Antimicrobial resistance (AMR) has emerged as one of the most pressing public health challenges of the 21st century. The World Health Organization (WHO) has declared AMR a top global health threat, with estimates suggesting that drug-resistant infections could cause 10 million deaths annually by 2050 if current trends continue [1,2]. In India, the burden of AMR is particularly high due to high infectious disease prevalence, widespread over-the-counter availability of antibiotics, and variable regulatory enforcement [3,4].

Antimicrobial stewardship (AMS) refers to coordinated interventions designed to improve and measure the appropriate use of antimicrobials by promoting the selection of the optimal antimicrobial drug regimen, dose, duration of therapy, and route of administration [5]. Effective AMS programs have been shown to reduce antimicrobial consumption, improve clinical outcomes, decrease the incidence of resistance, and lower healthcare costs [6,7].

Healthcare workers (HCWs), including physicians, nurses, pharmacists and interns, play pivotal roles in the success of AMS initiatives. Their knowledge of resistance mechanisms and stewardship principles, attitudes toward rational prescribing, and perceptions of institutional support directly influence antimicrobial prescribing behaviour and infection control practices [8,9]. Previous studies from various regions of India have reported satisfactory theoretical knowledge among clinicians but significant gaps in practice and limited formal training exposure [10–13].

Western India, particularly the Union Territory of Dadra and Nagar Haveli and Daman and Diu, has a unique demographic and healthcare landscape. NAMO Medical Education and Research Institute (NAMOMERI), Silvassa, is a relatively new government medical college established in 2019, attached to a 650+ bed tertiary care hospital. Data on KAP regarding AMS and AMR among HCWs in this setting are lacking. Such baseline information is essential before implementing or strengthening institutional AMS programs.

Therefore, the present study was undertaken to assess the knowledge, attitude and perception of healthcare workers regarding antimicrobial stewardship and antimicrobial resistance at a tertiary care centre in Western India, and to identify specific educational and systemic gaps that require intervention.

2.1 Study Design and Setting This was a hospital-based, cross-sectional observational study conducted at NAMO Medical Education and Research Institute (NAMOMERI) and its attached tertiary care teaching hospital (NAMO Hospital / Shri Vinoba Bhave Civil Hospital), Silvassa, Union Territory of Dadra and Nagar Haveli and Daman and Diu, India. The hospital is a 650-bed multispecialty facility providing secondary and tertiary care services to a mixed urban–rural population. The study was carried out over a six-month period from January 2025 to June 2025. 2.2 Study Population and Sample Size All healthcare workers involved in patient care or antimicrobial-related decision-making were eligible, including faculty members, postgraduate residents, interns, nursing staff and pharmacists. Inclusion criteria were: (i) currently working at the institute for at least three months, (ii) willingness to provide informed consent, and (iii) ability to complete the questionnaire in English. Exclusion criteria included administrative staff without clinical contact and those on long leave during the study period. Sample size was calculated using the formula for proportion: n = Z²pq/d², assuming 50% prevalence of good knowledge (to maximize sample size), 95% confidence level (Z=1.96) and 6% absolute precision. The calculated sample size was 267. Allowing for 15% non-response, the target was set at 315. A total of 400 questionnaires were distributed; 310 complete responses were received (response rate 77.5%). 2.3 Study Tool A structured, self-administered questionnaire was developed after reviewing relevant literature and WHO AMS core elements [5,10,14]. The questionnaire was validated by three subject experts (one pharmacologist, one microbiologist and one infectious disease specialist) for content and face validity. A pilot study was conducted among 20 HCWs (not included in the final analysis) to assess clarity and reliability (Cronbach’s alpha = 0.81). The final questionnaire consisted of four sections: (A) Demographic and professional characteristics (age, gender, professional category, years of experience, department, prior AMS training); (B) Knowledge domain – 15 multiple-choice and true/false items covering causes of AMR, principles of AMS, WHO AWaRe classification, antibiogram use, de-escalation, and duration of therapy (maximum score 15); (C) Attitude domain – 10 statements on a 5-point Likert scale (Strongly Agree to Strongly Disagree) assessing beliefs about AMS impact, responsibility, patient pressure, and institutional support (maximum score 20 after reverse coding of negative items); (D) Perception domain – 15 items assessing perceived barriers, facilitators, confidence in prescribing, and institutional readiness for AMS (maximum score 15). Scoring and categorization: For knowledge and perception, scores 70% of maximum were classified as “Good”, 50–69% as “Average”, and <50% as “Poor”. Attitude scores 70% were considered “Positive/Favourable”. 2.4 Data Collection After obtaining institutional ethics committee approval (IEC/NAMOMERI/2024/087) and informed consent, the questionnaire was distributed in paper form during departmental meetings and via institutional email/WhatsApp groups. Participants were given 20–25 minutes to complete the form anonymously. Incomplete questionnaires (missing >20% of items) were excluded. 2.5 Statistical Analysis Data were entered into Microsoft Excel and analysed using IBM SPSS Statistics version 26.0. Continuous variables are presented as mean ± standard deviation (SD) or median (interquartile range). Categorical variables are expressed as frequencies and percentages. Comparison of mean scores across professional categories was performed using one-way ANOVA followed by Tukey’s post-hoc test. Associations between categorical variables were assessed using Chi-square or Fisher’s exact test. Pearson correlation was used to examine relationships between knowledge, attitude and perception scores. A two-tailed p-value <0.05 was considered statistically significant. 2.6 Ethical Considerations The study protocol was approved by the Institutional Ethics Committee of NAMO Medical Education and Research Institute, Silvassa. Written informed consent was obtained from all participants. Anonymity and confidentiality of responses were maintained throughout.

