# Barriers and Facilitators in the Implementation of a Syndromic Antibiogram for Pediatric Patients Hospitalized in Maputo, Mozambique: A Qualitative Study Using the Dynamic Adaptation Process (DAP) Framework

## TL;DR

This study explores challenges and enablers for using syndromic antibiograms in Mozambique to improve antibiotic use in pediatric care.

## Contribution

The study applies the Dynamic Adaptation Process framework to identify barriers and facilitators for implementing syndromic antibiograms in a low-resource setting.

## Key findings

- Barriers include limited awareness, poor communication, and insufficient resources at individual and organizational levels.
- Facilitators include health worker motivation, collaboration, and functional laboratory services.
- Successful implementation requires addressing systemic issues and fostering institutional support.

## Abstract

Introduction: The global rise in antimicrobial resistance poses a growing threat to public health, particularly in low- and middle-income countries where diagnostic capacity and surveillance systems remain limited. In these settings, optimizing empiric antibiotic prescribing is critical, and syndromic antibiograms offer a promising approach to support evidence-based decision-making. This study examines anticipated barriers and facilitators to the adoption of syndromic antibiograms from the perspectives of pediatric clinicians and laboratory professionals at Maputo Central Hospital in Mozambique. Methods: Guided by the Dynamic Adaptation Process (DAP) framework, this qualitative study used semi-structured interviews with eighteen healthcare professionals to explore empiric antibiotic prescribing practices, perceptions of syndromic antibiograms, and system-level barriers and facilitators. Data were analyzed thematically using deductive codes derived from the DAP framework alongside inductive codes generated from participants’ narratives. Results: Barriers were identified at individual, organizational, and systems levels. Individual barriers included limited awareness, reliance on traditional practices, and resistance to change. Organizational barriers included weak leadership support, insufficient training, poor communication between clinicians and laboratory staff, suboptimal sample collection, heavy workloads, and staff shortages. Systems-level barriers comprised shortages of laboratory supplies and medicines, delays in laboratory results, and weak monitoring mechanisms. Facilitators included health worker motivation for evidence-based practice, organizational collaboration, peer and team support, and the presence of influential champions. Systems-level enablers included functional laboratory services, supportive institutional environments, alignment with clinical guidelines, and recognition of clinical utility. Conclusions: Successful implementation of syndromic antibiograms in LMIC will require addressing systemic and organizational barriers while fostering professional motivation, collaboration, and institutional support. Sustainable integration will depend on coordinated strategies—including resource strengthening, continuous training, supportive leadership, and structured monitoring—that collectively strengthen antimicrobial stewardship and inform health policy.