Health system drivers of antimicrobial resistance: a qualitative exploration of implications for infection prevention and control in hospitals and long-term care facilities in Merseyside

Background
Antimicrobial resistance (AMR) transmission is shaped by a complex interplay of health system factors, many of which remain underexplored or insufficiently addressed. This study investigates concrete systemic transmission drivers in hospitals and long-term care facilities (LTCFs) for older adults in Merseyside, UK.

Methods
Qualitative data were collected through semi-structured interviews with 37 purposively selected participants across hospitals, LTCFs, community settings, and ambulance services. Interviews were informed by the WHO Health System Building Blocks framework and explored AMR transmission pathways and drivers, barriers to infection prevention and control (IPC) practices, and intervention strategies. Thematic analysis was conducted using NVivo 12.

Results
Three key perceived transmission points were identified: prolonged waits in overcrowded hospital areas, inter-facility transfers, and shared spaces within LTCFs and hospital wards. Contributing systemic AMR drivers included inadequate infrastructure, fragmented communication during care transitions, staff turnover, training gaps. Less recognised yet significant risks included the lack of consistent cleaning teams across wards; generic IPC guidelines ill-suited to specific care contexts; and weak administrative oversight of environmental hygiene. While AMR screening was widely recognised as problematic, its cost-effectiveness and clinical utility remain unclear. Communication failures during transfers emerged as an immediately addressable issue, while infrastructure deficits and workforce instability posed more persistent, systemic challenges.

Conclusion
Addressing AMR in care settings requires a context-specific, multi-component approach prioritising effective infection risk communication at care interfaces, tailored IPC protocols, and stable staffing. While long-term investment in infrastructure, screening and workforce is essential, immediate progress is possible through low-resource measures such as improved infection risk information systems and context-specific IPC guidelines.