Antimicrobial stewardship in acute exacerbations of COPD: a qualitative study of hospital pharmacists' perspectives.

INTRODUCTION: Acute exacerbations of chronic obstructive pulmonary disease (COPD) are a common cause of antibiotic use and hospital admissions. Although antimicrobial stewardship (AMS) programs are well established, the specific contribution of pharmacists to COPD-related antimicrobial decision-making remains unclear. AIM: To explore hospital pharmacists' perspectives on their roles, responsibilities, and application of AMS principles in the management of hospitalised patients with COPD exacerbations. METHOD: We conducted a qualitative study using semi-structured interviews with hospital pharmacists involved in COPD care and/or AMS activities at two public tertiary hospitals in Sydney, Australia. Our research was informed by a constructivist epistemology and critical realist orientation. Interviews were conducted via Zoom, audio-recorded, transcribed verbatim, and analysed inductively using reflexive thematic analysis. Recruitment continued until data saturation was reached. RESULTS: Seventeen pharmacists participated and three themes were identified. First, pharmacists described AMS as being a core component of their professional role, including reviewing antimicrobial indication, dose, duration, and spectrum, and promoting appropriate antimicrobial use. However, their involvement typically occurred after initial prescribing, with greater influence on treatment duration than agent selection. Second, organisational and structural factors shaped their scope of practice, including workload pressures, hierarchical prescribing cultures, limited prescribing authority, and electronic system challenges, particularly during transitions of care. Third, pharmacists described patient-centred roles alongside stewardship, including counselling on antibiotic use and discharge medicines, as well as support for inhaler technique, vaccination, and smoking cessation. CONCLUSION: Hospital pharmacists view AMS as a core part of managing COPD exacerbations. Their contributions include antimicrobial review, interdisciplinary communication, and patient education, but their involvement is often advisory and constrained by organisational structures, workload, and prescribing hierarchies.