Changing Antibiotic Prescribing Cultures: A Comprehensive Review of Social Factors in Outpatient Antimicrobial Stewardship and Lessons Learned from the Local Initiative AnTiB.

Antimicrobial resistance (AMR) constitutes a major global health challenge, driven significantly by inappropriate antibiotic use in human medicine. Despite the existence of evidence-based guidelines, variability in antibiotic prescribing persists, influenced by psychosocial factors, diagnostic uncertainty, patient expectations, and local prescribing cultures. Outpatient care, the setting in which most antibiotics are prescribed, is particularly affected by such challenges. Traditional top-down interventions, such as national guidelines, often fail to achieve sustained behavioral change among prescribers. In this comprehensive review, we provide an overview of the psychological and behavioral factors influencing antimicrobial stewardship (AMS) implementation, as well as describe a bottom-up project working to meet these challenges: the "Antibiotic Therapy in Bielefeld" (AnTiB) initiative. AnTiB employs a cross-sectoral strategy aimed at developing rational prescribing culture by means of locally developed consensus guidelines, interdisciplinary collaboration, and regularly held trainings. By addressing both the organizational and psychological aspects of prescribing practices, AnTiB has facilitated a harmonization of antibiotic use across specialties and care interfaces at the local level. The initiative's success has led to its expansion within Germany, including through the creation of the AMS-Network Westphalia Lippe and the development of AnTiB-based national pediatric recommendations. These projects are all grounded in social structures designed to strengthen the long-term establishment of AMS measures. Our efforts underscore the importance of considering local social norms, professional network, and real-world practice conditions in AMS interventions. Integrating behavioral and social science approaches into outpatient antimicrobial stewardship-exemplified by the practitioner-led AnTiB model-improves acceptability and alignment with stewardship principles; wider adoption will require local adaptation, routine outpatient resistance surveillance, structured evaluation, and sustainable support.