Abstract

Background/Objectives: Community-acquired pneumonia (CAP) imposes a significant health burden among low and middle-income countries (LMICs). The burden is exacerbated by antimicrobial resistance (AMR) often due to antibiotic misuse and gaps in antimicrobial stewardship (AMS) activities. This study aimed to explore physicians’ perspectives on the diagnosis, treatment, and prevention of CAP in Pakistan, with a focus on how international guidelines are interpreted and adapted to local clinical realities. Methods: A qualitative study was conducted using semi-structured interviews with 33 purposively selected physicians from various specialties, followed by a focus group discussion with 19 of them. Data were analyzed through thematic analysis. Results: Four cross-cutting themes were identified: (1) selective use of diagnostic agents based on severity and access; (2) pragmatic empiric prescribing influenced by resistance trends and antibiotic availability; (3) stewardship intentions constrained by delayed diagnostics and limited infrastructure; and (4) underutilization of preventive strategies including adult vaccinations due to cost and policy gaps. Physicians were aware of IDSA/ATS guidelines but adapted them to local challenges and AMR concerns. Conclusion: Most physicians were unaware of the exact prevalence of causative pathogens and their resistance patterns in Pakistan due to the unavailability of robust local data. Consequently, international guidelines were adapted to local challenges including resistance patterns, limited diagnostics, and resource constraints. Physicians prioritized beta-lactam use and restricted moxifloxacin and azithromycin to mitigate resistance propagation linked to multidrug-resistant (MDR) tuberculosis and extensively-drug resistant (XDR) typhoid. Efforts to improve antimicrobial utilization for CAP in Pakistan need to address implementation barriers and focus on enhancing diagnostic access, vaccine coverage and funding for treatment optimization.