Dentists’ perceptions and system-level barriers to antimicrobial stewardship in dental care in Karachi, Pakistan: a qualitative study

Abstract Background Antimicrobial resistance (AMR) is a major global health threat, and dental practice is an important but frequently overlooked contributor to inappropriate antibiotic use. In Pakistan, antimicrobial stewardship (AMS) in dentistry remains nascent, and dentists’ perceptions and the system-level factors influencing prescribing are poorly understood. This study is one of the first to examine dental AMS in Pakistan through an integrated, multi-level health-systems lens that combines clinician and policy-maker perspectives. Methods We conducted an exploratory, descriptive, cross-sectional qualitative study, underpinned by a pragmatic orientation, at two tertiary-care teaching institutions in Karachi, Aga Khan University Hospital (private sector) and Dow University of Health Sciences (public sector), between December 2022 and January 2023. Purposive sampling was used to recruit 12 dentists from multiple specialties and 5 key informants, including policy stakeholders, microbiology/pharmacology experts, and stewardship-committee members. Semi-structured interviews were analyzed using framework-guided thematic analysis based on the Multi-Level Antimicrobial Stewardship Implementation Framework (ML-ASIF), which integrates the WHO Health System Building Blocks, Donabedian’s structure-process-outcome model, and the Theory of Planned Behavior. Results Understanding of AMR was moderate, with 8 of 12 dentists describing it adequately; howeer, familiarity with AMS was very limited, as 11 of 12 dentists reported that the term was new to them. Prescribing was shaped largely by senior-led traditions rather than evidence-based guidelines, and no participant reported documenting the rationale for antibiotic prescribing. Institutional guidelines existed in the private sector but were accessed inconsistently, while public-sector participants reported having no access to such guidelines. Stewardship structures lacked dental representation, and outpatient prescribing, which a key informant estimated to account for over 90% of dental activity, was not routinely monitored or audited. These barriers operated across individual (knowledge gaps and reliance on senior practice), institutional (lack of dental audit and monitoring), and system levels (weak governance, accountability, and resources). Conclusions Within these two tertiary-care institutions, our findings indicate substantial gaps in dental AMS, including deficiencies in infrastructure, guideline access, dental representation on stewardship committees, and outpatient monitoring. Although the findings are not generalizable to all Pakistani dental settings, they highlight the need for contextually adapted interventions, curriculum reform, guideline implementation, pharmacist involvement, clinical audit, and health-system strengthening in alignment with Pakistan’s National Action Plan on AMR. They also identify clear priorities for future quantitative and intervention research.