Knowledge, perceptions and practices of community pharmacists towards antimicrobial stewardship: a systematic scoping review of survey studies

Problem

The use of community antimicrobial stewardship (AMS) programs is rising as the majority of antimicrobials are prescribed, dispensed and misused in primary care. Community pharmacists (CPs) are well positioned to facilitate AMS through general practitioners (GPs) and patients. However, the extent of the literature on the knowledge, perceptions and practices (KPP) of CPs towards AMS is unclear and the nature and scope of survey tools to measure CPs’ KPP is unknown. This systematic scoping review aimed to determine the breadth of existing survey literature, assess the survey tools for future use to measure CPs’ KPP towards AMS and analyse reported outcomes.

Approach

We used Arksey and O’Malley’s methodological framework and PRISMA-ScR guidelines to conduct this review. Seven databases and relevant pharmacy journals were searched to October 2018 to identify English language survey studies related to CP-AMS. Our search terms covered topics including; AMS, KPP, pharmacist and primary care. Two reviewers assessed the quality of surveys using published criteria. Literature synthesis was done to determine which domains of KPP have been investigated, the tools used to quantitatively measure KPP. KPP outcomes were analysed as median percentage of CPs’ agreement and interquartile range (IQR). Reported AMS barriers and facilitators were narratively summarized using a socioecological framework.

Findings

Of 1860 articles returned from databases, journals and snowball searches, ten surveys from six countries were eligible after reviewing the full text of 68. No articles were identified that assessed knowledge, but seven assessed perceptions or attitudes and eight described practices of CPs related to AMS. Upon quality assessment, we found four high quality and validated surveys for future use to measure CPs’ AMS perceptions and practices, but local testing should be conducted to ensure contextual suitability and validity.

Quantitative synthesis showed that most CPs (65%, IQR 63%-67%, n=2) had heard of AMS. CPs perceived that AMS improved patient care (86%, IQR, 83.3%-93.5%, n=6) and reduced inappropriate antibiotic use (84%, IQR, 83%-85%, n=2). With regards to AMS practices, CPs collaborated with prescribers (77.0%, IQR 55.2%-77.8%, n=5), educated patients (53.0%, IQR, 43.2%-67.4%, n=5) and screened guideline compliance of antimicrobial prescriptions (47.5%, IQR, 25.2%-58.3%, n=3). Major AMS barriers reported in three studies were AMS guidelines and training, GP-CP interactions, and reimbursement models. CPs’ willingness to participate in AMS was a major facilitator.

Consequences

A growing body of literature was found describing CP-AMS. Limited validated surveys are available to assess CPs’ perceptions and practices, but none to measure their AMS knowledge. CPs had positive perception towards AMS but their AMS practice improvements require relevant training, collaborative system structure, guidelines and role definitions. Future research is warranted to develop AMS knowledge measurement tools, and qualitative insights into KPP, barriers and facilitators for CPs to strengthen community-AMS.