Barriers and enablers to implementing antimicrobial stewardship for suspected urinary tract infection in residential aged care: a systematic review

Abstract Background/Objective Despite the importance of antimicrobial stewardship (AMS) in residential aged care homes (RACHs), implementation of AMS for suspected urinary tract infections (UTIs) remains inconsistent. This review synthesised reported barriers and enablers and mapped them to the Theoretical Domain Framework (TDF). Methods This systematic review followed JBI guidelines and reported in accordance with PRISMA 2020. Five databases were searched from inception to 12 February 2026. Studies explicitly reporting barriers and/or enablers to implementing AMS strategies for suspected UTIs in RACHs were included. Two reviewers independently screened studies, extracted data, and assessed methodological quality using the MMAT. Findings were synthesised inductively and mapped to the TDF. Results 12 studies met the inclusion criteria from 1130 records identified through database searches, supplemented by citation and trial registry searches. Common barriers included workforce instability and limited resources, reliance on established practice, social pressure from clinicians and families, gaps in staff knowledge and confidence, concerns about negative consequences, and limited stakeholder engagement. Key enablers included staff education and training, multidisciplinary collaboration, access to clinical decision-support tools, leadership support, and organisational policy alignment. Environmental Context and Resources, Social Influences, and Behavioural Regulation were among the most commonly represented TDF domains. Conclusion AMS implementation for suspected UTI in RACHs is influenced by multiple contextual and behavioural determinants. Resource constraints, social pressure, beliefs about consequences, and knowledge gaps were frequently reported barriers, whereas education, leadership support, and policy alignment were commonly reported enablers. Addressing these determinants may facilitate more effective and sustainable AMS implementation in RACHs.