Assessing Pharmacists’ Role in Antimicrobial Stewardship in Community Settings

Thesis Abstract

Antimicrobial resistance represents a critical global health threat, with community pharmacists positioned at the frontline of antibiotic dispensing and stewardship practices. Despite policy commitments and professional guidelines, evidence on how pharmacists contribute to antimicrobial stewardship (AMS) in community settings remains fragmented, particularly regarding everyday dispensing behaviors, patient counseling, and collaboration with prescribers. This study seeks to evaluate the role of community pharmacists in AMS, identify facilitators and barriers to optimal practice, and quantify the association between pharmacist-led interventions and antibiotic appropriateness at the point of sale. The aim is to assess the extent, quality, and outcomes of AMS activities performed by community pharmacists, and to elucidate how these activities influence antibiotic use patterns. Specific objectives are (1) to characterize dispensing practices related to antibiotics in community pharmacies; (2) to evaluate pharmacists’ knowledge, attitudes, and self-reported practices regarding AMS; (3) to identify organizational and systemic factors that enable or hinder AMS in the community setting; (4) to quantify the association between pharmacist-led AMS interventions and indicators of antibiotic appropriateness, including antibiotic necessity, documented indications, and duration in a defined patient cohort; (5) to explore patient and pharmacist experiences of AMS encounters to inform patient-centered strategies; and (6) to develop evidence-based recommendations for integrating AMS into routine community pharmacy practice. A mixed-methods design will be employed, combining a cross-sectional survey with a retrospective audit and qualitative interviews. The population comprises licensed community pharmacists practicing in urban and peri-urban locales and customers presenting for antibiotic purchases. A sample of 300 community pharmacists will be recruited for the survey, with a stratified random sampling approach to ensure representation by region and pharmacy type. Concurrently, a six-month retrospective audit of antibiotic dispensing records from 50 conveniently selected pharmacies will assess antibiotic appropriateness using standardized criteria aligned with WHO/CDC guidelines. In-depth semi-structured interviews will be conducted with 20 pharmacists and 20 patients to capture contextual insights. Data collection instruments will include a validated AMS knowledge questionnaire, a practice audit checklist, patient encounter observation guides, and interview protocols. Validity will be pursued through content validation with AMS experts and pilot testing (n=20) for reliability (Cronbach’s alpha ?0.70 for scales). Triangulation will integrate quantitative and qualitative findings. Quantitative analysis will involve descriptive statistics to summarize dispensing practices and AMS knowledge; multivariable logistic regression will examine predictors of appropriate antibiotic dispensing, adjusting for pharmacist demographics, pharmacy characteristics, and regional factors. The audit data will be analyzed to determine the proportion of antibiotic dispensings aligned with indications, duration, and dosing recommendations. The qualitative component will be analyzed using thematic analysis, guided by the Theory of Planned Behavior to interpret how attitudes, subjective norms, and perceived behavioral control influence AMS-related actions, and by Normalization Process Theory to understand integration into routine workflows. A convergent parallel design will merge results to identify convergences, divergences, and actionable implications. Expected findings include suboptimal rates of appropriate antibiotic dispensing in community settings, gaps in knowledge and confidence among pharmacists in applying AMS principles, and significant influence of workload, remuneration models, and interprofessional communication on AMS engagement. It is anticipated that higher levels of organizational support, access to rapid diagnostic information, and structured patient counseling protocols will be positively associated with appropriate dispensing and patient understanding of antibiotic use. The study’s contribution to knowledge lies in providing empirical evidence of AMS practices at the community level, linking pharmacist actions to antibiotic use outcomes, and informing policy and education strategies tailored to real-world community pharmacy environments. The conclusion will emphasize scalable, practice-oriented interventions, such as standardized AMS checklists, continuing professional development modules, and enhanced collaboration mechanisms with prescribers and public health bodies. Recommendations will focus on (1) integrating AMS prompts into pharmacy management systems, (2) mandating brief, structured patient counseling on antibiotic necessity and duration, (3) developing interprofessional communication pathways, (4) creating region-specific benchmarks for appropriate dispensing, and (5) guiding future research to evaluate interventions introduced in diverse community settings.