Demographic and Professional Characteristics

A total of 310 healthcare workers completed the questionnaire (response rate 77.5%). The mean age of participants was

31.8 ± 7.4 years (range 22–58 years). Females constituted 54.2% (n=168) of the sample. The professional distribution was: doctors (faculty and residents) 45.8% (n=142), nurses 31.6% (n=98), interns 13.5% (n=42) and pharmacists 9.0% (n=28) (Figure 1). The majority (61.3%) had 5 years of professional experience. Only 41.3% (n=128) reported having received any formal training or continuing medical education (CME) related to AMS or AMR in the preceding 12 months.

Table 1. Demographic and professional characteristics of study participants (N=310)

Figure 1. Distribution of study participants by professional category (N=310).

Overall, Knowledge, Attitude and Perception Scores

The mean knowledge score was 11.2 ± 2.1 out of a maximum of 15 (74.7% of maximum). The mean attitude score was

16.8 ± 2.4 out of 20 (84.0%), and the mean perception score was 11.5 ± 2.3 out of 15 (76.7%) (Figure 2). Using predefined cut-offs, 58.4% of participants demonstrated good knowledge, 72.3% had a favourable attitude, and 61.0% showed good perception regarding AMS and AMR (Figure 3, Table 2).

Figure 2. Mean knowledge, attitude and perception scores among healthcare workers (error bars represent SD).

Figure 3. Categorization of knowledge, attitude and perception levels among participants (N=310).

Table 2. Distribution of knowledge, attitude and perception levels (N=310)

Comparison of Scores by Professional Category

Significant differences were observed in mean knowledge scores across professional categories (ANOVA F=18.74, p<0.001). Doctors had the highest mean knowledge score (12.1 ± 1.8), followed by pharmacists (10.8 ± 2.0), nurses (10.4 ± 2.1) and interns (9.9 ± 2.3). Attitude scores also differed significantly (F=5.62, p=0.001), with doctors scoring highest. Perception scores showed a similar trend but the difference did not reach statistical significance after post-hoc adjustment for interns versus pharmacists (Table 3, Figure 4).

Table 3. Mean KAP scores by professional category

Figure 4. Mean knowledge, attitude and perception scores by professional category.

Item-wise Analysis of Knowledge Domain

Over 90% of participants correctly identified that AMR is a major global health threat and that overuse/misuse of antibiotics is a primary driver of resistance. However, only 38.7% were familiar with the WHO Access, Watch, Reserve (AWaRe) classification of antibiotics, and 62.9% correctly understood the role of local antibiograms in guiding empirical therapy. Awareness of de-escalation as a core AMS principle was present in 71.6% of respondents (Figure 5, Table 4).

Figure 5. Percentage of correct responses to selected knowledge items (green 70%, amber 50–69%, red <50%).

Table 4. Selected knowledge items and correct response rates (N=310)

Attitude Domain Findings

A large majority agreed or strongly agreed that AMS programs can reduce AMR (86%) and that their own prescribing behaviour influences local resistance patterns (86%). A high proportion (89%) expressed the need for more formal AMS training. Notably, 77% acknowledged that patient/relative pressure sometimes influences antibiotic prescribing decisions. Only 53% felt that the current hospital antibiotic policy was adequate and effectively implemented (Figure 6).

Figure 6. Distribution of responses to selected attitude statements (stacked percentages).

Perception and Barriers

The most frequently perceived barriers to rational antimicrobial use were: lack of updated institutional guidelines (reported by 58.4%), time constraints during busy clinical schedules (52.3%), limited access to rapid diagnostic tests (49.7%), and insufficient feedback on antimicrobial consumption and resistance data (47.1%). Facilitators identified included availability of infectious disease consultation (desired by 71.6%), regular antibiogram dissemination (68.4%), and mandatory AMS modules in induction training (74.2%).

