How can community pharmacists improve antibiotic use among outpatients? A qualitative study of pharmacists' clinical reasoning.

Background: Antibiotics are widely overused, with over 25% of prescriptions in primary care deemed unnecessary or inappropriate. In France, as in many countries, community pharmacists (CPs)-often in collaboration with prescribers-can modify inappropriate prescriptions or refuse to dispense antibiotics through pharmaceutical interventions (PIs). However, the role of PIs and the clinical reasoning underpinning pharmacists' decisions remain poorly described. Aim: To identify the factors considered by CPs when making PIs related to antibiotic dispensing, and to explore how these factors influence their practice. Methods: This qualitative study involved face-to-face interviews with French CPs. Data were analysed thematically using an integrative approach by two independent researchers. Results: Fifteen interviews were conducted, with data saturation reached after the 10th. PIs followed several steps: identifying the need for intervention, proposing therapeutic alternatives where necessary, contacting the prescriber, ensuring traceability, dispensing antibiotics and providing patient counselling. Pharmacists' clinical reasoning was influenced by factors related to patients, prescribers, their professional environment and broader contextual elements. Some factors were specific to antibiotics, while others were more general. Conclusions: PIs enable CPs to address inappropriate antibiotic prescribing and reduce unnecessary dispensing in outpatient settings. A better understanding of the factors influencing pharmacists' clinical reasoning-such as patient-related, prescriber-related and contextual determinants-could inform strategies to improve antibiotic use. These insights should be integrated into pharmacy education and professional development.