Table 1 Summary of themes, sub-themes and sample quotes from participants

Stakeholder mapping and governance structures

Community AMS stakeholder mapping

External high-level AMS team:

• “I would still suggest that there should be sort of like a regular stakeholder meeting that would involve people in the infectious diseases, microbiologists, laboratory pathologists… And there should then be feedback to the rest of the stakeholders, it would help our prescribing pattern” (D,3,GP).

• “I believe there is so much more the government could do to support us in many ways, and I’m not talking about financial support. I’m talking about, to have a go-to-person from the public health units or the department of health units. So, when people have questions or when people need further education and resources, we can go to them.” (N,15,AC).

Multidisciplinary AMS team:

• “I think it needs to be obviously a teamwork and get more education on it and more designated staff…” (P,1,AC, RMMR, HMR).

• “I think it’s feasible, but I don’t think it would be specific to AMS because of the size of general practices.…Whether or not the pharmacist-nurse-general practitioner team could work on AMS, absolutely! I think it would just come as part of a package of other things.” (P,12,GP, HMR)

Community AMS governance structures

AMS as a health facility requirement:

• I hope that these discussions of AMS become a little bit more structured in the very near future as in a more legislative requirement of the aged care standards.” (N,15,AC)

• “Feels like the only way that it’s going to happen is actually gonna be if it’s legislated. People don’t do work unless they have to do work.” (L,10,PS).

Roles and responsibilities of stakeholders:

• “…we don’t have a designated person for infection prevention control,…all of us are responsible for infection prevention and control.” (N,6,AC).

• “Yeah, I think we can do better than what we are doing now. There is no real coordination even though the therapeutic guideline is supposed to help guide our prescribing pattern. But you still have different prescribers prescribing different things.…there is really no sort of coordination. And I think it’s because of lack of regular education around this topic for prescribers to know that we have to be careful about prescribing pattern and our prescribing pattern can actually increase antibiotic resistance in the community.” (D,3,GP).

Communication strategy and system

Communication among stakeholders

Communication among health providers:

• “[It is] not very effective, no. So, usually we only call the doctor if there is a problem, but they don’t like hearing from us, to be honest.…I don’t think that engagement is very good. It’s probably better in a collaborative setting such as a hospital.” (P,11,CP).

• “I guess engagement with general practitioners is always a big challenge… We find a lot of them feel that if a resident or a client asks for antimicrobials that they need to prescribe them.” (N,14,AC).

Communication with patients:

• “In community pharmacy, I think the communication with consumers or clients can still be effective… Dedicated time I think is the key which you don’t always have in a community pharmacy with the general practitioner or the consumer. Yeah, workload time pressures for all parties– consumers, general practitioners and pharmacists.” (P,2,CP, HMR).

• “……sometimes it could be challenging explaining to patient that there is no clear indication for them to receive antibiotic at this moment.” (D,17,GP).

Community AMS communication system

Communication strategy:

• “I can only go to the doctor and talk about these things. There is no platform to provide feedback per say.” (N,5,GP).

• “Communication pathways can be anything from a corridor chat to a formal internal messaging system which can be linked to patients’ charts.” (P,12,GP, HMR).

External high-level communication strategy:

• “…being more open to collaboration and networking with all the sites. I think that would be the greatest improvement that we could do is having more open collaboration between multidisciplinary, all the different strings that are involved in AMS.” (L,10,PS).

• “I guess a database. A database that should be able to be accessible from clinicians, private pathology companies. Perhaps a database like that, that’s accessible for all of those bodies that do that work.” (L,9,PS).

Prescribing, dispensing and surveillance systems

Audit and surveillance data and system

Tracking and reporting of data:

• “On our own we don’t track the prescription data or the antimicrobial resistance patterns…… So yeah, we don’t track such.… then encouraging every facility to be able to track their antimicrobial use and resistance patterns.…So, having the authorities find a way to kind of include that in maybe the appraisals or something so that practices can do that.” (D,4,GP).