Demographic and Professional Characteristics

A total of 310 healthcare workers completed the questionnaire (response rate 77.5%). The mean age of participants was

31.8 ± 7.4 years (range 22–58 years). Females constituted 54.2% (n=168) of the sample. The professional distribution was: doctors (faculty and residents) 45.8% (n=142), nurses 31.6% (n=98), interns 13.5% (n=42) and pharmacists 9.0% (n=28) (Figure 1). The majority (61.3%) had 5 years of professional experience. Only 41.3% (n=128) reported having received any formal training or continuing medical education (CME) related to AMS or AMR in the preceding 12 months.

Table 1. Demographic and professional characteristics of study participants (N=310)

Figure 1. Distribution of study participants by professional category (N=310).

Overall, Knowledge, Attitude and Perception Scores

The mean knowledge score was 11.2 ± 2.1 out of a maximum of 15 (74.7% of maximum). The mean attitude score was

16.8 ± 2.4 out of 20 (84.0%), and the mean perception score was 11.5 ± 2.3 out of 15 (76.7%) (Figure 2). Using predefined cut-offs, 58.4% of participants demonstrated good knowledge, 72.3% had a favourable attitude, and 61.0% showed good perception regarding AMS and AMR (Figure 3, Table 2).

Figure 2. Mean knowledge, attitude and perception scores among healthcare workers (error bars represent SD).

Figure 3. Categorization of knowledge, attitude and perception levels among participants (N=310).

Table 2. Distribution of knowledge, attitude and perception levels (N=310)

Comparison of Scores by Professional Category

Significant differences were observed in mean knowledge scores across professional categories (ANOVA F=18.74, p<0.001). Doctors had the highest mean knowledge score (12.1 ± 1.8), followed by pharmacists (10.8 ± 2.0), nurses (10.4 ± 2.1) and interns (9.9 ± 2.3). Attitude scores also differed significantly (F=5.62, p=0.001), with doctors scoring highest. Perception scores showed a similar trend but the difference did not reach statistical significance after post-hoc adjustment for interns versus pharmacists (Table 3, Figure 4).

Table 3. Mean KAP scores by professional category

Figure 4. Mean knowledge, attitude and perception scores by professional category.

Item-wise Analysis of Knowledge Domain

Over 90% of participants correctly identified that AMR is a major global health threat and that overuse/misuse of antibiotics is a primary driver of resistance. However, only 38.7% were familiar with the WHO Access, Watch, Reserve (AWaRe) classification of antibiotics, and 62.9% correctly understood the role of local antibiograms in guiding empirical therapy. Awareness of de-escalation as a core AMS principle was present in 71.6% of respondents (Figure 5, Table 4).

Figure 5. Percentage of correct responses to selected knowledge items (green 70%, amber 50–69%, red <50%).

Table 4. Selected knowledge items and correct response rates (N=310)

Attitude Domain Findings

A large majority agreed or strongly agreed that AMS programs can reduce AMR (86%) and that their own prescribing behaviour influences local resistance patterns (86%). A high proportion (89%) expressed the need for more formal AMS training. Notably, 77% acknowledged that patient/relative pressure sometimes influences antibiotic prescribing decisions. Only 53% felt that the current hospital antibiotic policy was adequate and effectively implemented (Figure 6).

Figure 6. Distribution of responses to selected attitude statements (stacked percentages).

Perception and Barriers

The most frequently perceived barriers to rational antimicrobial use were: lack of updated institutional guidelines (reported by 58.4%), time constraints during busy clinical schedules (52.3%), limited access to rapid diagnostic tests (49.7%), and insufficient feedback on antimicrobial consumption and resistance data (47.1%). Facilitators identified included availability of infectious disease consultation (desired by 71.6%), regular antibiogram dissemination (68.4%), and mandatory AMS modules in induction training (74.2%).

Correlation Analysis

Pearson correlation analysis revealed a moderate positive correlation between knowledge and attitude scores (r=0.48, p<0.001), knowledge and perception scores (r=0.42, p<0.001), and attitude and perception scores (r=0.51, p<0.001). Participants who had received prior AMS training had significantly higher mean knowledge (12.0 vs 10.7, p<0.001) and attitude scores (17.4 vs 16.3, p=0.002) compared with those without recent training.

