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Peer-reviewedCC BY 4.0Frontiers in Public Health

Antibiotic prescribing patterns, antimicrobial stewardship implementation barriers and readiness at primary health care centres in eastern Uttar Pradesh, India

  • Neha Srivastava1
  • Ashok Kumar Pandey1,2
  • Laiba Jamal Ahmad1
  • Umaer Alam1,3
  • Rohit Beniwal4
  • Niraj Kumar2,4
  • Shailesh Kumar1
  • Sakshi Singh2
  • Hari Shanker Joshi5
5 affiliations
  1. 1Model Rural Health Research Unit (MRHRU Pali), ICMR-National Institute of Health Research
  2. 2Viral Immunology and Vaccine Research Division, ICMR- National Institute of Health Research
  3. 3Social and Behavioural Health Research Division, ICMR-National Institute of Health Research
  4. 4Molecular Biology Division, ICMR-National Institute of Health Research
  5. 5ICMR-National Institute of Health Research
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Abstract

Background: Inappropriate antibiotic use in primary care is a major contributor to antimicrobial resistance, particularly in resource-constrained settings where empirical treatment is common. Community Health Centres (CHCs) provide first-referral care for much of rural India, yet evidence on antibiotic prescribing patterns and preparedness for antimicrobial stewardship in these settings is limited.

Objective: We assessed paediatric outpatient antibiotic prescribing using the WHO Access, Watch, and Reserve (AWaRe) classification and evaluated clinicians’ knowledge, attitudes, and readiness to implement antimicrobial stewardship at rural CHCs in Gorakhpur, Uttar Pradesh, India.

Methods: We conducted this cross-sectional study between February and December 2025. The quantitative component comprised a prescription audit of paediatric outpatients (≤18 years) presenting with acute febrile illness, acute respiratory infection, acute diarrhoeal disease or presumptive urinary tract infection at a rural CHC. Prescribed antibiotics were classified according to the WHO AWaRe framework. We also surveyed 40 clinicians from Community Health Centres across Gorakhpur district using the questionnaire which included closed-ended items assessing antimicrobial stewardship knowledge, attitudes and practices to identify perceived barriers to antimicrobial stewardship implementation. Quantitative data were summarized descriptively and used to inform the proposed antimicrobial stewardship implementation framework.

Results: We reviewed 602 paediatric prescriptions. Antibiotics were prescribed in 98·8% of acute respiratory infections, 100% of acute diarrhoeal disease cases and 86·9% of acute febrile illness encounters. Only 18·8% of prescribed antibiotics belonged to the WHO Access category, substantially below the WHO target of at least 60%, whereas Watch antibiotics predominated across all clinical syndromes. Azithromycin was the most frequently prescribed antibiotic. Among clinicians, awareness of antimicrobial resistance was high (95%) and most were aware of national antimicrobial treatment guidelines (80%); however, familiarity with the WHO AWaRe classification (45%) and antimicrobial stewardship concepts (32·5%) was limited. Only six (33·3%) of the 18 clinicians familiar with AWaRe correctly identified Reserve antibiotics. Total 31 (77·5%) clinicians demonstrated a positive attitude towards antimicrobial stewardship and 92.5% clinicians considered implementation of a facility-level stewardship programme feasible despite reporting major barriers, including limited diagnostic capacity, absence of formal stewardship structures, workforce shortages and high patient workload.

Conclusion: Paediatric outpatient antibiotic prescribing at a rural Community Health Centre in eastern Uttar Pradesh was characterised by extensive use of WHO Watch-category antibiotics and limited use of Access antibiotics. High awareness of antimicrobial resistance contrasted with important gaps in antimicrobial stewardship knowledge and stewardship infrastructure. These findings suggest that improving antibiotic use in scrub typhus–endemic primary-care settings will require context-specific antimicrobial stewardship programmes that combine clinician education, AWaRe-based prescribing indicators, strengthened diagnostic support and routine prescription audit and feedback.

