European Journal of Cardiovascular Medicine

Antimicrobial resistance (AMR) is an escalating global public health threat that undermines the effectiveness of standard treatments, leading to prolonged illness, increased mortality, and rising healthcare costs (1). It is estimated that by 2050, AMR could result in 10 million deaths annually if left unaddressed (2). The inappropriate and excessive use of antimicrobials in clinical practice remains the primary driver of resistance, with evidence suggesting that a significant proportion of antibiotic prescriptions are either unnecessary or improperly dosed (3,4).

Medical interns and practicing clinicians play pivotal roles in antibiotic prescribing. However, their level of awareness, prescribing habits, and adherence to antimicrobial stewardship (AMS) principles vary widely based on clinical experience, institutional policies, and educational background (5). Studies have revealed that junior doctors often prescribe under the influence of seniors or peer behavior, sometimes lacking the confidence or knowledge to apply evidence-based antimicrobial protocols (6). Conversely, clinicians with years of experience may develop habitual prescribing patterns, which might not always align with current guidelines (7).

Recognizing these differences is critical for tailoring educational interventions and policy reforms. The World Health Organization (WHO) introduced the AWaRe (Access, Watch, and Reserve) classification as a strategic framework to guide rational antibiotic use globally (8). Despite its importance, awareness of the AWaRe classification among healthcare professionals, particularly interns, remains suboptimal in many regions (9).

This study aims to compare the prescribing practices and awareness of AMR between medical interns and practicing clinicians in a tertiary care setting. By identifying knowledge gaps and behavioral patterns, the findings can support the implementation of more targeted AMS training modules and encourage adherence to national and global prescribing standards.

This cross-sectional, questionnaire-based study was conducted over a period of three months at a tertiary care teaching hospital in India. The objective was to compare the knowledge, prescribing practices, and awareness regarding antimicrobial resistance (AMR) among medical interns and practicing clinicians.

A total of 100 participants were enrolled using purposive sampling, comprising 50 medical interns undergoing their mandatory rotatory internship and 50 clinicians actively involved in patient care for at least two years.

A structured and validated questionnaire was used as the primary data collection tool. The questionnaire consisted of three sections: (1) demographic details including age, gender, and years of clinical experience; (2) knowledge and awareness of antimicrobial resistance, including questions on causes, consequences, and the WHO AWaRe classification; and (3) prescribing practices, focusing on the frequency of empirical antibiotic use, guideline adherence, and factors influencing prescription decisions.

The questionnaire was distributed in both print and digital formats. Participants were given 20 minutes to complete the survey in a supervised setting to minimize discussion or external influence. The responses were anonymized and coded for confidentiality.

Data were entered into Microsoft Excel and analyzed using SPSS version 25. Descriptive statistics such as frequency and percentage were used to summarize categorical variables. Comparative analysis between interns and clinicians was performed using the Chi-square test. A p-value of less than 0.05 was considered statistically significant.

A total of 100 participants were included in the study, comprising 50 medical interns and 50 practicing clinicians. The demographic distribution showed a nearly equal gender ratio in both groups, with the average age of interns being 23.5 ± 1.2 years and that of clinicians being 36.7 ± 5.4 years.

Awareness and Knowledge of Antimicrobial Resistance

Table 1 summarizes the participants' awareness and knowledge regarding antimicrobial resistance. A higher percentage of clinicians (84%) demonstrated correct understanding of AMR compared to interns (68%). Awareness of the WHO AWaRe classification was significantly higher among clinicians (60%) than interns (28%) (p = 0.003). Moreover, 80% of clinicians recognized inappropriate prescribing as a major contributor to AMR, whereas only 56% of interns identified this correctly.

Table 1. Awareness and Knowledge of AMR among Interns and Clinicians

Prescribing Practices

Table 2 displays the comparison of prescribing practices. Only 40% of interns reported regularly following institutional antibiotic guidelines, compared to 72% of clinicians. A majority of interns (54%) admitted to prescribing based on senior direction rather than clinical evidence, while only 26% of clinicians reported similar behavior. Notably, empirical antibiotic use for common infections was reported in 78% of interns and 62% of clinicians.

Table 2. Comparison of Prescribing Practices Between Interns and Clinicians

Interpretation

The analysis indicates that clinicians outperform interns in both awareness of AMR and evidence-based prescribing. The difference was statistically significant in several areas including guideline adherence and knowledge of the AWaRe classification (Table 1, Table 2). These findings underscore the need for stronger integration of antimicrobial stewardship principles during internship training.

The findings of this study reveal notable differences in the awareness, knowledge, and prescribing practices regarding antimicrobial resistance (AMR) between medical interns and practicing clinicians. Clinicians demonstrated significantly greater understanding of AMR concepts, better adherence to prescribing guidelines, and higher awareness of the WHO AWaRe classification system. These observations are consistent with previous literature emphasizing the impact of clinical experience on responsible antimicrobial use (1,2).

The fact that 84% of clinicians correctly understood the mechanisms and implications of AMR, compared to 68% of interns, underscores the need for reinforcing AMR-related content during undergraduate medical training (3). Studies have shown that early exposure to structured antimicrobial stewardship (AMS) curricula can enhance knowledge retention and shape long-term prescribing behavior (4,5). Interns in our study frequently cited senior instructions as a primary influence on their antibiotic prescriptions, highlighting the hierarchical nature of medical decision-making and a possible lack of confidence in independent clinical reasoning (6,7).

Awareness of the WHO AWaRe classification was significantly higher among clinicians (60%) than among interns (28%). The AWaRe framework categorizes antibiotics into Access, Watch, and Reserve groups to encourage rational use and minimize the emergence of resistance (8). Lack of familiarity with this system among interns may lead to inappropriate selection of higher-tier antibiotics, further aggravating resistance patterns (9,10).

Adherence to institutional guidelines for antibiotic use was notably higher in clinicians (72%) compared to interns (40%). These results align with studies conducted in similar tertiary care settings where guideline adherence was positively associated with years of clinical practice and participation in continuing medical education (11,12). However, even among clinicians, there is room for improvement in areas such as reducing empirical antibiotic use and ensuring appropriate diagnostic confirmation before prescription (13).

Our findings also support the assertion that prescriber education alone may not suffice unless it is complemented by institutional support systems such as audit-feedback loops, availability of prescribing resources, and easy access to local antibiograms (14). A multifaceted approach involving real-time decision support tools, peer benchmarking, and periodic AMS workshops is essential for sustainable behavioral change across all levels of healthcare providers (15).

This study highlights significant differences in antimicrobial prescribing practices and awareness between medical interns and practicing clinicians. Clinicians demonstrated better adherence to guidelines and greater knowledge of AMR and the WHO AWaRe classification. These findings underscore the urgent need to strengthen antimicrobial stewardship education at the undergraduate level to promote rational antibiotic use and combat the growing threat of antimicrobial resistance.

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