Determinants of implementation of antimicrobial stewardship interventions for managing community adult acute respiratory onfections: qualitative analysis from the OPTIMAS-GP study co-design phase

Background/Objectives: Antimicrobial stewardship (AMS) interventions are critical to reducing inappropriate antibiotic prescribing for acute respiratory infections (ARIs) in primary care and mitigating antimicrobial resistance (AMR). While interventions are routinely employed in hospitals, implementation in general practice is nascent. This qualitative study, part of the OPTIMAS-GP project, explored determinants influencing the implementation of evidence-based AMS strategies in Australian general practice. Methods: Using Experience-Based Co-Design, three rounds of online focus groups were conducted with ten healthcare professionals (GPs, pharmacists, microbiologist, practice staff) and ten adult patients who had experienced ARI management in primary care. Participants discussed the feasibility and acceptability of AMS interventions: shared decision-making (SDM) tools, delayed prescribing (DP) and point-of-care testing (PoCT) for C-reactive protein (CRP). Results: Thematic analysis of focus group transcriptions identified four interrelated themes: ‘Patient acceptance and engagement’, ‘Practising within a system’, ‘Prescribing stewardship’, and ‘Diagnostic stewardship’. Patient engagement was dependent upon expectations, trust, and personalised care, while systemic factors such as continuity of care, practice culture, and resource availability influenced implementation. DP was viewed as a pragmatic but potentially confusing strategy, requiring clear patient guidance and interprofessional collaboration. SDM tools were conceptually supported but challenged by time constraints and poor health literacy. PoCT-CRP was cautiously welcomed for selective use, with concerns expressed about workflow integration and overreliance on testing. Findings were mapped to the Capability, Opportunity, Motivation-Behaviour (COM-B) and Theoretical Domains Framework (TDF) to identify behavioural determinants and inform future implementation strategies. Recommendations include co-designing patient-centred AMS tools with clear instructions and red flags, enhancing GP-pharmacist collaboration, and addressing barriers to PoCT integration. Conclusions: These insights highlight the complexity of implementing AMS interventions in general practice and underscore the need for tailored, system-supported approaches to optimise antibiotic use and reduce AMR.