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Sex and gender differences may significantly impact health outcomes, yet their role in antibiotic therapy remains underexplored. Despite the urgent threat of antimicrobial resistance, limited evidence exists on how biological, pharmacokinetic, and sociocultural differences affect antibiotic efficacy, safety, and usage. This gap is critical, as women are often underrepresented in clinical trials, leading to suboptimal treatment strategies and a higher incidence of adverse drug reactions.

This narrative review synthesizes current evidence on these disparities. We explore the biological basis for differential immune responses and drug pharmacokinetics, sociocultural drivers of prescribing patterns, gender-specific infections, and the intersection of gender with antimicrobial resistance. The review also addresses antibiotic use in pregnancy and highlights the profound lack of data for both cisgender and transgender women due to their exclusion from research.

Sex-aware prescribing is a practical and necessary step toward equitable care. Key obstacles include historical underrepresentation of women in trials and insufficient sex-disaggregated data. We advocate for powering future trials for sex-specific analyses, updating clinical guidelines, and using decision support tools for dose adjustments. Integrating a gender lens into all levels of antimicrobial stewardship is essential to move from simply describing disparities to actively closing them.