Community antimicrobial stewardship at the system level: an expert elicitation study with health system managers

Background Antimicrobial resistance (AMR) is a systems problem with implications for community care, where most antimicrobial prescribing and use occur. In Australia, antimicrobial stewardship (AMS) is supported by national standards and surveillance programmes, but implementation outside hospitals remains uneven, and accountability across community care settings is fragmented. This study aimed to characterise health system managers’ (HSMs’) perspectives on system-level factors shaping community AMS and refine a preliminary quality improvement (QI) strategy for future testing, contextual adaptation and potential implementation. Methods A structured expert-elicitation study involved semi-structured interviews with 11 HSMs in national, state and regional roles in Australia. Participants appraised strategy components; 1–5 ordinal ratings prompted reflection, not pooled scoring or formal consensus. Reflexive thematic analysis used a hybrid deductive–inductive approach: system-level perspectives were developed inductively, while strategy feedback was synthesised deductively against its components using a convergence/divergence matrix. Results HSMs framed community AMS as a system-level challenge spanning governance, data systems and feedback, resourcing and communication, rather than a prescriber-only problem. Five themes addressed institutionalising AMS through standards and accreditation with implementation support; clarifying roles and accountability across community care settings and supporting organisations; strengthening data systems, monitoring, feedback and access to specialist AMS expertise; aligning national direction and sustained resourcing with a regional coordination function, commonly envisioned as Primary Health Network (PHN)-enabled; and establishing communication systems supporting follow-up and consumer partnership. Judgements converged around three conditions for future implementation: clear accountability; fit-for-purpose data systems and timely, actionable routine audit and feedback; and sustained resourcing for regional coordination. Views diverged on the stringency of requirements and the organisational location and delivery model of that function. Findings informed refinements, including a role-clarity matrix, minimum viable measurement system and staged maturity roadmap. Conclusions HSMs’ expert judgements informed a proposed “national direction, local delivery” model for community AMS, linking national direction and accountability with a regional coordination function, typically PHN-enabled in Australia, and delivery through facility- or local-level leads where feasible. The refined strategy includes role-clarity, measurement and communication arrangements, consumer partnership, and a staged maturity roadmap. It has not been piloted; its feasibility, acceptability, equity, sustainability and effectiveness require prospective testing and contextual evaluation.