Practice-level mechanisms contributing to successful implementation of a UTI antibiotic stewardship intervention: a qualitative study in Dutch general practices

A recent multi-country cluster randomised trial (ImpresU) found that implementation of an antibiotic stewardship intervention (ASI) safely reduced antibiotic prescribing for suspected urinary tract infections (UTI) in frail older adults. However, it remains to be elucidated how the ASI achieved organisational change at practice-level. Therefore, the aim in this study, was to unravel practice-level mechanisms contributing to successful implementation of the ImpresU UTI ASI in Dutch general practices. A qualitative interview study with healthcare professionals from general practices and the older adult care organisations was performed. These general practices and older adult care organisations were part of all six Dutch intervention clusters in the ImpresU trial, where the UTI ASI has led to fewer antibiotic prescribing. Semi-structured interviews were performed with 15 health care professionals between November 2023 and February 2024. Interviews were transcribed verbatim and analysed using thematic analysis. We identified four practice-level mechanisms contributing to successful UTI ASI implementation: (1) scheduling a dedicated moment for interprofessional discussions about suspected UTIs, (2) making step-by-step work instructions visually available for all health care professionals involved, (3) structured steps and nudging to facilitate adoption of new practices and (4) enhancing motivation by a team champion. All of the mechanisms together seem to have led to a more adequate UTI care pathway in the general practices, through which they could reduce antibiotic prescribing. We identified four key practice-level mechanisms through which Dutch general practices implemented an ASI to improve their UTI care pathway for frail older adults. In-depth insight into how implementation works through these mechanisms can inform strategies for broader UTI ASI implementation in diverse general practice settings.