European Journal of Cardiovascular Medicine

Antimicrobial resistance (AMR) has emerged as one of the most serious global public health challenges, threatening the effective prevention and treatment of a wide range of infections caused by bacteria, parasites, viruses, and fungi (1). The overuse and misuse of antibiotics, both in the community and in healthcare settings, are major contributors to the acceleration of AMR (2). To combat this growing concern, Antimicrobial Stewardship Programs (ASPs) have been developed to promote the appropriate use of antimicrobials, thereby improving patient outcomes, reducing microbial resistance, and decreasing unnecessary costs (3,4).

ASPs involve coordinated interventions designed to optimize antimicrobial prescribing, including the selection of appropriate agents, doses, routes, and durations of therapy (5). These programs are now considered an essential part of infection control and quality assurance in healthcare institutions worldwide (6). However, their success depends significantly on the knowledge, attitudes, and practices of healthcare providers, including medical students, who represent the future generation of prescribers (7).

Incorporating ASP-related education during undergraduate medical training is crucial for fostering rational prescribing behaviors early in clinical practice (8). Previous studies have demonstrated variable levels of awareness and understanding of ASPs among medical students, indicating a need for standardized educational interventions (9). Moreover, assessing students’ attitudes and perceptions can provide valuable insights for designing effective training modules that align with global stewardship objectives (10).

This study aims to assess the knowledge, attitude, and perception of medical students regarding antimicrobial stewardship programs in a tertiary medical college setting, thereby identifying gaps and opportunities for curricular improvements.

A descriptive, cross-sectional survey was conducted over a period of three months at a tertiary care teaching medical college in India. The study aimed to assess the knowledge, attitude, and perception (KAP) of undergraduate medical students toward Antimicrobial Stewardship Programs (ASPs).

Study Participants
The target population comprised undergraduate medical students from the second, third, and final professional years. First-year students and interns were excluded to ensure that participants had adequate clinical exposure. A total of 350 students were approached using convenience sampling, and 312 students responded completely, yielding a response rate of 89.1%.

Survey Instrument
A structured, self-administered questionnaire was developed after an extensive review of literature and existing validated tools. The questionnaire consisted of four sections: demographic details, 10 knowledge-based multiple-choice questions (MCQs), 7 attitude-based items, and 8 perception-related statements. The attitude and perception sections used a five-point Likert scale ranging from "strongly disagree" to "strongly agree."

Validation and Pilot Testing
The questionnaire was reviewed by three subject experts for content validity. A pilot test was conducted on 30 students (excluded from final analysis) to assess clarity and reliability, yielding a Cronbach's alpha of 0.82, indicating good internal consistency.

Data Collection Procedure
Participants were invited to complete the survey via printed forms distributed during lecture hours. Informed consent was obtained prior to participation, and anonymity was ensured.

Scoring and Data Analysis
Each correct answer in the knowledge section was awarded one point, with a total possible score of 10. Attitude and perception scores were calculated based on the Likert scale responses. Data were entered into Microsoft Excel and analyzed using SPSS version 25. Descriptive statistics were used to summarize demographic and KAP scores. The chi-square test was used to compare categorical variables, and Pearson’s correlation was applied to determine the relationship between knowledge, attitude, and perception scores. A p-value of less than 0.05 was considered statistically significant.

A total of 312 medical students participated in the study, with a mean age of 21.3 ± 1.4 years. Of the respondents, 182 (58.3%) were male and 130 (41.7%) were female. The majority of participants were from the final professional year (42.9%), followed by third-year (35.6%) and second-year students (21.5%) (Table 1).

The mean knowledge score among participants was 6.1 ± 1.8 out of a maximum of 10. Based on score distribution, 61% (n = 190) of students demonstrated adequate knowledge (score ≥6), while 39% (n = 122) had poor knowledge. Higher academic year was significantly associated with better knowledge levels (p = 0.02) (Table 2).

Regarding attitudes, 73% of students (n = 228) agreed that antimicrobial stewardship is essential in reducing antibiotic resistance, and 65% (n = 203) felt confident in their future role as responsible prescribers. The mean attitude score was 28.5 ± 4.3 (out of a maximum of 35) (Table 3).

As for perception, 58% (n = 181) believed that ASP training should be integrated into the undergraduate curriculum. Additionally, 62% (n = 194) felt that current training on antibiotics was insufficient. The mean perception score was 30.2 ± 5.1 (Table 4).

Correlation analysis showed a significant positive relationship between knowledge and attitude scores (r = 0.48, p < 0.001), and a moderate correlation between knowledge and perception scores (r = 0.41, p < 0.01).

Table 1: Demographic Characteristics of Participants (n = 312)

Table 2: Knowledge Scores by Academic Year

Table 3: Attitude Responses Toward ASP (n = 312)

Table 4: Perception Toward ASP Education and Implementation (n = 312)

As shown in Tables 1–4, students generally expressed awareness and a positive outlook toward antimicrobial stewardship, though there remains a need to strengthen formal ASP education and training within the curriculum.

The present study explored the knowledge, attitude, and perception (KAP) of undergraduate medical students toward Antimicrobial Stewardship Programs (ASPs) in a tertiary teaching institute. The findings reveal moderate knowledge, a generally positive attitude, and a favorable perception toward ASPs among the participants. These observations align with previous reports from similar academic settings, highlighting the importance of incorporating ASP education into undergraduate curricula to promote rational prescribing habits early in clinical training (1,2).

The knowledge scores in this study indicated that 61% of participants had adequate understanding of ASP principles, which is comparable to findings from studies conducted in India and the Middle East, where medical students demonstrated basic awareness but limited depth of knowledge regarding antimicrobial resistance and stewardship strategies (3,4). The significantly higher scores among final-year students suggest that increased clinical exposure enhances comprehension, reinforcing the need for vertical integration of ASP concepts throughout the curriculum (5).

A notable 73% of students acknowledged the necessity of ASPs in reducing inappropriate antimicrobial use, reflecting a positive attitude that has been similarly reported among healthcare students globally (6,7). A strong attitude toward the importance of rational prescribing is crucial, as it is a key predictor of future clinical behavior (8). The positive correlation found between knowledge and attitude scores in this study supports the view that educational reinforcement directly influences attitudinal development (9).

The perception component revealed that over half of the students believe ASP training should be formally included in the undergraduate program. This finding is consistent with previous surveys indicating that students feel underprepared to make informed decisions about antimicrobial therapy without structured stewardship education (10,11). Moreover, concerns regarding insufficient antibiotic-related training suggest a curricular gap that needs urgent attention, as poor preparation has been linked to overprescribing and resistance development in early clinical practice (12).

Despite the encouraging results, the study also highlights some deficiencies. About 39% of students lacked adequate knowledge, pointing to variability in exposure and understanding. Earlier studies have emphasized the value of experiential learning, such as clinical case discussions, hospital ASP rotations, and simulation-based modules, to bridge such gaps effectively (13,14). Faculty development programs and incorporation of ASP topics in assessments could further reinforce the importance of prudent antimicrobial use (15).

The cross-sectional nature of this study limits causality, and its single-institution design may affect generalizability. Nevertheless, the high response rate and comprehensive assessment provide meaningful insights that can inform curriculum developers and policy makers.

In conclusion, the moderate knowledge and positive attitude among medical students in this study indicate readiness to embrace antimicrobial stewardship, provided appropriate educational support is given. Strengthening ASP-related content in undergraduate medical education is recommended to ensure the development of competent and responsible future prescribers.

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