• “…I think at the moment [currently] the audit that the aged care is collecting, the data is very basic.…Not enough information to review the appropriate use of antibiotics” (P,1,AC, RMMR, HMR)

Local community AMR data or pattern:

• “If I had knowledge of the local antimicrobial resistance pattern, then I wouldn’t be starting off with basic 101 antibiotic if it was already resistant to it. Because I have no knowledge of what the antimicrobial resistant pattern is in my area.…I just go blindly and hope the first course works. If it doesn’t, then I’ll try another one and then I am also adding to the resistance!” (D,13,GP).

• “I think it would really help us. I’m not aware of the resistant pattern in our community. In saying that, if we have this information clearly available, it will guide us as to which antibiotics would give in particular cases. You know, we won’t be giving patients antibiotics that we know people are commonly resistant to in the community. We can go for the antibiotics that will treat their infection. So, we need this information to be freely made available.” (D,3, GP).

Prescribing and dispensing strategies

Prescribing, medication reviews and dispensing practices:

• “The fact that you don’t give antimicrobials somebody else would give. Difficult patients and poor education,…I think sometimes the pressure that patients put on doctors can sometimes make doctors succumb to pressure.” (D,16,GP).

• “…. patient-doctor shopping like for example, somebody received antibiotics about 2 weeks ago for a particular illness, but because he or she has not been improving or getting well might go to another doctor for antibiotics. So, sometimes it takes time to cross check through my health record to confirm this patient have received antibiotics two weeks ago. It adds to the consultation time in order to cross check their previous medication history.” (D,17,GP).

Prescribing and dispensing software:

• “There is more than one software used for dispensing.…. we have clashing software now, so that’s why there need to be some linkages. Because there’s nothing linked and it’s a waste of data that nothing is linked. It’s a huge job, the government needs to support that software development and the linking.” (P,2,CP, HMR).

• “I can search for what prescriptions have been created by the GPs, but I can’t search for pathology results. I’d love to be able to do more searches that involve pathology results…. I’ve been told it’s not possible from an IT perspective, but that’s just in the software that GP practices use.…. I’m told that when the program conducts the search, it can’t read pathology results within the patient’s electronic medical record.” (P,12,GP, HMR).

Resources

Resource challenges

Awareness and education for stakeholders:

• “Well, educating the prescribers in the sense that making them aware of what tools, like you heard me say I am not aware of some of these tools and I’m sure many of my colleagues will say the same.” (D,4,GP).

• “I think our challenge is twofold. It is educating patients, which is easy, but educating prescribers, which is a little bit harder to do.” (P,11,CP).

Uptake of existing resources:

• “The company that I work for has done quite a lot of resources for antimicrobial stewardship since the clinical care for AMS has come through in aged care… So, we’ve given them to the aged care, but it has been not a great uptake of it. It seems like just from looking back at how they were using antimicrobials despite the resources that we have provided the aged care.” (P,1,AC, RMMR, HMR).

• “…they [the government] should publicise it first. I’m not sure many doctors are aware of this. So, my thoughts should be first they should try to make sure every doctor gets to be aware that such kind of documents or measures are out there.…The point is, if you don’t know about it, you don’t really have an opinion on it. So, I don’t even know that such things exist, and they should do more to publicise it.” (D,4,GP).

Resource gaps

Human resources:

• “…there is often short staff in the aged care. Also with the aged care doctors, a lot of them are quite elderly. And I feel like they may not be up to date with the latest guideline on the treatments. Yeah, I think that’s also a huge factor.” (P,1,AC, RMMR, HMR).

• “……the government needs to roll out so many adverts around there, employing more healthcare workers that can promote the use of antimicrobial resources that people can read whether online or through brochure or whether through healthcare magazines that are out there, for people to actually have a lot of support.” (N,6,AC).

Non-human resources:

• “We have the TG [therapeutic guideline or national guideline] at the moment, which is very good. But I would also prefer if there is more like a statewide [local] guideline that we can have easy access to and also statewide [local] resistance patterns. Yeah. If we have, like a policy statement or a policy guideline that we can easily default to, I think it would really help us.” (D,3,GP).

• “I think even just getting access to things like therapeutic guidelines would be really helpful.…it would be really helpful to have more resources available to the nurses and the general practitioners on appropriateness of antimicrobial prescribing and reviewing pathology. (N,14,AC).”