The latent system factors that influence antimicrobial use and governance in healthcare: a scoping review of high-income health systems.

BACKGROUND: Inappropriate antimicrobial use accelerates antimicrobial resistance (AMR), creating tensions between antimicrobial stewardship and timely treatment. Despite global calls to action, gaps between recommendations and practice persist, largely due to system factors shaping clinical work. This review examines how systems approaches have been applied to the use and governance of antimicrobials. METHODS: This scoping review followed PRISMA-ScR. Eligible sources included empirical studies, reviews, protocols, theses/dissertations, and improvement projects across healthcare settings in high-income countries. Studies required explicit use of systems approaches. EMBASE, MEDLINE, and CINAHL were searched in November 2024. Grey literature was added in February 2025. Search was updated in July 2025. Three researchers extracted data on study characteristics, systems approaches, and organisational implications. Review was preregistered (https://osf.io/p3xsf). FINDINGS: 25 articles were ultimately included. Seven focused on acute care and 18 leveraged interviews. Among studies involving participants (n = 18), 12 involved only frontline level participants, four involved participants from different organisational levels with a focus on frontline settings, and two focused on management settings. Implications of the use of systems approaches were identified across three organisational levels: micro (patient care), meso (management), and macro (leadership). INTERPRETATION: This is the first review to map the implications of systems approaches for AMR at different organisational levels. Findings suggest gaps in the application of systems approaches at levels most responsible for strategic decisions and implementation. Given recent criticism about safety management and calls for strong AMS leadership, this gap represents a missed improvement opportunity. Future research should explore how alignment toward AMS is impacted due to system factors within and between organisational levels. FUNDING: Supported by INEOS Oxbridge Initiative on Antimicrobial Resistance (Project number E4R00010).