Root cause analysis of the challenges to sustain effectiveness of clinical pharmacist-driven antimicrobial stewardship in a Chinese Tertiary Hospital.

Introduction: To optimize pharmacist engagement in antimicrobial stewardship (AMS), this study assessed general surgeons' knowledge, practices, and perspectives on AMS and pharmacist interventions. Although antibiotic utilization density has decreased consistently over three years following the involvement of clinical pharmacists, challenges to AMS persist. Methods: This study employed a root cause analysis of interviews with general surgeons at a hospital in Tianjin. The interviews were informed by a questionnaire developed using the Delphi method. Results: The interview analysis identified four key barriers: limited surgeon awareness of AMS guidelines, complex antibiotic selection driven by disease severity, patient-specific clinical factors, and unresolved complex cases requiring tailored approaches. Surgeons proposed four strategic recommendations: (1) refining the AMS system systematically; (2) sustaining AMS outcomes through multifaceted efforts; (3) increasing the frequency of pharmacistsurgeon interactions; and (4) expanding pharmacists clinical roles beyond supervision and training. Discussion: The findings underscore the necessity of enhancing surgeon education on AMS guidelines and policies. Furthermore, increasing the frequency of pharmacistsurgeon collaboration would better support antibiotic selection, adjustment, drug sensitivity test interpretation, and access to specialized treatment information, thereby addressing the clinical complexities hindering the efficacy of AMS. The study also highlights critical pathways to strengthen system-level management strategies amid evolving health care demands.