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Abstract
Background: Antimicrobial resistance (AMR) constitutes one of the most critical public health emergencies of the 21st century, threatening to reverse decades of medical progress. Low- and middle-income countries (LMICs), including Pakistan, bear a disproportionate burden of AMR-related morbidity and mortality. Antimicrobial Stewardship Programs (ASPs) represent the cornerstone of global efforts to combat AMR, yet their implementation in public-sector hospitals remains inconsistent and poorly evaluated. The effectiveness of these programs is fundamentally dependent on the knowledge, practices, and attitudes of healthcare professionals who prescribe, dispense, and administer antimicrobial agents. Despite the recognized importance of ASPs, comparative data on stewardship practices across major public hospitals in Pakistan remains scarce.
Objective: This study aimed to comparatively assess antimicrobial stewardship practices, knowledge levels, and perceived barriers among healthcare professionals at two major public-sector tertiary care hospitals in Lahore and Multan, Pakistan Nishtar Hospital and General Hospital and to identify inter-facility differences that could inform targeted interventions.
Methods: A cross-sectional analytical study was conducted from January to June 2025. A total of 420 healthcare professionals (physicians, pharmacists, and nurses) were approached using stratified random sampling from Nishtar Hospital (2,500-bed capacity) and General Hospital (1,800-bed capacity). A validated, self-administered questionnaire comprising four sections—demographics, knowledge assessment (20 items), self-reported practices (10 items), and perceived barriers (15 items on a 5-point Likert scale)—was employed for data collection. Knowledge scores were expressed as percentages, with ≥70% considered satisfactory. Data were analyzed using IBM SPSS version 26.0, employing descriptive statistics, independent t-tests for continuous variables, and chi-square tests for categorical variables. A p-value <0.05 was considered statistically significant.
Results: The overall response rate was 78.6% (n=330), with Nishtar Hospital contributing 168 responses (80.0%) and General Hospital 162 responses (77.1%). The mean age of respondents was 34.2 years (±8.7), with physicians comprising 36.4% (n=120), nurses 38.8% (n=128), and pharmacists 24.8% (n=82). Prior formal training in antimicrobial stewardship was reported by 18.5% (n=31) at Nishtar Hospital compared to only 11.7% (n=19) at General Hospital (p=0.048).
Overall mean knowledge score was 65.2% (±13.5), which is suboptimal. Nishtar Hospital demonstrated significantly higher mean knowledge scores (68.4% ± 12.3) compared to General Hospital (62.1% ± 14.7; p=0.032). Physicians outperformed all other groups (74.5% ± 9.8), followed by pharmacists (63.3% ± 12.1) and nurses (58.9% ± 14.6) (p<0.001). Only 34.5% of respondents could correctly define core stewardship components, and merely 38.8% understood antibiogram interpretation.
Awareness of functional ASPs was alarmingly low at 18.5% overall, significantly higher at Nishtar (23.2%) than General (13.6%) (p=0.043). Microbiological sampling prior to antibiotic initiation was practiced by only 28.8% of respondents, with no significant inter-hospital difference (p=0.091). Regular antibiotic review and de-escalation were reported by 24.5%, and IV-to-oral switching by 22.1%.
The top five perceived barriers were: lack of hospital administrative support (mean 4.25/5), inadequate training opportunities (4.14), absence of hospital-specific guidelines (4.01), limited microbiology laboratory facilities (3.85), and insufficient staffing (3.71). General Hospital participants rated all barriers significantly higher than Nishtar Hospital (p<0.05).
Conclusion: Significant knowledge deficits and practice gaps exist among healthcare professionals at both public-sector hospitals, with Nishtar Hospital demonstrating marginally better outcomes attributable to greater training opportunities. The universal endorsement of administrative apathy and inadequate training as primary barriers indicates that the problem is deeply entrenched in organizational culture and resource allocation. Urgent, targeted educational interventions, coupled with policy-level mandates and infrastructural investment, are critically needed to strengthen antimicrobial stewardship in Pakistan's public healthcare sector.