Barriers to rational antibiotic prescription in hospitals: a qualitative study in a developing country

Abstract Background Antimicrobial resistance (AMR) is a growing global threat. Antimicrobial stewardship programs (ASPs) represent a key strategy to combat AMR and to minimize the adverse effects associated with antibiotic use. Implementing ASPs in hospital settings faces significant challenges and barriers, particularly in low- and middle-income countries (LMICs). This study aims to identify the barriers to the implementation of ASPs in Iranian hospitals. Methods This qualitative study was conducted in 2023–2024, involving 41 stakeholders in antibiotic prescription within five public hospitals in Iran. The participants included physicians, administrators, pharmacologists, pharmacists, the secretary of the stewardship committee, microbiologists, laboratory managers, ICU nurses, nurse managers, quality improvement managers, infection control officers, and information technology managers. Participants were recruited using a convenience sampling method. Data were collected through semi-structured interviews and analyzed using conventional content analysis techniques. Results The barriers to implementing ASPs were categorized into three main categories, nine subcategories as follows: (1) Deficiencies in intelligent surveillance and monitoring of antibiotics prescribing (including inadequate health information technology for ongoing collection, collation and analysis of antibiotic prescribing pattern, and poor audit, and feedback mechanisms in HIS); (2) Deficiencies in health system governance, policies, and regulatory frameworks (including weak policy framework and clinical guidelines, limited policy learning and contextual adaptation and legal and regulatory gaps affecting clinical practice); and (3) Deficiencies in hospital-wide management and support structure (including poor organizational governance and structural capacity, ineffective interprofessional collaboration, weak leadership commitment and low stakeholder engagement, and inadequate professional competencies and limited technical skills). Conclusion The study underscores the multifaceted and heterogeneous nature of barriers to the implementation of ASPs in a LMIC. Enhancing information technology infrastructure, optimizing antibiotic prescribing practices, engaging physicians, strengthening financial and human resource capacity, and fostering supportive management attitudes were identified as potential effective strategies for facilitating successful ASP implementation in hospital settings in a LMIC.