Current Practices, Gaps, and Barriers in Antimicrobial Stewardship Implementation: Evidence from a Multi-stakeholder Study in India.

BACKGROUND

Antimicrobial resistance poses a critical threat to global health, and effective implementation of Antimicrobial Stewardship Programs remains a priority, particularly in low, middle-income countries. India has established national policy frameworks for stewardship, yet ground-level implementation remains limited.

METHODS

A cross-sectional survey was conducted among 351 healthcare professionals across Indian hospitals, with distribution facilitated through students of an Antimicrobial Stewardship Certificate Course. The survey assessed 30 stewardship practices and one barrier question across six WHO-aligned implementation domains, with each response classified as Gap, Suboptimal, Optimum, or Not Sure/Not Aware. Mean percentage of Optimum responses was calculated for each demographic category and groups were compared using the Kruskal-Wallis test.

RESULTS

Suboptimal practice dominated all six domains, accounting for 43.7% of responses. Optimum practice scores varied by domain: Prescribing Practices (20.9%), Education and Training (21.7%), Accountability (26.9%), Governance and Leadership (28.4%), Monitoring and Evaluation (28.4%), and Surveillance (34.0%). Gap and Not Sure/ Not Aware responses combined accounted for 29.6%. The leading barriers were absence of external regulatory mandates, lack of dedicated AMS personnel, and inadequate digital and laboratory infrastructure. Accreditation status showed the strongest association, with accredited facilities scoring 35.7% versus 12.1% in non-accredited settings (p<0.001). AMS team membership showed a progressive association, with active members reporting the highest Optimum scores (44.2%) and facilities with no AMS team the lowest (14.0%) (p<0.001). Professional role and years of general professional experience were not significantly associated with practice scores.

CONCLUSIONS

AMS implementation across Indian hospitals is characterized by widespread Suboptimal rather than absent practice, indicating a system in transition. Accreditation and AMS team membership are the strongest institutional drivers of stewardship quality. Priority actions include mandating AMS components through accreditation, investing in dedicated multi-professional stewardship teams, establishing a national training framework, and strengthening digital infrastructure for surveillance and audit.