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

This scoping review examined how systems approaches have been applied to antimicrobial use and governance in high-income healthcare settings. From 25 studies (mostly qualitative, with many using interviews), the review mapped implications at three organisational levels: micro (patient care), meso (management), and macro (leadership). Most research focused on frontline settings, while few addressed management or leadership levels where strategic decisions and implementation authority reside. The findings highlight that gaps between antimicrobial stewardship goals and practice are strongly shaped by latent system factors and underexplored organisational dynamics. The review concludes that limited use of systems approaches at leadership and management levels is a missed opportunity, and future research should investigate how better alignment across organisational levels can strengthen stewardship and combat AMR.