Evaluating a Community Pharmacy's Role in Antibiotic Stewardship Programs

Thesis Abstract

Antibiotic resistance remains a critical public health challenge, with community pharmacies playing a pivotal yet underutilized role in antimicrobial stewardship, particularly in initiating appropriate dispensing practices, patient education, and adherence monitoring. This study addresses the gap between stewardship guidelines and real-world community pharmacy practices, aiming to evaluate how a representative network of community pharmacies contributes to antibiotic stewardship programs and to identify barriers and enablers influencing effective implementation. The aim is to assess the extent of stewardship activities in practice, determine factors associated with higher-quality antibiotic dispensing, and generate actionable recommendations for optimizing community-pharmacy-led interventions. Specific objectives are (i) to quantify the prevalence of antibiotic dispensing aligned with stewardship principles among twenty-five community pharmacies within a defined urban region; (ii) to evaluate pharmacist knowledge, attitudes, and practices (KAP) toward antibiotic stewardship using a validated 30-item survey; (iii) to examine patient-level antibiotic use behaviors and adherence through pharmacoepidemiologic data and patient interviews; (iv) to explore organizational and external determinants of stewardship activities, including workflow design, access to guidelines, and collaboration with prescribers; (v) to synthesize qualitative insights from semi-structured interviews with thirty pharmacists and ten prescribers to elucidate perceived barriers and enablers; and (vi) to triangulate findings to develop a context-specific framework for enhancing community-pharmacy antimicrobial stewardship. A mixed-methods design will be employed, combining a cross-sectional survey of pharmacists (n=150) and patients (n=300), prescription data extraction for three months, and in-depth interviews. The population comprises licensed community-pharmacy professionals and adult patients who obtain antibiotics without a prescription or with prescription requests in the selected urban area. Data collection instruments include a structured questionnaire for pharmacists incorporating a Knowledge-Attitude-Practice (KAP) section, a standardized patient-adult interview guide, and a data extraction form for antibiotic dispensing records. Validity and reliability will be ensured through pilot testing, Cronbach’s alpha assessment for the KAP instrument (target ? ? 0.70), and inter-rater reliability checks for qualitative coding (Cohen’s ? ? 0.70). Data analysis will integrate descriptive statistics, multiple regression to identify predictors of stewardship-compliant dispensing, interrupted time-series analysis of dispensing trends where feasible, and thematic analysis of interview transcripts guided by the Consolidated Criteria for Reporting Qualitative Research (COREQ). A conceptual model drawing on the Theory of Planned Behavior and the Capability, Opportunity, Motivation-Behavior (COM-B) framework will structure analysis and interpretation. Expected findings include (i) measurable variability in stewardship practices across pharmacies, with a subset demonstrating high alignment to guidelines such as verification of indication, patient counseling on duration and adherence, and avoidance of non-prescription antibiotic dispensing; (ii) significant associations between pharmacist stewardship knowledge and dispensing practices, and between organizational factors (staffing, time pressure) and compliance; (iii) patient-level factors, including health literacy and prior experiences, influencing adherence and antibiotic-seeking behaviors; and (iv) salient barriers such as competitive dispensing pressures, limited access to current guidelines, and gaps in interprofessional collaboration, alongside enablers like continuing education programs, decision-support tools, and pharmacist-prescriber communication channels. The study’s contribution to knowledge lies in providing an empirically grounded, context-specific framework for optimizing community-pharmacy antimicrobial stewardship, integrating quantitative prevalence data with qualitative insights to inform policy, training, and operational interventions. The main conclusion is that targeted, multifaceted strategies—combining guideline-based training, streamlined workflow processes, and enhanced interprofessional collaboration—are essential to advance antibiotic stewardship in community settings. Recommendations include the development of regionally tailored training modules for pharmacists, implementation of standardized dispensing checklists integrated into pharmacy information systems, establishment of formal pharmacist-prescriber communication protocols, and policy support for monitoring and incentivizing stewardship activities within community pharmacies.