Barriers and Facilitators to Antimicrobial Stewardship in Antibiotic Prescribing and Dispensing by General Practitioners and Pharmacists in Malta: A Systematic Review

Objective: Antimicrobial resistance (AMR) is a top ten threat to global public health, and Malta remains among the highest antibiotic-consuming countries in the European Union. This systematic review aimed to identify barriers and facilitators influencing antimicrobial stewardship in Malta, focusing on general practitioners (GPs) and pharmacists. Methods and Measures: Eligible studies included GPs and/or pharmacists practising in Malta and explored influences on prescribing and/or dispensing. Systematic searches were performed in June 2025 and September 2025 using the following databases MEDLINE, PsycINFO, PsycArticles PubMed, and Google Scholar. Data were extracted using a modified Cochrane template, and quality was assessed using Joanna Briggs Institute tools. Findings were synthesised using the socio-ecological model and mapped to the COM-B framework. Results: Seven studies met inclusion criteria, with a total sample size of 495 participants. Barriers included diagnostic uncertainty, knowledge gaps, misconceptions about AMR, patient expectations, commercial pressures, limited diagnostic and IT infrastructure, and defensive prescribing linked to indemnity insurance. Facilitators included stewardship values, stronger guideline adherence among younger GPs, trust-based GP–patient relationships, GP–pharmacist collaboration, and intervention effects from a social marketing programme. Mapping to COM-B showed barriers and facilitators interacting across capability, opportunity, and motivation. Conclusions: Prescribing in Malta is shaped by diagnostic uncertainty, entrenched habits, patient expectations, and structural gaps. Although the evidence base was limited and partly overlapping, consistent findings across mixed method designs highlighted that effective stewardship will require rapid diagnostics, e-prescribing, over-the-counter enforcement, and GP–pharmacist collaboration, supported by policy reforms aligning indemnity and sick-leave systems with AMR goals.