Correlation Analysis

Pearson correlation analysis revealed a moderate positive correlation between knowledge and attitude scores (r=0.48, p<0.001), knowledge and perception scores (r=0.42, p<0.001), and attitude and perception scores (r=0.51, p<0.001). Participants who had received prior AMS training had significantly higher mean knowledge (12.0 vs 10.7, p<0.001) and attitude scores (17.4 vs 16.3, p=0.002) compared with those without recent training.

This cross-sectional study provides the first baseline assessment of knowledge, attitude and perception regarding antimicrobial stewardship and resistance among healthcare workers at a tertiary care teaching centre in the Union Territory of Dadra and Nagar Haveli and Daman and Diu. The overall findings indicate a generally favourable attitude toward AMS (72.3% positive) and moderately good knowledge and perception levels, yet several important gaps remain that warrant targeted interventions. The mean knowledge score of 74.7% is comparable to findings from other Indian tertiary care centres. A multicentric study among Indian clinicians reported satisfactory theoretical knowledge but noted discrepancies in case-based application [10]. In our study, while over 90% correctly recognized AMR as a major threat and the role of antibiotic overuse, awareness of the WHO AWaRe classification was only 38.7%. This is consistent with recent reports from Bengaluru where only 36% of interns and residents were familiar with AWaRe [12]. The AWaRe framework is a cornerstone of the WHO Global Action Plan on AMR and of India’s National Action Plan; its limited penetration among frontline HCWs highlights a clear educational priority [15]. Doctors scored significantly higher than nurses, pharmacists and interns in knowledge and attitude domains. Similar hierarchies have been documented in previous Indian studies, where faculty and senior clinicians demonstrated better KAP than junior cadres and nursing staff [13,16]. Nurses and pharmacists, however, are critical partners in AMS—nurses through administration, monitoring and patient education, and pharmacists through prescription review and formulary management. The relatively lower scores in these groups underscore the need for interprofessional AMS education rather than physician-centric approaches alone [17]. Attitude scores were the strongest domain (84% of maximum), with the large majority acknowledging personal responsibility and the potential of AMS to curb resistance. This positive disposition is encouraging and mirrors findings from other Indian KAP surveys [11,18]. Nevertheless, a substantial proportion reported experiencing patient pressure to prescribe antibiotics—a well-recognized barrier in both public and private settings in India [19]. Addressing this requires not only HCW training but also public awareness campaigns and institutional policies that support clinicians in declining inappropriate requests. Only 41.3% of participants had received formal AMS-related training in the past year. This figure is lower than desirable and aligns with national observations that structured AMS education remains patchy, particularly outside major metropolitan centres [20]. Participants who had received training scored significantly higher, reinforcing the value of continuous professional development. Incorporating mandatory AMS modules into induction programs for new staff and into postgraduate curricula would be pragmatic next steps for the institution. Perceived barriers—lack of updated guidelines, time pressure, limited rapid diagnostics and inadequate feedback—are classic challenges reported across Indian hospitals [21,22]. Strengthening the institutional AMS committee, ensuring regular dissemination of local antibiograms, implementing prospective audit-and-feedback, and investing in point-of-care diagnostics would address several of these systemic issues simultaneously. The moderate positive correlations among knowledge, attitude and perception domains suggest that improvements in one domain are likely to influence the others, supporting a multi-pronged educational and organizational strategy. The study’s strengths include a reasonably large sample, inclusion of multiple HCW categories, use of a validated questionnaire, and generation of local baseline data for a newly developing medical institute. Limitations include the single-centre design (limiting generalizability), self-reported data (possible social-desirability bias), and the cross-sectional nature that precludes causal inference. Practice behaviour was not directly observed; future mixed-methods or audit-based studies would complement these findings.

Healthcare workers at this tertiary care centre in Western India demonstrated moderately good knowledge and perception, and a predominantly positive attitude toward antimicrobial stewardship and the threat of antimicrobial resistance. Critical gaps were identified in awareness of the WHO AWaRe classification, utilization of antibiograms, formal AMS training exposure, and confidence in institutional policy implementation. Doctors outperformed other professional groups, indicating the need for tailored, interprofessional educational interventions. We recommend: (1) integration of structured AMS modules into undergraduate, postgraduate and induction curricula; (2) regular dissemination of local antibiograms and consumption data; (3) establishment or strengthening of a multidisciplinary AMS committee with audit-and-feedback mechanisms; and

(4) periodic KAP assessments to monitor progress. These measures will help translate favourable attitudes into consistent stewardship practices and contribute to the containment of AMR at the institutional and regional level.

ACKNOWLEDGEMENTS

The authors thank all the healthcare workers who participated in this study. We acknowledge the support of the Institutional Ethics Committee and the administration of NAMO Medical Education and Research Institute, Silvassa.

CONFLICT OF INTEREST

The authors declare no conflict of interest.

FUNDING

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.