A systems thinking approach for antimicrobial stewardship in primary care

ABSTRACT

Introduction

The establishment of antimicrobial stewardship (AMS) in primary care is central to substantially reduce the antimicrobial use and the associated risk of resistance. This perspective piece highlights the importance of systems thinking to set up and facilitate AMS programs in primary care.

Areas covered

The challenges that primary care faces to incorporate AMS programmes is multifactorial: an implementation framework, relevant resources, team composition, and system structures remain under-researched, and these issues are often overlooked and/or neglected in most parts of the world. Progress in the field remains slow in developed countries but potentially limited in low- and middle-income countries.

Expert opinion

The key AMS strategies to optimize antimicrobial use in primary care are increasingly known; however, health system components that impact effective implementation of AMS programs remain unclear. We highlight the importance of systems thinking to identify and understand the resource arrangements, system structures, dynamic system behaviors, and intra- and interprofessional connections to optimally design and implement AMS programs in primary care. An AMS systems thinking systemigram (i.e. a visual representation of overall architecture of a system) could be a useful tool to foster AMS implementation in primary care.

KEYWORDS:

• Antimicrobial stewardship
• primary care
• systems thinking

Article highlights

• Primary care is the most important setting to rationalize antimicrobial use since 75% of antimicrobial prescriptions occur in this setting and 30-50% are inappropriate in choice, dose, or duration.

• Primary care faces multifactorial challenges to establish antimicrobial stewardship (AMS) programs to optimize antimicrobial use.

• Systematic reviews in primary care support the effectiveness of various elements such as AMS education and training, antimicrobial audits and feedback, doctor-pharmacist collaboration, clinical decision support systems, point-of-care tests, patient-facing antibiotic checklists and leaflets, GP-pharmacy practice agreements, and antimicrobial use regulatory policies. However, system structures are not in place to incorporate and implement those AMS strategies in most parts of the world.

• A systems approach and an interprofessional collaborative approach are key to establish a system for AMS in primary care.

• Identification of key connections of primary care providers at an individual (e.g. doctor, pharmacist) and practice level (e.g. general practice, pharmacy) is of utmost importance to set up an interdisciplinary AMS program.

• An AMS systems thinking systemigram could assist to better understand the arrangement of AMS resources, system structure, dynamic system behaviours, intra- and interprofessional connections and feedback, and AMS governance to optimally design and implement AMS in primary care.

Acknowledgments

This work was a part of a PhD thesis of the first author, SKS. SKS acknowledges to Monash University for providing technical support and post-publication award 2021 to the development of this paper.

Author contribution

Conceptualizations and design: SKS, DCMK, DM, and KT; Background work: SKS, DCMK, DM, and KT; Review of literature: SKS; Interpretation: SKS and KT; Writing: SKS; Review of writing: SKS, DCMK, DM, and KT.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.