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Cite

BibTeXRIS
BibTeX
@article{srivastava2026antibiotic,
  title = {{Antibiotic prescribing patterns, antimicrobial stewardship implementation barriers and readiness at primary health care centres in eastern Uttar Pradesh, India}},
  author = {Neha Srivastava and Ashok Kumar Pandey and Laiba Jamal Ahmad and Umaer Alam and Rohit Beniwal and Niraj Kumar and Shailesh Kumar and Sakshi Singh and Hari Shanker Joshi},
  journal = {Frontiers in Public Health},
  year = {2026},
  month = oct,
  doi = {10.3389/fpubh.2026.1945074},
  url = {https://www.frontiersin.org/articles/10.3389/fpubh.2026.1945074/full},
  note = {CC BY 4.0},
}
RIS
TY  - JOUR
TI  - Antibiotic prescribing patterns, antimicrobial stewardship implementation barriers and readiness at primary health care centres in eastern Uttar Pradesh, India
AU  - Neha Srivastava
AU  - Ashok Kumar Pandey
AU  - Laiba Jamal Ahmad
AU  - Umaer Alam
AU  - Rohit Beniwal
AU  - Niraj Kumar
AU  - Shailesh Kumar
AU  - Sakshi Singh
AU  - Hari Shanker Joshi
PY  - 2026
DA  - 2026/10/22
JO  - Frontiers in Public Health
DO  - 10.3389/fpubh.2026.1945074
UR  - https://www.frontiersin.org/articles/10.3389/fpubh.2026.1945074/full
AB  - Background: Inappropriate antibiotic use in primary care is a major contributor to antimicrobial resistance, particularly in resource-constrained settings where empirical treatment is common. Community Health Centres (CHCs) provide first-referral care for much of rural India, yet evidence on antibiotic prescribing patterns and preparedness for antimicrobial stewardship in these settings is limited.  Objective: We assessed paediatric outpatient antibiotic prescribing using the WHO Access, Watch, and Reserve (AWaRe) classification and evaluated clinicians’ knowledge, attitudes, and readiness to implement antimicrobial stewardship at rural CHCs in Gorakhpur, Uttar Pradesh, India.  Methods: We conducted this cross-sectional study between February and December 2025. The quantitative component comprised a prescription audit of paediatric outpatients (≤18 years) presenting with acute febrile illness, acute respiratory infection, acute diarrhoeal disease or presumptive urinary tract infection at a rural CHC. Prescribed antibiotics were classified according to the WHO AWaRe framework. We also surveyed 40 clinicians from Community Health Centres across Gorakhpur district using the questionnaire which included closed-ended items assessing antimicrobial stewardship knowledge, attitudes and practices to identify perceived barriers to antimicrobial stewardship implementation. Quantitative data were summarized descriptively and used to inform the proposed antimicrobial stewardship implementation framework.  Results: We reviewed 602 paediatric prescriptions. Antibiotics were prescribed in 98·8% of acute respiratory infections, 100% of acute diarrhoeal disease cases and 86·9% of acute febrile illness encounters. Only 18·8% of prescribed antibiotics belonged to the WHO Access category, substantially below the WHO target of at least 60%, whereas Watch antibiotics predominated across all clinical syndromes. Azithromycin was the most frequently prescribed antibiotic. Among clinicians, awareness of antimicrobial resistance was high (95%) and most were aware of national antimicrobial treatment guidelines (80%); however, familiarity with the WHO AWaRe classification (45%) and antimicrobial stewardship concepts (32·5%) was limited. Only six (33·3%) of the 18 clinicians familiar with AWaRe correctly identified Reserve antibiotics. Total 31 (77·5%) clinicians demonstrated a positive attitude towards antimicrobial stewardship and 92.5% clinicians considered implementation of a facility-level stewardship programme feasible despite reporting major barriers, including limited diagnostic capacity, absence of formal stewardship structures, workforce shortages and high patient workload.  Conclusion: Paediatric outpatient antibiotic prescribing at a rural Community Health Centre in eastern Uttar Pradesh was characterised by extensive use of WHO Watch-category antibiotics and limited use of Access antibiotics. High awareness of antimicrobial resistance contrasted with important gaps in antimicrobial stewardship knowledge and stewardship infrastructure. These findings suggest that improving antibiotic use in scrub typhus–endemic primary-care settings will require context-specific antimicrobial stewardship programmes that combine clinician education, AWaRe-based prescribing indicators, strengthened diagnostic support and routine prescription audit and feedback.
SN  - 2296-2565
ER  -