A cross-sectional assessment of knowledge, attitude and practices towards antimicrobial resistance among the medical interns in Puducherry

Introduction

Antimicrobial resistance (AMR) has become one of the most pressing global public health challenges, undermining the effective prevention and treatment of infectious diseases. In India, the problem is particularly severe, with resistance extending beyond older antimicrobial agents to include critically important drugs such as carbapenems, which are often considered last-line therapies (Prestinaci et al., 2015) [1] . The rapid emergence of resistance compromises clinical outcomes, increases healthcare costs, and poses a serious threat to population health.

Although AMR has traditionally been studied in human medicine, increasing evidence indicates that livestock and food-producing animals play a significant role in the emergence and dissemination of resistant bacteria. In India, the burden of AMR in food animals remains poorly documented, with most data originating from small, localized studies that cannot be generalized at the national level. The limited regulatory control over the nontherapeutic use of antibiotics in animals, particularly for growth promotion and disease prevention, is likely contributing to an unrecognized and substantial AMR www.extensionjournal.com burden (Taneja et al., 2019) [2] . The dairy sector provides early and compelling evidence of antimicrobial resistance in food animals. Mastitis, one of the most common diseases affecting dairy cattle and buffaloes, has been associated with the presence of diverse bacterial pathogens exhibiting resistance to commonly used antibiotics. Milk from mastitis animals may harbour multidrug-resistant organisms, sometimes occurring as coinfections, thereby posing risks to both animal health and food safety (Pascu et al., 2022) [3] . Similar concerns have been raised in the poultry sector, where accurate estimates of antibiotic usage are lacking. Antibiotics are frequently administered through premixed feeds, often without clear labelling, making it difficult to quantify consumption levels. Studies have consistently reported high levels of antimicrobial resistance among bacteria isolated from poultry, animals, and seafood (Manyi-Loh et al., 2018) [4] . In contrast, the aquaculture sector in India is subject to comparatively stricter regulatory oversight. The Food Safety and Standards Authority of India has banned the use of several antibiotics and pharmacologically active substances in fisheries, leading to greater scrutiny of AMR in this sector (Walia et al., 2019) [5] . Legislative provisions aimed at restricting inappropriate antibiotic use are expected to influence resistance trends in aquaculture, although continued surveillance is required to assess their long-term impact (Andrew et al., 2020) [6] . India is one of the largest consumers of antibiotics for human health, with substantial use also reported in foodproducing animals. Although per capita antibiotic consumption is lower than in some high-income countries, the absolute volume is considerable. Notably, antimicrobial consumption in the food-animal sector is projected to increase significantly by 2030, raising concerns about accelerated resistance development if appropriate stewardship measures are not implemented (Ibrahim et al., 2020) [7] . The Global Action Plan on AMR emphasizes improving awareness and understanding through education, communication, and training across human and animal health sectors. In India, AMR surveillance has largely focused on disease-specific vertical programs, while an integrated, cross-sectoral surveillance system remains limited (Walia et al., 2019) [8] . Medical interns, as future prescribers, play a critical role in antimicrobial stewardship. Their knowledge, attitudes, and practices directly influence rational antibiotic use. Therefore, the present study was undertaken to assess the knowledge, attitude, and practices related to antimicrobial resistance among medical interns.

Materials and Methods

The present cross-sectional study was conducted in Puducherry with the objective of assessing the knowledge, attitude, and practices related to antimicrobial resistance among medical interns, with particular emphasis on their future antimicrobial prescribing behaviour.

Selection of respondents

A total of 200 medical interns were included in the study. The respondents were randomly selected from two government medical colleges in Puducherry, namely the Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER) and the Indira Gandhi Medical College and Research Institute (IGMC & RI). From each institution, 100 medical interns were enrolled to ensure equal representation.

Questionnaire design and data collection

A structured, self-administered questionnaire comprising 30 questions was developed to assess the respondents' knowledge, attitude, and practices related to AMR. The questionnaire consisted of three sections, with 10 questions each focusing on knowledge, attitude, and practices. Data were collected using Google Forms, and participation was voluntary. Prior to the main survey, the questionnaire was pre-tested among 25 medical interns who were not included in the final sample. Based on the feedback and experience gained during the pre-testing phase, necessary modifications were incorporated to improve clarity and relevance. The finalized questionnaire was then used for data collection.

