Adapting global guidelines to local contexts: optimising community-acquired pneumonia (CAP) specific prescribing in Pakistan to counter antimicrobial resistance

BACKGROUND/OBJECTIVES: Community-acquired pneumonia (CAP) imposes a significant health burden among low- and middle-income countries. The burden is exacerbated by antimicrobial resistance (AMR), often due to inappropriate antibiotic agent use and gaps in antimicrobial stewardship activities. This study aimed to explore physicians' perspectives on the diagnosis, treatment and prevention of CAP in Pakistan, with a focus on how international guidelines are interpreted and adapted to local clinical realities. METHODS: A qualitative study was conducted using semistructured interviews with 33 purposively selected physicians from various specialties, followed by a focus group discussion with 19 of them. Data were analysed through thematic analysis. RESULTS: Four cross-cutting themes were identified: (1) selective use of diagnostic agents based on severity and access; (2) pragmatic empiric prescribing influenced by resistance trends and antibiotic availability; (3) stewardship intentions constrained by delayed diagnostics and limited infrastructure and (4) underutilisation of preventive strategies including adult vaccinations due to cost and policy gaps. Physicians were aware of Infectious Diseases Society of America/American Thoracic Society guidelines but adapted them to local challenges and AMR concerns. CONCLUSIONS: Most physicians were unaware of the exact prevalence of causative pathogens and their resistance patterns in Pakistan due to the unavailability of robust local data. Consequently, international guidelines were adapted to local challenges including resistance patterns, limited diagnostics and resource constraints. Physicians prioritised beta-lactam antibiotics use and restricted moxifloxacin and azithromycin to mitigate resistance propagation linked to multidrug-resistant tuberculosis and extensively drug-resistant typhoid. Efforts to improve antimicrobial utilisation for CAP in Pakistan need to address implementation barriers and focus on enhancing diagnostic access, vaccine coverage and funding for treatment optimisation.