Implementing a multimodal antimicrobial stewardship programme in primary care in Kosova-a protocol for implementation...

Antimicrobial resistance is a growing global health crisis, with primary care settings being a major contributor due to inappropriate antibiotic prescribing. In Kosova, the overuse of antibiotics for upper respiratory tract infections remains a critical challenge, especially in primary care, driven by limited diagnostic tools, regulatory gaps, and prescribing behaviours. This paper presents the protocol for implementing and evaluating a multimodal antimicrobial stewardship programme in primary healthcare facilities to promote rational antibiotic use and reduce antimicrobial resistance.

The primary aim of the intervention is to improve the appropriate use of antibiotics for acute upper respiratory tract infections by implementing an antimicrobial stewardship programme in primary healthcare facilities, and use the knowledge from implementation to implement the programme on a larger scale in other primary care centres or other levels of care.

A mixed-methods implementation research approach will be adopted to examine the impact of the antimicrobial stewardship programme in Kosova, incorporating quantitative and qualitative methods. The multimodal antimicrobial stewardship programme is complemented by research components designed to measure implementation processes and programme performance. These research components are designed in line with multiple conceptual frameworks, such as RE-AIM and the Consolidated Framework for Implementation Research, as the theoretical basis. The study component focusing on the implementation of the antimicrobial stewardship programme in the pilot municipalities will examine barriers to and facilitators of change across all domains of potential influence, i.e., innovation/intervention, participants, inner setting, outer setting, and implementation process. The conjoint analysis examines a subgroup of participants, i.e., prescribers of antibiotics, and their preferences regarding antibiotic prescribing. The cost-effectiveness component contributes to the review of key outcomes of the intervention, i.e., antibiotic use and costs. In contrast, the cost of intervention analysis provides valuable information on inner and outer settings, i.e., the cost implications of implementation relevant to potential scale-up. The Chamber of Doctors of Kosova and its Institutional Review Board formally approved the project under Decision No. 122/24, dated 26.08.2024. All knowledge from the programme implementation will be disseminated through relevant channels and tools.

By piloting an antimicrobial stewardship programme aligned with national and international guidelines, key national stakeholders aim to strengthen stewardship practices through training, diagnostics, and continuous quality improvement. This intervention addresses critical gaps between antimicrobial resistance policy commitments and practical implementation in Kosova's primary care. The mixed-methods research design of study components, grounded in the relevant implementation science frameworks, will generate evidence on barriers, enablers, and economic impact, informing policy updates and scale-up strategies. While focused on Kosova, findings are expected to provide valuable lessons for other low- and middle-income countries facing similar antimicrobial resistance challenges.