Knowledge questions (True/False)

1. Superbug is a strain of bacteria that has become resistant to antibiotic drugs.

Attitude Towards Antimicrobial Resistance

The attitude assessment revealed a generally positive and concerned outlook towards AMR among interns, though variability existed across domains. Nearly two-thirds (64%) believed that India is likely to face an AMR crisis in the future, reflecting recognition of the seriousness of the issue. India's high infectious disease burden, widespread antibiotic use, and regulatory challenges likely influence this perception. Only 4% felt that Indian drug legislation is on par with global standards, while nearly half disagreed, indicating skepticism about regulatory effectiveness. This perception aligns with existing challenges in antibiotic enforcement and highlights the need for stronger policy awareness and implementation. A substantial majority (72%) supported culture and sensitivity-based prescribing, demonstrating a favourable attitude toward evidence-based antimicrobial use. Likewise, 60% agreed that skipping doses contributes to resistance, reinforcing awareness of adherence-related risks. These findings suggest that while theoretical understanding exists, translation into consistent practice may be lacking. An overwhelming 92% emphasized the importance of student involvement in AMR research, highlighting enthusiasm for academic engagement and interdisciplinary learning. This presents a valuable opportunity for institutions to integrate research-based learning modules focused on AMR. Attitudes toward broad-spectrum antibiotic use were mixed, with only 32% disagreeing with their routine first-line use. This ambiguity suggests incomplete understanding of ecological consequences and microbiome disruption. Similarly, attitudes toward restricting prophylactic www.extensionjournal.com antimicrobial use in food-producing animals were divided, with only 36% supporting bans. This reflects limited awareness of the One Health dimensions of AMR. Optimism regarding the development of new antimicrobials was observed in 68% of interns, though such confidence may underestimate the complexities of drug discovery pipelines. Importantly, 68% acknowledged the role of pharmaceutical wastewater in environmental AMR spread, indicating growing awareness of environmental contributors. The One Health perspective was strongly supported, with 88% agreeing that collaboration between medical and veterinary professionals is essential. This positive attitude provides a strong foundation for interdisciplinary AMR mitigation strategies.

Practices Related to Antimicrobial Use

Despite reasonable knowledge and generally positive attitudes, suboptimal practices related to antimicrobial use were evident. While 92% reported using antibiotics fewer than five times in the previous year, a concerning 60% admitted to consuming antibiotics without consulting a doctor. Self-medication is a major driver of resistance and reflects gaps in both regulatory enforcement and personal accountability. Additionally, 44% reported antibiotic use following telephonic consultation. While telemedicine has a role in healthcare delivery, inappropriate antibiotic prescribing without adequate clinical evaluation can exacerbate misuse. Notably, 88% reported discontinuing antibiotics once symptoms improved, reinforcing earlier findings of poor adherence practices. Positive practices included checking expiry dates (92%) and selecting antimicrobials based on academic knowledge (96%). However, 52% observed antimicrobial misuse in their training facilities, indicating systemic issues within healthcare settings that may normalize inappropriate prescribing behaviours. Prescribing antibiotics over the phone to friends or relatives was reported by 36% of interns, highlighting ethical and professional lapses that can contribute to resistance. On a positive note, 84% enquired about previous antibiotic use before prescribing, reflecting awareness of resistance risks and patient history relevance. The duration of antibiotic prescription varied according to disease severity in 76% of cases, suggesting individualized decision-making aligned with clinical judgment. Overall, while several responsible practices were observed, widespread inappropriate behaviours underscore the gap between knowledge and real-world application.

Conclusion

Overall, the study reveals a positive outlook toward antimicrobial resistance among medical interns, with most demonstrating sound basic knowledge, appropriate attitudes, and several responsible prescribing practices. High awareness of antibiotic side effects, resistance, MRSA management, and the importance of culture-based therapy reflects a strong academic foundation. The interns' recognition of AMR as a major future threat, support for interdisciplinary collaboration, and willingness to engage in AMR research further highlight their readiness to contribute to containment efforts. Although certain gaps in stewardship awareness and prescribing practices were identified, these should be viewed as opportunities for focused training rather than shortcomings. Given their receptive attitude and foundational competence, medical interns represent a highly promising group in whom structured antimicrobial stewardship education during internship can effectively promote rational antibiotic use and strengthen efforts to combat antimicrobial resistance.

References

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