Prescribing under pressure: Institutional barriers to stewardship among clinicians of different specialties in Saudi Arabia

<h2>Abstract:</h2><h3>Objectives</h3> To evaluate clinicians' antibiotic stewardship knowledge, prescribing behaviors, and opinions and identify demographic and institutional factors influencing stewardship effectiveness. <h3>Study Design</h3> Mixed-methods. <h3>Methods</h3> We used a validated questionnaire and focus group interviews to gather data from 116 clinicians. Qualitative analysis explored institutional and experiential barriers, whereas quantitative analysis examined associations between stewardship knowledge and clinician characteristics. <h3>Results</h3> Significant associations were found between stewardship knowledge and age (p = 0.0092), gender (p = 0.0045), and years of experience (p = 0.0460). Pediatricians demonstrated higher stewardship knowledge than family physicians (p = 0.0106). Focus group discussions revealed institutional barriers including time constraints, lack of monitoring mechanisms, and diagnostic uncertainty. One participant noted, "It's safer to prescribe antibiotics just in case, rather than risk a patient developing a severe infection." <h3>Conclusions</h3> Clinicians face both personal and institutional challenges in applying stewardship principles. We need local standards to reduce multidrug resistance; thus, targeted continuing medical education, structured case-based training, public awareness campaigns, and improved access to rapid diagnostics may enhance the effectiveness of antimicrobial stewardship programs across specialties.