target the environmental and systemic barriers shaping behavior — ones that help both clinicians and patients translate good intentions into action.

From Awareness to Action 

One program trying to address inappropriate antibiotic use and improve communication among doctors, pharmacists, nurses, and patients is AMR EDUCare, funded by the EU4Health program and run by Health Care Without Harm (HCWH). 

This online antimicrobial stewardship training provides healthcare professionals with the tools needed to minimize AMR risks in daily practice, such as how to engage with patients confidently and constructively and how to navigate prescribing guidelines. So far, the program has trained almost 6000 healthcare professionals in Portugal, Spain, Italy, Greece, Hungary, and Lithuania. Training is being rolled out soon in Malta and Germany with the goal of further expanding across Europe. 

Erik Ruiz, MA, MPH, Safer Pharma program manager at HCWH Europe, told Medscape News Europe that a survey conducted 3 months after participants completed the training found that 85% of doctors reported adopting more prudent prescribing habits.

“Crucially, they reported much better communication with their patients. By being equipped to clearly explain the rationale behind their decisions and the potential harms of inappropriate antibiotic use, doctors noted a noticeable decrease in patients actively insisting on receiving an antibiotic,” he said.

Ruiz said healthcare professionals were ideally positioned to challenge the views of patients who still believe antibiotics are a silver bullet for every health issue, but recognized that the burden shouldn’t be placed on time-strapped GPs. 

Balea agreed that education is important for tackling inappropriate antibiotic use, but in a country such as Romania, where access to over-the-counter antibiotics remains legal and, in some cases, encouraged, it’s a challenge. Tackling the issue properly, she said, requires multisectoral commitment to the One Health approach. 

“It’s not enough to just adopt some new legislation or guidelines. Authorities don’t monitor or do inspections, there’s just not the political will,” she said. 

Balea, Fenech, and Ruiz have reported no relevant financial relationships. 

Sophie Cousins, MIPH, is a global health journalist who has reported from more than 20 countries.