Disruption and Adaptation of Antimicrobial Stewardship Programs in Iranian Hospitals During the COVID-19 Pandemic: A...

Introduction Antimicrobial resistance (AMR) is a pressing global health issue, exacerbated by inappropriate antibiotic use. In Iran, the 2016 National Action Plan on AMR established hospital-based antimicrobial stewardship programs (ASPs), including audit-feedback, prescription restrictions, and guideline-based prescribing to promote rational prescribing. The COVID-19 pandemic disrupted these efforts, resulting in increased empirical antibiotic use. This qualitative study, using a descriptive phenomenological approach, explores healthcare providers' perceptions of antibiotic prescribing and ASP implementation in two Iranian teaching hospitals during the COVID-19 pandemic, focusing on context-specific barriers and adaptations. Methods Conducted from May 20, 2022, to January 20, 2023, at two 500-bed teaching hospitals in Qazvin, Iran, this descriptive phenomenological study involved 12 purposively sampled healthcare providers (10 physicians, one clinical pharmacist, one microbiology lab supervisor) until thematic saturation, achieved when no new themes emerged after the 10th interview, as confirmed by codebook review. Semi-structured interviews (45-60 minutes), conducted in Persian in private settings, explored prescribing changes, ASP disruptions, and adaptations. Transcripts were translated into English, anonymized, and analyzed thematically, generating ~150 codes clustered into four themes. Trustworthiness was ensured via triangulation, audit trails, and member checking, with translation accuracy verified by a second bilingual researcher. Ethical approval was granted by the Qazvin University of Medical Sciences Ethics Committee (IR.QUMS.REC.1403.091). Results Four themes emerged from the qualitative analysis, reflecting participant-reported experiences: (1) Increased empirical prescribing - all participants reported diagnostic uncertainty and public pressure driving preemptive use of broad-spectrum antibiotics (e.g., ceftriaxone, meropenem). (2) Disruption of stewardship programs - most participants (10/12) noted suspended ASP activities (e.g., audits) due to staff redeployment. (3) Systemic and laboratory constraints - all participants highlighted delayed cultures and antibiotic shortages as barriers. (4) Adaptations and lessons learned - most participants (10/12) described late-2021 adaptations like virtual consultations. All findings reflect participant-reported experiences and perceptions, not objectively verified outcomes. Conclusion This qualitative study provides exploratory insights into healthcare providers' perceptions of AMS disruptions in two Qazvin hospitals, with reported increases in empirical prescribing due to uncertainty and resource constraints. Participant-reported adaptations, such as virtual reviews, were noted, though their sustainability remains unevaluated. International comparisons with the UAE, UK, and India highlight shared challenges and the need for context-specific protocols and diagnostics. Findings are limited to participant perceptions and require further validation through mixed-methods research. Policymakers may consider exploratory strategies like virtual tools and public education, pending feasibility studies.