Clinical Experiences and Treatment Decision-Making for Infections due to Carbapenem- Resistant Organisms Across Sri Lanka: A Qualitative Study

Abstract

Introduction:Antimicrobial resistance is a major global health threat with rising mortality projected to exceed 8 million deaths annually by 2050. Of particular concern is the increasing prevalence of carbapenem-resistant organisms (CROs) which are associated with limited antibiotic options and high mortality. In low- and middle-income countries, including Sri Lanka, management of CROs is further complicated by limited diagnostic capacity and structural challenges. Moreover, there is limited qualitative evidence describing how microbiologists and physicians navigate diagnostic uncertainty and therapeutic decision making in real-world clinical setting. This study therefore aimed to explore microbiologist and physician experiences in managing CRO infections across Sri Lanka.Methods:This qualitative study used semi-structured interviews with 12 microbiologists and 12 physicians involved in the management of CRO infections across various hospital settings and stages of experiences in Sri Lanka. Participants were purposively sampled across teaching, district and base hospitals. Interviews were audio-recorded, transcribed and analyzed using thematic analysis with iterative codebook development and intercoder reliability assessments to ensure analytic rigor.Results:The findings from this study were organized into three thematic categories: diagnostic and therapeutic resources; workforce capacity; and stewardship, infection control and prevention which were grounded in the interview data and reflected the overarching factors shaping the practice of both microbiologists and physicians when managing infections due to CROs. Across these categories, three major interrelated challenges emerged: 1) limited diagnostic capacity and restricted antibiotic availability strongly influence treatment strategies, often leading to a preference for combination therapy; 2) structural and system-level constraints affect CRO management through hurdles related to staffing, antibiotic procurement and disparities between government and private sector hospitals; and 3) infection prevention, antimicrobial stewardship and surveillance are increasingly critical strategies deployed in settings where antibiotic options remain limited.Conclusion:Management of CRO infections across Sri Lanka is strongly shaped by limitations in diagnostics, antibiotic availability, workforce capacity and broader health system infrastructure. Although limited access to targeted antibiotics remains a significant challenge, the findings of this study indicate that expanding antibiotic options alone is unlikely to sustainably address the burden of CRO infections. Instead, containment of CROs will require coordinated strategies that strengthen laboratory capacity, expand workforce training and invest in infection prevention, antimicrobial stewardship and surveillance systems across Sri Lanka.