Self-reported antibiotic stewardship practices and perceived barriers and facilitators among healthcare workers in three tertiary hospitals in Sierra Leone: a convergent mixed- methods study

In hospitals around the world, doctors face a daily dilemma: a patient arrives with a serious infection, but the lab results that would identify the exact germ are not ready. In this moment of uncertainty, the doctor must choose a medicine to fight the illness. Often, they reach for a broad-spectrum antibiotic, a powerful drug designed to kill many different types of bacteria at once. While this approach saves lives in the short term, it carries a hidden cost. When these powerful drugs are used too often or without precision, bacteria learn to survive them. This process, known as antimicrobial resistance, turns once-treatable infections into deadly threats. The solution lies in stewardship, a set of practices where healthcare workers carefully manage these medicines to ensure they remain effective. It involves using the right drug, for the right patient, for the right amount of time. However, knowing the right thing to do is often different from being able to do it, especially in regions where resources are scarce and the pressure to treat a sick patient immediately is intense.

A recent study conducted in Sierra Leone sought to understand how this tension plays out in the daily lives of doctors, nurses, and pharmacists. Researchers traveled to three major teaching hospitals in the capital city, Freetown, to listen to the stories of healthcare workers and count their reported habits. They wanted to see if the gap between knowing the rules and following them was caused by a lack of knowledge, or by the difficult reality of working in a resource-limited environment. The team combined two methods: they asked 214 staff members to fill out a survey about their practices and beliefs, and they held in-depth conversations with 15 key workers to explore the reasons behind those answers. The goal was not just to list what was happening, but to understand why it was happening, so that future efforts to improve care could address the real obstacles.

The findings revealed a complex picture where good intentions often collided with structural barriers. Most of the healthcare workers surveyed knew that antibiotic resistance was a serious problem. They understood that using these drugs unnecessarily could make infections harder to treat later. They also knew that guidelines existed to help them choose the best medicine. Yet, when asked about their actual behavior, the researchers found that these guidelines were not always the deciding factor. In many cases, the choice of antibiotic was shaped by what was available in the pharmacy, what the patient could afford, and the pressure to act quickly when a patient's condition was critical.

One of the most significant hurdles identified was the lack of reliable diagnostic tools. In an ideal scenario, a doctor would wait for a lab test to confirm which bacteria is causing an infection before prescribing a specific drug. In the hospitals studied, these tests were often delayed or simply unavailable. Without this information, doctors felt forced to guess. They described a situation where they had to treat the patient immediately because waiting for a result could be dangerous. This uncertainty led to a reliance on broad-spectrum antibiotics, the "shotgun approach" that covers many possibilities but also kills off helpful bacteria and encourages resistance. The study showed that where diagnostic support was weakest, the use of these broad drugs was highest.

Money and supply chains played an equally critical role. The researchers found that doctors frequently considered a patient's financial situation before writing a prescription. If a recommended drug was too expensive, the patient might not be able to buy it, or might only be able to afford a partial course of treatment. Incomplete treatment is a major driver of resistance, as it allows the strongest bacteria to survive and multiply. Furthermore, the hospitals themselves struggled with stock-outs. When the specific antibiotic a doctor wanted was not on the shelf, they had to choose whatever was available, even if it was not the best option for the patient. In some cases, staff reported that they chose a broad-spectrum drug simply because it was the only one in stock, not because it was clinically necessary.

The study also highlighted the powerful influence of hospital culture and hierarchy. While written guidelines were available in the facilities, they were not always the first thing a doctor consulted. Instead, many healthcare workers, especially those with less experience, looked to their senior colleagues for guidance. They observed what the senior doctors were doing and followed those patterns. This created a culture where experience sometimes outweighed updated scientific advice. If a senior doctor had a habit of prescribing a certain strong antibiotic, junior staff were likely to do the same, even if a newer guideline suggested a different approach. This dynamic meant that changing behavior required more than just handing out pamphlets; it required engaging the leaders who set the tone for the entire team.

Despite these challenges, the healthcare workers expressed a strong desire to improve. They recognized that the current system was not working perfectly and that they needed better support. The researchers concluded that simply training doctors on the rules of stewardship would not be enough. The barriers were too deep and too practical. To make a real difference, hospitals need to ensure that diagnostic tests are fast and reliable, so doctors do not have to guess. They need to guarantee that the right antibiotics are always in stock and affordable for patients. Finally, they need to create a system where guidelines are visible, trusted, and supported by senior staff, so that the best practices become the standard routine rather than an exception. The path forward is not about blaming individuals for their choices, but about building a system that makes the right choice the easy choice.