Implementation of a community antibiotic stewardship program in two Portuguese municipalities

Antimicrobial resistance (AMR) represents one of the most pressing threats to public health, with implications for current and future generations. Infections caused by resistant bacteria have risen, driving increased morbidity, mortality, and healthcare costs. The overuse and misuse of antibiotics are key factors in the development of AMR. Almada-Seixal Local Health Unit serves two Portuguese municipalities. Between 2024 and 2025, the proportion of cephalosporins and quinolones among all antibiotics prescribed by general practitioners (GPs) increased. Additionally, 22% of GPs reported that they preferred not to prescribe an antibiotic at least once in the previous week, but felt unable to do so, citing fear of clinical deterioration or complications and diagnostic uncertainty as the main barriers. These findings underscore the need for a structured antibiotic stewardship program at the community level. We implemented a community-based antibiotic stewardship program targeting the most frequently diagnosed community-acquired bacterial infections: urinary tract infections, tonsillitis, and pneumonia. Key interventions included the development of a prescribing surveillance tool to monitor community GPs’ prescribing patterns, a Community Cumulative Antibiogram Report, and community-adapted evidence-based prescribing guidelines. We also provided GPs with training sessions focused on the cultural and emotional aspects of prescribing, and patient-directed educational materials to support shared decision-making. GPs reported high satisfaction with the training and perceived improved confidence in prescribing decisions. The main challenge was accessing microbiological data to develop the Cumulative Antibiogram Report from private laboratories. We also recognized that prescribing data alone is insufficient to capture prescribing behavior. Future steps include implementing targeted audit and feedback cycles directed at GPs to support sustained improvement.

Key messages

• Community antibiotic stewardship programs with surveillance, cumulative antibiograms and tailored GP training can shift prescribing culture.

• Fear and uncertainty drive inappropriate prescribing. Addressing GPs’ cultural and emotional barriers is essential for stewardship.